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.

GEORGETOWN BEHAVIORAL HEALTH INSTITUTE 3101 S AUSTIN AVENUE GEORGETOWN, TX Dec. 30, 2016
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation, interview and record review the facility's Governing Body failed to ensure its policies and procedures were inforced and provide a safe environment for patients.

Cross refer: FA0144, FA283, FA0386 and B0103
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interview and record review the facility failed to promote and protect patient's right to a safe environment.

Cross refer: FA0144, FA283, FA0386 and B0103
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on observation, interview and record review the facility failed to provide care in a safe environment when:

a.) The facility's coffee and hot water dispenser was set at a scalding temperature and left unsupervised and accessible to adolescents.

b.) Mental Health techs were not aware of a patient's "line of sight" observation level, leaving the suicidal patient at risk for self- harm. (Staffs #1 and #7)

c.) An incident report was not completed for a sexually acting out patient. (Patient #3) Patient #3's treatment plan was not reviewed for a higher level observation was not updated to reflect the patient's sexually acting out, placing other patients at risk.

d.) A physically aggressive patient assaulted another peer on two occasions in a twenty-four hour period. (Patient #1) Patient #1's level of observation was not increased and the treatment plan was not updated to reflect the aggressive behavior until a week later, leaving patients at risk for harm during that time.

Findings include:

a.) During a tour of the facility's cafeteria on the morning of 12/30/16 revealed a coffee and hot water dispensing machine sitting on the counter accessible to patients in the cafeteria. The dispenser was on and was unsupervised.

During an interview on the morning of 12/30/16 in the facility's cafeteria Staff #15, Certified Executive Chef when asked if the adolescents had access to the hot water dispenser stated, "Yes." When asked what the water temperature was Staff #15 opened the dispenser up to display the LED reading of 169. Staff #15 stated, "169 degrees."

Review of the information taken in part from The U.S. Consumer Product Safety Commission, <https://www.cpsc.gov/PageFiles/ 2/5098.pdf>, reflected "Most adults will suffer third-degree burns if exposed to 150 degree water for two seconds. Burns will also occur with a six-second exposure to 140 degree water or with a thirty second exposure to 130 degree water. Even if the temperature is 120 degrees, a five minute exposure could result in third-degree burns...."

b.) During the tour of the Adolescent Units (Star and Brazos) on the morning of 12/30/16 Staff #2 MHT was asked what the LOS on the patient observation form meant. Staff #2 stated, "When a patient is admitted we have to make sure they are eating enough, if we see they aren't eating we tell the nurse." When asked when she was taught what the LOS meant Staff #1 stated, "I learned how to use it in training...."

Upon leaving the Brazos unit on the morning of 12/30/16 Staff #14, CEO was asked if he heard what Staff #1 had stated, he answered "Yes, LOS means line of sight...she was wearing a red shirt which means she is a senior tech and trains the newer techs...we need to do more staff training...."

During a tour of the Adult psychiatric unit Staff #1, MHT when asked if there was anyone on LOS on the unit stated, "Yes, Patient #11...there he is sitting in the dayroom." Staff #1 pointed to a young Caucasian male. As the surveyor moved down the patient hallway Staff #1 asked Staff #7, MHT, at the end of the hall, if Patient #11 was on LOS. Staff #7 stated, "He's increased observation...I think he was taken off LOS." Patient #11 was located in his room with the door shut and the lights off.

Review of Patient #11's medical record revealed a [AGE] year old African American male admitted on [DATE] for suicidal ideation. The Physician's order was written on 11/29/16 for increased observation; LOS was written on the order but then crossed out by the nurse.

During an interview on the afternoon of 12/30/16 Staff #13, Risk Manager when asked what increased observation meant stated, "I'm not sure what increased observation means...the next level of observation from every 15 minutes would be Line of Sight..."

During an interview on the afternoon of 12/30/16 Staff #9, Chief Nursing Officer stated, "The increased observation means the house supervisor and nurse determine if it should be line of sight or one on one....he should have been on line of sight..."

The facility's policy for Levels of Observation did not include increased observation and the facility was unable to provide a policy for "Increased Observation" and it was not included in the staff's initial or annual training.

c.) Review of facility provided incident report dated 11/1/16 reflected [AGE] year old Patient #5 reported her roommate, [AGE] year old Patient #3 was making out with her. An incident report was completed on the alleged Victim, but was not completed on the Assailant.

