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.

MERCY HOSPITAL SPRINGFIELD 1235 E CHEROKEE SPRINGFIELD, MO 65804 June 2, 2020
VIOLATION: NURSING SERVICES Tag No: A0385
Based on interview, record review, policy review and video/audio review the hospital failed to:
- Ensure the safety of two patients (#1 and #2) when a physical altercation occurred between the two patients that resulted in physical injuries to both.
- Ensure that staff activated their panic buttons (devices worn by staff to alert Behavioral Health Unit, [BHU] staff and that activated the public safety staff to respond to the BHU building) and attempted de-escalation to prevent the physical altercation when Patient #1 loudly yelled as he walked down the hallway towards Patient #2's room.
- Visually monitor all patients, at all times, by either staff view or by video surveillance monitoring when one staff person briefly left the unit after he had just de-escalated Patient #1. The unit did not have a dedicated staff member that monitored the video surveillance while patients wandered in the hallways, dining/dayroom and in and out of their patient rooms. (A-0395)

These failures resulted in physical injuries to both Patient #1 and Patient #2 and placed all BHU patients and staff at risk for their health and safety.

These deficient practices resulted in the hospitals non-compliance with specific requirements found under 42 CFR 482.23 Condition of Participation: Nursing Services. The BHU census was 21. The hospital census was 274.

The severity and cumulative effect of these practices had the likelihood to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 06/02/20, after the survey team informed the hospital of the IJ, the staff put into place interventions to ensure the safety of the patients.

As of 06/02/20, the hospital had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Effective immediately a co-worker will be assigned to continuously monitor the video monitors on the BHU's.
-The panic alarm button will be activated to immediately notify the charge and primary nurses when escalated behavior is identified on a unit. The alarm buttons are currently in use by nursing staff.
- All video cameras in the BHU will be monitored by a monitor tech located on the Behavioral Health (BH) A unit. All video feeds are visible on the A unit.
-Co-worker assignments for oversight of the video surveillance monitoring by qualified co-workers 24/7 will be made by the manager of the BHU or designee.
- Qualified co-workers assigned to watch the video monitors cannot have other assignments and must be relieved by qualified co-workers when they go on break.
- All co-workers Registered Nurses (RN), Licensed Practical Nurses (LPN) and Behavioral Health Technicians (BHT) will complete training program and complete competency validation to perform the duties of monitor tech and constant observation of the BH A and B unit hallway and handoff procedure.
- Clinical practice bulletin was created to educate the BHU physicians and BHU float pool co-workers on video monitoring and supervision.
- Policy was developed to reflect continuous monitoring of all video surveillance. Education on policy included with training program.
- All co-workers on the BHU will complete the Behavioral Health Services Shift Assessment and Documentation education prior to working their next shift.
- All BHU patients have been reassessed for level of precautions needed based on patient assessment by RN's responsible for the patient care.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, policy review and video/audio review the hospital failed to:
- Ensure the safety of two patients (#1 and #2) when a physical altercation occurred between the two patients that resulted in physical injuries to both.
- Ensure that staff activated their panic buttons (devices worn by staff to alert Behavioral Health Unit, [BHU] staff and that activated the public safety staff to respond to the BHU building) and attempted de-escalation to prevent the physical altercation when Patient #1 loudly yelled as he walked down the hallway towards Patient #2's room.
- Visually monitor all patients, at all times, by either staff view or by video surveillance monitoring when one staff person briefly left the unit after he had just de-escalated Patient #1. The unit did not have a dedicated staff member that monitored the video surveillance while patients wandered in the hallways, dining/dayroom and in and out of their patient rooms.
These failures had the potential to place all patients and staff on the BHU at risk for their health and safety. The BHU census was 21. The hospital census was 274.

Findings included:

Review of the hospital policy titled, "Springfield Behavioral Health Services (BHS) Inpatient Precautions", revised 09/10/18 showed that:
- Precautions are ordered by the physician for patients who require a more intensive level of supervision for specific behaviors or clinical symptoms.
- Patient safety rounds are performed every 15 minutes in a random pattern unless otherwise specified by physician's order.
- Assault precautions may be indicated when a patient had any or a combination of the following, recent assault, impulse control problems, history of poor management of stressful situations, poor judgement or insight and threatening or intimidating behaviors.
- Assault precautions procedure is to obtain a physician order for assault precautions, obtain "no assault" agreement verbally, in the event of an assault, notify physician for further orders and move patient to the psychiatric intensive care area if necessary, follow physical crisis intervention safety practices when interacting with the patient.

