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Based on interview, record review, policy review, and video review the facility failed to:
- Protect one patient (#57) of one patient on the Behavioral Health Unit (BHU) from physical assault that resulted in injury and loss of consciousness. (Refer to A-0145)
- Provide an immediate physical assessment of Patient #57 after he was physically assaulted. (Refer to A-0145)
- Follow internal policies and procedures (P/P) on abuse and neglect (A/N) and reporting of high risk incidents or events. (Refer to A-0145)
- Complete a thorough investigation per facility policy. (Refer to A-0145)
- Protect all patients on the BHU from the potential for further assaults by not increasing the level of supervision for one patient (#53) of one patient after he physically assaulted his roommate. (Refer to A-0144)

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Patient Rights. The BHU census was 97. The facility census was 361.

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

On 02/10/16, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect the patients.

As of 02/11/16, at the time of survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- A Central Intake Checklist was developed to ensure that intake assessors had all forms and information needed to determine appropriate inpatient placement. This checklist included specific questions related to any history of violent interactions, any history of violent criminal convictions, any history of interactions with police or legal entities, and/or any history of convictions related to sexually inappropriate behavior. Education was given in relation to the additional questions of all patients that required an inpatient admission to the BHU.
- A Central Intake handoff form was developed to ensure pertinent patient information was shared between Central Intake and the BHU nursing staff. The nurses would be able to validate the appropriateness of the admission to the particular bed, room, roommate and unit milieu (environment). Education began on this form to all Central Intake and BHU nursing staff with required completion prior to their next shift.
- Education began to all Central Intake staff regarding the utilization of the newly developed checklist. All staff were required to complete the education prior to their next shift.
- Education began to all of BHU staff regarding the FYI communication tool in the electronic medical record (EMR) to ensure communication of high alert behaviors, such as assault, sexual inappropriateness, suicide attempts and self-injurious behaviors. All staff were required to complete this education prior to their next shift.
- Education began to all BHU staff regarding the addition of the FYI column to all the BHU staff 's patient worklist to ensure staff had awareness of patients with FYI information in their record related to high alert behaviors. Staff members were to immediately add the FYI column to their patient work list. All staff were required to complete this education prior to their next shift.
- A Risk/Regulatory team huddle was conducted and all Risk/Regulatory staff were educated on the facility P/P for A/N reporting.
- Video footage of any significant patient event that occurred on the BHU was to be immediately reviewed by the hospital's BHU supervisor.
- Within 24 hours of a significant patient event a member of the facility's BHU leadership (Director or above) and/or the facility Risk/Regulatory or Patient Safety Coordinator were to review any available footage by either remote access or onsite. Findings based on this review was for the event to have been escalated consistent with P/P for reporting of high risk incidents or events.
- BHU staff and leadership were educated on the process for video review and escalation pursuant to policy. All staff were required to complete this education prior to the start of their next shift.
- BHU staff and leadership were educated on the facility P/P for reporting of high risk incidents or events with the additional component that required escalation up the management/leadership chain of command if there were concerns regarding the response, or lack thereof, to a patient safety event. All Staff were required to complete this prior to their next shift.
- A change in the process for who were responsible for the investigation following a patient safety event that involved a BHU patient if in the event the BHU Risk/Patient Safety Coordinator were absent. The Director and/or Executive Director for Regulatory and Risk would assign an experienced and competent Regulatory & Risk Coordinator to conduct the investigation. All investigation summaries that involved instances of alleged abuse would be reviewed by the Director and/or Executive Director for Regulatory & Risk for completeness and accuracy.

Based on interview, record review, and policy review the facility failed to follow their policy to ensure trained and competent interpreters were provided to non-English speaking patients for two patients (#21 and #58) of two patients reviewed for language barriers. This failure placed patients at risk for substandard care and could potentially prevent the patient or their representatives from being involved in their care. In addition, the facility failed to provide the Important Message from Medicare (IM, information about a patients rights to appeal discharge) letter to five patients (#22, #44, #54, #55, #56 of eight patient records reviewed on the 5th floor nursing units and the Behavioral Health Unit (BHU). This failure had the potential to affect all patients with Medicare coverage from being made aware of their discharge rights. The BHU census was 97. The total facility census was 361.
Findings included:

1. Record review of the facility policy titled, "Communicating with Patients with Limited Proficiency and/or Physical and Cognitive impairment," dated 11/01/12, showed:
- It is the policy of the facility to provide equal access to, and equal participation in, health care activities for persons with limited English proficiency (LEP). The hospital provides communication assistance at no cost to the patient for discussion of information necessary for healthcare or financial decisions. It is the facility's policy to use qualified interpreters.
- Qualified Interpreter or Interpreter is defined as a specially trained professional who has been assessed for professional skills, demonstrates a high level of proficiency in at least two languages and has the appropriate training and experience to interpret in the medical setting with skill and accuracy while adhering to the National Code of Ethics and Standards Practice published by the National Council on Interpreting in health care. Only those interpreters deemed to be qualified should be used to interpret at this facility.
- Limited English Proficiency (LEP) patients are those patients who cannot speak, read, write or understand the English Language at a level that permits them to interact effectively with health care providers.
- Interpreters shall be used in any situation where an LEP patient has been identified and where clear and effective communication is necessary.
- The use of unqualified hospital staff and/or patients' family members, friends, or visitors is not an acceptable means of providing interpreter or translation services.

2. Record review of the undated facility document titled, "Patients with Communication Barriers," showed two non-English speaking patients. Patient #21 was in a room on 4 South and Patient #58 was in a room on 3 South.

3. Record review of Patient #21's medical record showed documentation on the History and Physical (H&P) that the patient only spoke Spanish and this made it very difficult to communicate with the patient.

During an interview on 02/08/16 at 4:40 PM, Staff CC, Registered Nurse (RN), stated that she assessed Patient #21's pain by asking family.

During an interview on 02/08/16 at 4:45 PM, Patient #21's son (the patient was too lethargic to interview) stated that he had not seen the facility utilize interpreter services when he was at the facility, but the staff used gestures to communicate to Patient #21.

During an interview on 02/10/16 at 3:25 PM, Staff BBBBB, Physical Therapist (PT), stated that family members were used to interpret if the family was present at the facility.

During an interview on 02/10/16 at 11:00 AM, Staff BB, Team Leader (TL) of 4 South, stated that interpreter services were available by use of a special phone or a person could be notified and requested to come to the hospital to interpret. She expected staff to use an interpreter when discussing health care needs with the patient.

4. During observation and concurrent interview on 02/10/16 at 9:20 AM, Staff YYY, RN, entered the room of Patient #58 who was admitted on 02/10/16. Staff YYY gestured to the patient and explained that the patient did not speak English and was Lebanese but that he would "look right at him. He understands some things. I gesture like for him to raise his arms. He has a son that speaks English and he translates when he is here".

Record review of the Care Plan showed the patient was non-English speaking and appropriate communication tools such as interpreter, interpreter phones, pictures and/or videos should be used (for explaining the blood draws, tests and teaching related to bleeding precautions and incision care).

During an interview on 02/10/16 at 9:30 AM, Staff C, Clinical Director, stated that the blue phone (interpreter services) could be used and put on speaker, but had not, so that the patient, son and staff could hear.

During an interview on 02/10/16 at 1:40 PM, Staff A, Chief Nursing Officer (CNO), stated that she had no idea that there were problems with the interpreter services.

5. Record review of the facility policy titled, "Important Message from Medicare," (IM) revised 06/2015, showed direction that, within 24 hours of admission, the Patient Access Department staff will provide the "Important Message from Medicare" to all Medicare beneficiaries.

6. Record review of medical records on 02/10/16 showed there were no IM letters signed by the following Medicare patients or the patient's representative within 24 hours of admission for:
- Patient #22 admitted on 02/04/16 (5 South);
- Patient #44 admitted on 02/07/16 (BHU);
- Patient #54 admitted on 01/07/16 (5 North);
- Patient #55 admitted on 02/08/16 (5 South); and
- Patient #56 admitted on 02/06/16 (5 South).

During an interview on 02/10/16 at 3:05 PM, Staff TTT, Regulatory Coordinator/Risk Manager, confirmed that there were no signed IM letters in the records for Patients #22,#44, #54, #55 and
#56. She stated that she checked other areas where the letters may have been put prior to being filed in the chart, but none were found.

During an interview on 02/10/16 at 3:25 PM, Staff NNN, Patient Access Supervisor (Registration), stated that the admission (initial) IM letter process was her department's responsibility for all hospital inpatient admissions. She stated that her staff obtained the required signatures at the time of admission or go to the floors/Emergency Department for the signature if the patient did not come through the admission department. Staff NNN stated there were some areas where the signature process "falls through the cracks and we need to fix that."


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Based on interview, record review, policy review, and Digital Video Disc (DVD) recording the facility failed to protect one discharged patient (#57) from physical assault by his roommate (#53) that resulted in injury and loss of consciousness. The facility also failed to protect patients by not increasing Patient #53's level of supervision/observation after the physical assault of one patient (#57.)
These failures to protect patients from harm created an unsafe environment and had the potential to affect all patients on the Behavioral Health Units (BHU). The BHU census was 97. The facility census was 361.

