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Based on document review, observation, and interview, facility nursing staff failed to prevent a patient from being physically assaulted in 1 of 10 medical records reviewed. (P1)

The cumulative effects of these systemic problems resulted in the facility's inability to provide nursing care in a safe manner.

Based on document review, observation, and interview, facility nursing staff failed to prevent a patient from being physically assaulted in 1 of 10 medical records reviewed. (P1)

Findings include:

1. Facility policy titled,"PSYCHIATRIC PATIENT RIGHTS", policy number RE.16, last reviewed 3/2023, indicated under PROCEDURE: You have the right to: 6. Reasonable protection from physical or emotional abuse or harassment.

2. P1's MR (Medical Record) review indicated the following:

Nursing note documentation dated 4/28/25 at 7:30 pm indicated loud yelling was heard coming from P2's room. When staff arrived they witnessed P2 hitting P1 approximately 3-4 times in the face and/or head. Staff immediately intervened separating the two patients. P1 was noted to have bruising and swelling to the lower left eye when assessed. After assessment P1 was escorted to his/her room without further incident.

Nursing note documentation dated 5/1/2025 at 2:54 am indicated P1 was pushed to the floor by P2 on 4/30/25 around 7:00 pm. At that time P1 was pushed down to the floor by P2. P1 fell on his/her buttocks. P1 was assessed . No injuries were noted. P2 indicated P1 came into P2's room, P1 pulled wool from P1's own brief and poured it on P2 while he/she was sleeping. P2 stated he/she got out of bed and went after P1. P2 pushed P1 out of anger.

Nursing note documentation dated 5/12/25 at 5:30 pm indicated P1 was physically assaulted by P11. P1 sustained a small laceration above the right eye. P1 was assessed, laceration cleaned, and bandage applied.

3. Incident Report documentation indicated the following:

On 4/28/25 at 6:40 pm indicated P1 was laying on P2's bed, P2 attempted to coax P1 out of P2's bed, P1 refused, P2 then struck P1 in the face and or head multiple times before staff separated the patients. P1 sustained a bruise to his/her left cheek below the eye.

On 4/30/25 at 7:00 pm indicated P1 entered P2 room reached into his/her brief and pulled a portion of the soiled material out then discarded the soiled material on the floor of P2's room. P2 then followed P1 to the milieu and pushed P1 causing him/her to fall, bottom first, to the floor.
On 5/12/25 at 1:45 pm P1 was head-butted by P11 without provocation. P1 sustained a small laceration above the right eye.

4. Camera footage was reviewed with A2 (Chief Executive Officer) on 5/27/25 at approximately 5:00 pm and indicated the following:

On 4/28/25 at 8:37 pm P1 can been seen laying in P2's bed. P2 enters the room, appears to attempt to wake P1 multiple times, when attempts were unsuccessful P2 pulled the pillow out from underneath P1's head. P1 attempts to take the pillow from P2, P2 then rapidly hits P1 in the head and/or face approximately 10 times before staff members separate the patients. The entire incident lasted approximately 1 minute.

On 4/30/25 at approximately 6:58 pm P1 can be seen entering the room of P2. P2 was laying in bed. P1 walks towards P2 bed, stops, P1 his/her hand down the front of their own brief, P2 motions for P1 to leave the room numerous times, P1 then turns to leave the room, removes his/her hand from the brief throwing what appeared to be a portion of the soiled brief to the side before exiting the room. P1 exits the room into the milieu. P2 follows P1 into the milieu, staff can be seen rushing to separate the two patients, but were unsuccessful. P2 pushed P1 forcefully causing P1 to fall to the floor on his/her backside. Nursing staff can be seen assessing P1. P2 was escorted back to their room by nursing staff. The incident lasted approximately 2 minutes.

On 5/12/25 at approximately 1:45 pm P11 can be seen at the doorway of his/her room. P1 was seen walking around the unit without being intrusive. As P1 was walking P11 initiated verbal contact with P1. P1 stopped walking and moved closer to P11. P11 then head-butted the patient quickly at close range once. Staff member responded quickly separating the patients.

5. In interview on 5/27/25 at approximately 2:00 pm with N1 (Registered Nurse) confirmed P2 attacked P1 on 4/28/25 and 4/30/35. N1 indicated P1 displayed wandering intrusive behaviors which contributed to his/her being assaulted by P2 twice. N1 indicated P11 attacked P1 without provocation on 5/12/25.

Based on document review, observation, and interview, facility nursing staff failed to complete and document patient observation checks as ordered by provider for 3 of 11 medical records reviewed. (P1, P2, & P11)

Findings include:

1. Facility policy titled,"PATIENT ROUNDING AND OBSERVATION", policy number NR.23, last reviewed 12/2024, indicated under PROCEDURE: Patient Rounds are recorded on the daily rounds sheet or in the electronic medical record by assigned staff member. All staff assigned will update the round sheets during their shift to reflect any changes in precaution level, room or bed changes. A new sheet will be started for patients at the time of admission. Staff initials will be used to indicate completion of rounds and must be legible and identified signature at the bottom of the page.

