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Based on interview and record review, the facility failed to prevent patient to patient physical abuse for one (#1) of six patients reviewed for abuse allegations and failed to identify a patient's triggers for aggression and behavioral warning signs of aggression and to document and consistently apply individualized de-escalation techniques and safety measures to protect others for one (#11) of five physically aggressive patients reviewed for incidents of patient to patient physical assault out of a total sample of 11, resulting in an incident of patient to patient abuse. Findings include:

On 6/10/19 at 0900 Patient #1 reported she was punched in the face without warning by Patient #11. Patient #1 reported that Patient #11 was confused, unpredictable, and verbally and physically aggressive. Patient #1 reported that Patient #11 was confused and disruptive during group therapy sessions and all the patients on the unit were afraid of him. Patient #1 stated that when Patient #11 talked about Christmas and said, "Merry Christmas" all the staff and patients knew that he was going to be physically or verbally aggressive. Patient #1 said that she did not have an X-ray after the incident but her jaw was still swollen and sore a month after the incident.

On 6/10/19 at 1500 Patient #1's clinical record was reviewed with Staff A and the following was revealed:

A face sheet documented that Patient #1 was a [AGE] year old female who was admitted to the facility on [DATE] with a diagnosis of Bipolar Disorder. Patient #1 was discharged on [DATE].

A Social Work note for Patient #1 dated 5/7/19 (no time indicated) noted that Patient #1 requested a transfer to another facility because, "I don't want to see people getting socked in the face."

A Nursing Note by Staff Nurse G dated 5/13/19 at 1250 (date of discharge) documented the following, "Patient (#1) was punched in the face by another patient."

A Nurse Practitioner Note for Patient #1 dated 5/13/19 (no time indicated) documented, "Patient was also seen prior to discharge for recent assault by another patient."

On 6/11/19 at 0900 Patient #11's clinical record and Adverse Event Reports were reviewed with Staff A and Staff S and revealed the following:

A Psychiatry Evaluation dated 5/20/19 at 0649 documented the following:

Patient #11 was a [AGE] year old male who was admitted to the facility on [DATE] and discharged on [DATE]. Diagnoses included Schizoaffective disorder, Bipolar Type, and Generalized Anxiety Disorder. Patient #11 was cognitively impaired due to a Traumatic Brain Injury, lived in a Group Home, and had a court appointed Legal Guardian. Patient #11 had a history of psychiatric hospitalization and was admitted on [DATE] after an episode of aggression and bizarre behavior. Police arrived at Patient #11's Group Home for another concern and Patient #11 became violently aggressive, was unable to be redirected and punched a police officer multiple times in the face and attacked another resident in the Group Home. The Psychiatrist did not document an assessment of Patient #11's risk for physical aggression to others on admission or on subsequent assessments throughout Patient #11's admission. The section for this on the admission Psychiatric Evaluation and on the Psychiatry Physician Progress notes from 5/1/19 through 5/17/19 was left blank (not completed).

On 6/11/19 at approximately 0910, the Director of Quality and Risk was asked about this and stated that the Physician was supposed to complete all areas of the assessment forms, including the section on "Risks", and noted that the Psychiatrist had consistently failed to complete this section on all of his assessments from 5/1/19 through 5/17/19 for Patient #11.

A Physician's order for admission to the facility dated 4/30/19 at 2330 documented that Patient #11 needed "Precautions for Assault". The only documented physician order or facility safety interventions to protect other patients from Patient #11's potential aggression were noted as visual checks every 15 minutes.

Review of Safety interventions for Patient #11 revealed enhanced or additional safety measures to protect other patients were not added after Patient #11's three documented episodes of physical assault on patients and staff members on 5/1/19, 5/5/19 and 5/13/19. The only documented safety measure to protect others throughout Patient #11's admission was to visually check on Patient #11 every 15 minutes.

Psychiatry Physician's Progress Notes for Patient #11 from 5/1/19 through 5/13/19 (date of assault on Patient #1) documented that Patient #11 was not meeting his treatment goals and was loud, incoherent, disorganized, confused, emotionally labile and unable to state his own name or where he was. These Progress Notes documented that Patient #11 had tangential and disorganized thoughts with impaired memory, auditory hallucinations and poor judgement. "Risk Factors" ( risk of harm to self or others) was left blank on all of these Notes.

