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Based on observation, interview and record review, the hospital failed to ensure appropriate supervision to maintain safety and to prevent patient to patient abuse for 1 of 7 sampled patients (Patient #2). This resulted in an assault on Patient #2 lasting several minutes in which Patient #2's roommate forcibly detached his eyes from his head, permanently blinding him, before staff intervention.

The cumulative effect of A144 and A145 resulted in Immediate Jeopardy at the Condition of Participation (CoP), Patient Rights, CFR 482.13, as not being met.

The findings included:

Based on observation, interview and record review, the hospital failed to ensure adequate supervision by staff to deter or be able to identify and intervene timely in case of altercations or emergencies to prevent serious injuries. This resulted in failure to stop an assault that lasted several minutes before resulting in permanent disfiguring injury and permanent loss of sight for 1 of 7 sampled patients (Patient #2). Contributing factors included decreased staff presence on the wing where Patient #2 resided in the hour leading up to the assault and no staff in proximity to that wing so they could identify signs of an altercation, such as unusual sounds and patient activities. Refer to A144.

Based on observation, interview and record review, the hospital failed to take adequate measures to deter or intervene timely to prevent abuse resulting in severe injury. This affected 1 of 7 sampled patients (Patient #2), who was assaulted by his roommate for several minutes without intervention until after his roommate forcibly removed both of his eyes, resulting in Patient #2 being permanently blind despite this occurring with the door open, in the room on his wing closest to the day room and nurses station and creating enough of a noticeable disturbance that other patients went to look in that room. Refer to A145.

Based on observation, interview and record review, the hospital failed to ensure adequate supervision by staff to deter or be able to identify and intervene timely in case of altercations or emergencies to prevent serious injuries. This resulted in failure to stop an assault that lasted several minutes and resulted in the traumatic removal of both eyes and permanent loss of sight for 1 of 7 sampled patients (Patient #2). Contributing factors included decreased staff presence on the wing where Patient #2 resided in the hour leading up to the assault and no staff in proximity to that wing so they could identify signs of an altercation, such as unusual sounds and patient activities.

This resulted in Immediate Jeopardy at the standard for Code of Federal Regulation (CFR) at 482.13(c)(2), Refer to A115.

The findings included:

The hospital's Policy and Procedure, titled, Supervision of Persons Served (patients), effective 08/22/23, documented, in part, "The purpose of this policy is to ensure the provision of a safe and secure environment, through the process of staff supervision and accountability" and "The minimum level of supervision is 30-minute checks."

The hospital's Policy and Procedure, titled, Person Served Rights & Responsibilities, effective 06/06/22, documented, in part, "South Florida State Hospital will also: ...provide a safe and humane environment for persons served and staff."

Review of Patient #2's record revealed he was admitted to the hospital on 04/20/23 and with diagnoses to include schizophrenia, psychosis, and attacking an elderly family member. Patient #2 became roommates with Patient #1 on 09/12/23.

Review of Patient #1's record revealed he was admitted to the hospital on 08/04/23. Patient #1's Comprehensive Psychiatric History dated 08/05/23 documented he has a history that included schizophrenia and intermittent explosive disorder, multiple psychiatric hospitalizations and was in a state hospital for several years due to "violent and aggressive behavior as well as continued extreme psychosis for several years as well as delusions and paranoia"; Patient #1 denied a history of harming others but there was documentation of "a history of extensive harm to others in the past"; he has a history of being unpredictable and becoming extremely violent at times, losing his temper for no reason; and that he has attacked multiple people, including family members multiple times and an employee at the receiving facility just prior to this admission.

Patient #1's Event Note for 09/10/23 at 3:30 AM documented around 3:00 AM the Mental Health Technician heard a noise coming out of the room and opened the door to find Patient #1 beating on his roommate (Patient #9), accusing him of running the water in the shower; afterwards stated if Patient #9 comes back in the room he will beat him up again; and that when counseled he denied remembering anything about what just happened. Patient #1's General notes by Psychiatry dated 09/11/23 at 4:22 PM documented Patient #1 assaulted his roommate last night and it appears he may not remember doing it; that the patient is dangerous; that he was pleasant during interview but can snap at any moment and has no awareness into his illness; and under Plan that medications were adjusted, assault precautions, patient is a danger to others, and continue inpatient treatment.
Patient #1's Event Note dated 09/12/23 at 5:52 PM documented P/S (patient or "person served") remains on SOR (Safety Observation Room with live camera monitoring) for "safety precaution and assault," attacked roommate in (sic) his sleep last Sunday, refused to vacate his room, security [was] called, and patient was placed on SOR in (room with Patient #2).
Patient #1's Psychiatric Weekly Progress Note dated 09/13/23 at 10:56, documented "start assault precautions," and "decrease to Level 1 access to grounds."
Patient #1's Psychiatric Weekly Progress Note, dated 09/21/23 at 5:22 PM, documented Patient #1's father requested to change him to Level 2 grounds privileges so he could visit.

During interview with Psychiatrist A on 09/29/23 at 2:30 PM, he reported since Patient #9 did not have any physical injuries after he was attacked by Patient #1 on 09/10/23, Patient #1 did not seem to him to be a deadly danger, he didn't seem capable of anything severely harmful, there was no indication of what would happen later, and there was no further incident with him until 09/22/23. Psychiatrist A reported, in the week before 09/22/23, Patient #1 seemed to be doing well and not a threat to others, was calm and pleasant and getting along with his peers. Psychiatrist A stated, "there was no reason for concern that he would do anything to anyone else or himself" and he accommodated the father so he could visit that week by taking Patient #1 off the SOR monitoring and changing him to Level 2 grounds privileges (supervised access to the grounds so he could leave the unit with staff), whereby they could visit. Psychiatrist A reported, the father visited Patient #1 on 09/22/23 before Patient #1 attacked Patient #2. Psychiatrist A, in speaking of the perceived incapability of Patient #1 to do anything severely harmful, did not reveal awareness of the Comprehensive Psychiatric History completed by the Medical Executive Director on 08/05/23 at 5:17 PM which documented "patient has history of extensive harm to others in the past."