Findings included:

1. Record review of the facility's policy titled, "Assessment, Investigation, and Reporting of Suspected Abuse/Neglect," dated 05/02/14 showed:
- Abuse of an adult (elder or disabled) was defined as the infliction of physical, sexual, or emotional injury or harm including financial exploitation by any person, firm, or corporation.
- Eligible adult was defined as any adult, aged 60 or older or 18-59 with a disability, which was defined as a mental or physical impairment that substantially limits one or more major life activities, whether the impairment was congenital or acquired by accident, injury or disease, where such impairment was verified by medical findings.
- Vulnerable person was defined as the failure to provide services to an eligible adult by any person, firm, or corporation with a legal or contractual duty to do so, when such failure presents either an imminent danger to the health, safety, or welfare of the client or a substantial probability that death or serious harm would result.

Record review of the facility's policy titled, "Safety Intervention Planning and Patient Safety Assistants," dated 01/2013, showed:
- All patients who were a safety risk were assessed to determine the patient's safety intervention plan.
- Appropriate interventions (including observation) were implemented to promote patient safety.
- Patient safety was optimized and supported by their environment.

Record review of the facility's policy titled, "Precaution and Observation Levels," dated 09/2011, showed:
- Patients were assessed for and assigned a precaution/observation level to assure the safety of all patients and staff.
- Patients that presented an imminent danger of harm to themselves or others were placed on an increased level of observation/precaution.
- A Registered Nurse (RN) initiated additional levels of observation based upon nursing judgment and then obtained a physician order.
- The level of observation was a minimum of 15 minute observation checks for all patients,
- Line of Sight (LOS) observation was assigned for patients with high risk behaviors of self injury or danger to others and staff were directed to be within patient view at all times.
- Within Arm's Length Reach Observation was assigned for patients who were at imminent risk for self injury, or high risk of danger to others such as, overt gestures, statements or actions that were potentially harmful to themselves or others. Staff were directed to be within arm's length reach of the patient at all times including bathroom, shower, and sleeping.

Record review of the facility's BHU policy titled, "Sexual Acting Out Behaviors, Management of," dated 12/2010, showed that:
- The RN placed a patient on the appropriate level of sexual precaution.
- Sexual Abuse Management 1 (SAM 1) precautions were required for minor behaviors such as, exposing self, flashing, kissing, and inappropriate sexual comments.
- Sexual Abuse Management 2 (SAM 2) precautions were required for major sexual acting out behaviors such as, perpetrator of sexual assault, current sexual acting out, inappropriate touching and public display of masturbation.
- A patient with SAM 2 precautions should not be in room at the same time as roommate, including bedtime. Patients may be assigned LOS observation if identified as an immediate threat.

Record review of the facility's policy titled, "Assault Precautions-Patient management of," dated 06/2011, showed that patient safety was maintained through the identification of patients who exhibit behaviors that may be threatening or potentially dangerous and interventions were implemented to promote unit safety.

2. Record review of discharged Patient #53's Central Intake Pre-Admission Behavior Note dated 12/19/15 at 1:30 PM, documented that the patient had a diagnosis of Schizophrenia (a chronic disorder characterized by psychotic symptoms; such as, false ideas about what is taking place or who one is) and was a Registered Sex Offender for attempted sodomy and first degree sexual assault.

Record review of Patient #53 High Risk Alert section (a section of the medical record that carries over high risk alerts from admission to admission) showed that on 03/11/14 Patient #53 was placed on a high risk alert for SAM 2 and was a registered sex offender. On 04/11/14 a note was entered that he was downgraded to a SAM 1 per the Team Leader (assessment).

Record review of the Patient #53's Nursing Assessment dated 12/19/15 showed the patient was admitted to the BHU with a high risk for impulsivity with agitation.

Record review of Patient #53 Physician orders from 12/19/15 to 12/21/15, showed an order for Suicide precautions on 12/19/15 and SAM 1 precautions on 12/21/15.

There was no nursing assessment documentation to show that the patient was a registered sexual offender and showed sexually inappropriate behaviors prior to admission. The RN failed to identify the patient at risk for SAM 2 and contact the physician for orders, per policy.

Record review of Patient #53's nurses notes dated 12/29/15 at approximately 6:30 PM, showed documentation that he was observed straddled over the body of his roommate (Patient #57) and punching him in the head.

Record review of Patient #53's Daily Observation Flowsheets showed that he was located in his Patient Room (PR) at 5:48 PM, 6:03 PM, and 6:15 PM; in the Quiet Room (QR) at 6:30 PM and 6:50 PM; and in the Hall (HL) at 7:00 PM. On 12/30/15 at 1:45 AM, A/V (assault/violence) precautions were added to the precautions column of the form.

Orders for assault precautions were obtained but the RN failed to identify the patient's risk potential and obtain physician orders for an increased level of observation such as, Line of Sight Observation or Within Arm's Length Reach Observation, per policy to prevent an assault to other patients.

3. Review of the facility's DVD recording titled with facility name, dated 12/29/15, showed:
- At 6:26:00 the patient's bathroom door opened and Patient #53 placed his hands on Patient #57's right arm and pulled him up to a standing position.
- Patient #57 walked out of his room and into the day room pulling up his jeans with Patient
#53 right behind him.
- At 6:26:03 PM Patient #53 pushed Patient #57 out of the doorway and onto the floor.
- Patient #53 knelt beside the patient and hit him four times with a closed fist striking him in the head.
- Staff VVVV, Psychiatric Technician, (Psych Tech), walked towards both patients with his hands up (as if he was signaling to Patient #53 that he was just approaching the situation.)
- Patient #53 hit Patient #57 one more time before he stopped and stood up.
- Staff VVVV knelt down at the head of Patient #57.
- Staff TTTT, RN, Clinical Support Nurse, (CSN), walked towards Patient #57 and stopped approximately five feet away.
- Patient #53 walked into his room and Staff TTTT remained in the same location with her hands in her pockets.
- Patient #53 closed the door to his room.
- Patient #53 opened his door and remained inside his room, and no staff were viewed going into the patients room with him.
- Staff TTTT, RN, CSN moved closer to the patient and stopped approximately two feet from him and got out her phone and made a call.
- Staff SSSS, Psych Tech, walked towards the Patient #57 and stood at the patients doorway.
- Staff TTTT, RN, CSN walked towards the head of Patient #57, looked down at him and then walked away.
- Staff SSSS, Psych Tech closed the door to the patients room with Patient #53 inside.
- Staff UUUU, Licensed Practical Nurse, (LPN), walked towards Patient #57 and also stood approximately five feet from the patient.
- At 6:26:51 PM Staff SSSS, Psych Tech, opened the door to the patient's room and Patient #53 walked out. He walked in between Staff UUUU, LPN and Patient #57 and walked towards the nurses' station out of view of the camera.
The physical assault began at 6:26:03 PM. Patient #53 did not leave the area until approximately 48 seconds after the assault and was not visible on camera after that.

During an interview on 02/11/16 at 10:35 AM, Staff TTTT, RN, CSN, stated that:
- She felt the other patients were protected from Patient #53 because he was in the quiet room following the assault.
- Patient #57 had been moved to another unit upon his return from the Emergency Department (ED) so he was safe from Patient #53.
- It was at the end of her shift and if it had been earlier in the day she may have called for a line of sight order for Patient #53 but he wasn't going to have a roommate so she felt that he had sufficient supervision.

After the assault, Staff TTTT took no action to protect other patients and keep them safe
from assault by increasing the level of supervision for Patient #53.

During an interview on 02/10/16 at 1:50 PM, Staff N, Adult BHU Team Leader, stated that were no specific guidelines for roommate assignments; they were made based upon a nursing assessment of current behavior, not past history.

Staff N took no action to protect Patient #57 (age 62, a vulnerable person per policy) from abuse by Patient #53 who had a known risk for sexual offense. After the assault, she took no action to protect other patients from assault by increasing the level of supervision for Patient #53.

During an interview on 02/10/16 at 1:40 PM, Staff A, Chief Nursing Officer (CNO), stated that she was not made aware of the abuse event at the time and had not seen the video before this week. She stated that the Abuse Policy and Procedure was not followed and should have been immediately reported.





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Based on interview, record review, policy review, and Digital Video Disc (DVD) recording review, the facility failed to:
- Prevent assault of one discharged patient (#57) of one eligible adult psychiatric patient on the Behavioral Health Unit (BHU) when the patient was physically assaulted and injured by his roommate.
- Provide an immediate physical assessment of Patient #57 after he was physically assaulted.
- Follow their internal policy to report the abuse to the appropriate State agency.
- Complete a thorough investigation per facility policy.
These failures had the potential to place all patients admitted to the facility at risk for their safety from assault. The BHU census was 97. The facility census was 361.

