The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

LAKELAND BEHAVIORAL HEALTH SYSTEM 440 S MARKET SPRINGFIELD, MO April 21, 2017
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on interview and record review the Governing Body (GB) failed to ensure that their responsibility to review and resolve grievances was delegated in writing to a grievance committee. This failure could potentially endanger all patients if allegations were not investigated for systemic problems that could lead to patient harm. The facility census was 117.

Findings included:

1. Record review the facility's document titled, "Governing Body (GB) Meeting, Fourth Quarter and Annual 2015," dated 04/15/16, showed the GB appointment and approval of the Patient Advocate to respond to complaints and grievances.

2. Record review of the facility's policy titled, "Patient Complaint/Grievance Process," dated 02/16/16, showed the Patient Advocate reviewed complaints received and attempted to respond to all grievances.

During an interview on 04/19/17 at 1:57 PM, Staff AC, Chief Executive Officer (CEO), stated that he was a voting member of GB. The GB was not aware that the complaint and grievance process had to be delegated to a committee when the GB appointed and approved the Patient Advocate to respond to complaints and grievances.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview, record review and policy review, the facility failed to:
- Immediately remove staff from patient care after allegations of staff to patient abuse for one patient (#26) of two reported cases reviewed. (A-0144)
- Notify administration, the physician or the guardian/parent after an allegation of staff to patient abuse for one patient (#26) of one patient reviewed for allegation of abuse. (A-0145)
- Adequately investigate allegations of a staff to patient abuse for one patient (#26) of one patient reviewed for allegation of abuse. (A-0145)
- Complete a physical examination for one patient (#26) of one patient reviewed for the allegation of abuse. (A-0145)
- To ensure that staff followed facility policy when they did not modify the care plans for three patients (#10, #5, and #27) of three patients care plans reviewed following an episode of restraint and/or seclusion. (A-0166)
- Ensure that the responsibility to review and resolve grievances was delegated in writing to a grievance committee. (A-0119)
- Provide a written notice of resolution of patient grievances for two (#26 and #30) of two grievance files reviewed (A-123)

These failures resulted in the overall non-compliance with 42 CFR 482.13, Condition of Participation: Patient's Rights. The cumulative effect of these systemic practices had the potential to place all patients at risk for their safety, also known as Immediate Jeopardy (IJ).

On 04/21/17, at the time of survey exit, the facility provided an immediate Plan of Correction sufficient to remove the IJ by implementing the following:
- The policy 2.5 Abuse/Neglect/Exploitation; Serious Occurrences, Assessment and Mandatory Reporting (Hotline) showed a revision that gave any staff member the authority to require another staff member to be removed from patient care when abuse was alleged.
- Revision of the 2.6 Grievance Policy showed the directive for staff to date, time, and sign the Patient Concern Notification (a form which patients/patient representative documented complaint/grievances) when they received the complaint.
- Patient Concern Notification to be hand delivered to a Manager, Supervisor, or Director.
- An abuse/neglect investigation should include interview with the alleged victim or person who completed the grievance, all witnesses, two to three patients that were not directly involved, and staff as necessary to identify care patterns of the alleged perpetrator, chart review and video from the camera reviewed.
- The video from the camera for unsubstantiated incidents will be kept for one year and substantiated events will be transferred to a disc and placed with the incident file.
- Mandatory reporting would be completed with the appropriate agencies.
- Immediate in person education of all staff started on 04/20/17 at 11:00 PM through review of the abuse/neglect policy and its application by staff regarding the definition of abuse/neglect within the facility and allegations of abuse/neglect with competency testing and scenarios.
- Education for newly hired staff would be modified to include changes made on abuse/neglect allegations and the grievance process with competency tests.
- There will be frequent and ongoing monitoring of staff's validation of understanding of allegations of abuse/neglect education through scenario review and application of the process by staff.
- Competency tests will be reviewed daily in Flash Meeting (meeting of leadership staff) by the Director of Nursing (DON) or the Administrative Designee and issues of noncompliance will be immediately addressed.
- All incident reports, Patient Concern Notifications, and investigations will be reviewed daily in a Flash Meeting by Performance Improvement and Risk Management Director or Administrative Designee and issues of noncompliance would be immediately addressed.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on interview, record review, and policy review, the facility failed to provide a written notice of resolution of a patient's grievance for two (#26 and #30) of two grievance files reviewed. This had the potential to affect all patients and or patient's representatives who file a grievance by denying them needed information regarding their grievance. The facility census was 117.