2. Review on P1's MR (Medical Record) indicated the following:
Order documentation dated 4/17/25 indicated P1 was ordered a standard level of observation. On 4/29/25 at 11:48 am P1 was placed on a Line of Sight level of observation as a result of an incident that occurred on 4/28/25. The duration of this increased level of observation was 24 hours and ended at 4/30/25 at 11:48 am.

Patient Checks documentation for P1 indicated the following:

Lacked documentation of patient checks including but not limited to 4/28/25 at 6:00 pm, 6:15 pm, 7:15 pm, 7:45 pm, 8:30 pm, and 11:45 pm.

Lacked documentation of patient checks including but not limited to 4/29/25 at 1:15 am , 2:00 am, 4:00 am, 8:30 am, 9:30 am, 12:15 am, 3:15 am, 3:30 pm, 4:15 pm, 5:15 pm, 6:15 pm, 6:45 pm, 9:00 pm.

Lacked documentation of patient checks including but not limited to 4/30/25 at 12:00 am, 2:45 am, 5:00 am, 5:45 am, 6:30 am, 7:15 am, 7:30 am, 9:30 am, 10:15 am, and 10:45 am.

On 5/1/25 P1 was placed on a 1:1 (one to one) level of observation at 10:22 am. 1:1 level of observation was implemented for ongoing confusion and altercations with P2. The duration of the 1:1 order was 24 hours ending at 5/2/25 at 10:22 am.

Patient Checks documentation for P1 indicated the following:
Lacked documentation of patient checks including but not limited to 5/1/25 at 10:45 am, 12:00 pm, 12:45 pm, 2:15 pm, 3:45 pm, 5:00 pm, 6:00 pm, 7:00 pm, 7:30 pm, 8:00 pm, 8:30 pm, 9:15 pm, 9:30 pm, 10:00 pm, 11:00 pm.

On 5/12/25 at 2:49 pm P1 was placed on a Line of Sight level of observation as a result of P11 head-butting P1. P1 remained on a Line of Sight level of observation until 5/15/25 at 1:30 pm.

Patient Checks documentation for P1 indicated the following:
Lacked documentation of patient checks including but not limited to 5/12/25 at 8:15 am, 8:45 am, 9:15 am, 10:45 am 11:15 am, 11:45 am, 12:00 pm, 12:15 pm, 12:45 pm, 1:30 pm, 1:45 pm, 2:15 pm, 2:30 pm, 2:45 pm, 3:15 pm, 3:30 pm, 3:45 pm, 4:15 pm, 4:30 pm, 4:45 pm,


3. Review of P2's MR indicated on 4/29/25 at 11:52 am P2 was placed on Line of Sight level of observation. The increased level of observation lasted 24 hours ending at 4/30/25 at 12:00 pm.

Patient Checks documentation for P2 indicated the following:
Lacked documentation of patient checks including but not limited to 4/28/25 at 4:00 pm, 4:15 pm, 5:15 pm, 6:00 pm, 6:15 pm, 7:00 pm, 7:30 pm, 9:30 pm, and 11:45 pm.

Lacked documentation of patient checks including but not limited to 4/29/25 at 12:00 pm, 12:45 pm, 3:15 pm, 4:30 pm, 5:15 pm, 5:30 pm, 6:15 pm, and 8:30 pm.

Lacked documentation of patient checks including but not limited to 4/30/25 at 4:15 pm, 5:15 pm, 5:30 pm, 6:15 pm, 6:45 pm, 7:15 pm, 7:30 pm, 8:15 pm, 8:30 pm, 9:30 pm, and 11:00 pm.


4. Review of P11's MR indicated on 5/12/25 P11 head-butted P1, received 25 mg (milligram) IM (Intramuscular) Benadryl. MR for P11 lacked documentation of an increased level of observation initiated after the incident.

Patient Checks documentation for P11 indicated the following:

Lacked documentation of patient checks including but not limited to 5/1/25 at 11:15 am, 11:45 am , 12:00 pm, 12:15 pm, 12:45 pm, 1:30 pm, 1:45 pm, 2:15 pm, 2:30 pm, 2:45 pm, 3:15 pm, 3:30 pm, 4:15 pm, 4:30 pm, and 4:45 pm.


5. In interview on 5/27/25 at approximately 5:30 pm with A1 (Chief Executive Officer) confirmed patient observations for P1, P2, and P11 were not completed by nursing staff as ordered and should have been.