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

The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review 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,"PATIENT RIGHTS", no policy number, date of issue 4/2020, indicated under PROCEDURE: Patient Rights: 1. The following rights shall be afforded to all patients and are not subject to modification: g. Patients have the right to be protected by the Hospital from neglect; from physical, verbal and emotional abuse (including corporal punishment); and from all forms of misappropriation and /or exploitation.


2. Incident Report documentation from 4/7/25 at 7:35 am indicated P1 was attacked by P2 in the cafeteria during breakfast. P1 was kicked and/or punched repeatedly by P2.


3. In interview on 4/18/25 at approximately 10:50 am with BHT4 (Behavioral Health Tech) confirmed P2 attacked P1 in the cafeteria because P1 was taking too long to eat. P2 knocked bowl of food out of P1's hand, P1 confronted P2, then P2 punched and kicked P1 multiple times.

Based on document review and interview, facility nursing staff failed to complete and document every fifteen minute safety checks as ordered by provider for 2 of 10 medical records reviewed (P1 & P2), failed to increase level of observation for 1 of 10 medical records reviewed. (P2), and failed to complete a nursing assessment of the patient who was abused for 1 of 10 medical records reviewed. (P1)

Findings include:

1. Facility policy titled," OBSERVATIONS, PATIENT", no policy number, last revised 11/2024, indicated under Documentation: 1. Documentation of Observations will be completed in real time (as observations are being conducted) and by person conducting the Observations. Note: there may be times in which actual entries are delayed due to an emergency. Documentation should be made as a late entry as soon as possible with a noted indicating the reason for the delay if appropriate. 2. Documentation will be completed utilizing ObservSmart. Observations will be documented on paper during planned/unplanned downtime.

2. Facility policy titled,"ABUSE AND NEGLECT", no policy number, date of issue 4/2020, indicated under PROCEDURE: 3. Patient-to-Patient Abuse. a. The registered nurse will place the patient committing the offense on Q 5 minute observations 1:1 observation and notify the attending /covering physician. b. The registered nurse will complete a nursing assessment of the patient who was abused to evaluate the patient's physical and mental condition.

3. Incident Report documentation from 4/7/25 at 7:35 am indicated P1 was attacked by P2 in the cafeteria during breakfast. P1 was kicked and/or punched repeatedly by P2 before nursing staff members quickly intervened separating the patients.

4. Review of P1's MR (Medical Record) indicated a lack of every 15 minute observation safety checks from 7:15 am - 9:30 am on 4/7/25 and lacked a documented nursing assessment of P1 after he/she was physically assaulted by P2 at approximately 7:35 am on 4/7/25.

5. Review of P2's MR indicated a lack of every 15 minute observation safety checks from 7:15 am - 9:30 am on 4/7/25 and lacked documentation of increased level of observation after P2 physically assaulted P1 at approximately 7:35 am on 4/7/25.

6. In interview on 4/18/25 at approximately 10:50 am with BHT4 (Behavioral Health Tech) confirmed every 15 minute observation safety checks were not completed on 4/7/25 from 7:15 am - 9:30 am but should have been. BHA4 confirmed P2 attacked P1 in the cafeteria because P1 was taking too long to eat. P2 knocked bowl of food out of P2's hand, P2 confronted P1, then P1 punched and kicked P2 multiple times.

7. In interview on 4/18/25 at approximately 11:40 am with N1 (Registered Nurse) confirmed a nursing assessment should have been documented on 4/7/25 for P1 after he/she was assaulted by P2 but was not and should have placed P2 on an increased level of observation following the assault but did not.