Review of Patient #3's treatment plan, following her alleged sexual assault on 11/1/16, did not reflect a review or changes to her treatment plan. The facility blocked Patient #3 from having a roommate but did not put any other interventions or precautions in place to minimize the risk other vulnerable patients. Patient #3 remained on every 15 minute observations.

Review of the facility provided document Basic Rights for All Patients (undated) reflected, "... 5. You have the right to be free from mistreatment, abuse, neglect, and exploitation...."

INCIDENT REPORT POLICY #800.04 (dated 7/7/14) "...PURPOSE: The purpose of this policy is to establish consistent guidelines to report and document adverse care events or other accidental occurrences involving patients and visitors.... The goal of the policy is to improve the quality of services provided by identifying the causes of the events and instituting corrective actions as necessary to minimize and/or eliminate the potential for injury.
POLICY: The foundation of a Risk Management program is based-upon the ability to promptly obtain important facts and the details of the circumstances surrounding an event within a reasonable time frame of when the event occurred. To this end, an Incident Report is to be completed for every occurrence which meets the following definition: any happening not consistent with the routine care or operation of the facility, or the desired routine care of the patient and/or operation of the facility....The following categories, not limited to, are reported on the incident report form: Abuse allegation, Neglect allegation and Assaultive behavior to peer, Assaultive behavior to staff...Boundary violation with peer..."

During an interview on the afternoon of 12/30/16 in the conference room Staff #13, Risk Manager when asked if the an incident report needed to be completed for the assailant as well as the victim Staff #13 stated, "Yes."

d.) Review of the facility provided incident reports reflected on 11/28/16 Patient #1 attacked a Patient #7. Patient #7 was hit in the face and kicked in the stomach. Patient #1's treatment note dated 11/28/16 for the 7p - 7a shift did not communicate her assaulting another peer.

On 11/29/16 at 7:40 p.m. Patient #1 attacked Patient #3. Patient #3 had ice thrown at her and was pinned to the floor punched and had some of her hair pulled out. Staff had to physically remove Patient #1 from Patient #3.

The treatment plans for Patient #1and Patient #3 were not reviewed and updated to reflect the facility's attempts to identify the risk, increase observations and try to find out what is going on. The treatment plan did not address the attacks and Patient #1's increased aggressions and risk to Patient #3 and other patients until 12/5/16. The level of observation was not increased and remained every 15 minutes throughout Patient#1's and Patient #3's stay.

Review of Patient#4's medical records revealed assaults on peers on 11/30/16, 12/3/16 and 12/4/16. Patient #4's assault on Patient #3 was not document. Patient#4's treatment plan was not changed to address the increased aggression until 12/6/16. The level of observation was not increased and remained every 15 minutes.

Review of Patient #10's Nurses shift report reflected Patient #10 as instigating the assault on Patient #3 on 11/29/16. The facility incident reports did not reflect Patient #10 had instigated the assault on Patient #3. Precautions were not put in place to protect Patient#3's safety. Patient# 10's treatment plan did not address this change in her behavior.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on observation, interview and record review the facility's nursing administration failed to ensure the quality of patient care provided when:

a.) Mental Health techs (Staffs #1 and #7) were not aware of a patient's "line of sight" observation level, leaving the suicidal patient at risk for self- harm and the facility nursing staffs were using the a level of observation (Increased observation) that the facility did not have an interpretation or a policy or procedure for. The staff did not discuss outcome and plan of care for assaultive/combative patients as the policy states.

b.) An incident report was not completed for a sexually acting out patient. (Patient #3) Patient #3's treatment plan was not reviewed for a higher level observation was not updated to reflect the sexually acting out placing other patient at risk.

c.) A physically aggressive patient assaulted another peer on two occasions in a twenty-four hour period. (Patient #1) Patient #1's level of observation was not increased and the treatment plan was not updated to reflect the aggressive behavior until a week later, leaving patients at risk for harm during that time.

Findings include:

a.) During the tour of the Adolescent Units (Star and Brazos) on the morning of 12/30/16 Staff #2 MHT was asked what the LOS on the patient observation form meant. Staff #2 stated, "When a patient is admitted we have to make sure they are eating enough, if we see they aren't eating we tell the nurse." When asked when she was taught what the LOS meant Staff #1 stated, "I learned how to use it in training...."