Review of the facility's video from the Las Olas C-wing hall facing the nursing station on 09/22/23 from 2:40 PM to 3:43:55 PM with the Risk Manager, who identified staff, revealed decreased staff presence. (The C-wing hall camera time was found to be 9 minutes and 27 seconds behind that of the camera in these patients' room.) From this camera view, the hallway opens to the day room on the right before a set of double doors, one of which is propped open throughout the time reviewed, that lead to the center of the unit and nursing station. No staff are visible on the C-wing from 2:40 PM until a Mental Health Technician (MHT) enters the wing through the double doors from the general direction of the nursing station at 2:53:07 (hours:minutes:seconds) PM and leaves through the double doors at 2:53:49 PM (42 seconds later). No staff are seen on the C-wing until an Registered Nurse (RN) comes through the double doors at 3:01:44 PM and leaves the wing through the double doors at 3:01:50 PM (6 seconds later). At 3:04:34 PM, staff enters the C-wing through the double doors and goes in front of a room across the hall from the room Patients #1 and #2 shared before leaving the C-wing at 3:05:01 PM (27 seconds later). At 3:10:52 PM, an unidentified staff comes through the double doors, picks up a brown paper trash bag just inside the door, sets it back down and walks away (4 seconds on the unit). Up until 3:22:57 PM, no staff came to the C-wing as patients are walking around. At 3:26:00, a MHT comes on the C-wing, looks around, and by 3:27:30 PM (no more than 90 seconds), she left the wing through the double doors. At 3:36:10 PM, a MHT comes on the C-wing, unlocks the door to let Patient #1 into his room at 3:36:28 PM and leaves the C-wing at 15:37:08 through the double doors, just as the door to room 127 opens before Patient #1 punches Patient #2 and the assault begins. In total, staff came onto the C-wing for a total of 3 minutes and 47 seconds during the hour and 3 minutes reviewed before the assault.

Patient #1 attacked Patient #2 on 09/22/23 at 3:47 PM (per time on the in-room camera) while their room door was open, repeatedly punching Patient #2, traumatically removed and detached both of Patient #2's eyes with his bare hands, and restrained Patient #2 on the floor for several minutes before the first staff arrived at 3:54 PM. Review of the camera footage from the C-wing hall revealed 2 patients came from the C-wing day room to look in the room Patients# 1 & 2 shared almost immediately after the assault started and one patient observed the altercation from outside the doorway at length. No staff were observed on that wing during the assault from 3:47 PM until the first staff arrived outside the room at 3:54 PM. Facility documentation reviewed with the Risk Manager revealed no report of staff hearing or seeing signs of a disturbance in that room until another patient came and informed staff at the nursing station of an altercation. Since the order for live camera observation in their room had been discontinued by the physician the day before (09/21/23) to accommodate Patient #1's family's request to increase privileges for visitation, no one was observing the room at the time of the assault to request help. Cross reference to A145.

Patient #2 was taken to a hospital Emergency Room as a Level 1 trauma (highest trauma urgency) and admitted to the Intensive Care Unit on 09/22/23. Imaging studies showed bilateral globe rupture (the eyes were no longer intact) with significant edema (swelling), hemorrhage (bleeding) and subcutaneous emphysema (air pockets under the skin) in the orbits (eye sockets) and periorbital soft tissues (around the eye sockets); right nasal (nose) bone fracture and deformity of the left nasal bone. Although his eyes were put on ice by a facility staff member and sent with him, they could not be reattached, and Patient #2 is permanently blind in both eyes. Patient #2 was hospitalized until 10/04/23, when he returned to the psychiatric hospital.

During an interview with the Chief Nursing Officer (CNO) on 09/29/23 at 5:25 PM, he explained the current electronic monitoring system used to scan patient bracelets from in proximity prompts staff using blocks of time. The CNO acknowledged persons with an order for 30-minute checks (the most infrequent monitoring of patients who have gained that privilege) could be scanned as long as 59 minutes apart and this still shows as in compliance as long as each scan was in a different 30 minute block of the clock hour, but that this is "okay" because they are still within the 30 minute blocks and it takes most of that time to get all the patients scanned. The CNO said since this event, they realized when staff scan patients as in programs (where program staff are with them continuously), the system locked out for 3 hours, which has now been changed to 2 hours, during which staff cannot scan them until the time is up, even if the patients changed their mind and doesn't go or return to the unit. The CNO reported, Patients #1 and #2 were both logged as in programs when this event happened, but they were on camera in their rooms and did not go to programs that afternoon. This enabled staff not to have to check on Patients #1 and #2 and scan their bracelet devices for over 3 hours.

During interview on 10/10/23 at 11:51 AM, Risk Manager E stated, the new electronic monitoring system is better because now staff don't have to get as close to the patients or have to scan barcodes, they can scan from the door and do not even have to go in the room. When asked about checking for signs of life, seeing the patient to ensure they are okay and not just that the wristband is in range, she responded, it explains right here and started reading out loud the color coding used for the dashboard display, which the previous system also had. When asked about the required intervals on the new system, which are now up to one minute and twice as long as the interval a physician orders, she did not respond to this but resumed description of the color coded dashboard and the color representing being out of range of the device on wristbands.

