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Based on observation, interview, record review and policy review, the hospital failed to ensure a safe environment for patients when one patient (#3) was physically assaulted and suffered facial burns from a patient (#16) who was known to be an aggressor. The hospital failed to implement interventions to ensure the safety of all patients (A-144).


This failure had the potential to place all patients admitted to the hospital at risk for their safety. The cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13, Condition of Participation: Patient's Rights. The hospital census was 74.

Based on observation, interview, record review and policy review, the hospital failed to ensure a safe environment for patients when one patient (#3) was physically assaulted and suffered facial burns from a patient (#16) who was known to be an aggressor. The hospital failed to implement interventions to ensure the safety of all patients. The hospital census was 74.

Findings Included:

Review of the hospital's policy titled, "Patient Rights and Ethics," dated 05/16/22, showed that patients have the right to be protected from neglect, physical, verbal and emotional abuse.

Review of the hospital's policy titled, "Alleged Abuse Neglect," dated 05/16/22, showed that:
- Abuse was defined as the willful infliction of injury resulting in physical harm, pain or mental anguish, this included infliction of injury of one patient by another.
- Neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. This includes, but is not limited to, failure to provide adequate supervision during an event in which one individual causes serious injury to another.
- After patient-to-patient abuse the Registered Nurse (RN) would place the patient committing the offense, on every five minute observations, or one to one (1:1, continuous visual contact with close physical proximity) observations and notify the attending/covering physician.

Review of the hospital's policy titled, "Observation & Patient Monitoring - Acute Services," dated 05/17/21, showed that:
- Observation levels were initiated by a provider order.
- During rounds, staff are to make direct visual contact and look for signs of danger or distress.
- Staff were to remain vigilant for specific risks to patients on Special Precautions.
- Staff were to observe the patient's environment for potential hazards that could be corrected.
- A patient would be placed on five minute checks if their behavior was unpredictable and potential risk for harm to self/or others, yet behavior is not at the point of requiring 1:1 observations.
- 1:1 was the highest level of precautions and was reserved for patients who were so unpredictable that without a dedicated staff member there was a risk of the patient harming self or others.
- Patients who actively harm self or others require increased monitoring and appropriate interventions.

Review of the hospital's policy titled, "Assault Precautions and Prevention: Early Identification, Observations, Intervention, Response and Notification," dated 04/30/21, showed that:
- Staff assigned to monitor patients on Assault Precautions shall be vigilant for identification of aggressive/assaultive behaviors.
- If the patient's aggression or threats were focused on a particular peer, separate the two to avoid the trigger and alleviate risk.
- Implement/Update the treatment plan to address aggressive/assaultive problems, patient goals and staff interventions.
- Conduct ongoing safety checks of the environment for potential contraband.
- Staff shall identify risk factors, noting those which can be modified to reduce risk.
- Staff shall determine level of risk and choose appropriate interventions to address and reduce risk.

Review of the hospital's undated document titled, "Program Orientation Booklet," showed:
- 3 South (3S) was an 18 bed co-ed adolescent step-down unit.
- Patients were to avoid inappropriate physical contact and that it was a "no touch" facility.
- If patients were unable to maintain appropriate boundaries with peers they would be placed on Limited Peer Interaction (LPI).
- LPI was an intervention that staff would enforce to ensure that the patient and the peer were separated for safety.
- Unit Activities Only (UAO) was a restriction where the patient would have to remain on the unit only, for up to 24 hours, or until deemed safe by staff.

Although requested, the hospital failed to provide a copy of the "Incident Report Form" as that was considered a "Patient Safety Work Product."