Findings included:

1. Record review of the facility's policy titled, "Patient Complaint/Grievance Process," dated 02/16/16, showed directive for the Patient Advocate to attempt to respond to all grievances in writing within seven calendar days of receipt of the grievance. Due to the nature and complexity of the grievance, if a written response cannot be made within seven calendar days, the Patient Advocate will inform the patient or representative that the hospital is still working to resolve the grievance and that a written response will be made within thirty calendar days of the receipt of the grievance.

2. Record review of two grievances showed Patient #26 filed a grievance on 08/16/16 and Patient #30's representative filed a grievance on 09/06/16. The grievance files contained no documentation that showed resolution letters had been sent to the patient/patient representative.

During an interview on 04/19/17 at 1:25 PM, Staff B, Director of Performance Improvement and Risk Management, stated that she took care of grievances and she failed to send a written response to Patient #26 and Patient #30's representatives.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interview, record review, and policy review the facility failed to immediately remove staff from patient care after allegations of a staff to patient abuse of one patient (#26) of two reported cases reviewed. This failure created an unsafe environment, and could affect all patients. The facility census was 117.

Findings included:

1. Record review of the facilities policy titled, "Abuse/Neglect/Exploitation; Serious Occurrences, Assessment and Mandatory Reporting (Hotline) When Alleged Abuse Occurs within the Facility between Staff and Patient/Residents," dated 12/05/14, showed the directive for staff that the Manager or Nursing Supervisor will suspend the staff pending investigation.

2. Record review of the document titled, "Patient Concern Notification, (a form for patients/patient representatives to write a complaint or grievance)" dated 08/16/16 at 7:22 AM showed:
- Patient #26 wrote that at 07:12 AM in room 726 (two South), Staff NN, Behavioral Health Technician (BHT) had assaulted him.
- Patient #26 stated that he talked with his roommate and then Staff NN pushed him and left red marks on him.
- The report was received on 08/17/16 at 7:30 AM.
- Staff reviewed a video. The patient was escorted out of the room and down the hall and there was no evidence of malicious intent.
- On 8/17/16 at 11:09 AM, Staff B, Director of Performance Improvement and Risk Management, stated that there were no injuries observed on 08/16/16 at 3:20 PM.

3. Record review of Staff NN's witness statement dated 08/16/16 at 7:30 AM showed:
- Patient #26 awoke and attempted to awaken his roommate.
- The roommate asked Patient #26 several times to leave him alone.
- The staff asked multiple times for Patient #26 to leave and go down the hall.
- Patient #26 left the room, but attempted to return and the roommate planned to fight with Patient #26.
- Staff NN turned Patient #26 around and guided him away for his safety.

4. Record review of the document titled, "Time Detail," dated 08/14/16 - 08/20/16, showed Staff NN continued to work on 08/16/16 until 3:21 PM. He worked on 08/17/16 from 6:24 AM to 3:13 PM.
The facility did not remove Staff NN from patient care.

During an interview on 04/20/17 at 9:05 AM, Staff NN stated that:
- He was asked by Staff LL, Nurse Manager of 2 Center (C) and 2 South (S), to write the witness statement.
- He worked the rest of the day.
- When allegations occurred an incident report was completed and staff were sent to another unit to work until the patient was discharged .
- It depended on how serious the allegation was by the patient.
- If the allegation was serious enough then the staff may be suspended and terminated.
- Typically, when there was an allegation made by a patient against a staff the staff were not immediately removed from patient care.

During an interview on 04/20/17 at 9:39 AM, Staff LL, stated that:
- She wrote the date, time and her name along with Staff Z's, Nursing Compliance Manager, name on Patient #26's Patient Concern Notification form.
- The video review information was Staff Z's.
- She did not remember this incident.
- Typically, when she received an allegation she sent the staff to another unit to work until she was able to get her facts straight.
- If she reviewed the video and the allegation looked as if it occurred, then the staff needed to be suspended.
- "We do not send an alleged perpetrator (staff accused of hurting a patient) home immediately."