Findings included:

1. Record review of the facility's policy titled, "Assessment, Investigation, and Reporting of Suspected Abuse/Neglect," dated 05/02/14 showed:
- Abuse of an adult (elder or disabled) was defined as the infliction of physical, sexual, or emotional injury or harm.
- Eligible adult was defined as any adult, aged 60 or older or 18-59 with a disability, defined as a mental or physical impairment that substantially limits one or more major life activities, whether the impairment was congenital or acquired by accident, injury or disease, where such impairment was verified by medical findings.
- Vulnerable person was defined as the failure to provide services to an eligible adult by any person, firm, or corporation with a legal or contractual duty to do so, when such failure presents either an imminent danger to the health, safety, or welfare of the client or a substantial probability that death or serious harm would result.
-Staff members were to assess, investigate, and report abuse and neglect to the appropriate State agencies.

Record review of the facility's policy titled, "Precaution and Observation Levels," dated 09/2011, showed:
- Patients were assessed for and assigned a precaution/observation level to assure the safety of all patients and staff.
- Patients that presented an imminent danger of harm to themselves or others were placed on an increased level of observation/precaution.
- A Registered Nurse (RN) initiated additional levels of observation based upon nursing judgment and then obtained a physician order.
- The level of observation was a minimum of 15 minute observation checks for all patients,
- Line of Sight (LOS) observation was assigned for patients with high risk behaviors of self injury or danger to others and staff were directed to be within patient view at all times.
- Within Arm's Length Reach Observation was assigned for patients who were at imminent risk for self injury, or high risk of danger to others such as, overt gestures, statements or actions that were potentially harmful to themselves or others. Staff were directed to be within arm's length reach of the patient at all times including bathroom, shower, and sleeping.

Record review of the facility's BHU policy titled, "Sexual Acting Out Behaviors, Management of," dated 12/2010, showed that:
- The RN placed a patient on the appropriate level of sexual precaution.
- Sexual Abuse Management 1 (SAM 1) precautions were required for minor behaviors such as, exposing self, flashing, kissing, and inappropriate sexual comments.
- Sexual Abuse Management 2 (SAM 2) precautions were required for major sexual acting out behaviors such as, perpetrator of sexual assault, current sexual acting out, inappropriate touching and public display of masturbation.
- A patient with SAM 2 precautions should not be in the room at the same time as the roommate, including bedtime. Patients may be assigned LOS observation if identified as an immediate threat.

Record review of the facility's policy titled, "Assault Precautions-Patient management of," dated 06/2011, showed that patient safety was maintained through the identification of patients who exhibit behaviors that may be threatening or potentially dangerous and interventions were implemented to promote unit safety.

2. Record review of discharged Patient #57's History and Physical showed he was an elderly male who was admitted to the facility on 12/20/15 with a history of depression, Parkinson's disease (progressive disorder of the nervous system that affects movement) and new onset of anxiety with hallucinations (an image, sound or smell that seems real but does not exist). Review of nursing documentation on the Daily Observation Flowsheet showed he was on Assault/Violence precautions.

3. Record review of discharged Patient #53's Central Intake Pre-Admission Behavior Note dated 12/19/15 at 1:30 PM, documented that the patient had a diagnosis of Schizophrenia (a chronic disorder characterized by psychotic symptoms; such as false ideas about what is taking place or who one is) and was a Registered Sex Offender for attempted sodomy and first degree sexual assault. Review of nursing documentation on the Daily Observation Flowsheets and Physician Orders from 12/30/15 to 01/06/16 (discharge) showed he was on SAM 1 and Assault/Violence precautions without an increased level of observation such as LOS or Within Arms Reach Length Observation.

4. Review of the facility's DVD recording titled with facility name, dated 12/29/15, showed:
- At 6:25:48 PM Patient #53 stepped out of his room and looked at Staff ZZZZ, Housekeeper, who was approximately 15 feet from the patient's room. He went back into his room.
- The door to the patients room was open and the bathroom door was visualized as being closed.
- The bathroom door opened and Patient #53 placed his hands on Patient #57's right arm and pulled him up to a standing position.
- Patient #57 walked out into the day room pulling up his jeans with Patient #53 right behind him.
- At 6:26:03 PM Patient #53 pushed Patient #57 onto the floor.
- Patient #53 knelt beside the patient and hit him four times with a closed fist striking him in the head.
- Staff VVVV, Psychiatric Technician, (Psych Tech), walked towards both patients.
- Patient #53 hit Patient #57 one more time before he stopped and stood up.
- Staff VVVV knelt down at the head of Patient #57.
- At 6:26:14 PM Staff TTTT, RN, Clinical Support Nurse, (CSN), walked towards Patient #57 and stopped approximately five feet away.
- Patient #53 walked into his room and Staff TTTT remained in the same location with her hands in her pockets.
- Patient #53 closed the door to his room.
- Patient #53 opened the door but remained inside his room with no staff members with him.
- Staff TTTT, RN, CSN moved closer to Patient #57 and stopped approximately two feet from him and got out her phone and made a call.
- Staff SSSS, Psych Tech, walked towards the Patient #57 and stood at the patients doorway.
- Staff TTTT, RN, CSN walked towards the head of Patient #57, looked down at him and then walked away.
- Staff SSSS, Psych Tech closed the door to the patients room with Patient #53 inside by himself.
- Staff UUUU, Licensed Practical Nurse, (LPN), walked towards Patient #57 and also stood approximately five feet from the patient.
- Staff SSSS, Psych Tech opened the door to the patient's room and Patient #53 walked out. He walked in between Staff UUUU, LPN and Patient #57 and walked towards the nurses' station out of view of the camera.
- Staff UUUU, LPN walked away from camera view.
- At 6:27:16 Patient #57 moved his right hand (this was the first movement seen by the patient since 6:26:05 PM) and Staff JJ, RN, walked towards the patient with the vitals machine (equipment used to take blood pressures and measure oxygen level) and assisted Staff SSSS, Psych Tech in placement of the blood pressure cuff to Patient #57's arm.
- Staff JJ returned to the vitals machine and started the blood pressure machine.
- Staff RRRR, RN, BHU House Supervisor arrived with the crash cart and stood over Patient #57 and looked down at him.
- At 6:28:08 PM the Rapid Response Team (a team of healthcare providers that respond to hospitalized patients with early signs of clinical deterioration to provide rapid response measures to avoid further deterioration) arrived.
- Staff WWWW, Physician, Hospitalist, arrived and replaced Staff VVVV, Psych Tech at the head of the Patient #57, she assessed and evaluated him.
The patient appeared unconscious for approximately one minute, 10 seconds.

5. Record review of ED nursing documentation in Patient #57's medical record dated 12/29/15 at 7:31 PM showed the patient arrived with a cervical (neck) collar in place and a bandage over his right ear.

Record review of the Discharge Summary showed Patient #57 was discharged from the BHU on 12/30/15 and admitted to a medical unit for continued care. He was discharged from the facility on 02/06/16 to an assisted living center.

6. During an interview on 02/11/16 at 4:10 PM Staff VVVV, Psych Tech, stated that:
- At approximately 6:30 PM on 12/29/15 he was talking to a patient with his back to Patient #57's room.
- He heard the housekeeper yell that there were patients fighting and when he turned around he saw Patient #53 with his arm pulled back with closed fist and that he saw him punch Patient #57 two times.
- He yelled at Patient #53 to back off right now, stop hitting and move away.
- When he got to Patient #57 he was lying on the floor unresponsive.
- He assessed the patients pulses (heartbeat) but did not assess his breathing.
- The patients' eyes were closed and they didn't open when he talked to him.
- There was blood on the patients' ear.
- Patient #53 went into his room and later came out and walked to a table in the day area and sat down.
- He was unsure of the amount of time Patient #53 was seated at the table.
- No staff members were at the table with Patient #53 and that the table was approximately 20 feet from where Patient #57 was lying on the floor.
The fact that Patient #53 remained in the day room unattended placed all patients at risk for the potential for assault.

During an interview on 02/11/16 at 10:35 AM, Staff TTTT, RN, CSN stated that:
- She was talking with a male Psych Tech in the day room when she heard the housekeeper yell not to do that and that someone needed to help.
- She and Staff VVVV, Psych Tech immediately went to the situation with Patient #53 and #57.
- Patient #53 was straddling Patient #57 and punching him in the head.
- Patient #57 was unconscious because he wasn't moving so she called the Rapid Response team and also called a code "Crew 13," which indicated an escalating patient situation.
- She didn't think to assess Patient #57 because she was most concerned that Patient #53 stay inside his room and with calling the Rapid Response Team.
- She felt Patient #57 was being taken care of because there were other nurses at his side and that Staff WWWW, Physician, Hospitalist (physicians whose primary professional focus is the general medical care of hospitalized patients) was on the unit and had asked her what had happened so she knew that the Hospitalist was going to assess him.
- She felt the other patients were protected from Patient #53 because he was in the quiet room.
- Patient #57 had been moved to another unit upon his return from the Emergency Department (ED) so he was safe from Patient #53 and she felt that other patients were safe because Patient #53 was not going to have a roommate.
- It was at the end of her shift and if it had been earlier in the day she may have called for a line of sight order for Patient #53 but he wasn't going to have a roommate so she felt that he had sufficient supervision.
Staff TTTT was the first licensed nurse that responded to Patient #57 but she did not complete an assessment to determine his level of consciousness or his injuries. She also failed to recognize the potential for further assault to patients on the BHU by Patient #53.