Upon leaving the Brazos unit on the morning of 12/30/16 Staff #14, CEO was asked if he heard what Staff #1 had stated, he answered "Yes, LOS means line of sight...she was wearing a red shirt which means she is a senior tech and trains the newer techs...we need to do more staff training...."

During a tour of the Adult psychiatric unit Staff #1, MHT when asked if there was anyone on LOS on the unit stated, "Yes, Patient #11...there he is sitting in the dayroom." Staff #1 pointed to a young Caucasian male. As the surveyor moved down the patient hallway Staff #1 asked Staff #7, MHT at the end of the hall if Patient #11 was on LOS. Staff #7 stated, "He's increased observation...I think he was taken off LOS." Patient #11 was located in his room with the door shut and the lights off.

Review of Patient #11's medical record revealed a [AGE] year old African American male admitted on [DATE] for suicidal ideation. The Physician's order was written on 11/29/16 for increased observation; LOS was written on the order but then crossed out by the nurse.

During an interview on the afternoon of 12/30/16 Staff #13, Risk Manager when asked what increased observation meant stated, "I'm not sure what increased observation means...the next level of observation from every 15 minutes would be Line of Sight..."

During an interview on the afternoon of 12/30/16 Staff #9, Chief Nursing Officer stated, "The increased observation means the house supervisor and nurse determine if it should be line of sight or one on one....he should have been on line of sight..."

Review of the facility provided document MANAGEMENT OF ASSAULTIVE/COMBATIVE PATIENTS POLICY #200.21 (dated 7/07/14)
"...in the event that a patient escalates and becomes assaultive/combative, all safety measures shall be provided to the patient, other patients and staff, with the least restrictive interventions possible based on the level of acuity and patient needs.... H. Upon completion of intervention, the intervention team will meet to discuss outcome and plan of care for assaultive/combative patients...."

Levels of Observation. POLICY #200.39 (dated 7/7/14)
POLICY: All patients shall be assessed for safety risks and assigned the appropriate level of observation.
Patients assessed as having safety risks will be managed in such a way to minimize the threat of injury or harm. Safety risks include ideation, impulses, or behavior indicating that they are a danger to themselves or others. Risks also include the risk for falls or severely disordered behavior. Other risks may be identified that warrant an increased level of observation.
PURPOSE:
" ...1. Guidelines for the safe management of patients identified as at risk.
2. Appropriate protection and treatment for patients or others at risk.
PROCEDURE:
The level of observation is a matter of clinical judgment. The clinical judgment is based on clinical risk assessment of all available information and recorded in the medical record. In general, patients identified as a low risk should be assigned to Level I observation. Patients identified as a moderate risk should be assigned to Level II observation. Patients identified as high risk for violence and/or suicide should be assigned to Level III observation. Patients assessed to be at risk for assaultive or severe acting out behaviors may be assigned to a "no roommate" status, in addition to the Levels of Observation.
...Patient observation/rounds ...Rounds are done every 15 minutes on all units ....
...Level I - Q 15 Minute Observation ... Shift reports, provider rounds, and treatment team meetings will be used to communicate observations status for continuity of care indicating the Level and type of precaution. 3. The level of observation may be changed or increased at the discretion of the charge nurse for the patient's safety or for the safety of others.
4. The patient, with a provider order, may be transferred to the Psychiatric
Intensive Care Unit (PICU) if appropriate, for safety purposes.
...Level II - Line of Sight (LOS)
A. Patient assessment indicates a safety risk that cannot safely be managed with Level I Observation:
Patient is actively suicidal but does not have the means to act on suicidal intentions and/or patient presents with active, aggressive behavior ....Sexually acting out ...5. Patients with suicide, assault or sexually acting out risks may be transferred to the PICU, if appropriate, to meet the patient's needs and to keep other patients safe.
...Level III - Continuous Observation or 1:1..."

ROUNDS FOR PATIENT OBSERVATION POLICY #200.29 (dated 7/7/14)
"...MHT responsibilities ...
1. Review and update patient observation forms. Reflect changes in individual patient observation level, precaution type, room or bed changes, new admissions and /or discharges as they occur.
2. Observe each patient, a minimum of every 15 minutes according to observation level and precaution type and indicate these on the patient observation form.
3. Perform rounds at staggered intervals and in a varying pattern or sequence throughout the unit to minimize planned acting out opportunities
4. Verify correct patient by:
a) Patient photo, asking the patient to tell you his/her first and last name and/or birth date, or have another staff member verify the patient identity.
b) Document patient location and behavior when the observation occurs on the patient observation form...."