Review of Patient #1's Emergency Department (ED) Initial Face to Face Psychiatric Evaluation, dated 05/19/20 at 8:35 AM showed that:
- The patient was a [AGE] year old male with a past psychiatric history of Bipolar Disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels and the ability to carry out day-to-day tasks), Schizophrenia (serious mental disorder in which people interpret reality abnormally), homicidal ideations (HI, thoughts or attempts to cause another's death), post-traumatic stress disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury of severe psychological shock), alcohol abuse and cannabis (psychoactive drug from the cannabis plant used primarily for medical or recreational purposes) use.
- The patient presented with erratic (not even or regular in pattern or movement; unpredictable) and violent behavior.
- He was aggressive in the ED and stabbed a security guard with a pen.
- He required four-point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) due to his attempts to kick, bite and punch staff.
- During his time in the ED he had a one-to-one sitter (1:1, continuous visual contact with close physical proximity).
- Due to his behaviors in the ED the patient was a risk to his own and other's safety and would benefit from an inpatient psychiatric admission on the BHU's A-Unit.

Review of Patient #1's inpatient medical showed that:
- He was admitted to the BHU's A-Unit on 05/20/20 at 4:45 PM.
- He was unable to recall the reason for his admission.
- He was placed on suicide and assault precautions.
- On admission to the BHU he was placed on 15 minute observation rounds.
- He was non-compliant with staff requests.
- He did not want to follow unit rules.
- He would become uncooperative, displayed posturing (positioning of the body in an aggressive manner), and was aggressive with little warning.
- Staff attempted verbal de-escalation with minimal success.
- He threw a unit telephone and broke it after staff were unable to find him a phone number he had requested.
- He attempted to gain access to the nurse's station while staff attempted to close the door.
- He attempted to barricade himself in the unit's dayroom with table and chairs.
- Security had to be called for assistance and he was placed in restraints in the acute care area.
- He continued to be out of control and fight restraints; he was placed in seclusion.
- While in seclusion he smeared food onto the walls, threw a glass of water and attempted to hit staff.
- He covered the seclusion room camera with a sock and attempted to barricade the door with a mattress.
- He scored a five on the Broset Violence Checklist (BVC, an instrument in predicting violence within the next 24-hour period) on 05/21/20 at 12:45 AM, which means he was considered "very high risk of violence".
- Patient remained in either restraints or seclusion throughout the night and returned to his room at 4:20 AM on 05/21/20.
- After he returned to his room he was placed back on 15 minute observation rounds.

Review of Patient #2's medical record dated 05/17/20 showed that:
- The patient was a [AGE] year old male that had a history of Major Depressive Disorder (MDD, persistent depressed mood or loss of interest in activities, causing significant impairment in daily life), opiate use disorder (misuse of prescribed pain medication), methamphetamine (a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant) use, PTSD, and panic disorder (panic attacks, which are sudden feelings of terror when there is no real danger).
-He presented to the ED with, suicidal ideations (SI, thoughts of causing one's own death) depression (extreme sadness that doesn't go away) and anxiety (a feeling or fear or worry experienced intermittently).
- He was admitted to the BHU's A-Unit and placed on suicide precautions.
- He was placed on 15 minute observation rounds.

Review of Patient #2's medical record dated 05/21/20 showed that:
- He was attacked by another male peer on 05/21/20 at 11:15 AM.
- He was hit in the head several times and acquired a small laceration to the left eyebrow that did not require sutures.
- He acquired two knots to the back left side of the head and redness to the face.
- His right hand was swollen as he hit the other male patient several times in an attempt to defend himself.
- He was transferred to the BHU's B-unit at 12:25 PM.