During an interview on 02/11/16 at 9:40 AM, Staff RRRR, RN, House Supervisor, (HS) stated that:
- She heard the overhead speaker announce the "Crew 13 code 1000 hall" that indicated an escalating patient situation on BHU and prompted staff to respond to the unit to provide assistance.
- When she arrived to the unit Patient #57 was on the floor with staff around him.
- She took the crash cart (a cart on wheels that has emergency medical equipment and medication) to the patient.
- After Patient #57 was taken to the Emergency Department (ED) she called and reported the incident to Staff FFF, RN, Team Leader (TL) on call, Staff GGG, Administrator on call and Staff N, RN, Team Leader for Adult BHU.
- She didn't usually call the Risk Manager on call unless directed to do so by the Administrator on call.

During an interview on 02/09/16 at 3:05 PM, Staff FFF, RN, TL for BHU Children's unit, stated that:
- She was the TL on call the night of the event.
- She received a call from the HS with a report that an elderly adult was assaulted by another patient and that he was unconscious.
- She directed the HS to call her back with the patients' condition after he had been evaluated by the ED.
- She directed the HS that if patient was cleared to come back to the BHU he was to go to another unit away from the patient who assaulted him.
- She directed the HS to call the administrator on call.

During an interview on 02/09/16 at 3:20 PM, Staff GGG, Director of Youth Services stated that:
- She was the administrator on call the night of the event.
- She received a call from the HS with a report that a patient had hit another patient;
- The hit caused the patient to fall to the floor and the Rapid Response Team was called.
- She asked the HS to call her back after the patient had been evaluated by the ED.
- She contacted Staff EEE, Network Vice President (VP) of Behavioral Health and reported the incident to her.

During an interview on 02/10/16 at 1:50 PM, Staff N, RN, TL stated that:
- She received a call from the HS that Patient #57 had been hurt by Patient #53.
- She directed the HS to place Patient #57 onto a different unit when he returned from the ED.
- She remote accessed the video recording through her laptop computer but was unable to see exactly what had occurred.
- The recording kept skipping and she wasn't able to see how many times Patient #57 had been punched.
- She contacted Staff SSS, Social Worker and Staff J, Director of the BHU and informed them what had occurred and from what she could see on the video that the patient had been punched at least twice, that it was very violent and she cried when she had watched it.
- She was able to view the video more clearly the following day but still unable to determine how many times Patient #57 was punched.
- She contacted the Information Technology, (IT), department the following week and requested a copy of the DVD.
- She viewed the DVD recording and was able to see the incident clearly.
- Patient #53 had taken Patient #57 out of the bathroom and pushed him to the floor then punched him five times.
- After she viewed the DVD she again informed Staff J Director of BHU that she had been able to view it more clearly and that it was more violent than what she had first thought and that she (Staff J) needed to view it but she didn't think Staff J watched the video.
- She completed a Root Cause Analysis (RCA a method of problem solving used to identify the root cause or reason of faults or problems) of the event.
- She informed Staff M, RN, VP of Nursing of the event when she (Staff M) returned from vacation on 01/05/16.
- Staff N stated that Patient #53 should have been made a higher level of precautions following the incident.
Staff N, TL was not able to clearly view the video recording on the night of the event nor the day after. Staff N waited one full week before she requested IT to make a copy of the recording. At that time, Staff N was able view the recording clearly and recognized the severity of the event. Staff N was the only staff member to have viewed the recording until the Administrative staff and Quality/Risk viewed the DVD after surveyor entrance on 02/08/16.

During an interview on 02/10/16 at 3:20 PM, Staff J, Director of BHU stated that:
- She received a call from Staff N, TL the night of the incident but was unsure if Staff N had viewed any video recording prior to the call.
- She informed Staff N that she would view the video recording the following day but she did not.
- She was able to have viewed the video from her home the night it occurred but she did not.
- She stated that if Staff N had thought the event was serious then Staff N would have taken her "by the hand and sat her down" and told her that she really needed to view the DVD recording and then she would have.
- She viewed the DVD recording for the first time on 02/09/16.
Staff J, Director of the BHU viewed the DVD recording of the event on 02/09/16, 42 days following the date of the event on 12/29/15 and the date when she was first made aware that it had occurred.

During an interview on 02/08/16 at 4:15 PM, Staff DDD, Executive Director of Regulation and Risk, stated that the patient to patient altercation was not reported to the State Agency due to other responsibilities of the Risk Manager.
The facility failed to follow their Assessment, Investigation and Reporting policy and report to the State Agency.

During an interview on 02/09/16 at 1:35 PM, with Staff EEE, Network VP of Behavioral Health; Staff DDD, Executive Director of Regulation and Risk; Staff M, RN, Network VP of Nursing and Staff K, RN, Patient Safety Quality and Risk; Staff EEE stated that the order of escalation with the event was followed correctly. She stated that the CSN reported to the HS whom reported to the Nursing TL on call and the administrator on call. Staff EEE stated that the failure was that the usual risk manager (Staff K) was on vacation and the Risk Department was not made aware of the seriousness of the event and when Staff K returned from vacation she was busy with other responsibilities.
Staff EEE, Staff DDD, Staff M and Staff K all stated that they had not viewed the DVD recording until this week after the surveyors entrance; over 40 days after the event occurred on 12/29/15.

During an interview on 02/11/16 at 9:35 AM, Staff K, Patient Safety, Quality and Risk stated that she was on vacation at the time of the assault and that the Risk Manager that was on call was not notified of the event on the night it occurred. She was unsure why staff had not notified the Risk Manager on call but they should have been.

7. Record review of the facility's policy titled, "Sentinel and Serious Event," dated 07/30/14, showed that:
- A sentinel event (SE) was a patient safety event that resulted in severe temporary harm.
- A serious safety event, (SSE) was defined as an event where a breach or deviation from the standard of care (preventable) resulted in moderate to severe harm or death.
- The Patient Safety/Risk designee was to initiate investigation of a potential SE immediately after notification.
- The patient safety preliminary investigation was to be completed within seven working days and entered into Riskmaster, the facility networks information system.
- When an event was witnessed, staff were to complete an online report with notification and follow-up email sent to Patient Safety/Risk designee per the facility Algorithm (a process or set of rules to be followed for problem solving operations.).
The facility's on call designee for Patient Safety/Risk was not immediately notified of this SE/SSE on the night it occurred as staff did not follow their procedure as indicated on the Sentinel and Serious Event Algorithm.

8. Record review of the facility document titled, "Miscellaneous Root Cause Analysis," dated 01/11/16, completed by Staff N, TL showed:
- Patient #57 was hit in the head multiple times by his roommate on 12/29/15.
- The roommate had chronic paranoid schizophrenia (a chronic disorder characterized by mistaken beliefs that a person or some individuals were plotting against them or their loved ones) and thought that Patient #57 was making sexual advances towards him.
- Patient #57 was seen walking out of his room and then was pushed to the floor by his roommate.
- Patient #57 was hit several times in the head by the roommate before staff could intervene.
- Rapid Response was called because Patient #57 was unresponsive for a short time, approximately 90 seconds.
- Staff was immediately present to stop the peer from hurting Patient #57 any further.
- The roommate stopped hitting Patient #57 as soon as the staff asked him to stop.
- The roommate left and went to the quiet room.
The RCA conflicts with the DVD recording review and the interview with Staff VVVV, Psych Tech. The DVD recording showed the roommate re-entered his room by himself then he walked out into the day room and out of the camera view. Staff VVVV, Psych Tech stated that the roommate sat down at a table in the day room. Staff N failed to include in the RCA that the DVD showed the staff's lack of immediate assessment of Patient #57 and his injuries and the lack of immediate protection of all patients on the unit from Patient #53.

9. Record review of the undated facility document titled, "Patient Safety Work Product Sentinel Event RCA Form," dated 01/25/16, completed by Staff AAAAA, RN, Patient Safety and Quality Coordinator showed:
- Date of event was 12/29/15;
- Submitted to Patient Safety Quality Committee on 02/04/16;
- Brief summary of event that Patient #57 was hit in the hallway by his roommate Patient #53.
- Patient #57 was sent to the ED for evaluation and suffered an ear laceration that required stitches, a knee laceration and facial pain.
- Prior to discharge (from the BHU) on 12/30/15 he complained of dizziness and was evaluated in the ED. He was admitted to the medical floor with a low sodium level.
Staff AAAAA failed to include in the RCA staff's failure to immediately
assess Patient #57 and his injuries and the staff's failure to immediately protect all patients on the unit from Patient #53.

During an interview on 02/11/16 at 8:55 AM, Staff AAAAA, RN, Patient Safety and Quality Coordinator stated that:
- On 01/25/16 she was asked by Staff DDD, Executive Director of Regulatory and Risk to complete an RCA of the incident that had occurred on 12/29/15 on the BHU.
- The RCA was completed by medical record review and she did not view any video recording of the incident.
- She concluded that the care provided to the patient that was injured appeared to be appropriate per medical record review.

