HospitalInspections.org

Based on document review and interview the facility failed to ensure safety requirements were met during an altercation between a staff member and patient in one (1) instance. (Patient # 10)

Findings include:

1. The hospital policy titled, Patient Rights Statement, Policy Number: BE 3, indicated on page two (2) - section - Policy Statement/Purpose - The patient had the right to - number thirteen (13) - Receive every consideration of safety in their surroundings. This policy was last revised on 05/2023.

2. Patient care security video from 02/05/2025 from approximately 11:03:40 am through 11:04:49 am was observed with A # 1 (Quality Director). The video showed patient # 10 walking in the hall with other patients and staff. Patient # 10 on three (3) different occasions went at M # 1 (Mental Health Worker III) by trying to initiate physical contact. Patient # 10 went toward M # 1 from the front at 11:03:40 am and again at 11:04:03 am. At approximately 11:04:44 am patient # 10 quickly ran up behind M # 1 who spun around and physically redirected (hands on patient's chest) patient # 10 up against a wall. At approximately 11:04:49 am the video showed M # 1 shoving patient # 10 in the chest again to direct patient # 10 toward the entrance of the patient # 10's room.

3. Behavioral Health Services - Mental Health Worker III - Job Description - indicated on page three (3) - main section - Job Responsibilities - number six (6) - Job Specific - number 6.9 - Regularly assesses and implements non-violent crisis intervention strategies for each patient on the psychiatric units.

4. In interview on 03/05/2025 at approximately 10:30 am with administrative staff member A # 1, confirmed the patient care security video was stored for up to forty-five (45) days.

5. In interview on 03/05/2025 at approximately 12:35 pm with patient care staff member R # 1 (Recreation Therapist), confirmed M # 1 turned around, grabbed patient # 10's shirt, and pushed patient # 10 up against the wall.

Based on document review and interview the registered nurse failed to ensure an event/occurrence report was completed related to an altercation between a staff member and patient in one (1) instance. (Patient # 10)

Findings include:

1. The hospital policy titled, Patient Safety and Risk Management Program, Policy Number: QAI 6.25, indicated on page one (1), Guiding Principles - number 3.2 - Individuals are still held accountable for compliance with patient safety and risk management practices. On page two (2), Definitions - number 1 - Adverse event or incident: An undesired outcome or occurrence, not expected within the normal course of care or treatment, disease process, condition of the patient, or delivery of services. This policy was last revised on 07/2019.

2. Patient care security video from 02/05/2025 from approximately 11:03:40 am through 11:04:49 am was observed with A # 1 (Quality Director). The video showed patient # 10 walking in the hall with other patients and staff. Patient # 10 on three (3) different occasions went at M # 1 (Mental Health Worker III) by trying to initiate physical contact. Patient # 10 went toward M # 1 from the front at 11:03:40 am and again at 11:04:03 am. At approximately 11:04:44 am patient # 10 quickly ran up behind M # 1 who spun around and physically redirected (hands on patient's chest) patient # 10 up against a wall. At approximately 11:04:49 am the video showed M # 1 shoving patient # 10 in the chest again to direct patient # 10 toward the entrance of the patient # 10's room.

3. Incident Report Log was reviewed for the months of January and February 2025. The log lacked an Occurrence/Event Report related to patient # 10 and/or his/her representative for 02/05/2025.

4. In interview on 03/05/2025 at approximately 11:50 am with nursing staff member CN # 1 (Registered Nurse-RN/Charge), confirmed M # 1 told CN # 1 that patient # 10 ran up on him/her, more than once, during the hallway walking group. The patient's nurse would be the one responsible for completing an event report related to staff to patient altercation. If M # 1 pushed patient # 10 then yes, the nurse should have completed an event report.

5. In interview on 03/05/2025 at approximately 12:35 pm with patient care staff member R # 1 (Recreation Therapist), confirmed M # 1 turned around, grabbed patient # 10's shirt, and pushed patient # 10 up against the wall.

6. In interview on 03/05/2025 at approximately 1:45 pm with B # 1 (Behavioral Health Services-BHS/Nurse Manager), confirmed N # 2 should have completed an occurrence/event report related to M # 1 physically redirecting patient # 10 on 02/05/2025.