Review of the hospital's video/audio recording titled, "A-Unit Dining Room", dated 05/21/20, showed the camera view of the BHU A-Unit dining/dayroom. The review showed:
- 10:33:50 AM Patient #1 and an unidentified patient were having a conversation in the dayroom about cannabis and tetrahydrocannabinol (THC, a crystalline compound that is the main active ingredient in cannabis).
- 10:34:05 AM Patient #1 made a statement about taking "a shit in that bag" while he pointed to a paper garbage sack next to a cabinet on the floor.
- 10:34:12 AM Patient #1 walked over to the cabinet, stood over the paper sack and put his hands on his scrub pants and appeared as if he was going to lower them.
- 10:34:13 AM the unidentified patient stated, "Are you fucking kidding me? You're going to go in a bag?"
- 10:34:15 AM Patient #1 walked away from the paper sack and back towards the unidentified patient.
- 10:34:22 AM the unidentified patient stated, "For real? Take a dump in it. Oh My God! I would laugh so fucking hard!" Patient #1 began to laugh.
- 10:34:24 AM Patient #1 continued to laugh and unidentified patient stated, "Oh, you farted! Oh God! Geez!"
- 10:34:31 AM Patient #1 and the unidentified patient exited the dayroom.
- 10:37:57 AM Patient #1 entered the day room followed by the unidentified patient. Patient #1 covered his nose with his scrubs shirt and stated, "What does it smell like in here?"
- 10:38:00 AM the unidentified patient responded, "It doesn't smell bad in here, maybe like cats. Did you go to the bathroom, did you tear it up?"
- 10:38:07 AM Patient #1 had his back to the garbage sack and reached behind himself and picked up the paper garbage sack.
- 10:38:09 AM the unidentified patient stated, "Not in there! Did you shit in the bag? You did?"
- 10:37:17 AM Patient #1 exited the dayroom with the paper garbage sack and headed down the hall toward the patient rooms.
- 10:41:43 AM Patient #1 entered the dining room slowly, and held the paper sack in his right hand.
- 10:41:46 AM Patient #1 placed the paper sack carefully on the floor and adjusted the edges of the bag to ensure the bag was open.
- 10:41:52 AM Patient #1 took a paper towel from the dispenser, wiped his hand and right thigh, disposed of the paper towel in the paper sack and exited the dayroom.
- 10:42:31 AM Patient #1 paced the hall outside the day room.
- 10:43:03 AM Patient #1 entered the dayroom doorway and glanced down at the paper sack.
- 10:43:09 AM the unidentified patient entered the dayroom, walked past Patient #1 and sat down at a table.
- 10:43:12 AM Patient #1 looked into the paper sack again, pulled his scrub shirt over his nose and began to laugh.
- 10:43:16 AM the unidentified patient asked, "What?" followed by, "What is it? Fuck no!"
- 10:43:20 AM the unidentified patient stood up, walked over to the paper sack and asked Patient #1, "Dude, you took a shit in there?"
- 10:43:28 AM Patient #1 nodded his head yes while laughing. The unidentified patient stated, "Oh my God" and exited the dining room towards the patient rooms.
- 10:43:33 AM Patient #1 exited the dayroom.