10. Record review of two progress notes in Patient #57's medical record, dated 12/29/15 at 6:30 PM and 6:50 PM by Staff TTTT, RN, CSN showed that:
- She and Staff VVVV, Psych Tech had witnessed a patient on the floor outside of his assigned room being straddled by his roommate and punched in the head.
- Patient was unresponsive.
- Rapid Response was called by the Nursing Supervisor.
- The patient was taken on a stretcher with head and neck immobilized to the ED by the Rapid Response Team. The patient was talking and following commands.
These were the only two entries into Patient #57's medical record of the event from the unit staff that witnessed the assault.

The DVD recording showed evidence that staff failed to immediately assess Patient #57 and his injuries and failed to provide protection of all patients from Patient #53. By only reviewing the medical record and not viewing the DVD the facility failed to do a thorough investigation of the event.

During an interview on 02/10/16 at 10:20 AM, Staff K, Patient Safety Quality and Risk stated that the Risk Department learned of the event by a daily report but the event was not triggered as something to "look" at. Staff K stated that the TL (Staff N) did not convey the severity of the event. Staff K stated that she had just viewed the DVD recording for the first time on 02/08/16.

During an interview on 02/11/16 at 9:20 AM, Staff DD, Risk Coordinator stated that a day or two following the event, she saw a report regarding it on the daily report log but did not look into it any further. She stated that she had not viewed the DVD recording.














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Based on interview, record review, policy review, and review of the facility's Digital Video Disc (DVD) recording, the facility failed to:
- Ensure an adequate nursing physical assessment was performed for one (#57) of one discharged patient after he was physically assaulted by his roommate that resulted in injury and loss of consciousness while a patient on the Behavioral Health Unit (BHU, a unit for care of patients with mental health issues). (Refer to A-0395)
- Ensure adequate evaluation and supervision of nursing care needs when making bed assignments for one (#53) of one discharged patient who physically abused his roommate. (Refer to A-0395)
- Ensure adequate evaluation and increased level of supervision for one (#53) of one discharged patient after he physically assaulted his roommate to prevent further assaults. (Refer to A-0395)
- Ensure four (#9, #43, #44, and #45) of four current patients received an evaluation of safety needs while making room assignments to prevent patient to patient assaults. (Refer to A-0395)
These failures resulted in actual harm and placed all patients within the BHU at risk for their safety. The BHU census was 97. The facility census was 361.

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

On 02/10/16, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect patients within the entire facility.

As of 02/11/16, at the time of survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- A Central Intake Checklist was developed to ensure that intake assessors had all forms and information needed to determine appropriate inpatient placement. This checklist included specific questions related to any history of violent interactions, any history of violent criminal convictions, any history of interactions with police or legal entities, and/or any history of convictions related to sexually inappropriate behavior. Education was given in relation to the additional questions of all patients that required an inpatient admission to the BHU.
- A Central Intake handoff form was developed to ensure pertinent patient information was shared between Central Intake and the BHU nursing staff. The nurses would be able to validate the appropriateness of the admission to the particular bed, room, roommate and unit milieu (environment). Education began on this form to all Central Intake and BHU nursing staff with required completion prior to their next shift.
- Education began to all Central Intake staff regarding the utilization of the newly developed checklist. All staff were required to complete the education prior to their next shift.
- Education began to all of BHU staff regarding the FYI communication tool in the electronic medical record (EMR) to ensure communication of high alert behaviors, such as assault, sexual inappropriateness, suicide attempts and self-injurious behaviors. All staff were required to complete this education prior to their next shift.
- Education began to all BHU staff regarding the addition of the FYI column to all the BHU staff 's patient worklist to ensure staff had awareness of patients with FYI information in their record related to high alert behaviors. Staff members were to immediately add the FYI column to their patient work list. All staff were required to complete this education prior to their next shift.
- A Risk/Regulatory team huddle was conducted and all Risk/Regulatory staff were educated on the facility P/P for A/N reporting.
- Video footage of any significant patient event that occurred on the BHU was to be immediately reviewed by the hospital's BHU supervisor.
- Within 24 hours of a significant patient event a member of the facility's BHU leadership (Director or above) and/or the facility Risk/Regulatory or Patient Safety Coordinator were to review any available footage by either remote access or onsite. Findings based on this review was for the event to have been escalated consistent with P/P for reporting of high risk incidents or events.
- BHU staff and leadership were educated on the process for video review and escalation pursuant to policy. All staff were required to complete this education prior to the start of their next shift.
- BHU staff and leadership were educated on the facility P/P for reporting of high risk incidents or events with the additional component that required escalation up the management/leadership chain of command if there were concerns regarding the response, or lack thereof, to a patient safety event. All Staff were required to complete this prior to their next shift.
- A change in the process for who were responsible for the investigation following a patient safety event that involved a BHU patient if in the event the BHU Risk/Patient Safety Coordinator were absent. The Director and/or Executive Director for Regulatory and Risk would assign an experienced and competent Regulatory & Risk Coordinator to conduct the investigation. All investigation summaries that involved instances of alleged abuse would be reviewed by the Director and/or Executive Director for Regulatory & Risk for completeness and accuracy.

Based on interview, record review, policy review, and review of the facility's Digital Video Disc (DVD) recording the facility failed to:
- Ensure adequate nursing physical assessment for discharged Patient #57 following a physical assault which resulted in a loss of consciousness and injury.
- Ensure adequate evaluation and increase the level of observation/supervision for Patient
#53 after he assaulted his roommate to prevent further assault.
- Ensure adequate evaluation and supervision of nursing care needs when making bed assignments for one discharged patient (#53) of one discharged patient who assaulted his roommate.
- Ensure four patients (#9, #43, #44, and #45) of four current patients received an evaluation of safety needs while making room assignments to prevent patient to patient assault.
The lack of adequate evaluation and supervision of patient safety needs had the potential to affect all patients on the Behavioral Health Units (BHU). The BHU census was 97. The facility census was 361.

Findings included:

1. Record review of the facility's policy titled, "Assessment of Patient Timelines and Documentation," dated 12/2015, showed that:
- Assessment of patients was the responsibility of the Registered Nurse (RN).
- Nurses were required to document focused assessments based on active problem areas noted in prior nursing reports or documented problems that needed to be addressed.
- In BHU the assessment of patients included a precautions determination.
- Reassessment was based on the patient's diagnosis, the care setting, a change in condition, previous abnormal findings, and response to previous care.

Record review of the facility's policy titled, "Safety Intervention Planning and Patient Safety Assistants," dated 01/2013, showed:
- All patients who were a safety risk were assessed to determine the patient's safety intervention plan.
- Appropriate interventions (including observation) were implemented to promote patient safety.
- Patient safety was optimized and supported by their environment.

Record review of the facility's policy titled, "Precaution and Observation Levels," dated 09/2011, showed the following:
- Patients were assessed for and assigned a precaution/observation level to assure the safety of all patients and staff.
- Patients that presented an imminent danger of harm to themselves or others were placed on an increased level of observation/precaution.
- The levels of observation were ordered by the attending psychiatrist. A RN initiated additional levels of observation based upon nursing judgment and then obtained a physician order.
- Patients who were on Line of Sight (LOS) observation (patient is within direct eyesight of staff at all times) were at high risk for self injury or danger to others and included behaviors such as; ambivalence concerning commitment to safety, poor impulse control, and minimal insight into existing problems.
- Within Arm's Length Reach Observation was assigned for patients who were at imminent risk for self injury, or high risk of danger to others such as, overt gestures, statements or actions that were potentially harmful to themselves or others. Staff were directed to be within arm's length reach of the patient at all times including bathroom, shower, and sleeping.

Record review of the facility's policy titled, "Assault Precautions-Patient management of," dated 06/2011, showed that patient safety was maintained through the identification of patients who exhibit behaviors that may be threatening or potentially dangerous and interventions were implemented to promote unit safety.

Record review of the facility's BHU policy titled, "Sexual Acting Out Behaviors, Management of," dated 12/2010, showed the following:
- All patients admitted to the psychiatric units with identified sexual acting out behaviors were placed on appropriate sexual precautions.
- The RN placed a patient on the appropriate level of sexual precaution.
- Sexual Abuse Management 1 (SAM 1) precautions were required for minor behaviors such as, exposing self, flashing, kissing, and inappropriate sexual comments.
- Sexual Abuse Management 2 (SAM 2) precautions were required for major sexual acting out behaviors such as, perpetrator of sexual assault, current sexual acting out, (sexually) inappropriate touching and public display of masturbation.
- A patient with SAM 2 precautions should not be in room at the same time as roommate, including bedtime. Patients may be assigned LOS observation if identified as an immediate threat.

2. Record review of discharged Patient #53's Emergency Department (ED) Nurses Note dated 12/19/15 at 12:36 PM, showed the following:
- The patient's fiancé called the ED to report recent behaviors of the patient that led to eviction from her home.
- The patient had been increasingly confused, sexually inappropriate, and experiencing insomnia.
- He was going into her teenage daughter's room at night and openly masturbating.

Record review of Patient #53's Central Intake Pre-Admission Behavior Note dated 12/19/15 at 1:30 PM, showed the following:
- The patient had a diagnosis of Schizophrenia (a chronic disorder characterized by psychotic symptoms; such as, false ideas about what is taking place or who one is).
- He had a history of being a Registered Sex Offender for attempted sodomy and first degree sexual assault.
- He appeared to be hearing voices and laughing inappropriately at times.