During an interview on 04/20/17 at 2:25 PM Staff M, Assistant Director of Nursing (ADON), stated that it depended on the allegation, if a staff was sent to another unit or suspended and sent home. If staff stated that the allegation did not occur then staff was sent to another unit and if staff say the allegation occurred then the staff was
suspended and sent home.

During an interview on 04/20/17 at 2:45 PM, Staff OO, Nurse Manager 3S, stated that staff were not always immediately removed from patient care.

During an interview on 04/20/17 at 3:25 PM Staff J, DON, stated that when an allegation was made of alleged staff abuse the staff was removed from patient care. The exception would be when a patient alleged they were abused during a restraint and all the staff stated the allegation did not occur. Then the allegation was immediately unsubstantiated. If the allegation of staff abuse was verbal we might be able to send the staff to another unit.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on interview, record review, and policy review the facility failed to:
- Notify administration after an allegation of staff to patient abuse for one patient (#26) of one patient reviewed for allegation of abuse.
- Adequately investigate allegations of a staff to patient abuse for one patient (#26) of one patient reviewed for allegation of abuse.
- Complete a physical examination for one patient (#26) of one patient reviewed for the allegation of abuse.
- Notify the physician and the guardian/parent for one patient (#26) of one patient reviewed for the allegation of abuse.
- Complete mandatory reporting to the appropriate agencies.
These failures placed all patients at risk for abuse. The facility census was 117.

Findings included:

1. Record review of the facility's policy titled, "Abuse/Neglect/Exploitation; Serious Occurrences, Assessment, and Mandatory Reporting (Hotline)-When Alleged Abuse Occurs within the Facility between Staff and Patients/Residents," dated 12/05/14, showed the directive for facility staff to:
- Ensure the patient/resident was safe and medical issues were stabilized;
- Notify the Unit Manager and/or the Nursing Supervisor immediately. The Manager or Nursing Supervisor will suspend the staff pending the investigation;
- Complete an incident report;
- Begin the internal investigation:
- Notify the Director of Nursing, Performance Improvement and Risk Management Director, and attending physician during normal business hours. If after normal business hours notify the Administrator on Call (AOC) and the Physician.
- Interview staff on duty and have them document their responses.
- Interview the patient making the allegation and document their responses or have them document their perspective of the incident.
- Review security cameras when appropriate, document findings.
- Notify the parent/guardian of the allegation and investigation, if necessary by the end of the shift.
- Forward incident report and all documentation to Performance Improvement and Risk Management Director.

2. Record review of the facility's document titled, "Patient Concern Notification (a form for patients/patient representative to write a complaint or grievance)," dated 08/16/16 at 7:22 AM showed:
- Patient #26 wrote that at 07:12 AM in room 726 (two South), Staff NN, Behavioral Health Technician (BHT) had assaulted him.
- Patient #26 wrote that Staff NN, Behavioral Health Technician (BHT) had assaulted him.
- Patient #26 stated that he talked with his roommate and then Staff NN pushed him and left red marks on him.
- The report was received on 08/17/16 at 7:30 AM.
- Staff LL, Nurse Manager of 2 S and 2 Central (C) and Staff Z, Nursing Compliance Officer, addressed the concern immediately
- A video from the camera was reviewed, but the reviewer failed to sign, date and time the review. The video review showed there was no evidence of malicious intent. The patient was escorted out of the room and down the hall.
- The time was 07:12 AM at room 726.
- On 8/17/16 at 11:09 AM, Staff B, Director of Performance Improvement and Risk Management, stated that there were no injuries observed on 08/16/16 at 3:20 PM (this was from an assessment after a restraint, forcible confinement, and seclusion, solitary confinement, over eight hours after the alleged abuse.)

There was no documentation of an immediate patient assessment, any interviews with the patient, the alleged perpetrator (AP, staff accused of abuse), or other patients. No documentation of notifications to administrative staff, the physician, or the parent/guardian.

3. Record review of Staff NN's written witness statement dated 08/16/16 at 7:30 AM showed:
- Patient #26 awoke and attempted to awaken his roommate.
- The roommate asked Patient #26 several times to leave him alone.
- The staff asked multiple times for Patient #26 to leave and go down the hall.
- Patient #26 left the room, but attempted to return and the roommate planned to fight with Patient #26.
- Staff NN turned Patient #26 around and guided him away for his safety.

