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Based on observation, record review and interview, the psychiatric hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice is evidenced by the failure to fully investigate and identify the manner in which Patient #1 obtained the weapon used to attack Patient #2.

Review of psychiatric hospital document titled "Hospital/Licensed Provider Abuse/Neglect Initial Report" revealed in part: Patient-to-Patient Physical Assault involving client on 2:1 observation physically assaulted another client on 08/15/2025 at 7:12 PM. The incident occurred in Building 'A' on ward 'Ad' hallway. Description of the alleged incident: Incident Report: While Patient #1 was being monitored, Patient #1 walked up the hallway and hit Patient #2 in the face with a piece of metal. Staff quickly intervened and redirected Patient #1 back to his room. Patient #2 was sent to the hospital. Patient #1 was on 2:1 Direct Observation and was able to pull out an older shower holder object from the wall near the showers and conceal it in his pants as Patient #1 described to S4RN about his intentions.
Description of injuries and treatment provided: Patient #2 with Acute right mandibular ramus fracture sent to Hospital 'B'. No injuries noted for Patient #1.
Patient observation status: Patient #1 was on 2:1 Direct Observation. Patient #2 was not on restrictive management.
Initial actions taken: Patient #1 remains on 2:1 Direct Observation. The 2 guards were moved to another unit. Patient #2 was sent to Hospital 'B'.
The investigation was concluded with the following video review: Video footage (Camera: Camera View: W4 Hall Frnt EH-135): 19:08:48: Patient #1 turns in the direction of Patient #2 places his left hand inside the front of his pants and pulls something out of his pants. Patient #1 then runs in Patient #2's direction and begins hitting Patient #2 with the object. The CGT standing approximately 6-8 feet from Patient #1 begins to run in the direction of Patient #1 and Patient #2. 19:09:04: The CGT's successfully separate Patient #1 and Patient #2 at this time. 19:09:06: Something shiny (possibly metal) can be seen in Patient #1's hand at this time as two CGT's are holding client. 19:09:15: The shiny object is removed from Patient #1's hand at this time.
Final comments: DVD available upon request.
Note: Due to technical issues over the weekend, it was not clear if this report was received by HSS, therefore, Program Monitor S16PM resubmitted this report.

Further review of "Hospital/Licensed Provider Abuse/Neglect Initial Report" failed to reveal further video review and interviews in order to identify the manner in which Patient #1 obtained the weapon used to attack Patient #2.


Observation on 08/26/2025 between 9:30 AM- 11:45 AM of recorded video from camera EH W4 Hall Mid F on 08/15/2025 from 5:29 PM to 7:09 PM, with S16PM navigating the video monitor revealed the following:
7:02 PM: Patient #1 was in the hallway outside of his room talking with a group of approximately 3 other patients when one of the group, Patient #R1, turned and walked down hallway into bathroom followed by Patient #1 who did not walk into the bathroom but turned and went back into his room.
7:03 PM: Patient #1 walked out of his room and walked into bathroom with guard behind him who stayed in hallway by door.
7:04 PM: Patient #1 in bathroom with a guard stationed on both sides of the bathroom doorway.
7:04:25 PM: Patient #1 walked out of the bathroom and then to his room at 7:04:31 PM.
7:04:53 PM: Patient #1 left his room and went back into bathroom doorway, then down hall, then turned back around and went in his room at 7:05:25 PM.
7:05:30 PM: Patient #R1 came out of bathroom and went into Room 'a'.
7:05:56 PM: Patient #1 walked out of his room and walked into Room 'a'.
7:06:08 PM: Guard in hallway when Patient #1 walked out of Room 'a' and into his room hand in pocket on left.
7:07:19 PM: Patient #1 walked out of his room and walked down hall towards nurses' station/dayroom then walked back to his room then walked back out into hallway with guards behind him.
7:08:08 PM: Patient #1 walked back to his room then back out into hall, leaned against the wall then walked back into his room with guards by his doorway and in hallway.
7:08:40 PM: Patient #1 walked out of his room into the hallway towards the nurses' station/dayroom with two guards following.
7:08:48 PM: Patient #1 reached into the left side of his pants pulled out a rectangular shaped, hand-sized shiny object and proceeded to hit Patient #2 who was leaning against the wall in the hallway near the dayroom with the object. Guards intervened and separated Patient #1 from Patient #2.

During an interview on 08/20/2025 at 3:25 PM, S2LT stated he believed another patient who was not on 1:1 or 2:1 observations pulled the piece of metal used by Patient #1 out of the bathroom wall and gave it to Patient #1 on the night of the incident. He reported he was almost certain of this because Patient #1 was on 2:1 observations since June 2025 and the guards had been closely sticking with him.

During an interview on 08/26/2025 at 11:45 AM, S16PM agreed with the above findings and stated, the guard did not have visual on Patient #1 for only a few seconds while he was in Room 'a'.

During an interview on 08/26/2025 at 1:00 PM, S17SEC stated the guards should have been inside the room with the client, they should always be in close proximity to client. There should be no barrier between client and guard, they cannot see past a room wall. It was against hospital policy and protocol when the guards did not walk into the room with patient and lost sight of him.