During an interview on 10/11/23 at 12:00, Security Officer D initially said he was not sure the event was preventable. Upon being told staff spent a total of 3 minutes and 47 seconds on the wing where this occurred in the 1 hour 4 minutes before it started, Officer D stated that could have contributed to it and that "when they [patients] know there's no one around, it's an opportunity."

Based on observation, interview and record review, the hospital failed to take adequate measures to deter or intervene timely to prevent abuse resulting in severe injury. This affected 1 of 7 sampled patients (Patient #2), who was assaulted by his roommate for several minutes without intervention until after his roommate forcibly removed both of his eyes, resulting in Patient #2 being permanently blind despite this occurring with the door open, in the room on his wing closest to the day room and nurses station and creating enough of a noticeable disturbance that other patients went to look in the room.

This resulted in Immediate Jeopardy at the standard for Code of Federal Regulation (CFR) at 482.13(c)(3), refer to A115.

The findings included:

The hospital's Policy and Procedure, titled, Supervision of Persons Served [patients], effective 08/22/23, documented, in part, "The purpose of this policy is to ensure the provision of a safe and secure environment, through the process of staff supervision and accountability" and "The minimum level of supervision is 30-minute checks."

Review of Patient #2's record revealed he was admitted to the hospital on 04/20/23 and with diagnoses to include schizophrenia, psychosis, and attacking an elderly family member. Patient #2 became roommates with Patient #1 on 09/12/23.

Review of Patient #1's record revealed he was admitted to the hospital on 08/04/23. Patient #1's Comprehensive Psychiatric History dated 08/05/23 documented he has a history that included schizophrenia and intermittent explosive disorder, multiple psychiatric hospitalizations and was in a state hospital for several years due to "violent and aggressive behavior as well as continued extreme psychosis for several years as well as delusions and paranoia"; that Patient #1 denied a history of harming others but there was documentation of "a history of extensive harm to others in the past"; that he has a history of being unpredictable and becoming extremely violent at times, losing his temper for no reason; and that he has attacked multiple people, including family members multiple times and an employee at the receiving facility just prior to this admission.

Patient #1's Event Note for 09/10/23 at 3:30 AM documented around 3:00 AM, the Mental Health Technician heard a noise coming out of the room and opened the door to find Patient #1 beating on his roommate (Patient #9), accusing him of running the water in the shower; afterward stated if Patient #9 comes back in the room he will beat him up again; and that when counseled he denied remembering anything about what just happened. Patient #1's General notes: Psychiatry dated 09/11/23 at 4:22 PM documented Patient #1 assaulted his roommate last night and it appears he may not remember doing it; that the patient is dangerous; that he was pleasant during interview but can snap at any moment and has no awareness into his illness; and under Plan that medications were adjusted, assault precautions, patient is a danger to others, and continue inpatient treatment.
Patient #1's Event Note dated 09/12/23 at 5:52 PM documented P/S [patient or "person served"] remains on SOR (Safety Observation Room with live camera monitoring) for "safety precaution and assault," attacked roommate in (sic) his sleep last Sunday, refused to vacate his room, security [was] called, and patient was placed on SOR in (room with Patient #2).
Patient #1's Psychiatric Weekly Progress Note dated 09/13/23 at 10:56 documented "start assault precautions," and "decrease to Level 1 access to grounds."
Patient #1's Psychiatric Weekly Progress Note dated 09/21/23 at 5:22 PM documented Patient #1's father requested to change him to Level 2 grounds privileges so he can visit.

During interview with Psychiatrist A on 09/29/23 at 2:30 PM, he reported since Patient #9 did not have any physical injuries after he was attacked by Patient #1 on 09/10/23, Patient #1 did not seem to him to be a deadly danger, he didn't seem capable of anything severely harmful, there was no indication of what would happen later, and there was no further incident with him until 09/22/23. Psychiatrist A reported in the week before 09/22/23, Patient #1 seemed to be doing well and not a threat to others, was calm and pleasant and getting along with his peers. Psychiatrist A stated, "there was no reason for concern that he would do anything to anyone else or himself" and he accommodated the father so he could visit that week by taking Patient #1 off the SOR monitoring and changing him to Level 2 grounds privileges, (supervised access to the grounds so he could leave the unit with staff), whereby they could visit. Psychiatrist A reported the father visited Patient #1 on 09/22/23 before Patient #1 attacked Patient #2. Psychiatrist A, in speaking of the perceived incapability of Patient #1 to do anything severely harmful, did not reveal awareness of the Comprehensive Psychiatric History completed by the Medical Executive Director on 08/05/23 at 5:17 PM which documented "patient has history of extensive harm to others in the past."

Review of camera footage from the C-wing hall from 2:40 PM to 3:43:55 (times per that camera) on 09/22/23 revealed staff came onto the C-wing for a total of 3 minutes and 47 seconds during that hour and 3 minutes. Refer to A144.