The Nursing Admission Assessment for Patient #11 dated 5/1/19 at 0005 was not completely filled out. The section at the end of the form to document updates for uncompleted areas (if the patient was unable to answer the questions on admission) were also blank.

On 6/11/19 at 0930 Staff A was asked about the blank areas in the Nursing Admission Assessment for Patient #11 and the blank areas for updated information. Staff A reported that patient #11 was unable to respond meaningfully to questions on admission but the instructions clearly printed on the admission assessment form indicated that the nurse should document additional attempts to complete the form when the patient was stabilized on treatment and could answer questions meaningfully, and if Patient #11 was still unable to answer questions meaningfully throughout his admission, the nurse should have documented the attempts rather than leaving the spaces blank on the form.

The Activity Therapy Assessment form for Patient #11 dated 5/1/19 at 1200 was completely blank (not filled out). On 6/11/19 at 0940 Staff A was asked about this and stated that Patient #11's activity therapy assessment could not be completed because he was unable to respond to questions meaningfully. Staff A stated that the Activity Therapist should have documented this on the form, or should have contacted a guardian, family member or the Group Home for the information needed to complete the assessment of his activity preferences and activities that helped to calm him down.

A Psychosocial Assessment for Patient #11 dated 5/11/19 at 1200 noted that Patient #11, "presents as confused, bizarre and incoherent", and had a history of aggression. "Conclusions and Recommendations" noted a goal as, "patient will demonstrate improved, as evidenced by not engaging in physically aggressive."

On 6/11/19 at 0935 Staff A was asked how the facility protected patients from physical abuse from Patient #11. Staff A said the facility Interdisciplinary Treatment Team (IDT) developed Care Plans for patients with aggressive behaviors and updated the Care Plan interventions after any violent or combative incidents.

Review of Interdisciplinary Team (IDT) Care Plans for Patient #11 at this time revealed a Problem (#2) dated 4/30/19 "Anger/Aggression". Interventions included the following:

1. Dated 4/30/19: "Physician Practitioner will assess (Patient #11) and discuss with him ways to live a healthy lifestyle with medication management, evaluate medications."

2. Dated 4/30/19: "Nursing will communicate rules, expectations and consequences of actions on the unit."

On 6/11/19 at 1000 the Assistant Director of Nursing (ADON) Staff S was asked how these interventions would protect others from violent assault by Patient #11. Staff S was unable to explain how these interventions would protect other patients if Patient #11 was not coherent enough for meaningful discussions. Staff S stated that Patient #11 was given one time emergency injections of antipsychotic and antianxiety medications (PRN, as needed) after each incident. Staff S stated that Patient #11's intervention to prevent assaults on others was to visually check on him every 15 minutes. Staff S was unable to explain how discussions of healthy lifestyle choices and and rules and expectations were likely to be effective methods to prevent violence to others if Patient #11 was too incoherent and disorganized to state his name.

Review of all Psychiatrist documentation for Patient #11 from 5/1/19 through 5/17/19 revealed no Psychiatrist documentation of Patient #11 's three documented physical assaults on staff or other patients. There was no documentation to indicate a psychiatric evaluation was done to identify triggering factors or warning signs for violent behavior. There was no Psychiatrist assessment of Patient #11's risk of harming others after these assaults. There were no additional physician's orders for enhanced or additional safety measures to minimize the risk violence to others after these assaults.

Review of Adverse Events Reports for Patient #11 revealed he punched other patients or staff in the face on three occasions during this admission.

An Adverse Event Report dated 5/1/19, and Nursing and Mental Health Aide (MHA) documentation for 5/1/19 documented that Patient #11 punched another patient in the face on 5/1/19 at 1700. The Nursing note for this incident, dated 5/1/19 at 1700 documented the following, "Patient (#11) punched peer in the face for no apparent reason. Said, "Merry Christmas", and then hit the peer."

The only updates to Patient #11's IDT Anger/aggression careplan after this incident were noted as:

1. Dated 5/1/19: "Therapist will provide daily steps to help (Patient #11) identify triggers of anger and develop healthy ways to manage emotions."

