HospitalInspections.org

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Based on interview, document review and medical record review, it was determined that the hospital failed to meet the Condition of Participation for Governing Body. The Governing Body failed to implement systems and processes to address patient safety when there was prior knowledge of a physical altercation between Patient #1 and Patient #2. Patient #1 was then assaulted by Patient #2 and seriously injured after receiving sedating medications and placed in 5 point restraints (each limb is tied down and a strap is placed across the waist then tied to the bed frame to prevent movement of the arms, legs and body) and unable to protect him/herself. There was a lack of patient assessments, debriefings, supervision and monitoring from the time of the physical altercation on the evening of 8/15/2015 to 8/18/2015 when Patient #2 was transferred to a forensics unit. Refer to Tag # 115.

Findings include:

Western State leadership to include the Nurse Executive and Medical Director were aware of the altercation that took place on the evening of 8/15/2015. Patient #2 threw a liquid on Patient #1. Patient #1 responded by hitting Patient #2 in the eye with a fist.

Patient #2 then assaulted Patient #1 on 8/16/2015 during the night shift while s/he was sedated and in 5 point restraints. Patient #2 used both a shoe and his/her fist to strike Patient #1 in the face which resulted in a nasal fracture, lacerations and head trauma requiring transfer to an emergency room for evaluation and treatment.

The facility policy titled: SERIOUS ASSAULT REPORTING POST EVENT MANAGEMENT TO ENSURE SAFETY states, "If patient is not in seclusion or restraint and cannot be moved [to a forensic unit-a unit with specialized staff to deal with assaultive patients] the same day, clinical staff will follow Nursing Standards Protocol 301 "Management of Aggressive/ Assaultive Behavior" and use behavioral 1:1 as needed, in compliance with Nursing Standard Protocol 304 "Management of the Patient Requiring Therapeutic Observation" to ensure patient and staff safety."

The facility Protocol 301 states the desired outcome included, "RN [Registered Nurse] Assessment, 1. Note that a single patient may display several different types of aggression. It is important to assess each situation." There was no documentation in Patient #2's record to support the patient was assessed after the altercation on 8/15/2015 at 8:05 p.m. There was no documentation to support the patient was monitored or supervised after the event on the subsequent night shift. There were no restrictions implemented to prevent Patient #2 access to Patient #1.

Patient #2 had the ability to move about the unit unsupervised at 1:50 a.m. on 8/16/2015 when s/he assaulted Patient #1 while Patient #1 was in 5-point restraints and medicated with sedating medication. Patient #1 required a hospital visit for a fractured nose and lacerations to the face and severe facial swelling.

When Patient #1 returned from the hospital s/he was placed on the same ward as Patient #2 and there was no documentation of a plan to keep Patient #1 safe from Patient #2. There was no documentation to support 1:1 staffing or other enhanced supervision was in place to prevent Patient #2 from assaulting other patients.
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Based on interview, document review and medical record review, it was determined that the hospital failed to meet the Condition of Participation for Patient Rights for 1 of 8 patients (# 1) reviewed for care in a safe setting. The hospital failed to assure the safety of Patient (#1) after s/he was medicated for self-destructive behavior with sedating medications, placed in a seclusion room and in 5-point restraints (each limb is tied down and a strap is placed across the waist then tied to the bed frame to prevent movement of the arms, legs and body). Patient #1 also had a staff member monitoring him/her at the entrance of the open door to the seclusion room. Patient #1 was assaulted when Patient #2 entered the seclusion room and beat Patient #1 with a shoe and then his fist which resulted in a nasal fracture, lacerations and facial trauma.

Findings include:

Patient #1 was admitted to the hospital on 1/5/2015 with mental health disorders. The patient had a history of hospitalizations for mental health problems. The record indicated Patient #1 was placed on a 24 hour hold on 8/15/15 for returning from ground privileges (GP) 15 minutes late. This meant Patient #1 lost the ability to go out onto the grounds of the hospital until 12:35 p.m. on 8/16/2015.

Patient #2 was admitted to the hospital on 4/10/2015 with mental health disorders. The record indicated the goal for Patient #2 was to follow his/her medication schedule and not be a danger to others. On 8/15/2015 at 7:30 p.m. Patient #2 had a verbal altercation with a patient (unknown) and Patient #2 responded by spitting on the patient. No documentation was recorded after this event to indicate an assessment of the incident was conducted.

Documentation in the record dated 8/17/2015 indicated that Patient #1 and Patient #2 "have a long Hx [history] of verbal altercations. "Patient #1 would, "whisper to ...you need to go back to your homeland." The next entry in the record stated, "Requesting case conference to separate these pts [patients]."

According to documentation from hospital security, at 8:05 p.m. on 8/15/15, security was summoned to respond to a "Code Green" (meaning there is a combative person- and assistance is requested and announced to communicate and mobilize a response to protect patients, staff, and property in the event that a person becomes combative).

Patient #1 and Patient #2 had an altercation a short time prior to 8:05 p.m. and were separated by staff. The record indicated Patient #2 then approached Patient #1 and threw liquid on Patient #1. Patient #1 responded by hitting Patient #2 in the right eye with his/her fist. The two patients were separated. Patient #2 was not placed on Line of Sight observation or 1:1 supervision. Patient #1 was initially placed in his room. Patient #2 again approached Patient #1 and was stopped by staff. Patient #1's behavior escalated and he was placed in seclusion in a locked room.