Video footage was reviewed from the SOR (Safety Observation Room) camera in the patients' room located in the opposite corner from the hallway door as well as a C-wing camera facing the nursing station that views the doorway to that same room, using the SOR camera's times for reference.
The summary of that observation is as follows: A Mental Health Technician (MHT) unlocks the bedroom door and lets Patient #1 into the room at 3:46:54 (hours:minutes:seconds) PM. Patient #1 enters the room and folds something on his bed with his back to camera as Patient #2 starts to walk towards the door. Patient #2 pauses and they appear to speak to each other calmly before Patient #2 continues walking towards the door. At 3:47:26 PM, Patient #1 puts the item he is folding down on the bed and comes around the bed towards the door. Patient #2 opens the door, just as the Mental Health Technician walks off the C-wing through the double doors, and he steps back turning to face Patient #1. Patient #1 appears to be heading out the door but suddenly stops, turns and punches Patient #2 on his left. Patient #2 falls back against the wall, then comes forward, arms and hands outstretched, and tries to swing back. Two other patients come quickly from the direction of the day room and look in the room, and walk away. One patient stands and observes the two patients from the hallway. There are no staff on the wing to see the patients' respond or hear what attracted their attention from around the corner in the day room. The two patients punch and wrestle, struggling their way from inside the partially open door to the right until Patient #2 ends up on his back on the head of bed 1 (on the door side of the room) as Patient #1 does most of the hitting. Patient #2 tries to hit back and pulls Patient #1's shirt over his head. Patient #1 pulls his shirt off and hits Patient #2 about the head and/or shoulders. Patient #2 slides off the bed and onto the floor on the opposite side of the bed from the camera, and Patient #1 kneels over him, still punching, then reaches with one hand to Patient #2's face by his eyes. At 3:48:02 PM, Patient #1 is holding Patient #2 down as his hand stays on Patient #2's face. Patient #1 swings both arms at Patient #2 again, then reaches towards Patient #2's eyes. At 3:49 PM, Patient #2 briefly breaks away and lunges towards the doorway. Patient #1's arm swings around as he turns, smearing blood on the wall before regaining hold of Patient #2. Patient #2 faces the floor, with his head down towards the still open door, and seems to be trying to keep his head away from Patient #1. Patient #1 leans over top of Patient #2 and reaches around over Patient #2's head with his left hand as his right hand pushes down on Patient #2's back, holding him down. At 3:50 PM, the door is open further as they struggle in the doorway. Patients are seen in the hall walking past with some looking in. At 3:50:49 PM, Patient #2 is still held down on his knees by Patient #1. At 3:51:31 PM, Patient #2 straightens his legs behind him and lies flat, then on his side facing towards the camera, still being held down, as another patient walks by. At 3:52:30 PM (adjusted time), a patient is seen on the hall camera to come from the day room around the corner and looks in the doorway, then to walk off the wing towards the nursing station.
At 3:53:22 PM, an MHT enters through the double doors and heads towards the patients' doorway. At 3:54 PM, the first staff is seen outside the room, from the SOR camera, since the assault started, who seems to call for others, then there are 2 staff and 1 patient visible in the hallway near the room. Other staff arrive and soon multiple staff are in the hall. The staff appear to be talking and gesturing from the hallway without entering the room or touching the patients. Patient #1 finally gets up at 3:55 PM and leaves the room. Patient #2 rolls forward, head down on floor, seemingly in exhaustion. Staff do not enter the room. Psychiatrist A is seen standing watching the activity from the double doors to the wing as staff gesture, beckoning him to come to the room. At 3:56:25 PM, Psychiatrist A is seen at the room doorway, leaning and looking in. Patient #2 rolls on his right side facing the camera. The camera is unclear and only dark shadows can be seen where his eyes should be. One staff is visible in the hall with Psychiatrist A. At 3:57:19 PM, Psychiatrist A enters the room and appears to look at Patient #2's face. At 3:57:44 PM, several more staff come into view in the hall and they start to enter the room and initiate First Aid.
Fire Rescue arrived with a stretcher at 4:10 PM and takes Patient #2 away at 4:12 PM.

Facility documentation revealed no report of staff hearing or seeing signs of a disturbance in that room until another the patient came and informed staff at the nursing station of an altercation. Since the order for live camera observation in their room had been discontinued by the physician the day before (09/21/23) to accommodate Patient #1's family's request to increase privileges for visitation, no one was observing the room at the time of the assault to request help.

Patient #2 was taken to a hospital Emergency Room as a Level 1 trauma (highest trauma urgency) and admitted to the Intensive Care Unit on 09/22/23. Imaging studies showed bilateral globe rupture (the eyes were no longer intact) with significant edema (swelling), hemorrhage (bleeding) and subcutaneous emphysema (air pockets under the skin) in the orbits (eye sockets) and periorbital soft tissues (around the eye sockets); right nasal (nose) bone fracture and deformity of the left nasal bone. Although his eyes were put on ice by the facility staff and sent with him, they could not be reattached. Patient #2 is permanently blind in both eyes. Patient #2 was hospitalized until 10/04/23, when he returned to the psychiatric hospital.

Review of camera footage from the C-wing hall revealed 2 patients came from the C-wing day room to look into the room of Patients #1 and #2 almost immediately after the assault started and one patient observed the altercation from outside the doorway at length.

During an interview with the Chief Nursing Officer (CNO) on 09/29/23 at 5:25 PM, and discussion of the current electronic monitoring system, the CNO acknowledged patients with an order for 30-minute checks (the most infrequent monitoring of patients in the hospital) could be scanned with an interval up to 59 minutes instead of 30 minutes, and patients with orders for 15 minute checks could be scanned up to 29 minutes apart rather than as ordered by the physician.

During interview on 10/10/23 at 11:51 AM, Risk Manager E stated the new electronic monitoring system is better because now staff don't have to get as close to the patients or have to scan barcodes, they can scan from the door and do not even have to go in the room. When asked how this is better and about checking for signs of life, seeing patients to ensure they are okay and not just that the wristband is in range of the scanner, she responded matter-of-factly that it is explained right here and started reading out loud about the color coding used for the dashboard display for on time and late scans, which the previous system also had. When asked about the required intervals on the new system, which are now up to one minute and twice as long as the physician-ordered interval, she did not answer the question but resumed reading aloud colors and their meanings on the dashboard display.

During an interview on 10/11/23 at 12:00, Security Officer D said he was not sure the event was preventable. Upon being told staff spent a total of 3 minutes and 47 seconds on the wing where this occurred in the 1 hour 4 minutes before it started, Officer D said that could have contributed to it and "when they [patients] know there's no one around it's an opportunity."