Based on record review and interview, the psychiatric hospital failed to ensure 1 (#2) of 4 (#1-#4) client medical records contained a plan of care addressing all of the patient's medical conditions as identified problems.
Findings:

Review of psychiatric hospital's policy titled "Components and Guidelines for Treatment Planning Process", last revised on 07/08/2025, revealed in part: "I. Definitions: E. Planning of Care: Individualized planning and provision of care, treatment and services that addresses the needs, safety and will-being of the client. Policy: It is the policy of ELMHS that each client shall have an integrated plan of care that is specific, individualized, comprehensive, dynamic, unique and appropriate to the client's identified needs for treatment. Procedure: 3. The treatment plan shall include: a. A substantiated diagnosis, psychiatric or medical, that is identified by the attending physician or licensed independent practitioner, and used by the treatment team as the primary focus upon which the treatment planning will be based."

Review of Patient #2's medical record revealed a 35 year-old male admitted on 07/30/2025.

Review of Patient #2's Psychiatric Evaluation dated 07/31/2025 revealed diagnoses included Schizophrenia, Intellectual Disability, mild, Substance abuse, Hypertension, Dyslipidemia, Tenia Pedis, Chronic Constipation, Diabetes Mellitus and GAF 35.

Review of Patient #2's Psychiatry Provider Progress Note, dated 08/08/2025, revealed the following provider documentation: Treatment Plan: Problem 3. Intellectual Disability-"We will take it into consideration when developing treatment plan and we will assist him in achieving higher level of functioning."

Review of Patient #2's Treatment plan dated 08/09/2025, failed to reveal Intellectual Disability addressed as a problem with interventions and goals to assist him in achieving higher level of functioning.

During an interview on 08/25/2025 at 12:05 PM, S3TQM confirmed Patient #2's Treatment Plan failed to include Intellectual Disability addressed as a problem with interventions and goals to assist him in achieving higher level of functioning.

Based on record review and interview, the psychiatric hospital failed to ensure the Registered Nurse (RN) completed staff assignment sheets as evidenced by failure to include all patients and their room numbers on staff assignment sheets when assigning staff to patients on 2 of 2 Building/Unit Assignment sheets reviewed.
Findings:

Review of Building/Unit Assignment sheets dated 08/14/2025 and 08/15/2025 for Building 'A' revealed the following:
-The forms were divided into sections, 1 section for each of the 4 wards: Units Aa, Ab, Ac, and Ad.
-Each section contained a list of the names of clients that were on precautions other than routine observation.
-Each section was signed by an RN under the list of staff assigned to each ward.
-The form failed to reveal the names of the clients who were on routine observation.
-The form failed to reveal the room numbers associated with each patient listed.

During an interview on 08/25/2025 at 12:05 PM, S1TQM confirmed the patients on routine observation were not included on the staff assignment sheets and stated that the nurses usually use the shift report to identify the room numbers of each patient.

Review of psychiatric hospital document titled Building 'Aa' "Shift Report" dated August 14, 2025
Revealed 24 patients listed. The section titled "RM" (Room) was blank for all 24 patients listed.

Review of psychiatric hospital document titled Building 'Ab' "Shift Report" dated August 14, 2025
Revealed 31 patients listed. The section titled "Hall/Room" revealed only the hallway location of each of the 31 patients listed.

Review of psychiatric hospital document titled Building 'Ac' "Shift Report" dated August 14, 2025
Revealed 32 patients listed. The section titled "Hall/Room" was blank for all 32 patients listed.

Review of psychiatric hospital document titled Building 'Ad' "Shift Report" dated August 14, 2025
Revealed 22 patients listed with 3 patients in the sick bay. The section titled "Hall/Room" listed room numbers for only 10 of the 22 patients.

Review of psychiatric hospital document titled Building 'Aa' "Shift Report" dated August 15, 2025
Revealed 24 patients listed. The section titled "RM" (Room) was blank for all 24 patients listed.

Review of psychiatric hospital document titled Building 'Ab' "Shift Report" dated August 15, 2025
Revealed 32 patients listed. The section titled "Hall/Room" revealed only the hallway location of each of the 32 patients listed.

Review of psychiatric hospital document titled Building 'Ac' "Shift Report" dated August 15, 2025
Revealed 32 patients listed. The section titled "Hall/Room" was blank for all 32 patients listed.

Review of psychiatric hospital document titled Building 'Ad' "Shift Report" dated August 15, 2025
Revealed 22 patients listed with 3 patients in the sick bay. The section titled "Hall/Room" listed room numbers for only 10 of the 22 patients.

During an interview on 08/25/2025 at 12:15 PM, S3TQM confirmed the patients did not have their room numbers identified on the assignment sheets and that only a few patients had a room number listed on the shift report. S3TQM stated nursing staff have been concerned about this and are trying to address it.

During an interview on 08/26/2025 at 1:20 PM, S18RN stated the hospital used identification bands on the patients to confirm each patient's identity therefore there was no need for room numbers on the staffing assignment sheets or shift reports.