Basic Rights for All Patients (undated)
"... 5. You have the right to be free from mistreatment, abuse, neglect, and exploitation...."

The facility's policy for Levels of Observation did not include increased observation and the facility was unable to provide a policy for "Increased Observation" and it was not included in the staff's initial or annual training.


b.) Review of facility provided incident report dated 11/1/16 reflected [AGE] year old Patient #5 reported her roommate, [AGE] year old Patient #3 was making out with her. An incident report was completed on the alleged Victim but was not completed on the Assailant.

Review of Patient #3's treatment plan, following her alleged sexual assault on 11/1/16, did not reflect a review or changes to her treatment plan. The facility blocked Patient #3 from having a roommate but did not put any other interventions or precautions in place to minimize the risk other vulnerable patients. Patient #3 remained on every 15 minute observations.

INCIDENT REPORT POLICY #800.04 (dated 7/7/14) "...PURPOSE: The purpose of this policy is to establish consistent guidelines to report and document adverse care events or other accidental occurrences involving patients and visitors.... The goal of the policy is to improve the quality of services provided by identifying the causes of the events and instituting corrective actions as necessary to minimize and/or eliminate the potential for injury.
POLICY: The foundation of a Risk Management program is based-upon the ability to promptly obtain important facts and the details of the circumstances surrounding an event within a reasonable time frame of when the event occurred. To this end, an Incident Report is to be completed for every occurrence which meets the following definition: any happening not consistent with the routine care or operation of the facility, or the desired routine care of the patient and/or operation of the facility ... The following categories, not limited to, are reported on the incident report form: Abuse allegation, Neglect allegation and Assaultive behavior to peer, Assaultive behavior to staff...Boundary violation with peer..."

During an interview on the afternoon of 12/30/16 in the conference room Staff #13, Risk Manager when asked if the an incident report needed to be completed for the assailant as well as the victim Staff #13 stated, "Yes."

c.) Review of the facility provided incident reports reflected on 11/28/16 Patient #1 attacked a Patient #7. Patient #7 was hit in the face and kicked in the stomach. Patient #1's treatment note dated 11/28/16 for the 7p - 7a shift did not communicate her assaulting another peer.

On 11/29/16 at 7:40 p.m. Patient #1 attacked Patient #3. Patient #3 had ice thrown at her and was pinned to the floor punched and had some of her hair pulled out. Staff had to physically remove Patient #1 from Patient #3.

The treatment plans for Patient #1and Patient #3 were not reviewed and updated to reflect the facility's attempts to identify the risk, increase observations and try to find out what is going on. The treatment plan did not address the attacks and Patient #1's increased aggressions and risk to Patient #3 and other patients until 12/5/16. The level of observation was not increased and remained every 15 minutes throughout Patient#1's and Patient #3's stay.

Review of Patient#4's medical records revealed assaults on peer on 11/30/16, 12/3/16 and 12/4/16. Patient #4's assault on Patient #3 was not document. Patient#4's treatment plan was not changed to address the increased aggression until 12/6/16. The level of observation was not increased and remained every 15 minutes.

Review of Patient #10's Nurses shift report reflected Patient #10 as instigating the assault on Patient #3 on 11/29/16. The facility incident reports did not reflect Patient #10 had instigated the assault on Patient #3. Precautions were not put in place to protect Patient#3's safety. Patient# 10's treatment plan did not address this change in her behavior.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview and record review the facility failed provide an organized nursing services.

Cross refer: FA0144, FA283, FA0386 and B0103
VIOLATION: QAPI Tag No: A0263
Based on observation, interview and record review the facility's failed to develop, implement and maintain an effective quality assessment and performance improvement program.

Cross refer: FA0144, FA283, FA0386 and B0103
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on observation, interview and record review the facility failed to collect data to identify and implement program activities that affect patient safety when:

a.) Incident reports were not being filled out to reflect aggressive patients and sexually acting out patients.
b.) The facility did not conduct extra rounds to verify Q 15 minute checks are being done accurately as the Committee of the whole meeting minutes reflected.

Findings Include:

a.) Review of the facility provided incident reports reflected an incident report had not been completed on 11/1/16, for a sexually acting out patient (Patient #3) and on11/29/16 Patient #4's assault on Patient #3 was not documented.