Review of the hospital's video/audio recording titled, "A-Unit Patient Hallway", dated 05/21/20, showed the camera view of the BHU A-Unit hallway. The review showed:
- 11:12:19 AM Patient #2 exited his bedroom and walked down the hall towards the dayroom.
- 11:12:26 AM Patient #2 asked loudly, "Alright, what's this I hear about someone taking a shit in a cup and putting it in here?"
- 11:12:30 AM someone not in camera view was overheard to have asked, "What?"
- 11:12:31 AM Patient #2 stated, "You can't smell that? Come raise your hand, who did it?"
- 11:12:37 AM Staff G, BHT, entered the camera view and asked Patient #2, "Who did what?"
- 11:12:38 AM Patient #2 asked again, "Who did it?"
- 11:12:39 AM Staff G asked Patient #2, "Who did what?"
- 11:12:44 AM Patient #2 asked Staff G, "You can't smell that?"
- 11:12:48 AM Patient #2 and Staff G entered the dayroom.
- 11:12:53 AM Patient #2 exited the dayroom back into the hallway.
- 11:12:55 AM Patient #1 entered the camera view and walked toward Patient #2. Staff G stood in dayroom doorway.
- 11:12:56 AM Patient #2 shouted, "Raise your hand if you know who did this? Raise your hand", while he and Patient #1 began to walk in a circle and stare at each other.
- 11:13:01 AM Patient #1 asked, "What?"
- 11:13:02 AM Patient #2 stated, "Fess up."
- 11:13:05 AM Patient #2 shouted, "Quit shitting in cups man."
- 11:13:09 AM Patient #2 turned around and walked back toward his room.
- 11:13:10 AM Patient #1 made an inaudible statement.
- 11:13:12 AM Patient #2 turned around, gestured with his hands and stated, "Bring it on, bitch."
- 11:13:14 AM Staff G moved toward Patient #1 and Patient #2 and stated, "no, no no" and stepped between both patients.
- 11:13:16 AM Patient #1 squatted down and postured into a fighting stance and attempted to advance toward Patient #2.
- 11:13:20 AM Staff G attempted to re-direct Patient #1 stating, "Stop, let's go, it's time for lunch."
- 11:13:22 AM Patient #2 told Patient #1 to stop as Staff G told Patient #1 it was about time to eat.
- 11:13:29 AM Patient #1 reached around Staff G and tapped Patient #2 on the left arm/elbow area. Staff G told Patient #1 "no".
- 11:13:34 AM Patient #1 turned around and took a few steps away from Staff G & Patient #2.
- 11:13:36 AM Patient #2 shouted at Patient #1, "I've got a problem with you taking a shit in the dayroom."
- 11:13:41 AM Patient #1 turned back around and asked, "How do you know it was me?" and began to walk back towards Patient #2 where they began to argue again.
- 11:13:43 AM Staff G stated, "No, nobody is doing anything like that" as he continued to attempt to de-escalate Patient #1.
- 11:13:49 AM Patient #1 stated, "There is no evidence."
- 11:13:53 AM Patient #2 stated, "Then why would there be shit in there?"
- 11:13:54 AM Patient #1 responded, "I don't know who put that in there bro."
- 11:14:02 AM Patient #2 stated, "I'm not trying to start a fight, I just wish someone would shit in the proper receptacle."
- 11:14:09 AM Staff G asked, "Where is this poop you are talking about?" Patient #2 pointed to the dayroom and stated, "In that bag right there, you can't smell it?"
- 11:14:16 AM Staff G asked Patient #1, "Do you smell it?"
- 11:14:18 AM Patient #2, Staff G and Patient #1 walked into the dayroom.
- 11:14:19 AM Staff H, BHT, entered the camera view, pushing the meal tray cart.
- 11:14:22 AM Patient #2 asked Staff G "Stick your head in there, you can't smell that?"
- 11:14:28 AM Staff G responded, "Yeah I can smell it."
- 11:14:30 AM Patient #2 exited the dayroom, walked down the hallway and entered his room.
- 11:14:48 AM Staff G exited the dayroom with the paper sack and stated, "Yeah someone did, someone did, yeah someone did, yeah, yeah" and walked out of the camera view with the garbage sack in hand.
- 11:14:54 AM Patient #1 exited the dining/dayroom and stated to Staff H, "He's lucky I didn't go", then postured into a fighting stance where he punched the air and again stated, "He's lucky I didn't do that."
- 11:15:01 AM Patient #1 turned away from Staff H at the meal cart and began to shout down the hall, "Come on, let's go, let's roll!"
- 11:15:03 AM Female staff member off camera stated to Patient #1, "Come on Patient #1, we are eating lunch". Patient #1 continued to walk down the hallway repeating the "come on, let's go, let's roll".
- 11:15:06 AM Staff H stated to Patient #1, "Patient #1 your lunch meal is here."
- 11:15:11 AM Patient #1 approached Patient #2's room and shouted loudly, "Where you at?"
- 11:15:15 AM Patient #2 came to the entrance of his room as Patient #1 approached.
- 11:15:17 AM Patient #1 pulled his right arm back and with a closed fist struck Patient #2 in the head.
- 11:15:18 AM Staff H, BHT shouted, "Hey quit", turned and left the camera view. Staff J took a few steps toward Patients #1 and #2 but then turned and ran in the opposite direction.
- 11:15:19-33 AM Patient #1 and Patient #2 continued to fight with no staff intervention.
- 11:15:31 AM Staff I, RN, ran down hallway toward Patient #1 & Patient #2.
- 11:15:34 AM Staff J walked down the hall toward Patient #1 & Patient #2.
- 11:15:33-47 AM Staff I continued to attempt to separate Patient #1 and Patient #2 without success.
- 11:15:38 AM An overhead page announced "Code 10, A-unit hallway".
- 11:15:47 AM Staff G, BHT entered the camera view and ran toward Patient #1 and Patient #2.
- 11:15:47 AM the unidentified patient reached out from his room and grabbed Patient #1 by the right arm. That allowed Staff I to effectively separate Patient #1 and Patient #2.
- 11:15:52 AM Staff I told Patient #2 to go to his room and Patient #1 to walk away from Patient #2's room.
- 11:15:55 AM Patient #1, Staff I and Staff G walked back down the hall away from Patient #2's room.
- 11:16:07 AM Staff I, RN attempted to re-direct Patient #1 into a room, instead Patient #1 turned around and walked back toward Patient #2's room and began to shout. All staff present followed and Staff I attempted to re-direct Patient #1 unsuccessfully.
- 11:16:14 AM as Patient #1 approached Patient #2's room Staff I told Patient #2 to shut the door to his room.
- 11:16:13 AM additional staff entered the camera view in response to the Code 10 that was called.
- 11:16:20 AM Patient #1 pounded on the door to Patient #2's room, staff continued to attempt to de-escalate him.
- 11:16:30 AM Patient #1 turned away from Patient #2's door and walked back down the hall with staff.