Record review of Patient #26's Progress Note showed Staff N, Behavioral Health Technician (BHT) documented that Patient #26 irritated his roommate; the roommate asked the patient to be quiet and Patient #26 got irritated. Staff directed Patient #26 away from the room and he yelled, "Don't push me!" then walked to the nurses station and yelled, "I want to fill out a complaint form." The Nursing Progress Care Record-Acute showed on 08/16/16 an untimed assessment that showed his skin was warm and dry.

There was no specific documentation of the allegation, an assessment for any possible red marks, notification of the physician, staff, or the parent/guardian.

During an telephone interview on 04/24/17 at 2:59 PM, Staff N, stated that she failed to remember the specific incident or if Patient #26 completed a Patient Concern Notification.

During an interview on 04/20/17 at 9:05 AM, Staff NN, BHT, stated that he was asked by Staff LL to complete the witness statement and he believed he returned it to her when he completed the documentation. The managers would review the video from the cameras immediately to see if the allegation occurred. He was unaware of any further investigation.

During an interview on 04/20/17 at 9:39 AM, Staff LL, RN, stated that she did not remember the incident. Typically, she talked with the patient alone. She then documented on the Patient Concern Notification and how the incident could be resolved. There were times she typed her questions, the paitents answers, and attached the documentation to the Patient Concern Notification. She reviewed the video from the camera to see if the allegation occurred. Then she took this information to the Director of Nursing. She did not typically notify the guardian because they had so many allegations when the patient's became upset. The physician would not be notified until the investigation was completed. This was how investigations were handled throughout the facility.

During an interview on 04/19/17 at 3:35 PM, Staff Z, Nursing Compliance Officer, stated that he reviewed the video and that Staff NN, touched the patients back with an open hand to escort the patient out of the room. Staff NN was not an aggressive type of person.

During an interview on 04/19/17 at 1:25 PM and 04/20/17 at 4:05 PM, Staff B, Director of Performance Improvement and Risk Management, stated that there was no immediate patient assessment related to the patients allegation of red marks completed by staff after the abuse allegation. An incident report should have been completed for the abuse allegation on 08/16/16. She failed to ensure that an incident report, an interview with the patient and a review of the investigation was completed. The investigation review should have been sent to the parent/guardian.

The facility failed to interview the alleged perpetrator, the patients roommate, other patients, possible witnesses, and complete mandatory reporting to the appropriate agencies.

During an interview on 04/20/17 at 3:25 PM, Staff J, Director of Nursing (DON) stated that if an abuse allegation occurred during the week the Nurse Managers should be notified. After hours or weekends the House Supervisors should be notified and they should notify the AOC. The AOC would help ensure the staff followed the policy. There should be witness statements obtained, video from the camera reviewed, an incident report completed, and parent/guardian notified.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on interview, record review and policy review, the facility failed to ensure that staff followed the facility policy when they did not modify three patients (#5, #10 and #27) Master Treatment Plan (MTP)-Individual Crisis Management Plan (ICMP) of four patients' reviewed following an episode of restraint (to restrict someone's movement by holding the patient, or by the use of a device that restricts their movement) and/or seclusion (to physically separate from others). This had the potential to affect all patients that encountered an episode of restraint and/or seclusion. The facility census was 117.

Findings included:

1. Record review of the facility's policy titled, "Treatment of the Patient, 4.5.3 Multidisciplinary Treatment," reviewed 09/2017, showed directives for staff to:
-Add short-term goals and/or interventions as needed. Ensure they are measurable, attainable, and time framed.
-Add additional goals or interventions as appropriate to any identified problems.
-Update goals and interventions on MTP and/or ICMP as appropriate.

2. Record review on the geriatric psychiatric unit of Patient #10's S.T.O.P Review (Safety, Treatment Plan, Observation, Process) dated 04/12/17 showed the patient was put into seclusion on the following dates and times:
- 04/09/17 at 6:35 AM;
- 04/09/17 at 7:53 AM; and
- 04/12/17 at 5:31 AM.

Record review of the patient's MTP-ICMP showed staff did not update, include goals/interventions or add identified problems, after he was placed into seclusion three times.