Based on observation, interview, and record review, the facility failed to analyze an adverse event involving a violent patient on patient assault without prompt intervention in order to seek effective preventive measures to protect patients and staff from assaults. The lack of sufficient safety measures places all patients at risk for harm.

(This resulted in the non-Immediate Jeopardy standard level deficiency for Patient Safety for QAPI (Quality Assurance and Performance Improvement) at CFR 482.21(a),(c)(2), (e)(3).)

The findings included:

Per camera review, Patient #1 attacked his roommate Patient #2 on 09/22/23 at 3:47 PM (time per in-room camera) while their door was open, repeatedly punched him, traumatically removed and detached both of Patient #2's eyes with his hands, and restrained Patient #2 on the floor for several minutes before the first staff arrived at 3:54 PM. Review of camera footage from the C-wing hall revealed 2 patients came from the C-wing day room to look in the room Patients #1 and #2 shared, almost immediately after the assault started and one patient observed the altercation from outside the doorway at length. No staff were observed on that wing during the assault from 3:47 PM until the first staff arrived outside the room at 3:54 PM. Refer to A145 for details.
Facility documentation reviewed with the Risk Manager revealed no report of staff hearing or seeing signs of a disturbance in that room until another patient left the wing and informed staff at the nursing station of an altercation. Since the order for live camera observation in their room had been discontinued by the physician the day before (09/21/23), to accommodate Patient #1's family's request to increase privileges for visitation, no one was observing the room at the time of the assault to request help.

Patient #1's Comprehensive Psychiatric History dated 08/05/23 documented his history to include schizophrenia and intermittent explosive disorder, multiple psychiatric hospitalizations including in a state hospital for several years due to "violent and aggressive behavior as well as continued extreme psychosis for several years as well as delusions and paranoia"; Patient #1 denied a history of harming others but there was documentation of "a history of extensive harm to others in the past"; he has a history of being unpredictable and becoming extremely violent at times, losing his temper for no reason; and he has attacked multiple people, including family members multiple times and an employee at the receiving facility just prior to this admission.

Review of camera footage from the C-wing hall from 2:40 PM to 3:43:55 PM (hour/minutes/seconds) (as times per that camera) revealed staff came onto the C-wing for a total of 3 minutes and 47 seconds during that hour and 3 minutes immediately before Patient #1 assaulted Patient #2. Refer to A144 for details.

During interview with the Quality Manager on 09/29/23 at 12:05 PM, she discussed the Action Plan, that to address supervision of patients, they decreased the 'lock out' time for patients going to programs to 2 hours instead of 3, but included no plans to ensure staff supervision on all wings where patients are, including at times, other than during programs. Efforts she described included audits of the electronic dashboard for "late" scans but no plans to watch staff that they are visible and in sufficient numbers to monitor patients, or to audit the electronic system against program attendance to ensure staff do not log patients as in programs who did not go, or to address the time flexibility of the monitoring system to enable checks on persons at the frequency ordered instead of intervals of 1 to 59 minutes.

During an interview with the Chief Nursing Officer (CNO) on 09/29/23 at 5:25 PM, and discussion of the current electronic monitoring system, the CNO acknowledged patients with an order for 30-minute checks (the most infrequent monitoring of patients in the hospital) could be scanned with an interval up to 59 minutes instead of 30 minutes, and patients with orders for 15 minute checks could be scanned up to 29 minutes apart rather than as ordered by the physician. He reported the system had been in place for approximately a month before the assault. The CNO provided no definite plans to ensure patients would be monitored at the prescribed frequencies or of staffing to enable physical presence of staff with patients, not only at scan times.

During interview on 10/10/23 at 11:51 AM, Risk Manager E stated the new electronic monitoring system is better because now staff don't have to get as close to the patients or have to scan barcodes, they can scan from the door and do not even have to go in the room. When asked how this is better and about checking for signs of life, seeing patients to ensure they are ok and not just that a wristband is in range of a scanner, she responded matter-of-factly it explains right here and started reading out loud the color coding scheme used for the dashboard display for on time and late scans, which the previous system also had. When asked about the required intervals on the new system, which are now up to one minute and twice as long as the physician-ordered interval, she did not answer the question but resumed reading aloud colors and their meanings on the dashboard display.

The ineffectiveness of the plan implemented following the survey of 10/05/22 failed to provide measures to prevent and/or respond quickly to Patient #1 attacking Patient #2 on 09/22/23. Review of the hospital's plan of correction related to deficient practices cited on 10/05/22, related to an adverse event in which a patient was found on the floor unresponsive and without vital signs for an undetermined time after staff had not checked on him throughout the night at the frequency ordered, included to follow the new policy "Supervision of Patients Served" to use the electronic system that was in place at that time to take pictures of patients (rather than scanning a bar code outside the room), including in their room and at night unless they were in the bathroom or shower, and to observe them for signs of life at the physician-ordered frequency, of which the most infrequent checks that could be ordered were every 30 minutes.

Based on interview with the Risk Manager (above), the facility has since changed to a system that can scan patients from outside of the room by proximity to a wrist band without having to step inside the room or, as the Risk Manager stated, "having to get as close to patients." Furthermore, since the new system is designed to require scans within fixed 15 or 30 minute blocks of time, instead of every 15 or 30 minutes as ordered, as acknowledged by the Chief Nursing Officer in interview above, minimal scanning frequencies have been expanded to one minute and double the frequency ordered by the physician with no capability to ensure wristband checks every 15 minutes and no practice to ensure wristband checks every 30 minutes. Although past issues with staff noncompliance of rounding on patients and/or falsifying patient checks were identified and deficient practice cited during surveys on 10/05/22 and 05/17/19, the Risk Manager and Chief Nursing Officer provided no evidence of auditing staff by observation to ensure they physically round and are seeing patients to verify their activities and signs of life, but reported they monitor compliance by auditing the electronic dashboard which tracks scans of wrist devices from up to 30 feet away.