There was no documentation to support that an assessment or debriefing of Patient #2 took place after the two incidents occurred on the evening shift 8/15/2015. Patient #2 was not monitored after the incident and no restriction was implemented to limit Patient #2's access to Patient #1 or other patients.

After Patient #1 was placed in seclusion, attempts to assess the patient took place. An Administrative Report of Incidents (AROI) dated 8/16/15 at 12:01 a.m. indicated Patient #1 hit staff members while staff members were attempting to conduct an assessment. A second Code Green was called. Assistance arrived and Patient #1 was escorted to the "Comfort Room" (Room used to apply restraints). Patient #1 continued to hit and kick at staff during the walk to the Comfort Room (The Comfort Room was located next to Patient #1's room). Patient #1 was placed in 5-point restraints without incident.

The Registered Nurse (RN #1) and Licensed Practical Nurse (LPN #1) caring for the patient on the night of 8/15/2015 and 8/16/2015 stated medication (Benadryl and Ativan) was ordered and administered to alleviate the Patient #1's anxiety, anger and agitation. Both medications have a sedative effect.

Patient #1 was in 5-point restraints in the comfort room with a staff member sitting at the open door to the room to monitor the patient and alert staff members if the patient required assistance.

Interviews on 9/2/2015 with staff member Mental Health Tech (MHT #1) stated s/he was familiar with Patient #1 and knew who s/he was. MHT #1 stated s/he was not familiar with Patient #2. MHT #1 stated that s/he had not worked on this particular unit for several months. MHT #1 did not have knowledge of the altercation between Patient #1 and Patient #2 that occurred that evening at 8:05 p.m. MHT #1 stated, "Not knowing who everyone was contributed to the incident."

While MHT #1 was sitting at the door of the comfort room, at 1:50 a.m. on 8/16/2015, Patient #2 came to the area of the comfort room. Patient #2 was not restricted from the area, and was not being monitored or supervised at this time. The record di not indicate that there had been interaction between staff members and Patient #2 since the altercation between Patient #1 and Patient #2 that occurred at 8:05 p.m.

Staff members reported that Patient #2 tried to enter Patient #1's regular room but the door was locked. Since Patient #1's room was right next door to the comfort room, Patient #2 saw Patient #1 in the comfort room. A second MHT (#2) saw Patient #2 near Patient #1's room and asked what s/he was doing. MHT #2 and MHT #1 both activated their "panic buttons" (the panic button activated a Code Green). Both MHT #1 and MHT #2 stated there was a delay in the response to the activated panic button and that it took approximately 20 to 30 seconds before the announcement came over the communication system for a Code Green.

When Patient #2 was asked what he was doing he responded, "This" and walked into the Comfort Room with a shoe in his hand. Patient #2 moved past MHT #1, entered the comfort room and struck Patient #1 in the face and head with a shoe, then struck Patient #1 with his/her fist. MHT #1 stated s/he entered the Comfort Room and physically restrained Patient #2 by grabbing him/her from behind. MHT #1 stated, "I thought [Patient #2] was going to kill [Patient #1]." Multiple Staff members also responded, intervened and assisted with stopping the assault. Patient #1 was assessed by a physician and transferred to a hospital emergency room for evaluation and treatment of a nasal fracture, lacerations and facial trauma.


An entry in the Progress Record for 8/16/15 indicated that after the 1:50 a.m. incident, Patient #2 stated to staff members, "he hit me so I have to hit him back." An entry in the progress notes indicated Patient #2 was placed in seclusion. Review of the order sheet revealed no order for seclusion in the medical record until 8/17/2015. Documentation in the record indicated Patient #2 stayed in his room but there was no documentation indicating s/he was supervised or monitored after this event.


On 8/17/2015 at 8:45 a.m. there was no documentation to indicate Patient #2 was restricted to his/her room. At 11:55 on 8/17/2015 an order was written for Level 1 (restricts the patients privileges to be independent and is monitored). There was no consistent documentation to support staff monitored the patient after the Level 1 was written.

On 8/18/2015 an entry stated the patient "mostly remained in his room and kept away from peer who he assaulted." There was no additional documentation indicating the patient's whereabouts were being monitored. At 11:00 a.m. on 8/18/2015 an order was written to transfer the patient to a forensic unit. The first entry in the record which reflects Patient #2 arrived to the forensic unit was timed at 10:00 p.m.

Patient #1 was returned from the hospital emergency department to the same ward at Western State Hospital on 8/16/2015 at 9:00 a.m. This was the same ward where Patient #2 continued to reside without supervision or monitoring. Patient #1 was not placed on medical observation 1:1 for 24 hours after the patient's return to the hospital. An order was written for 1:1 medical observation on 8/17/15 at 1:40 p.m.

Staff members stated that on 8/16/2015 Patient #2 was off of Seclusion restrictions at 8:45 a.m. and staff members were told to "keep an eye on him." The patient was not on 1:1 staffing.

The hospital was aware of Patient #1's and Patient #2's history of verbal altercations. Documentation could not be located to support that the hospital assessed both patients regarding the altercations. Plans to keep the patients safe were not located in the record. When Patient #1 was placed in restraints and medicated, Patient #2 had unrestricted access to Patient #1 and was able to attack Patient #2 following an earlier altercation.

The hospital assigned a staff member to monitor Patient #1 who was unaware of the altercation that occurred earlier in the evening and did not know who Patient #2 was or the significance of Patient #2 approaching Patient #1 with a shoe in hand.

The facility failed to assure the safety of Patient #1.