Review of the facility provided document INCIDENT REPORT POLICY #800.04 (dated 7/7/14) "...PURPOSE: The purpose of this policy is to establish consistent guidelines to report and document adverse care events or other accidental occurrences involving patients and visitors.... The goal of the policy is to improve the quality of services provided by identifying the causes of the events and instituting corrective actions as necessary to minimize and/or eliminate the potential for injury.
POLICY: The foundation of a Risk Management program is based-upon the ability to promptly obtain important facts and the details of the circumstances surrounding an event within a reasonable time frame of when the event occurred. To this end, an Incident Report is to be completed for every occurrence which meets the following definition: any happening not consistent with the routine care or operation of the facility, or the desired routine care of the patient and/or operation of the facility... The following categories, not limited to, are reported on the incident report form: Abuse allegation, Neglect allegation and Assaultive behavior to peer, Assaultive behavior to staff...Boundary violation with peer..."

During an interview on the afternoon of 12/30/16 in the conference room Staff #13, Risk Manager when asked if the an incident report needed to be completed for the assailant as well as the victim Staff #13 stated, "Yes."

b.) During a tour of the Adult psychiatric unit Staff #1, MHT when asked if there was anyone on LOS on the unit stated, "Yes, Patient #11 ...there he is sitting in the dayroom." Staff #1 pointed to a young Caucasian male. As the surveyor moved down the patient hallway Staff #1 asked Staff #7, MHT at the end of the hall if Patient #11 was on LOS. Staff #7 stated, "He's increased observation ...I think he was taken off LOS." Patient #11 was located in his room with the door shut and the lights off.

Review of Patient #11's medical record revealed a [AGE] year old African American male admitted on [DATE] for suicidal ideation. The Physician's order was written on 11/29/16 for increased observation; LOS was written on the order but then crossed out by the nurse.

During an interview on the afternoon of 12/30/16 Staff #13, Risk Manager when asked what increased observation meant stated, "I'm not sure what increased observation means ...the next level of observation from every 15 minutes would be Line of Sight..."

During an interview on the afternoon of 12/30/16 Staff #9, Chief Nursing Officer stated, "The increased observation means the house supervisor and nurse determine if it should be line of sight or one on one....he should have been on line of sight..."

Review of the facility provided policies and meeting minutes reflected:
Committee of the whole meeting minutes from 1/13/16 discussed Q15 [every 15 minute checks] and stated in part, "Training continues to be done to ensure they are being done. Also the CNO and house supervisors will be doing extra rounds on the units to verify Q15 checks are being done accurately...." This topic was not discussed in the remainder of the meeting minutes for 2016.

The facility did not provide evidence of the house supervisors rounding to verify Q 15 minute checks are being done accurately.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on observation, interview and record review the facility failed to track adverse events and implement preventative actions and learning throughout the hospital when:

a.) Mental Health techs were not aware of a patient's on "line of sight" observation level, leaving the suicidal patient at risk for self- harm. (Staffs #1 and #7)

b.) An incident report was not completed for a sexually acting out patient. (Patient #3) Patient #3's treatment plan was not reviewed for a higher level observation was not updated to reflect the sexually acting out, placing other patients at risk.

c.) A physically aggressive patient assaulted another peer on two occasions in a twenty-four hour period. (Patient #1) Patient #1's level of observation was not increased and the treatment plan was not updated to reflect the aggressive behavior until a week later, leaving patients at risk for harm during that time.

Findings include:

a.) During the tour of the Adolescent Units (Star and Brazos) on the morning of 12/30/16 Staff #2 MHT was asked what the LOS on the patient observation form meant. Staff #2 stated, "When a patient is admitted we have to make sure they are eating enough, if we see they aren't eating we tell the nurse." When asked when she was taught what the LOS meant Staff #1 stated, "I learned how to use it in training...."

Upon leaving the Brazos unit on the morning of 12/30/16 Staff #14, CEO was asked if he heard what Staff #1 had stated, he answered "Yes, LOS means line of sight...she was wearing a red shirt which means she is a senior tech and trains the newer techs...we need to do more staff training...."