3. Record review on four south of Patient #5's Seclusion and Restraint Provider/LIP Orders and Seclusion and Restraint Documentation-Acute showed the following:
- 04/14/17 at 3:10 PM she was placed in physical restraint and seclusion.
- 04/14 /17 at 3:10 PM she was placed in physical restraint and at 3:12 PM seclusion.
- 04/15/17 at 2:05 PM she was placed in physical restraint and then into seclusion.
- 04/17/17 at 3:10 PM she was placed in physical restraint and at 3:11 PM seclusion.

Record review of Patient #5's MTP-ICMP, showed staff did not update, include goal/interventions or add identified problems, after the patient's physical restraints and/or seclusion episodes.

4. Record review on two South of Patient #27's Seclusion/Restraint Provider/LIP and Seclusion/Restraint Documentation-Acute, showed the following:
- 03/24/17 at 12:50 PM, he was placed in physical restraint.
- 04/11/17 at 10:06 AM, he was placed in seclusion.
- 04/13/17 at 8:50 AM, he was placed in seclusion.

Record review of Patient #27's MTP-ICMP, showed staff did not update, include goals/interventions or add identified problems, after the patient's restraint or seclusion episodes.

During an interview on 04/18/17 at 1:45 PM, Staff F, Charge Nurse, stated that after a physical restraint or seclusion the ICMP should be updated with the date, the time, the behavior that lead to the restraint and seclusion, and the safety interventions. She was unable to explain why the update to the ICMP had not been completed.

During an interview on 04/18/17 at 1:45 PM, Staff J, Registered Nurse (RN), Director of Nursing (DON), stated that the patient (#10) did not have safety interventions/strategies documented on the MTP-ICMP for his episodes of seclusions on 04/09/17 and 04/12/17. Staff J stated that he expected staff to include a plan in a patient's MTP-ICMP following an episode of restraint and/or seclusion. On 04/20/17 at 3:46 PM, he stated that the patient's MTP-ICMP should be updated when the patient was placed in restraints and/or seclusion.

During an interview on 04/18/17 at 1:55 PM, Staff S, RN, Unit Manager - Geri Psych Unit stated that her expectation is for staff to document on the MTP-ICMP what they identified that caused the patient to escalate and what plan the staff utilized to decrease or prevent the escalation in the future. Staff S stated that she would expect staff to complete the MTP-ICMP after they completed the staff debriefing following a restraint, seclusion and/or chemical restraint.

During an interview on 04/18/17 at 2:00 PM, Staff T, Behavioral Health Technician (BHT) stated that the MTP-ICMP should be filled out as staff completes the paperwork for restraint, seclusion and/or chemical restraints. Staff T stated that the MTP-ICMP should be filled out with each incident.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on interview, record review and policy review, the facility failed to ensure nursing staff implemented interventions to prevent two patients (#20 and #27) of two patients reviewed who were at high risk for assault, from assaulting or repeatedly assaulting other patients (A-0395). The severity and cumulative effect of this systemic practice had the potential to place all patients and staff at risk for their health and safety, also known as Immediate Jeopardy (IJ).

As of 04/21/17, at the time of survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- All current inpatient records were reviewed for evidence of patient aggression. All patients with evidence of aggression were identified by nursing administration for further review of the Master Treatment Plan (MTP), the Individual Crisis Management Plan (ICMP) and orders. The MTP, ICMP and orders were updated as necessary to address the patient's aggression. The ICMP form was modified to document weekly that the interventions specific to the patient's aggression were reviewed in the patient's weekly Treatment Team Meeting. The treatment team will document whether to continue the current interventions or initiate new interventions.
- A form was created and put into place which will be completed by staff any time a patient has an incident of physical confrontation. The form addressed documentation for the interventions implemented and notification of provider and guardian. The form, after completion, will be placed on a providers (physician or physician assistant) clipboard for review and signature. The form will be a permanent part of the patient's record.
- A new process was put into place to communicate and respond to patient's aggression. Education to the new process was put into place immediately. The process included immediate notification of the provider to obtain new orders, such as increasing the patient's level of observation, limiting patient to patient interaction, medication changes, etc. In addition, nursing supervisors will obtain a list of patients who had physical confrontation. The nursing supervisors and managers will directly review the incident report, medical record, and interventions following an episode of patient aggression, which will be reviewed in the daily Safety Huddle (meeting between staff to review potential patient safety risk factors and prevention) and in Flash Meeting (meeting of leadership staff). The Risk Manager will verify that an incident report was completed on all patients listed to have an aggressive episode.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and policy review, the facility failed to implement interventions to prevent two patients (#20 and #27) of two patients reviewed who were at high risk for assault, from assaulting or repeatedly assaulting patients and staff. This had the potential to affect all patients' and staffs' health and safety. The facility census was 117.