Review of Patient #1's nursing notes dated 05/21/20 showed that:
- He had postured at staff.
- He physically attacked another male patient after being confronted about having a bowel movement in the dayroom trash.
- A Code 10 was called and security was called for assistance due to his physical altercation with a male peer.
- He was re-directed from peer with difficulty.
- He attempted to go after peer again after re-direction and continued to punch peer.
- He was re-directed again with difficulty and resistance.
- He stopped at the meal cart, searching for peer's meal tray and spit in cart.
- He had bleeding from left nostril, swelling and bruising of the nose.
- A computed tomography (CT, a combination of X-rays and a computer to create pictures of organs, bones and other tissues, which show more detail that a regular X-Ray) of his facial bones was ordered.
- He spit and smeared blood on walls.
- He grabbed a RN's arms and smeared blood on the nurse.
- He continued to make statements of intent to harm male peer.
- He was placed in seclusion where he continued to spit and smear blood on walls and floor.
- He verbalized SI.
- He asked the psychiatrist to "shoot" him.
- He was released from seclusion and returned to the unit.
- Upon return to the unit he hit a Behavioral Health Technician (BHT) in the arm with a sock and stated, "see that could've been a knife".
- He stated that if he saw the male peer from the altercation earlier he "will murder him".

Review of Patient #1's history and physical (H&P) by Staff K, Psychiatrist dated 05/21/20 at 3:54 PM showed that:
- He was "still very irritable and agitated".
- During the interview with psychiatrist he was going to "shit in his pants".
- His concentration was severely impaired.
- He had been "very violent, aggressive and agitated".
- His affect (observable behaviors that are the expression of one's feeling state) was unpredictable and that he was "at high-risk for violence".
- He continued on 15 minute observation rounds.

Staff K, despite his awareness of the physical altercation with Patient #2 and documentation that Patient #1 was at "high-risk for violence", did not increase Patient #1's level of observation for the remainder of his inpatient stay to prevent further altercations or injuries to patients or staff.

During an interview on 06/01/20 at 4:30 PM, Staff G, BHT, stated that:
- He remembered there was an argument when lunch trays were about to be passed.
- He remembered Patient #1 hitting Patient #2's elbow and that's when he stepped in between them.
- After speaking with both patients he thought he had de-escalated the situation and proceeded to take the paper sack out of the dayroom to the trash.
- He did not press his panic button (a button which, when pressed, activates an alarm by sending a signal to either a local emergency team or a monitoring service).
- He did not see the altercation start but when he returned to the unit and saw the altercation happening he ran to help assist.
- He "just left at a bad time".