During a tour of the Adult psychiatric unit Staff #1, MHT when asked if there was anyone on LOS on the unit stated, "Yes, Patient #11...there he is sitting in the dayroom." Staff #1 pointed to a young Caucasian male. As the surveyor moved down the patient hallway Staff #1 asked Staff #7, MHT at the end of the hall if Patient #11 was on LOS. Staff #7 stated, "He's increased observation...I think he was taken off LOS." Patient #11 was located in his room with the door shut and the lights off.

Review of Patient #11's medical record revealed a [AGE] year old African American male admitted on [DATE] for suicidal ideation. The Physician's order was written on 11/29/16 for increased observation; LOS was written on the order but then crossed out by the nurse.

During an interview on the afternoon of 12/30/16 Staff #13, Risk Manager when asked what increased observation meant stated, "I'm not sure what increased observation means...the next level of observation from every 15 minutes would be Line of Sight..."

During an interview on the afternoon of 12/30/16 Staff #9, Chief Nursing Officer stated, "The increased observation means the house supervisor and nurse determine if it should be line of sight or one on one....he should have been on line of sight..."

The facility's policy for Levels of Observation did not include increased observation and the facility was unable to provide a policy for "Increased Observation" and it was not included in the staff's initial or annual training.

Review of the facility provided document Basic Rights for All Patients (undated) reflected, "... 5. You have the right to be free from mistreatment, abuse, neglect, and exploitation...."

b.) Review of facility provided incident report dated 11/1/16 reflected [AGE] year old Patient #5 reported her roommate, [AGE] year old Patient #3 was making out with her. An incident report was completed on the alleged Victim but was not completed on the Assailant.

Review of Patient #3's treatment plan, following her alleged sexual assault on 11/1/16, did not reflect a review or changes to her treatment plan. The facility blocked Patient #3 from having a roommate but did not put any other interventions or precautions in place to minimize the risk other vulnerable patients. Patient #3 remained on every 15 minute observations.

INCIDENT REPORT POLICY #800.04 (dated 7/7/14) "...PURPOSE: The purpose of this policy is to establish consistent guidelines to report and document adverse care events or other accidental occurrences involving patients and visitors .... The goal of the policy is to improve the quality of services provided by identifying the causes of the events and instituting corrective actions as necessary to minimize and/or eliminate the potential for injury.
POLICY: The foundation of a Risk Management program is based-upon the ability to promptly obtain important facts and the details of the circumstances surrounding an event within a reasonable time frame of when the event occurred. To this end, an Incident Report is to be completed for every occurrence which meets the following definition: any happening not consistent with the routine care or operation of the facility, or the desired routine care of the patient and/or operation of the facility ... The following categories, not limited to, are reported on the incident report form: Abuse allegation, Neglect allegation and Assaultive behavior to peer, Assaultive behavior to staff...Boundary violation with peer..."

During an interview on the afternoon of 12/30/16 in the conference room Staff #13, Risk Manager when asked if the an incident report needed to be completed for the assailant as well as the victim Staff #13 stated, "Yes."

c.) Review of the facility provided incident reports reflected on 11/28/16 Patient #1 attacked a Patient #7. Patient #7 was hit in the face and kicked in the stomach. Patient #1's treatment note dated 11/28/16 for the 7p - 7a shift did not communicate her assaulting another peer.

On 11/29/16 at 7:40 p.m. Patient #1 attacked Patient #3. Patient #3 had ice thrown at her and was pinned to the floor punched and had some of her hair pulled out. Staff had to physically remove Patient #1 from Patient #3.

The treatment plans for Patient #1and Patient #3 were not reviewed and updated to reflect the facility's attempts to identify the risk, increase observations and try to find out what is going on. The treatment plan did not address the attacks and Patient #1's increased aggressions and risk to Patient #3 and other patients until 12/5/16. The level of observation was not increased and remained every 15 minutes throughout Patient#1's and Patient #3's stay.

Review of Patient#4's medical records revealed assaults on peer on 11/30/16, 12/3/16 and 12/4/16. Patient #4's assault on Patient #3 was not document. Patient#4's treatment plan was not changed to address the increased aggression until 12/6/16. The level of observation was not increased and remained every 15 minutes.

Review of Patient #10's Nurses shift report reflected Patient #10 as instigating the assault on Patient #3 on 11/29/16. The facility incident reports did not reflect Patient #10 had instigated the assault on Patient #3. Precautions were not put in place to protect Patient#3's safety. Patient# 10's treatment plan did not address this change in her behavior.