Based on observation, interview and record review, the facility failed to ensure availability of nursing personnel in all patient areas to monitor and ensure prompt intervention to emergencies and altercations.

The effect of A398 resulted in Immediate Jeopardy at the Condition of Participation (CoP), Nursing Services, 482.23, as not being met.

The findings included:

Based on observation, interview and record review, the facility failed to supervise staff to ensure monitoring of patients on all wings and the ability to respond promptly to signs of emergencies and altercations. This affected 1 of 7 sampled patients (Patient #2) whose roommate assaulted him and forcibly detached both of Patient #2's eyes before staff responded several minutes later by request of another patient. Refer to A398.

Based on observation, interview and record review, the facility failed to supervise staff to ensure monitoring of patients on all wings and the ability to respond promptly to signs of emergencies and altercations. This affected 1 of 7 sampled patients (Patient #2) whose roommate assaulted him and forcibly detached both of Patient #2's eyes before staff responded several minutes later by request of another patient. As a result of this incident, Patient #2 is permanently blind and has expressed wishes to die and for someone to kill him because he cannot see.

This resulted in Immediate Jeopardy at the standard level deficiency for Nursing Services, Code of Federal Regulations (CFR) 482.23(b)(6), refer to A385.

The findings included:

Review of the hospital's Policy and Procedure, titled, Supervision of Persons Served (patients), effective 08/22/23, documented, in part, "The purpose of this policy is to ensure the provision of a safe and secure environment, through the process of staff supervision and accountability" and "The minimum level of supervision is 30-minute checks."

Review of the hospital's Job Description for Nurse Manager, created October 2014, last revised October 2017, documented, in part, Job Responsibilities that include "plans, coordinates, and supervises the delivery of nursing care by licensed nurses and mental health technicians for assigned nursing unit. Assigns responsibilities to nursing staff and unit program staff ... and oversees the therapeutic environment of the unit."

Review of the hospital's Job Description for Mental Health Technician [MHT], created October 2014, last revised October 2017, documented, in part, Job Responsibilities that include: "overall supervision of P/S [patients or persons served]."

Review of Patient #2's record revealed he was admitted to the hospital on 04/20/23 with diagnoses to include schizophrenia, psychosis, and attacking an elderly family member. Patient #2 became roommates with Patient #1 on 09/12/23.

Review of Patient #1's record revealed he was admitted to the hospital on 08/04/23. Patient #1's Comprehensive Psychiatric History dated 08/05/23 documents he has a history that includes schizophrenia and intermittent explosive disorder, multiple psychiatric hospitalizations, and was in a state hospital for several years due to "violent and aggressive behavior as well as continued extreme psychosis for several years as well as delusions and paranoia"; Patient #1 denied a history of harming others but there was documentation of "a history of extensive harm to others in the past"; he has a history of being unpredictable and becoming extremely violent at times, losing his temper for no reason; and he has attacked multiple people, including family members multiple times and an employee at the receiving facility just prior to this admission.

Patient #1's Event Note for 09/10/23 at 3:30 AM documented around 3:00 AM the Mental Health Technician (MHT) heard a noise coming out of the room and opened the door to find Patient #1 beating on his roommate (Patient #9). Patient #1's General notes: Psychiatry dated 09/11/23 at 4:22 PM documented Patient #1 assaulted his roommate last night and it appears he may not remember doing it; that the patient is dangerous; that he was pleasant during interview but can snap at any moment and has no awareness into his illness; and under Plan that medications were adjusted, assault precautions, patient is a danger to others, and continue inpatient treatment.
Patient #1's Event Note dated 09/12/23 at 5:52 PM documented P/S remains on SOR (Safety Observation Room with live camera monitoring) for "safety precaution and assault," attacked roommate in (sic) his sleep last Sunday, refused to vacate his room, security (was) called, and patient was placed on SOR in (room with Patient #2).
Patient #1's Psychiatric Weekly Progress Note dated 09/13/23 at 10:56 documented "start assault precautions," and "decrease to Level 1 access to grounds."
Patient #1's Psychiatric Weekly Progress Note dated 09/21/23 at 5:22 PM documented Patient #1's father requested to change him to Level 2 grounds privileges so he can visit.

During interview on 09/29/23 at 2:30 PM, Psychiatrist A reported an order for assault precautions is a way to communicate for staff to be more conscious that the pt can be assaultive to others, but denies awareness of any set protocol, and denies recall if that order was discontinued for Patient #1 before 09/22/23. He also reported he accommodated the father's request to visit by discontinuing Patient #1's SOR order on 09/21/23 and upgrading his grounds privileges so he could visit.

During interview on 09/29/23 at 3:30 PM, Risk Manager E denied any protocol for "assault precautions" but stated psychiatry can order specific measures.

Review of camera footage from the C-wing hall from 2:40 PM to 3:43:55 PM (hours, minutes/seconds) (times per that camera) revealed staff came onto the C-wing for a total of 3 minutes and 47 seconds during that hour and 3 minutes.
Refer to A144.
Patient #1 attacked Patient #2 on 09/22/23 at 3:47 PM (per time on in-room camera) while their door was open, repeatedly punched him, traumatically removed and detached both of Patient #2's eyes with his bare hands, and restrained Patient #2 on the floor for several minutes before the first staff arrived at 3:54 PM. Review of camera footage from the C-wing hall revealed 2 patients came from the C-wing day room to look in the room Patients #1 and #2 shared almost immediately after the assault started and one patient observed the altercation from outside the doorway at length. No staff were observed on that wing during the assault from 3:47 PM until the first staff arrived outside the room at 3:54 PM.
Facility documentation reviewed with the Risk Manager revealed no report of staff hearing or seeing signs of a disturbance in that room until another patient came and informed staff at the nursing station of an altercation. Since the order for live camera observation in their room had been discontinued by the physician the day before to accommodate Patient #1's family's request to increase privileges for visitation, no one was observing the room at the time of the assault to request help.
Refer to A145.