2. Dated 5/1/19: "Activity Therapist/Recreational Therapist will provide groups to educate (Patient #11) on emotional regulation activities to decrease aggression."

On 6/11/19 at 1015 Staff S was asked how these interventions would protect other patients from physical aggression by Patient #11 if he could not identify his own name, and was too disorganized and confused for the Activity Therapist to do an assessment. Staff S was unable to provide documentation of any staff identification of Patient #11's specific "triggers of anger" or any individualized "emotional regulation activities" to decrease aggression.

An Adverse Event Report for Patient #1 dated 5/5/19 noted that Patient #11 punched Staff Nurse M in the face without warning as he was bending down to assist another patient. Staff M required medical treatment for the injury. There was no documented root cause analysis of this incident to identify any triggers of anger for Patient #11 or warning signs of aggression. There were no documented identified "emotional regulation activities" to decrease aggression. Patient #11 received a emergency (PRN, (as needed)) injection of an antipsychotic medication and an antianxiety medication and was placed in four point physical restraints (all four limbs) for four hours after this incident.

The only update to Patient #11's IDT anger/aggression care plan was:

Dated 5/5/19, "Patient will have one to one interaction to help de-escalate patient to reduce the need for restraints and or seclusions."

On 6/11/19 at 1025 Staff S was asked how this would protect other patients from physical assault. Staff S stated that this did not mean that Patient #11 received one on one supervision. Patient #11 remained on visual checks every 15 minutes as the method of supervision. Staff S said that this intervention directed staff to try to talk to him to calm him down if they noticed that Patient #11 was getting agitated or angry. Staff S was unable to explain how staff knew when Patient #11 was likely to assault someone if his usual behavior was loud, bizarre, and emotionally labile with incoherent speech, auditory hallucinations and tangential thought. Staff S was unable to identify specific emotional regulation activities for Patient #11 to decrease aggression and was unable to explain how talking to Patient #11 would calm him down if he had limited ability to comprehend, was emotionally labile and had a history of assaulting staff.

An Adverse Event Report for Patient #11 dated 5/13/19 at 1300 documented that Patient #11 punched Patient #1 in the face without provocation. The report noted, "Patient was standing at swing door into nursing station and turned around without warning and punched (patient #1) in the jaw for no obvious reason or without precipitating event." There was no root cause analysis to identify possible triggers or warning signs of aggression, and no added interventions to protect other patients from future aggression. There were no updates to the IDT care plan for Anger/Aggression or added safety measures to protect others.

On 6/11/19 at 1130 MHA Staff P who was assigned on Patient #11's unit reported that she remembered Patient #11 very well. Staff P said, " He (Patient #11) was more aggressive than normal. Everybody was scared of him. If he said, 'Merry Christmas' you knew you had to step back because he was going to hit someone." When asked if Patient #11 participated in Group Therapy, Staff P said, "Kinda, Sorta. He wasn't all there."

On 6/11/19 at 1145 MHA Staff Q reported that she remembered Patient 11 very well. Staff Q said she witnessed Patient #11 punching Patient #1 in the face on 5/13/19. Staff Q said, "We all knew when he started talking about Christmas we needed to get him a coffee and take him somewhere quiet to calm down."

On 6/11/19 at 1200, Licensed Practical Nurse (LPN) Staff R was interviewed regarding Patient #11's assault on Staff M. Staff R said that she thought that Patient #11 got agitated when it was noisy. Staff R said that one of the nurses had spoken to the Supervisor at Patient #11's group home who recommended coloring, coffee and music to calm Patient #11 down. Staff R was asked whether the IDT team was aware of this, and whether this was documented so all direct care staff would know what to do. Staff R stated that she was not sure.

On 6/11/19 at 1215, Patient #11's Social Worker, Staff O was interviewed. Staff O stated that she did not know that it was a sign that Patient #11 was becoming aggressive when he started talking about Christmas. Staff O was unaware that Patient #11 could be calmed down with offers of coffee or coloring.

On 6/13/19 at 1500 review of the facility policy entitled, "Responding to Aggressive/Assaultive Behaviors, dated 11/18 revealed the following statements, "Staff are responsible for recognizing and observing the signs of potential violent behavior and reporting it to the appropriate staff" and, "Staff will assess the patient daily for the potential for assault."