During an interview on 06/02/20 at 10:14 AM, Staff H, BHT, stated that:
- She was about to pass lunch trays when Staff G, BHT was speaking with Patient #1.
- Patient #2 approached Staff G and stated that Patient #1 had defecated in a cup and put it in the dining room trash.
- Patient #2 walked with Staff G into the dayroom to look at the trash.
- Staff G took the trash out of the dining room and went to throw it away.
- Patient #2 returned to his room.
- Patient #1 returned to the hallway, waving his fists and saying "I should've done this to him".
- Patient #1 began walking toward Patient #2's room and Patient #2 came out of his room.
- Patient #1 hit Patient #2 at least three times and finally Patient #2 struck back.
- Staff I, RN, ran down the hall to assist the patients.
- She attempted to close patient doors and the food cart when staff brought Patient #1 back by the food cart.
- Patient #1 asked where Patient #2's tray was.
- She believed she pressed her panic button, "I know I probably did", she was unsure if any other staff pressed their alarm.

During an interview on 06/03/20 at 4:20 PM, Staff I, RN, stated that:
- She was charting when she heard a loud thud in the hall so she left the nurse's station and pushed her panic button on the way out the door.
- She asked another staff member at the nurse's station to call security.
- When she exited the nurse's station she saw Patient #1 and Patient #2 fighting at the far end of the hall.
- She ran down the hall and attempted to get Patient #1 off of Patient #2.
- She heard the Code 10 called and other staff came to assist her.
- She attempted to get Patient #2 to go back to his room and for Patient #1 to come with her.
- Patient #1 then attempted to go back to Patient #2's room and she again attempted to re-direct him.
- She believed after that security arrived and they were able to get him to the acute care area where he was restrained.
- All staff working on the BHU were required to complete Mandt Training (a workplace violence instructor-led training that focuses more on de-escalation through communication versus physical skills).

During an interview on 06/03/20 at 10:00 AM, Staff K, Psychiatrist, stated that:
- He admitted patients with lower acuity to the B-Unit.
- He admitted patients with higher acuity such as violent/assaultive patients, patients with substance abuse issues, suicidal patients and sex offenders to the A-Unit.
- On the A-Unit patients were on 15 minute observations, 1:1 sitters were utilized when necessary and the unit had 24-hour video monitoring in all areas except the bathroom and shower.
- The 24-hour video monitoring had a staff member at the monitor at all times.
- Having staff watch these monitors they would be able to anticipate situations that may need de-escalation.
- The A-Unit also had at least two psych techs out on the unit at all times to "keep an eye" on patients.
- He was aware that Patient #1 had stabbed a security guard while in the ED.
- He believed that if Patient #1 was placed on a 1:1 on the BHU that it would have agitated him further.
- He believed that Patient #1 needed less stimulation and more space to reduce his paranoia.
- His expectation would be that psych techs would be present on the unit at all times and that there would be a staff member at the video monitor at all times.

During an observation on the BHU A-Unit on 06/01/20 at 3:30 PM there was not a staff member present at the video monitor.

During an interview on 06/01/20 at 3:20 PM, Staff F, RN, BHU Manager stated that:
- Patient #1 was not violent on the unit prior to the 5/21/20 incident and had only been violent in the ED.
- She debriefed with all staff after Patient #1's 05/20/20 incident and told staff members that he "needed to be watched".
- Per video recording review she thought that Staff G had pressed his panic button.
- After the 05/21/20 incident she coached staff on how the patients were "sizing each other up and that Staff G should have intervened sooner".
- If one staff member pressed their panic button an overhead silent light flashed. If more than one person pressed the alarm, Public Safety Officers were notified.
- All staff that worked at the BHU were trained in Advanced Mandt (workplace violence instructor-led training that focuses more on de-escalation through communication versus physical skills).
- Patients admitted to the A-Unit were in need of closer nursing supervision.
- Broset score interventions were determined by the physician.
- 1:1 or LOS observation were typically only put into place after a suicide attempt.
- Assault precautions require placement on the A-Unit, 15 minute observations and depending on the situation a private room.