Patient #2 was hospitalized at an acute hospital from 09/22/23 to 10/04/23, is now permanently blind and suffered a broken nose, and after his return to the facility on 10/04/23 has expressed wishes to die and for someone to kill him because he cannot see.

During an interview with the Chief Nursing Officer (CNO) on 09/29/23 at 5:25 PM, he explained the current electronic monitoring system used to scan patient bracelets by proximity prompts staff using blocks of time. The CNO acknowledged persons with an order for 30-minute checks (the most infrequent monitoring of pts who have gained that privilege) could be scanned with intervals as long as 59 minutes apart and still be considered in compliance as long as each scan was in a different 30 minute block of the clock hour, but that this is "ok" because they are still within the 30 minute blocks and it takes most of that time to get all the patients scanned. The CNO stated since this event they realized when staff scan patients as in programs (where program staff are with them continuously), the system is locked out for 3 hours, which has now been changed to 2 hours, during which staff cannot scan them until that time is up. The CNO reported Patients #1 and #2 were both logged as in programs when this event happened, although they did not go to programs that afternoon. This enabled staff not to have to check on Patients #1 and #2 or scan their patient bracelets for over 3 hours. The CNO reported this has since been addressed by shortening the lock out time for programs to 2 hours but reported no means to check that staff do not continue to log persons as in programs when they do not go to programs and to ensure they continue patient checks at the physician-ordered frequency.

During interview on 10/10/23 at 11:51 AM, Risk Manager E stated the new electronic monitoring system is better because now staff don't have to get as close to the patients or have to scan barcodes, they can scan from the door and do not even have to go in the room, and when asked about checking for signs of life, seeing the patient to ensure they are ok and not just that the wristband is in range, she responded it explains right here and started reading out loud the color coding used for the dashboard display, which the previous system also had. When asked about the required intervals on the new system, which are now up to one minute and twice as long as the interval a physician orders, she did not respond to this but resumed description of the color coded dashboard and the color representing being out of range of the device on wristbands. Risk Manager E provided no plans to ensure staff maintain a presence in all areas where there are patients so as to supervise their activities other than to conduct proximity scans at intervals up to 29 to 59 minutes

During an interview on 10/11/23 at 12:00, Security Officer D initially said he was not sure the event was preventable. Upon being told staff spent a total of 3 minutes and 47 seconds on the wing where this occurred in the 1 hour 4 minutes before it started, Security Officer D stated that could have contributed to it and that "when they know there's no one around, it's an opportunity."

Based on interviews and record review, the facility failed to ensure the clinical team re-evaluated a patient's condition after significant changes, to determine readiness for discharge, and arrange an appropriate discharge where needs could be met for 1 of 3 sampled patients (Patient #2), reviewed for discharge planning.

(This resulted in the non-Immediate Jeopardy standard level deficiency for Discharge Planning, at CFR 482.43(a)(6), as not being met.)

The findings included:

Patient #2 was admitted to the facility under Civil status on 04/20/23. He was hospitalized following a patient-to-patient altercation on 09/22/23 which resulted in the avulsion ("the action of pulling or tearing away") of both of his eyes. Patient #2 was re-admitted to the facility on 10/03/23 from an actue care hospital.

Patient #2 had a psychiatric history significant for Psychosis, Personality Disorder, Self-Injurious Behaviors, Schizophrenia, and Aggressive Behaviors.

In an interview conducted on 10/10/23 at 10:43 AM with the facility's Administrator, he stated, "We [the facility] asked the Department of Children and Families (DCF) to divert [Patient #2] to the state run facility outside of [J.....]" because they and Patient #2's family "felt it was not a good idea for him to return to this facility". The Administrator said, "we were hopeful that DCF would have been able to make other arrangements" but that he "feels perfectly confident that we will be able to take the best care of him and provide the best care". He stated he had heard Patient #2 was "very aggressive at the hospital and was in restraints" so the administration staff wanted to make sure he was stable with the facility staff and his medication regimen. The Administrator stated they also planned to establish a Physical and Occupational Therapy (PT and OT) schedule for Patient #2 so he could feel more comfortable in his surroundings due to his new medical status of blindness but that it had not happened yet. He also said it was important that security officers stayed close during Patient #2's visitations with his family "in case he lashes out at his dad again" as he had a history of attacking his elderly father.

In an interview conducted on 10/10/23 at 10:24 AM with the facility's Risk Manager, she stated the facility was arranging for Patient #2 to receive PT and OT services since his return. She said Patient #2's mood had been "quiet", and he had "not been acting out toward staff". The Risk Manager said Patient #2 "needed help to become psychiatrically stable" by taking his ordered medications but that he had a history of refusing his medications. She confirmed Patient #2 had still been refusing his medications often. She also stated she felt that Patient #2 coming back to this facility was "not a good idea due to the trauma" but that the facility's administration team "did not have a say in it".

