HospitalInspections.org

Based on document reviews and interviews, it was determined that the hospital failed to take appropriate actions to ensure the patient was free from physical abuse.

1. On Friday, September 12, 2025, at approximately 12:19pm, Patient #1 assaulted Patient #2 resulting in a broken nose and sore ribs. The following reasons shows deficient practice and keep the patient free from physical abuse.

2. Use of improper channels of communication (Epic Rover) by a Psychological Technician (Psy tech) #1, to report an urgent concern of Patient #1's stated intent to physically harm Patient #2. Patient #1 approached the Psy Tech #1, and shared he had intrusive thoughts of, "wanting to punch Patient #2." It is noted that the previous evening Patient #1 entered Patient #2's room unauthorized and against protocol, placed a cup in a paper bag filled with his feces.

3. Psy tech #2 failed to receive a report concerning her 1:1 (one staff to one patient) assignment with Patient #2 and failed to receive the urgent concern from Psy tech #1, with the communication of the intent to physically harm Patient #2 thus not receiving that message. As per policy, she is not to carry the Epic Rover device while in a 1:1 assignment. This was confirmed by Nursing Director #1. A 1:1 assignment provides constant direct visualization from a trained staff member who will be stationed within arm's length of their assignee.

4. Nursing Director #1 during interview stated in part ... "the [Epic] Rover (chat) is an informal communication tool. If there is a concern that a patient is being aggressive, you would not want to put that [communication] put in a chat. This should be communicated verbally. That is how Psy Tech #1 would have been trained." She continued saying that the staff in general is aware but continues to use this mode of communication.

5. On September 24, 2025 at 11:10AM the Nursing Director #1 confirmed that the staff failed to follow hospital protocal by using the Rover for communication for a 1:1 assignment.