Finding included:

1. Record review of the facility policy titled, "Observation, Patient Monitoring and Precautions - Acute Services," dated 02/17/17, showed:
- When a patient's assessment indicated a need to increase the observation category, staff should consider implementation of individualized interventions to maintain patient safety.
- Individualized interventions may include, but are not limited to, placing a patient on "opposites" (placing a patient on opposite sides of a room during groups/activities) or limiting peer interactions (separating one patient from another to prevent interactions).
- Assault Precautions meant that the patient had been assessed to be at an increased risk of assault and that staff were to be alert of the need to increase monitoring of the patient for escalation, aggressive body language and appropriate boundaries with other patients and staff.

2. Record review of Patient #20's medical record on 04/19/17, showed the following:
- Admission orders dated 03/25/17 at 11:30 PM (received the night prior to the patient's admission on 03/26/17) for Suicide Precautions (to observe for the potential of self-harm) and Assault Precautions.
- Review of "15 Minute Checks & Points - Acute" (documentation every 15 minutes which showed where the patient was physically located, and what the patient was doing, to ensure the patient was safe) documented that the patient was observed for Assault Precautions from 03/26/17 through 04/06/17.
- Review of "15 Minute Checks & Points - Acute" documented that the patient was not observed for Assault Precautions from 04/07/17 through 04/19/17.
- Review of all Physician Orders from 03/25/17 through 04/19/17 showed no order for Assault Precautions to be discontinued.

Record review of a Multidisciplinary Treatment Plan Notes and Update (similar to a care plan in which hospital staff formulate a plan along with the patient to address the patient's behavioral health needs) showed the following:
- On 04/12/17 at 1:00 PM, the patient was a danger to self or others, with aggression.
- The patient told a patient on 04/14/17 at 2:10 PM, "Shut the fuck up before I punch you in the face. You are so fucking annoying".
- On 04/14/17 at 10:20 PM, Patient #20 kicked a patient in the face, and was "pulled off" of the patient.
- The patient attempted to attack another patient on 04/16/17 at 2:10 PM.

Record review of Incident Reports related to Patient #20 showed that on 04/14/17 at 4:00 PM, he kicked a patient in the jaw. Interventions by hospital staff were limited to "processed (talk about what happened, why it happened, and how to prevent it from occurring again) with patient". There were no interventions to prevent the patient from the continued assault of other patients.

3. Record review of Patient #27's medical record showed the following:
- A Psychiatric Evaluation dated 03/15/17, documented that the patient was admitted on [DATE] with homicidal ideations (thoughts of killing someone) and aggressive behavior, which included hitting his grandmother and mother, punching a friend in the genitals so he could not urinate, putting a BB gun to the head of his eight year old sister "trying to pretend to kill" her, and carrying an ax around as if he was trying to hit somebody.
- The Psychiatric Evaluation documented that the patient could get very aggressive and violent, according to his mother's reports.
- Admission orders dated 03/14/17 at 8:47 PM (ordered prior to patient's admission) for Assault Precautions.
- An Individual Crisis Management Plan (ICMP, similar to a care plan in which hospital staff formulate a plan along with the patient to address the patient's behavioral health needs) dated 03/15/17, which documented that the patient had concerning behaviors which included threats (with weapons) to people and animals, attempted to break his little sister's finger, death threats, slapped and kicked people and had no remorse for physical or emotional hurt to others.
- The ICMP showed concerns to address during the admission included homicidality and aggression.

