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Based on Interview, Observation and Record Review the hospital failed to provide care in safe setting for 2 of 2 Patients (Patient #1 and Patient #2), by failing to place appropriate precautions in place and separate the patient after engaging in altercations.

Findings Include

Based on Interview with Staff #8 on 04/16/2025 at 11:00 AM, indicated that Patient #1 was experience a Psychosis episode and is IDD. Staff #8 indicated that Patient #1 was requesting to discharge upon admission and verbally and physically aggressive upon arriving on unit. The Patient engaging in self-injurious behavior by banging head against wall, throwing items and pulling mattress off of bedframe. These behaviors took place on 04/10/2025. This information was reported but not thoroughly documented in the record.
Based on Interview with Staff #10 04/16/2025 at 11:30 AM was asked to elaborate as to why staff is not documenting thoroughly in the medical record of the incident. Staff #10 indicate that they were unsure.
Based on Interview with Staff #10 04/16/2025 at 1:30 PM was about why Staff #9 failed to exit nursing station stating 'Patient #2 verbally threatened to cause harm to Staff #9.' Staff #10 indicated that is not okay, and would be addressed.

Based on Observation with hosptial Staff #4 video footage was reviewed, on 04/12/2025 and it revealed Patient #1 was experiencing a pychosis by appearing in the hallway fully nude and refusing to put clothing on when prompted. Patient #1 was banging the telephone up and down on the wall and receiver not following directives and waking peers up. Patient #2 was woken up and heard Patient #1 banging the telephone on the wall. Patient #1 and Patient #2 began exchanging words. Patient #1 and Patient #2 then approached one another and started punching each other. Staff #11 and Staff #12 intervened separating the patients but did nothing to put precautions in place. Patient #1 and Patient #2 remained in the hallway, Patient #1 obtained a cup of water and started throwing it at Staff #11, and Staff #12. Patient #1 then spit on Staff and Patient #2 and they began exchanging punches again.
Staff #11 separated the patients again, but nothing was put in place. Patient #1 sat on the bench in the hallway with another cup of water. Staff #12 was moping the water previously thrown. Patient #1 and Patient #2 were at the opposite end of the hallway and started to exchange punches again. At this time Staff #13 exits nursing station and is able to communicate with Patient #1 and she sat on the hallway and floor infront of the telephone. Patient #1 was the encouraged to put some clothing on.

Policy:
The hospital Policy on Patient Rights 11/2021 reflected, "It is the policy of Millwood Hospital and Excel Centers to ensure that all patients receive a copy of the Patient handbook, which includes the Patient Bill of Rights as well as an oral explanation of those rights both in their primary language and in simple non-technical terms. We will strive to abide by and respect all patient rights without regard to race, religion, creed, ethnicity, gender, age, sexual orientation or handicap. Millwood Hospital and Excel Centers shall support and protect the fundamental human, civil constitutional and statutory rights of the individual patient and recognize and respect personal dignity of the patient at all times."

The hospital Policy on Abuse 04/2025, "It is the policy of Millwood Hospital to report all incidents of patient abuse, neglect and exploitation as soon as possible after the time the incident is identified."

The hospital Policy on Nursing Services 12/2022, "IT is the policy of Millwood Hospital to ensure that the appropriate numbers and qualifications of nursing staff are available at all times for the care of patients. The Chief Nursing Officer (CNO) is responsible for the development and ongoing review of staffing requirements based on numbers of patients, population served, acuity and measurements of patient outcomes that include patient falls, restraint/seclusion, medications errors, infection rates, patient complaints and grievances, as well as other types of incident occurrences. The staffing plan for Nursing Services is designed to comply with all applicable regulatory standards and is reviewed annually."