Record review of Patient #53's High Risk Alert (a section of the medical record that identified high risk alerts and carried the information over from admission to admission) showed that on 03/11/14 Patient #53 was placed on a high risk alert for SAM 2 and was a registered sex offender. On 04/11/14 a note was entered that he was changed to a SAM 1 per Team Leader (assessment).

Record review of Patient #53's Psychiatric Evaluation dated 12/19/15, showed the patient was delusional, suspicious, paranoid, had poor attention span, poor concentration, was uncooperative, withdrawn, and had intermittent thoughts of suicide.

Record review of Patient #53's Nursing Assessment dated 12/19/15 showed the following:
- Patient was admitted to the BHU on the same date.
- Behaviors observed included difficulty dealing with stress, ineffective problem solving, poor decision making, and poor judgment.
- The clinical impression documented that the patient was quiet, manipulative, and struggled to take responsibility for actions.
- Behavioral risk factors included high risk for impulsivity with agitation.
There was no documentation of the patient's sexual offender history as indicated in the High Risk Alert section of the record nor of the reported sexually inappropriate and potentially abusive behaviors shown prior to admission and reported by his fiancé.

Record review of Patient #53's nurses documentation on the Daily Observation Flowsheets and Physician Orders from 12/19/15 to 12/29/15 showed he was on SAM 1 precautions/observation. (The patient had current sexually acting out behaviors and was a registered sex offender. Per policy he should have been on SAM 2 precautions.)

Record review of Patient #53's nurses notes dated 12/29/15 at approximately 6:30 PM, showed he was observed straddled over the body of his roommate (Patient #57) and punching him in the head.

Record review of Patient #53's nurses documentation on the Daily Observation Flowsheets and Physician Orders from 12/30/15 to 01/06/16 (discharge) showed he was on SAM 1 and Assault/Violence precautions without an increased level of observation such as LOS or Within Arms Reach Length Observation.

3. Record review of discharged Patient #57's History and Physical dated 12/20/15, showed he was an elderly male with a history of depression, obsessive compulsive disorder (mental disorder where people feel the need to check things repeatedly) and a new onset of hallucinations (sensory experience where a person can see, hear, smell, taste or feel something that was not there). He had one level of observation/precaution for assault/violence.

During an interview on 02/11/16 at 10:10 AM, Staff SSSS, Psychiatric Technician, (Psych Tech), stated that prior to 12/29/16 when the assault had occurred Patient #53 had informed her (and other staff) that Patient #57 always changed his clothes in front of him and never shut the bathroom door in their room when he used the bathroom and showed his "private" parts to him. She stated that she never reported this to anyone because she felt that since Patient #53 was paranoid that he might have taken it out of context.
Staff SSSS did not report this to nursing staff which could have potentially changed the level of observation for both Patient #53 and Patient #57 and/or their room assignments.

4. Review of the facility's DVD recording titled, facility name, dated 12/29/15, showed:
- At 6:26:03 PM Patient #53 pushed Patient #57 out of the doorway of their shared room and onto the floor in the day room.
- Patient #53 knelt beside the patient and hit him four times with a closed fist striking him in the head.
- Staff TTTT, RN, Clinical Support Nurse, (CSN), walked towards Patient #57 and stopped approximately five feet away.
- Patient #53 walked into his room and Staff TTTT remained in the same location with her hands in her pockets.
- Patient #53 then closed the door to his room.
- Patient #53 then opened his door and remained inside his room without any staff with him.
- Staff TTTT, RN, CSN moved closer to the patient and stopped approximately two feet from him and got out her phone and made a call.
- Staff TTTT, RN, CSN walked towards the head of Patient #57, looked down at him and then walked away.
- Staff SSSS, Psych Tech closed the door to the patients room with Patient #53 inside.
- Staff UUUU, Licensed Practical Nurse, (LPN), walked towards Patient #57 and also stood approximately five feet from the patient.
- Staff SSSS, Psych Tech opened the door to the patient's room and Patient #53 walked out. He walked in between Staff UUUU, LPN and Patient #57 and walked towards the nurses' station out of view of the camera.
- Staff UUUU, LPN walked away from the area.
- At 6:27:16 Patient #57 moved his right hand (this was the first movement seen by the patient since 6:26:05 PM) and Staff JJ, RN, walked towards the patient with the vitals machine (equipment used to take blood pressures and measure oxygen saturation) and assisted Staff SSSS, Psych Tech in placement of the blood pressure cuff to Patient #57's arm.
- Staff JJ returned to the vitals machine and started the blood pressure machine.
- Staff RRRR, RN, BHU House Supervisor arrived with the crash cart and stood over Patient #57 and looked down at him.
- At 6:28:08 PM the Rapid Response Team (a team of healthcare providers that respond to hospitalized patient with early signs of clinical deterioration to provide rapid response measures to avoid further deterioration) arrived.
- Staff WWWW, Physician, Hospitalist, (physicians whose primary professional focus is the general medical care of hospitalized patients) arrived and replaced Staff VVVV, Psych Tech at the head of the Patient #57, she assessed and evaluated him.

The physical assault began at 6:26:03 PM. Four licensed nurses were in close proximity to the patient but no physical assessment was made to Patient #57 until 6:28:08 PM by the Hospitalist. The patient appeared unconscious for approximately one minute, 10 seconds.

During an interview on 02/09/16 at 3:40 PM, Staff JJ, RN, stated that after the assault he obtained the vitals machine and took it to Patient #57 and that Patient #57 was unconscious.

During an interview on 02/11/16 at 9:40 AM, Staff RRRR, RN, BHU House Supervisor stated that when she arrived Staff JJ, RN, was on the floor next to Patient #57 so she assumed he was assessing him. She asked where Patient #53 was at and was told he was in the quiet room.

During an interview on 02/11/16 at 10:35 AM, Staff TTTT, RN, CSN, stated that:
- Patient #53 was straddling Patient #57 and punching Patient #57 in the head.
- Patient #57 was unconscious because he wasn't moving so she called the Rapid Response team.
- She stated she was most concerned that Patient #53 stayed inside his room.
- She felt Patient #57 was being taken care of because there were other staff at his side.
- It was at the end of her shift and if it had been earlier in the day she may have called for a LOS order for Patient #53 but he wasn't going to have a roommate so she felt that he had sufficient supervision.

During an interview on 02/11/16 at 4:10 PM Staff VVVV, Psych Tech stated that:
- When he got to Patient #57 he was lying on the floor unresponsive.
- He assessed the patients pulses (heartbeat) but did assess his breathing status.
- The patients' eyes were closed and they didn't open when he talked to him.
- There was blood on the patients' ear.
- The next to arrive were Staff TTTT, RN, CSN, and Staff UUUU, LPN.
- When Patient #53 came out of his room he walked to a table in the day area and sat down.

During an interview on 02/10/16 at 1:50 PM, Staff N, Adult BHU Team Leader, stated that:
- She viewed the video recording of the assault and observed that two nurses arrived on the scene and failed to perform a physical assessment of Patient #57, who was lying on the floor unconscious.
- Following the assault, she had no concern that Patient #53 was a potential assault risk to other patients.
- In retrospect, the patient's (#53) level of supervision should have increased to LOS observation following the assault.
- Prior to the assault, she thought that Patient #57 should have been admitted to the other adult unit or to a geriatric unit due to his age and dementia.
- There were no specific guidelines for roommate assignments; they were made based upon a nursing assessment of current behavior, not past history.

The BHU Team Leader failed to:
- Evaluate the potential for physical assault between patients (#53 and #57), one with a history of SAM 2.
- Evaluate the need for reassignment of rooms or provide an increased level of supervision, per policy, to prevent Patient #53's physical assault to Patient #57.
- Evaluate the need and assigning an increased level of observation/supervision for Patient #53 following the assault to prevent an assault to others.

5. Record review of current Patient #9's ED progress notes dated 01/23/16 showed that he was brought to the ED by the police for threats to drown self and he jumped into a pool in an attempt to harm self. His brother reported that the patient was hearing voices and taking to self; and became agitated, aggressive, and threatened to kill him. Patient was agitated upon arrival, threatened to spit at staff, and required medication and four point restraints (cuffs applied to the wrists and ankles and affixed to a bed with straps to limit patient movement.)

Record review of Patient #9's High Risk Alert dated 12/15/15 showed he was a high risk for SAM 2.

Record review of Patient #9's Psychiatric Evaluation dated 01/24/16, showed that the patient was readmitted with a history of acute psychosis (a disorder characterized by false ideas about what is taking place or who one is) and threatening behaviors towards his brother. In the ED he was spitting at staff, belligerent, and agitated; and had been hostile in the ED in the past.

Record review of Patient #9's nursing assessment dated 01/24/16 showed the following:
- The patient was admitted to the BHU on 01/24/16.
- He made threats of harm and assaulted others.
- He was at high risk for suicide and aggression.
- He reported addictive behaviors that included sexual comments.
- He had ineffective coping patterns including dangerous behavior, difficulty dealing with stress, poor decision making, poor impulse control, and poor judgment.
- He had ineffective behaviors including hypersexual, uncooperative, paranoid (having an idea with the belief that one is being harassed, persecuted, or unfairly treated), and withdrawn.
- He had a history of playing with his penis in front of staff.
- His problem list included a potential to harm self or others and sexually inappropriate behavior.

