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SALT LAKE BEHAVIORAL HEALTH 3802 SOUTH 700 EAST SALT LAKE CITY, UT 84106 Feb. 14, 2019
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and record review, it was determined that the hospital failed to promote and protect each patients' rights.

Findings include:

The hospital failed to ensure patients received care in a safe setting. (Refer to tag A-144)
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review it was determined the hospital failed to ensure patients received care in a safe setting. Specifically, patients were left unsupervised and staff members did not inform other staff members when incidents occurred between patients. (Patient identifier: 3.)

Findings include:

Patient 3 was admitted on [DATE], with diagnoses of disruptive mood dysregulation disorder, chronic post traumatic stress disorder, and aggressive behaviors.

On 2/13/19 at 11:48 AM, an interview was conducted with patient 3. Patient 3 stated he had been involved in three physical confrontations with other patients since his admission. Patient 3 stated two incidents occurred with patient 4 and one incident with patient 8. Patient 3 stated the first incident occurred in the group room, where he was punched in the face and stomach by patient 4. Patient 3 stated staff were not present during the incident, but that Registered Nurse (RN) 1 "came in after". Patient 3 stated the second incident occurred between himself and patient 8 in the main area of the unit, but that staff was, "behind desk doing paperwork" and "weren't even paying attention to us." Patient 3 stated he pushed a chair at patient 8, lifted his leg up and then patient 8 stated, "square up, so I did" and he hit me in the jaw. Patient 3 stated the third incident occurred in the hallway, when patient 4 "came up and punched me in the face." Patient 3 stated he had not had any incidents today or yesterday, and that he felt safe.

On 2/13/19 at approximately 12:10 PM, an interview was conducted with RN 1. RN 1 stated he had not witnessed the confrontation between patient 3 and patient 4, but that he had walked into the room where the confrontation took place as it was subsiding. RN 1 stated he had let patient 4 into the group room for "quiet time", as he was agitated and wanted space. RN 1 stated male patients could be left in the group room alone or with other male patients, "but not with girls, that's my rule." RN 1 further stated he left patient 4 in the group room and went to the nurses station. RN 1 stated as he was walking to the nurses station he saw some female patients walking down the hall, although he did not know exactly where they were going. RN 1 stated he was unsure how long he had left patient 4 unattended in the group room, "could have been one minute or it could have been five to 10 minutes." RN 1 further stated the "best" way to know how long the patients were alone in the group room was "to look at the video". RN 1 then stated when he returned to the group room he observed several patients in the room and patient 3 and patient 4 stated they had hit each other. RN 1 stated some of the patients who observed the confrontation stated patient 1 started it, and the others stated patient 4 started it. RN 1 stated in hind-sight he should not have left patient 4 alone in the group room.

A review of patient 3's medical record was completed on 2/14/19.

The following incident's were documented in patient 3's medical record:

a. On 2/10/19 RN 1 documented the following, "... Unobserved Physical confrontation (with) other male cohort, sides said others hit first, no complaints of pain, no s/s (signs and symptoms) of pain, no s/s of redness shoulder/stomach. Supervisor/family called and updated will consult (with) therapist/Dr (doctor)"

b. On 2/11/19 at 10:00 PM, a RN documented the following, "(Patient 3) had gotten into a physical confrontation with another patient around 1845 (6:45 PM) (Patient 3) had separated himself from the milue to sit in the hallway due to patient stating another peer had been calling him rude names. Pt (patient) was sitting in the hallway by himself when another pt had stood across from (patient 3) about 20 feet away looking at him. Other patients had begun to surround the other patient. When staff asked the other patients what was going on, (Patient 3) had picked up a chair which had triggered the other patient. The other patient had pushed through other peers and went around a staff member and punched (patient 3) in the face. Both patients were separated and went into their rooms to de-escalate. (Patient 3's) face had been examined, mild swelling was observed and no pain reported unless touched... (Patient 3's) face examined two times more, the minimal swelling had gone away and patient complained of minimal pain upon touch. X-ray ordered upon parents request. MD (medical doctor) and parents both notified... (Patient 3) reported getting punched today during day shift by a different patient, which no physical confrontation was reported by day staff. (Patient 3) had also reported getting punched in the stomach twice during day shift yesterday, which was also not reported to night staff. Patients have been placed on a 10 foot rule where they are to be at least 10 feet away from each other at all times..."

No evidence of a third physical confrontation was found in patient 3's medical record. However, an incident report for another patient, patient 8, dated 2/11/19 at 3:48 PM, revealed the following incident between patient 3 and patient 8, "Pt had a verbal altercation that led to a physical altercation. (Patient 3) grabbed pt's leg and tried to flip him over. (Patient 3) than (sic) hit pt and pt hit peer back lightly and then grabbed peer's shirt. Therapist broke pts up." Note: The surveyors watched the video recording of the altercation listed above. A nurse was observed to be at the nurses station during the incident, however he was on the phone and was not observed to look up from the desk. A therapist did come into the room and break up the incident after the patients had hit one another.

On 2/14/19 at 9:40 AM, an interview was conducted with technician 1. Technician 1 stated if male and female patients were together in the group room staff had to be present. Technician 1 further stated if only male patients or only female patients were in the group room staff did not need to be present, but the door to the room had to remain open.

On 2/14/19 at 10:39 AM, an interview was conduced with the Risk Manager (RM). The RM stated there were no cameras in the group room on the adolescent unit.

On 2/14/19 at 10:42 AM, an interview was conducted with the house supervisor (HS) and RM. The HS stated patients were not allowed to be left unattended in the group room, and that the group room should be locked when it was not being used for therapy. The RM confirmed patients should not be left unattended in the group room. The HS confirmed the nurse on the adolescent unit on 2/11/19 should have been informed of the physical altercations between patient 3 and other patients.