During an interview on 06/02/20 at 2:30 PM, Staff M, Charge RN, stated that:
- On A-Unit staff would be out on the hall with the patients, patients would be on 15 minute rounds, 1:1 if needed, private rooms and restraint/seclusion if needed.
- There was no dedicated monitor technician.
- The monitors at the nurse's station had no audio.
- The video did not record and staff could only see the live feed, so if someone were to step away for a moment they would not be able to go back and see the video.
- Although she had not been dedicated to monitor the video, as the charge nurse she would be "at the nurse's station at all times unless there's an incident or I am out passing a medication".
- Panic buttons should be pressed when de-escalation attempts happened to be unsuccessful or if staff "feel threatened".
- Security would be alerted when a panic button was pressed but staff also had to call if security was needed.
- When staff noticed the flashing light from the panic alarm they were to look around for other co-workers to see where they need to go.
- 1:1 sitters were typically ordered for patients who would be self-harming or aggressive.

During an interview on 06/02/20 at 1:55 PM, Staff L, Personal Care Assistant (PCA), stated that:
- There was always at least one technician on the floor.
- No dedicated staff member watched the monitor but there was always a nurse inside the nurse's station.
- Panic buttons were to be pressed if de-escalation was unsuccessful or if a co-worker needed to go hands-on with a patient.
- Staff were trained on de-escalation and re-direction of patient's.
- Anyone that worked on the BHU or the ED was required to complete the training.

Review of the hospital policy titled, "Mercy System-Wide Human Resource Workplace Violence Training" revised 01/01/20 showed that:
- The workplace violence training program helps co-workers avoid or mitigate the risk of workplace violence through a combination of training and preparations.
- New co-workers will be assigned an online workplace violence course upon hire.
- Mandt System levels of training are based on the co-worker's exposure to individuals more likely to become aggressive or violent.
- Levels of training are identified as Mandt System Non-Clinical, Mandt System Clinical, and Mandt System High Risk.
- Mandt System High Risk is for co-workers in Behavioral Health, Emergency Department and Public Safety and other areas as determined by local leadership.
- Human Resources, Managers and Employee Health will determine if co-worker can return to patient care locations if they are not able to complete the physical requirements of the required training.

Review of the Staff G, BHT, and Staff H, BHT Personnel Records showed that both staff had been employed since 02/20/20.

Review of the Staff G, BHT, and Staff H, BHT "Student & Group Transcript Report", dated 06/02/20 showed that both staff had not yet received any Advanced Mandt training.

During a telephone interview on 06/02/20 at 5:17 PM, Staff F, RN, BHU Manager stated that:
- Both Staff G and Staff H were scheduled to take the Advanced Mandt training but the classes were canceled due to COVID-19 (highly contagious, and sometimes fatal, virus) and the courses had not yet been re-scheduled.
- Both Staff G and Staff H had completed the training titled, "Care of Patients at Risk for Harm to Self or Others".
- According to Staff G's training on "Care of Patients at Risk for Harm to Self or Others" it was appropriate to intervene with Patient #1 and Patient #2 but that it was not a "true Mandt Maneuver".

Staff were aware of Patient #1's assault precautions, aggressive behaviors and incident on the evening of 05/20/20 but still discounted the verbal argument between Patient #1 and Patient #2 that led up to the physical altercation on 05/21/20. Staff K admitted Patient #1 to the BHU's A-Unit due to his actions and presentation in the ED. Staff K was under the assumption that Patient #1 and other patients would be safe due to the 24-hour continuous monitoring on the unit, however, the monitoring of patients was not continuous. In addition, Staff G and Staff H who were present in the hall at the time of the incident had not been thoroughly trained on how to respond or de-escalate a situation of this nature.

These failures in addition to the lack of supervision by the licensed nursing staff for these high acuity patients, who were known to have assaultive, aggressive and self-injurious behavior, placed all BHU patients and staff at risk for their safety and health.