An interview was conducted with Psychiatrist B, the Sanibel Unit psychiatrist on 10/11/23 at 1:25 PM. The psychiatrist confirmed that he did not know Patient #2 prior to his readmission on 10/04/23 and that he had not previously assessed Patient #2's mentation or behavioral status prior to the readmission. He stated he had been working with Patient #2 for one week. He said Patient #2 continued to refuse to take his medications about 50% of the time. He said Patient #2 was on one-to-one observation with a Mental Health Technician (MHT) for safety because of his new condition. He said Patient #2 made a "comment 2 or 3 nights ago that he wants someone to harm him or choke him out because he cannot see" and that because of that statement, the psychiatrist also put him on "suicide precautions". At the end of this interview, Psychiatrist B stated he thought Patient #2 was being discharged from the facility on 10/12/23. When asked to elaborate, he stated he did not know for sure, but he thought Patient #2 was being discharged.

Interviews were conducted on the morning of 10/12/23 with the facility's Administrator, Risk Manager, and Compliance Director regarding Psychiatrist B's statement that Patient #2 may be discharged on 10/12/23. Each member of the administration team stated they did not know about Patient #2 being discharged but would get back to the surveyors with information later in the day.

An interview was conducted with the facility's Compliance Director on 10/12/23 at 1:35 PM. She stated Patient #2 had been received at his new facility, a nursing home in the [M....] area. The surveyors asked her to provide documentation that showed Patient #2 was assessed and found to be appropriate for discharge to a nursing home. She stated she would have to look through his chart for this documentation.

An interview was conducted with the facility's Administrator on 10/12/23 at 2:08 PM. He stated that he did not know it would be an issue for Patient #2 to be discharged to a nursing home at that time and that if it made the surveyors more comfortable, he was willing to send a Mental Health Technician to the new facility to act as a sitter until any concerns were resolved. When asked who wrote the order to discharge Patient #2, he stated Psychiatrist B wrote the order. When asked if this was an administrative decision, he stated, "the administration staff would never interfere with a physician's decision to discharge a patient".

The facility's Compliance Director provided a form, titled, Emergency Discharge Notification Sheet, dated 10/11/23 at 10:00 AM. When asked why this was considered an emergency discharge, she stated she did not know.

The facility's Compliance Director provided a packet of information she stated had been sent in the referral to the receiving facility, including a Discharge Plan Recovery form which was done on 10/11/23 at 12:32 PM, which documented "[Patient #2] has displayed discharge readiness during his stay" and described Patient #2 as "medication compliant". Within the packet was also an old head-to-toe assessment from the admission on 04/20/23 which documented Patient #2's vision acuity from before the loss of both eyes. Notably missing from the packet of information was any information regarding the patient-to-patient altercation and 2-week long hospitalization that followed.

Review of a Social Work Note dated 10/12/23 at 11:00 AM documented a discharge meeting for [Patient #2] was held with the Sanibel Treatment Team; that [Patient #2] was informed of his placement location, date and time of his outpatient psychiatric and medical follow-up appointment, aftercare services, case management services, and benefits information; and that [Patient #2] understood what was explained to him.

Review of a Treatment Team Note written on 10/12/23 at 12:19 PM documented, "Treatment team met to inform [Patient #2] about his discharge. He presented as happy about the news. Please see discharge plan for further details".

The Compliance Director was unable to provide documentation showing Patient #2 was assessed to be appropriate for a discharge to a nursing home setting. Nursing Notes and Treatment Team Notes were provided, dated 10/04/23 through 10/11/23. These notes documented Patient #2 made comments to staff numerous times regarding wanting someone to harm him because he wanted "to see like you see" and that "he did not want to live anymore as living was pointless". These notes also documented that Patient #2 refused his medications almost daily. When he refused his medications, the staff would give him injections of Haldol (a potent antipsychotic medication). When this happened, Patient #2 told the staff he was going to "sue the hospital". There were care plans in place regarding "lack of insight into mental illness" (started 10/06/23) and "self-injurious behaviors" (started 10/10/23) that were still in Active status when Patient #2 was discharged.

In an interview on 10/13/23 9:36 AM, Psychiatrist B stated he received a telephone call on 10/11/23 that Patient #2 would be discharged on 10/12/23 and that the person needed him to write the order for the discharge. When asked who called him regarding this, he said he did not know but that it may have been a social worker. Psychiatrist B stated he then talked to the Administrator who confirmed they were discharging Patient #2. Psychiatrist B stated he thought it would have been better for Patient #2 to spend more time at the facility before he was discharged. Psychiatrist B reported Patient #2 was only taking his medications about 50% of the time and needed PT and OT services.

In an interview conducted with the facility's Social Services Director on 10/13/23 at 12:45 PM, she stated the plan to discharge Patient #2 to a nursing home started before he returned from the hospital and that "the conversation about the nursing home started on 09/27/23". She said she spoke to the social worker at the hospital and to Patient #2's family about this plan while he was still at the hospital. When asked why this was not documented, she stated she did not know. She also said, "it was never the intention for him to return to this facility for an extended period of time". She said Patient #2 was "stable" on his psychiatric medications, specifically the Haldol for approximately 3 weeks since he entered the hospital. She said when he returned to the facility, his mood was "improved", and he was taking his medications. When the surveyor informed the Social Worker that the Nursing Notes reflected he was only taking his medications less than 50% of the time and that his mood could theoretically change back to unstable at any time because of that, she nodded her head in agreement. When the surveyor asked if it would have been better to keep him for longer than 1 week to assess his mood and behavior further, she shrugged her shoulders and did not respond verbally. The Social Services Director then said that it was unfortunate that he went to the new facility and had to come right back after surveyor intervention because that may have been traumatic for him, having to come back. The Social Services Director did not acknowledge that the discharge of Patient #2, who had a history of violence including toward elderly family members, to a nursing home before the clinical team determined he was psychiatrically stable after the traumatic removal of both eyes by a roommate in an attack on 09/22/23, was an inappropriate discharge or that it put other persons at risk of harm.