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.

WESTERN STATE HOSPITAL 9601 STEILACOOM BLVD SW TACOMA, WA 98498 Aug. 28, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview, record review and review of hospital policies and procedures the hospital failed to implement policies and procedures to assess and help direct the care of patients displaying signs of verbal aggression (Tag A 144 Patient has the right to receive care in safe setting and Tag A 145 Patient has the right to be free from all forms of abuse).

Failure to implement policies and procedures for verbally aggressive patients may have contributed to the serious injuries for a patient (patient #1) by not developing a prevention plan for patient safety.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interview, record review and review of facility policies and procedures the facility failed to provide a safe environment for a patient (Patient #1).

Failure to ensure a safe environment puts all patients at risk for serious injury/harm and possibly even death.

Findings include:

1. The facility policy titled "Medical Records Procedure: Immediate Post Altercation Risk Assessment (IPARAT) (WSH 23-116) Reviewed 2/17 read in part "an IPARAT (WSH 23-116H) will be completed for each patient involved in an altercation". The IPARAT "should be completed by Registered Nurse (RN) within 30 minutes post assault". The IPARAT assessment tool evaluated four types of agression: verbal agression, agression towards property, autoagression and physical agression.

2. Medical record review on 8/25/17 revealed the following:

a) On 8/17/17 Patient #1 had a verbal outburst using racial slurs directed towards their peers while outside during yard time. The psychiatric security attendant reported this to the nurse on duty. The nurse on duty documented the incident but did not complete the IPARAT form or update the patient's plan of care.

b) On 8/20/17 Patient #1 again had a verbal outburst with racial slurs directed towards their peers while outside for yard time. The staff on duty talked to Patient #1 to refrain from using racial slurs and to Patient #2 as the recipient of the racial slurs. Staff felt the incident was resolved. Upon return to the ward Patient #2 punched Patient #1 in the face. Patient #1 sustained a skull fracture, sphenoid fracture and a epidural hematoma (traumatic brain injury with buildup of blood between the dura mater and the skull) and was transported to the hospital where they were treated for their injuries.

3. On 8/24/17 at 10:00 AM Staff F (registered nurse) stated all incidents of aggression which included verbal aggression needed to be assessed by the registered nurse. The nurse then needed to complete the IPARAT and update the patient's plan of care which would alert staff about interventions to keep the patient safe and avoid confrontations with other patients.

4. On 8/24/17 at 11:00 AM staff G (registered nurse/supervisor) verified the above information.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on interview, record review and review of facility policies and procedures the facility failed to implement interventions which may have prevented an assault on a patient (Patient #1).

Failure to implement safety measure resulted in Patient #1 being seriously injured with a skull fracture, fracture of sphenoid bone, and an epidural hematoma.

Findings include:

1. The facility Nursing Protocol 301 titled "Management of Aggressive/Assaultive Behavior", revised July 2016 read in part "Recognition of triggers in the potentially aggressive or assaultive patient". "Aggressive/assaultive behavior is a forceful verbal or physical action a person take to meet legitimate or perceived unmet needs or wants".

"At the foundation of all behavior is a legitimate unmet need. Accurate nursing assessment is critical. Being able to recognize patient's unmet needs, hospital staff have a key role in preventing violence. Interventions and responses that match the patient's level of dangerousness can help the patient de-escalate, meet their needs safely, and may-prevent violent incidents".

2. The facility policy titled "Medical Records Procedure: Immediate Post Altercation Risk Assessment (IPARAT) (WSH 23-116) Reviewed 2/17 read in part "an IPARAT (WSH 23-116H) will be completed for each patient involved in an altercation". The IPARAT "should be completed by the Registered Nurse (RN) within 30 minutes post assault". The IPARAT assessment tool evaluated four types of agression: verbal agression, agression towards property, autoagression and physical agression

3. Medical record review on 8/25/17 revealed the following:

a) On August 17, 2017: Patient #1 had an episode of verbal aggression towards their peers while outside during yard time. The patient had used racial slurs which caused their peers to become angry with Patient #1.
No nursing care addendum was done to address the incident on 8/17/17. No "Immediate Post Altercation Risk Assessment Tool" (IPARAT) was completed about the incident.

b) On August 20, 2017 during the afternoon shift yard break Patient #1 began using racial slurs again. Patient #2 became upset by Patient #1's use of racial slurs. Staff talked to the patients while on yard break and felt the incident was taken care of. The nurse on duty was not told of the yard incident when it occurred. When the Patient #1 and Patient #2 returned to the ward, Patient #2 punched Patient #1 in the face. Patient #1 lost consciousness for several minutes. Patient #1 was transported to hospital for treatment of a head injury.

4. On 8/25/17 at 2:00 PM, Staff A (registered nurse) was interviewed. Staff A worked on 8/20/17 when Patient #1 was injured by Patient #2. Staff A was not aware of the Patient #1's verbal aggression history on 8/17/17 towards peers with racial slurs until after the incident on 8/20/17. Staff A stated anytime a patient had behaviors which put them at risk the nurse needed to fill out a IPARAT form and update the patient's care plan to reflect the behaviors. The nurse also needed to call the patient's physician about the behavior as well.

5. On 8/25/17 at 2:30 PM, Staff C (psychiatric safety attendant) was interviewed. Staff C remembered Patient #1 saying racial slurs and upsetting Patient #2 during the yard break time on 8/20/17. Staff C talked to both patients and felt the incident was resolved. When the patients returned to the ward, Patient #2 punched Patient #1 in the face as patients were lining up for dinner. Staff C was not aware of the Patient #1's history of verbal aggression. Staff C stated all incidents of verbal aggression needed to be reported to the nurse to assess the situation and had Staff C known about the history would have reported it when it occurred rather than waiting until the patients returned to the unit.

6. On 8/25/17 at 2:45 PM Staff E (registered nurse) was interviewed. Staff E verified the above with Surveyors #1 and #2. Staff E stated they had worked the day of the incident on 8/17/17 and was concerned about Patient #1's use of racial slurs and possibly causing the other patients to react to them negatively. Staff E reported the information to the oncoming shift but did not complete the IPARAT report or up the patient's plan of care to address verbal aggression or contact the patient's physician about the incident.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on interview, record review and review of hospital policies and procedures, the hospital failed to ensure nursing staff developed and kept current a nursing care plan.

Failure to update the nursing care plan with interventions for a verbally agressive patient (Patient #1) resulted in a physical assault with serious injuries.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on interview, record review and review of facility policies and procedures the facility failed to ensure a patient's (Patient #1) care plan was updated to reflect the patient's behaviors.

Failure to have an updated care plan resulted in the patient being assaulted and possibly put all patients at risk for serious harm/injury.

Findings include:

1. The facility Nursing Protocol 301 titled "Management of Aggressive/Assaultive Behavior", revised July 2016 read in part "Accurate nursing assessment is critical. Being able to recognize patient's unmet needs, hospital staff have a key role in preventing violence".

2. Review of Patient #1's medical record revealed on 8/17/17 during yard break Patient #1 began using racial slurs which upset their peers on the ward. The nurse on duty assessed the situation but did not update the patient's care plan, complete an immediate post altercation risk assessment tool (IPARAT) or call the patient's physician about the incident.

3. On 8/25/17 at 2:45 PM Staff E (registered nurse) verified the above with Surveyors #1 and #2. Staff E stated the Patient #1's care plan should have been updated to reflect the incident as well as completed the IPARAT and notified the physician so interventions could be put in to place.