6. Record review of current Patient #43's Psychiatric Evaluation dated 01/31/16 showed the following:
- Patient was brought in by the police after being notified that the patient reported his wife was the devil and he was on fire.
- Patient had a history of schizophrenia.
- He displayed manic (elevated and grandiose behaviors and easily distracted), psychotic, mood labile (marked fluctuations in mood), and anxiety behaviors.

Record review of Patient #43's nursing assessment showed the following:
- Patient was admitted to the BHU on for acute mental status changes including psychosis.
- He had poor judgment, poor decision making, poor impulse control, and dangerous behavior.
- He had difficulty in problem solving, being in crowds, dealing with stress, trusting others.
- He was anxious, defiant, attention seeking, restless, and needed redirection.

7. Record review of the Daily Nurse's Report form dated 02/08/16 showed Patient #9 in Room 1403, Bed one and Patient #43 in Room 1403, Bed two. Patient #9 was on SAM 2 precautions and had a roommate without LOS observation, against facility policy.

8. Record review of current Patient #44's Psychiatric Evaluation dated 02/07/16 showed the following:
- Patient had a history of schizophrenia.
- Patient lived in a group home and was admitted for verbal aggression towards staff, refusal to cooperate with redirection, specific threats of harm.
- Patient had an intellectual developmental disability (IDD, characterized by problems with both intellectual functioning - the ability to learn, reason, and problem solve; and adaptive functioning - everyday social and life skills).

Record review of Patient #44's nursing assessment dated 02/07/16 showed the following:
- The patient was admitted to BHU on 02/07/16.
- The patient had a high risk for impulsivity and aggression.
- He had an extensive detailed, violent and lethal plan for violence.
- He showed dangerous behavior, inappropriate expression of feelings, volatile mood swings, ineffective problem solving, and highly intrusive behaviors.
- He had inadequate cognitive functioning.

9. Record review of current Patient #45's Psychiatric Evaluation dated 02/06/16 showed the following:
- The patient had multiple hospitalizations for behavior problems and aggression.
- The patient was tearing up the house, attacking his sisters, and family was no longer able to restrain his behavior.
- Patient was diagnosed with schizophrenia, IDD and autistic disorder (deficits of social communication accompanied by excessively repetitive behaviors, restricted interests, and insistence on sameness).

Record review of Patient #45's nursing assessment dated 02/05/16 showed the following:
- Patient was admitted for increased aggression at home, threats to mother, physically abusive to sister, and destruction of property.
- High risk for aggression, volatile mood swings, and helplessness.
- Patient showed inappropriate boundaries, hypersexual behaviors, and impulsivity.
- Patient had poor impulse control, poor judgment, short attention span, ineffective problem solving, reckless behaviors, and difficulty dealing with stress.
- Patient had a liability of inadequate cognitive functioning.

10. Record review of the Daily Nurse's Report form dated 02/08/16 showed Patient #44 in Room 1410, Bed one and Patient #45 in Room 1410, Bed two. Patient #45 was on SAM 2 precautions and had a roommate without LOS observation, against facility policy.

During an interview on 02/09/16 at approximately 10:30 AM, Staff V, RN Team Leader verified and stated that:
- Patients (#9 and #44) were roommates in Room 1403. Patient #9 was on SAM 2 precautions.
- Patients (#44 and #45) were roommates in Room 1410. Patient #45 was on SAM 2 precautions.
- Patients with SAM 2 precautions did not need to be in a private room unless they had a history of same sex acting out. If they had a history of sex with the opposite sex, they assessed their behavior need each shift.
- She was not concerned about the patient's precautions and level of observation/supervision in relation to the patients' roommate assignments.

The Team Leader for the BHU failed to:
- Evaluate the potential for sexual/physical assault between patients; one with SAM 2 precautions.
- Recognize the potential for sexual/physical abuse between two vulnerable patients with IDD and one with SAM 2 precautions.
- Assess the need for reassignment or increased level of observation/supervision, per policy.





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Based on interview, record review and policy review, the facility failed to individualize interventions and/or goals for five current patients (#9, #21, #43, #56, and #58) of ten current patients and one discharged patient (#53) of two discharged patients care plans reviewed. These failures had the potential to affect all patients by having unidentified patient needs which could lead to poor patient outcomes. The facility census was 361.

Findings included:

1. Record review of the facility policy titled, "Care Planning (section of medical record that contained goals and interventions entered by nurses and other staff that directed the care of the patient) Policy" showed that:
- To provide overall guidelines for planning individualized care for patients receiving care/treatment or services.
- The care plan will include individualized, measurable goals with interventions identified to help the patient reach the established goals/outcomes.
- Planning for care, treatment and services is individualized to meet the patient's unique needs.

2. Record review of Patient #21's History and Physical (H&P) showed he only spoke Spanish, "So difficult to communicate".

During an interview on 02/08/16 at 4:40 PM Staff CC, Registered Nurse (RN), stated that she had to use gestures, the family, or an interpreter service to communicate with Patient #21 for him to understand.

Record review and concurrent interview on 02/08/16 at 4:05 PM of Patient #21's care plan showed no individualized goals or interventions related to his communication needs. Staff BB, Team Leader, for 4 South, stated that staff should have developed and implemented a communication care plan.

3. Record review of Patient #58's H&P dated 12/03/15 showed the patient had a language barrier to learning. The patient did not speak English.

Record review of Patient #58's Care Plan showed no individualized interventions or goals to address communicating with the patient in his language.

During an interview on 02/10/16 at 9:20 AM Staff YYY, RN, explained that the patient did not speak English.

4. During an interview on 02/09/16 at 9:15 AM, Patient #56 stated that she was legally blind due to macular degeneration (visual loss related to inability to see fine details, sharp images). She stated that she mostly saw shadows and colors.
Record review of Patient #56's H&P showed that she was admitted to the facility for nausea and abdominal pain on 02/06/16. The physician noted that the patient had a history of bilateral macular degeneration and legal blindness.
Record review of Patient #56's Learning Assessment showed that vision would be a potential barrier to the patient's ability to learn.
Record review of Patient #56's Care Plan showed no individualized goals or interventions related to blindness for this patient.
During an interview on 02/09/16 at 3:15 PM Staff XXXX, Unit Manager, stated that Patient #56 definitely should have goals and interventions related to blindness on her care plan. Staff XXXX stated that must have been overlooked by the nurses.

5. Record review of the facility's BHU policy titled, "Sexual Acting Out Behaviors, Management of," dated 12/2010, showed that:
- All patients admitted to the psychiatric units with identified sexual acting out behaviors were placed on appropriate sexual precautions.
- The RN placed a patient on the appropriate level of sexual precaution.
- Sexual Abuse Management 1 (SAM 1) precautions were required for minor behaviors such as, exposing self, flashing, kissing, and inappropriate sexual comments.
- Sexual Abuse Management 2 (SAM 2) precautions were required for major sexual acting out behaviors such as, perpetrator of sexual assault, current sexual acting out, inappropriate touching and public display of masturbation.
- A patient with SAM 2 precautions should not be in room at the same time as roommate, including bedtime. Patients may be assigned Line of Sight observation (staff have direct visual of patient at all times) if identified as an immediate threat.

6. Record review of discharged Patient #53's Emergency Department (ED) nurse's note dated 12/19/15 at 12:36 PM, showed that:
- The patient's fiancé called the ED to report recent behaviors of the patient that led to his eviction from her home.
- The past two days the patient had been increasingly confused, sexually inappropriate, and experiencing insomnia.
- He was going into her teenage daughter's room at night and openly masturbating.

Record review of Patient #53's Central Intake Pre-Admission Behavior Note dated 12/19/15 at 1:30 PM, showed that the patient had a diagnosis of Schizophrenia (a chronic disorder characterized by psychotic symptoms; such as, false ideas about what is taking place or who one is) and was a registered sex offender for attempted sodomy and first degree sexual assault.

Record review of Patient #53's Nursing Assessment showed:
- Patient was admitted to the BHU on 12/19/15.
- Behaviors observed included difficulty dealing with stress, ineffective problem solving, poor decision making, and poor judgment.
- Behavioral risk factors included high risk for impulsivity with agitation.

Record review of Patient #53's Care Plan showed no goals or interventions related to his past criminal history of sexual assault and recent sexually inappropriate/abusive behaviors that precipitated his admission to the Behavioral Health Unit (BHU).

7. Record review of Patient #9's Psychiatric Evaluation dated 01/24/16, showed that the patient was admitted with a history of acute psychosis (a disorder characterized by false ideas about what is taking place or who one is) and threatening behaviors towards his brother. In the ED he was spitting at staff, belligerent, and agitated; and had been hostile in the ED in the past.

Review of Patient #9's High Risk Alert section of the medical record dated 12/15/15, showed he had SAM 2 high risk .