Record review of Multidisciplinary Progress Notes showed on:
- 03/18/17 at 2:29 PM, the patient put another patient in a head lock (both arms are placed around another person's head and held tightly to prevent head movement or to inflict pain);
- 03/19/17 at 2:50 PM, the patient stomped on another patient;
- 03/22/17 at 2:25 PM, he put a patient in a head lock and continued to place the patient in a head lock, and later smacked another patient in the face;
- 03/23/17 at 2:05 PM, he kicked a patient twice and then punched him in the face;
- 03/24/17 at 12:50 PM, he hit a staff member in the face (also documented in a physical restraint note);
- 03/24/17 at 10:00 PM, he punched another patient in the face, which caused the patient's nose to bleed;
- 03/25/17 at 2:25 PM, he punched a patient while in group and grabbed another patient's glasses;
- 03/31/17 at 8:46 PM, he hit a patient, broke the patient's glasses and then punched the patient's arm;
- 04/01/17 at 6:34 PM, that he smacked another patient in the face twice;
- 04/03/17 at 1:18 PM, he was physically aggressive and fought with a patient;
- 04/03/17 at 10:00 PM, he walked into the group room and went after a patient, but was separated by staff. When walking out of the group room, he slapped a staff member and said, "Don't touch me, Bitch".
- 04/04/17 at 2:10 PM, he "hit a kid", then "hit another kid";
- 04/10/17 at 7:00 PM, he chased a patient into their room, and punched, kicked and threatened the patient;
- 04/11/17 at 10:06 AM, he punched one patient in the face and then kicked another in the face (also documented in a Seclusion Episode note);
- 04/13/17 at 8:30 AM, he took a patient by the head, hit the patient's head against a wall and began to punch the patient while in group (also documented in Seclusion Episode note);
- 04/13/17 at 2:15 PM, he was transferred to another unit; and
- 04/14/17 at 2:45 PM, he punched a patient in the face.

Record review of Incident Reports related to Patient #27 showed on:
- 04/01/17 at 3:20 PM, he slapped a patient. Interventions by hospital staff were limited to the administration of a medication to decrease the patient's agitation, and "time out" (placing a patient in an unlocked room during activities and groups).
- 04/11/17 at 10:06 AM, he punched a patient in the eye and then attempted to attack another patient. Interventions by hospital staff were limited to the administration of a medication to decrease the patient's agitation, and the patient was restricted to the unit (could not leave the unit for mealtime).
- 04/12/17 at 7:35 PM, he hit a patient and then grabbed the patient by the neck and pulled the patient to the ground. Interventions by hospital staff were limited to the administration of a medication to decrease the patient's agitation.
- 04/13/17 at 8:50 AM, he grabbed a patient by the head, and pushed the patient's head into a wall. Interventions by hospital staff were limited to the administration of a medication to decrease the patient's agitation.
- 04/14/17 at 10:58 AM, he punched another patient in the right side of the face. Interventions by hospital staff were limited to "processed with patient" (spent time with the patient to reflect on what happened and how to prevent reoccurrence).
- 04/16/17 at 2:45 PM, he went into another patient's room, attempted to attack the patient, and bent the patient's finger back. Interventions by hospital staff were limited to administration of a medication to decrease the patient's agitation, and "placed on visuals" (to continuously watch).

The facility failed to implement interventions to prevent Patient #27 from the continued assault of other patients.

During an interview on 04/20/17 at 3:46 PM, Staff J, Director of Nursing, stated the following were steps that could be taken to prevent patients from assaulting other patients:
- Continue to redirect the patient.
- Ask the patient's physician to review the patient's medications.
- Separate the patient from other patients.
- Limit the patient's interaction with other patients.
- Move the patient to another unit.
- Provide Level I monitoring (staff member assigned to be within arm's reach of the patient at all times, except for sleeping).
- "Aside from getting the patient discharged , that is all we can do".
Staff J added that issues with Patient #27 had been "ongoing".

During an interview on 04/20/17 at 2:48 PM, Staff RR, Behavioral Health Technician (BHT) stated that she was aware Patient #27 had assaulted other patients because it was reported to her. Staff RR stated, "We have to make sure kids are safe," but added that the interventions the facility implemented did not prevent Patient #27 from assaulting other patients. Staff RR added that Patient #27 was not placed on Level I monitoring, was not separated from other patients, and when he was placed opposite of other patients, he still assaulted them.