Record review of Patient #9's Nursing Assessment showed:
- The patient was admitted to the BHU on 01/24/16.
- He made threats of harm and assaulted others.
- He reported addictive behaviors that included sexual comments.
- He had hypersexual behaviors and a history of playing with his penis in front of staff.

Record review of Patient #9's Care Plan showed a problem of sexually inappropriate behavior. There were no goals or interventions in the care plan to address the sexually inappropriate behaviors assessed and his High Risk Alert for SAM 2.

8. Record review of Patient #43's Nurse's note dated 02/02/16 at 8:40 PM showed that he was sitting in the television area, exposed himself to patients and staff, and was grabbing self (part of body not described). The patient was placed on SAM 1 precautions.

Record review of Patient #43's Care Plan showed no goals or interventions to address the exposure of self to others and resultant SAM 1 precautions.



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31891

Based on observation, interview and record review the facility failed to ensure that medications were administered safely and accurately for:
- One patient (#10) of one patient observed whose Intravenous Push (IVP, medication given through the vein) medication was administered in two separate doses instead of the ordered one dose.
- One patient (#23) of one patient observed whose medication was ordered by mouth (PO) but was given through a G-tube (a tube surgically inserted into the stomach to deliver medications or nutrition).
-One patient (#30) of one patient observed whose mediation was ordered PO but was given through a nasogastric (NG) tube (a thin plastic tube that is inserted into the stomach through the nose).
- One patient (#26) of one patient whose medication was not given as ordered.
- Two patients (#42 and #51) of two patients observed that had a dosage of less than one milliliter (ml, unit of measure) and were not drawn up in a device to give an accurate dosage.
This had the potential to place all patients at risk for harm, death or compromised treatment by administering inappropriate or inaccurate medications. The facility census was 361.

Findings included:

1. Record review of the facility's policy titled, "Medication Administration," revised 05/2014, showed the following: Verify medications against the original order and/or the Medication Administration Record (MAR) immediately prior to administration utilizing the "5 Rights of Medication Administration: Right patient, right drug, right dose, right route, and right time".

2. During observation and concurrent interview on 02/08/16 at 2:30 PM showed Staff G, Registered Nurse (RN) entered the room of Patient #10 and administered five mg (measurement equal to 1/1000 of a gram) of Hydralazine (a medication given to decrease blood pressure) by IVP, through the vein. Staff G stated that she gave five mg of the drug and would give five mg more in a few minutes. She stated that she gave it in two doses in order to see if the patient would have an adverse reaction to the smaller dose. She stated that there was not a protocol which directed her to give the drug in that way. The physician order was for Hydralazine 10 mg and was not ordered to be given in separate 5 mg doses.

The nurse should have called the physician for an order reflecting that the medication could be given in two separate doses.

During an interview on 02/09/16 at 9:20 AM, Staff E, Team Leader (TL) stated that there were no order sets or protocols for giving the drug in intermittent doses.

3. Record review of the facility's document titled, "Nursing Practice Council Meeting Minutes," dated 10/20/15, showed that the Council had recognized a problem with medication administration routes with the following documentation:
- Remember to watch the five rights, especially the PO (by mouth) vs NG (a tube passed through the nose, past the throat, and down into the stomach, used for feeding and administering drugs) route;
- If you see an error in the medication order, please send message to pharmacy to change.
- Remember that some medications are not to be crushed, ask pharmacy if unsure; and
- Pharmacy to develop list of medications that cannot be crushed.

Record review of the facility's document titled, "Nursing Practice Council Meeting Minutes," dated 11/17/15, again showed that the Council further discussed and recognized a continued problem with medication administration routes with the following documentation:
- Route is very important with medication administration;
- Pharmacy should be consulted if patient has new G-tube placed and they will address medications.
- A staff member is trying to add the ISMP (Institute for Safe Medication Practices) "Do not crush" list to the intranet for easier access for nurses.

Record review of the facility's document titled, "Nursing Practice Council Meeting Minutes," dated 11/17/15, again showed that the Council addressed and put an action into place to "Consult pharmacy for meds (medications) with G-tubes".

4. Observation on 02/09/16 at 8:25 AM showed Staff QQQQ, RN, entered the room of Patient #23 and administered an Aspirin 325 mg (a medication used to treat pain, fever, inflammation or to prevent heart attacks, strokes or blood clots) through a G-tube. The order for the medication was PO.

During an interview on 02/09/16 at 2:25 PM, Staff QQQQ, stated that he did not give the medication by mouth because the patient could not swallow. He confirmed that he should have called the pharmacy or the physician to have the order changed to be give by G-tube.

5. Observation on 02/09/16 at 9:05 AM showed Staff OO, RN, nursing instructor from the local community college, and nursing student verified five medication orders in Patient #30's MAR were ordered to be administered by the PO (by mouth) route (the path by which a drug, fluid, or other substance is taken into the body). One of the ordered medications specifically stated, "Do not crush, chew, or cut in half" and included "Administration Instructions" that explained why the medication physical structure should not be altered.

6. During observation and concurrent interview on 02/09/16 at 9:05 AM, Staff OO pointed to the computer screen where the physician's order was viewed and stated, "The orders are for PO administration, but we are going to give them in the NG tube". He instructed the student nurse to crush the medications, add water to the medications, and inject them into Patient #30's NG tube.

7. Record review of Patient #30's physician orders showed that the patient had an NG tube placed on 02/08/16.

During an interview on 02/09/16 at 2:45 PM, Staff C, RN, Director of 7 North, 7 South and 2 South, stated that there was no excuse for Staff OO's actions. She stated that the pharmacy/physician should have been notified and requested a change in the medication administration route. She stated that when she asked Staff OO about the observation he stated that it was "OK, because he was going to call the pharmacy".

During an interview on 02/10/16 at 1:40 PM, Staff A, Chief Nursing Officer (CNO), stated that when she heard about the observation with Staff OO and Patient #30 that she couldn't believe it and that it should not have happened especially during the instruction of a nursing student.

8. During observation and concurrent interview on 02/09/16 at 9:55 AM showed Staff HH, RN, entered the room of Patient #26 and administered medications by G-tube. Staff HH did not administer the ordered Sensipar (a medication for patients on long term dialysis with kidney disease. Staff HH stated that she "held" the medication because the patient could not swallow and she could not administer it by G-tube because the medication could not be crushed. She confirmed that she should have called the pharmacist to get another form of the medication.

9. Observation on 02/09/16 at 10:30 AM showed Staff UU, RN, in Patient #42's room. Staff UU prepared medication for administration to the patient. The medication dose of 60 mg equaled a dosage of 0.96 ml. The liquid medication was drawn into a three ml syringe that did not have marks on it to pull up exactly 0.96 ml.

During an interview on 02/09/16 at 11:00 AM Staff UU stated that she failed to administer an accurate dose because she did not have access to a device (syringe) that allowed her to draw up exactly 0.96 ml.

10. Observation on 02/09/16 at 2:20 PM showed Staff BBBB, RN, in Patient #51's room. Staff BBBB, had a medication dose ordered of 0.96 ml. She drew the medication up into a three ml syringe that did not have exact markings to draw up 0.96 ml.

During an interview on 02/10/16 at 9:10 AM, Staff BBBB stated that she should have used a
one ml syringe instead of the three ml syringe to be exact.

During an interview on 02/10/16 at 9:23 AM, Staff AAAA, TL on 7 North, stated that Staff BBBB should have reached out to pharmacy to get one ml syringes.




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36473

Based on observation, interview and record review the facility failed to ensure the safety of one patient (#31) of one patient observed for appropriate monitoring during a blood transfusion. This had the potential to place all patients who receive blood transfusions at risk for unidentified reactions that could be life threatening. The facility census was 361.

Findings included:

1. Record review of the facility's policy titled, "Blood Transfusion: Transfusion of Blood and Blood Products and Routine Vital Signs," revised 08/20/15 showed the following:
- Obtain baseline vital signs.
- Initiate infusion.
- Stay with the patient for the first 15 minutes to monitor for reaction and repeat vital signs.
- Take vital signs hourly until blood is infused.
- Vital signs within one hour after completion of the infusion.
- CAUTION: Transfusion reactions most frequently occur in first 15 minutes of start of transfusion.

2. Observation on 02/09/16 at 9:55 AM showed Staff PP, Registered Nurse (RN), at the bedside in Patient #31's room to monitor a blood transfusion.

During an interview on 02/09/16 at 9:55 AM, Staff PP stated that he was a fairly new employee (five months) and this was the first time that he had monitored a patient while blood was being infused. Staff PP could not verbalize the proper procedure for monitoring the patient during infusion. He stated that he did not know the intervals that he should be taking the patient's vital signs which were used as indicators of adverse blood transfusion reactions.

During an interview on 02/09/16 at 2:58 PM, Staff AAA, Charge Nurse, stated that she should have inquired about his knowledge of the policy and stayed in the patient's room to mentor Staff PP.

During an interview on 02/10/16 at 9:00 AM, Staff XXX, Education Manager, stated that Staff PP should not have been assigned to Patient #31 due to his lack of knowledge of the facility's policy and procedures for blood transfusion. She stated that Staff AAA knew that Staff PP was a new employee and should have inquired about his knowledge of a blood transfusion and stayed in the room to mentor him during the procedure.