Review of Patient #3's medical record showed that:
- She was a 14-year-old female who was admitted on 05/25/23 for oppositional defiant disorder (ODD, a disorder marked by defiant and disobedient behavior to authority figures) and self-harm behaviors.
- She was on Assault Precautions.
- She was on LPI.
- An Individual Crisis Management Plan dated 09/22/23, noted she failed to abide by the LPI rules that were put into place between herself and Patient #16. She received a loss of privileges (LOP) times two.
- On 10/21/23, a Post Incident Assessment Form showed that Patient #16 attacked her and pulled her hair. The physician was contacted and there were no new orders.
- On 10/28/23, a Post Incident Assessment Form showed Patient #16 threw a cup of hot water in her face. Staff N, Psychiatric Mental Health Nurse Practitioner (PMHNP), was contacted and she was sent to the Emergency Department (ED) for treatment.
- A Practitioner Order Sheet showed the patient suffered a second degree burn (damage to the outer layer and the layer underneath of skin by heat, chemicals, electricity, or radiation) to her face.
- A Progress Note dated 10/28/23, at 12:50 PM, showed that in the ED, Patient #3 told the nurse that a peer "threw hot water on my face and punched me in the head a few times" and that she was "scared and would be uncomfortable if peer (Patient #16) was still on the unit" when she returned.
- A Progress Note dated 10/28/23, at 6:05 PM, showed that the patient returned to the unit and "became anxious when she saw peer (Patient #16)" but that "staff would continue to monitor for safety."
- She remained on the same unit as Patient #16, and continued on five minute checks, from 10/28/23 through 10/30/23 at 1:45 PM, when she was placed on 1:1 observation.

Review of Patient #16's medical record showed that:
- She was a 16-year-old female initially admitted on 07/06/23.
- A Psychiatric Evaluation dated 08/02/23, showed she was recently discharged, and was in the process of being transported, when she ran away from her caseworker and was returned to the hospital.
- A Psychological and Neurobehavioral Evaluation dated 07/06/23, showed she had a history of behavioral acting out and non-compliance. She had "pending charges for assault towards a peer" and "has been in physical altercations that have included hitting another multiple times in head, pulling hair and pulling and assaulting staff."
- She was on Assault Precautions.
- She was on LPI.
- On 09/30/23, a Seclusion and Restraint Progress Note showed she was in a group when she became upset at another peer, put the peer in a headlock and then used her hands to attempt to choke the peer. Intervention was a "homework exercise to increase positive self-image and confidence in an effort to help with poor impulse control."
- On 10/05/23, a Post Incident Assessment Form and Seclusion and Restraint Progress Note showed the patient yelled at a peer, hit her on the back and when the peer turned around she started punching the peer. The physician was contacted with orders to "monitor for safety."
- An Individual Crisis Management Plan dated 10/05/23, showed she was placed on UAO and had a LOP times three.
- On 10/13/23, a Post Incident Assessment Form and Seclusion and Restraint Progress Note showed she ran to the end of the hall and stabbed herself 12 times in the left arm and right hand with a pencil.
- An Individual Crisis Management Plan dated 10/13/23, noted showed she was placed on five minute checks and UAO.
- On 10/21/23, a Post Incident Assessment Form showed she hit Patient #3 and pulled her hair. The physician was contacted and no new orders were received.
- An Individual Crisis Management Plan dated 10/21/23, noted showed she was placed on LPI, UAO, and on a writing utensil restriction for 48 hours due to aggression.
- A Progress Note dated 10/28/23 at 11:46 AM, showed while waiting in line for group therapy, she filled a cup with hot water and threw it in Patient #16's face and then "lunged on top of her and was repeatedly hitting her until staff split the patients up."
- On 10/28/23, a Post Incident Assessment Form showed she threw hot water in Patient #16's face. Staff H, PMHNP, was contacted and her response was "ok".
- A Progress Note dated 10/28/23 at 1:13 PM, showed that she was agitated most of the shift, rude and inappropriate with staff, telling other patients they can't talk to her and that they "need to walk away" from her.
- An Individual Crisis Management Plan dated 10/28/23, showed she was placed on UAO and had a LOP times three.
- A Multidisciplinary Treatment Plan Update, with multiple dates from 10/16/23 through 10/30/23, showed "patient is on her own agenda, shows absolutely no remorse, intentionally assaults other patients and has no intention of working any type of program".
- She remained on 3S, on every five minute checks from the time of the altercation on 10/28/23 until 10/30/23 at 1:40 PM, when she was placed on 1:1 observation and moved to the 4 South unit for "patient safety."

Observation on 3S, on 10/30/23 at 10:20 AM, showed Patient #3 and Patient #16 participating in a group activity together. Neither patient was on 1:1 observation.

During an interview on 10/30/23 at 10:20 AM, Patient #3 stated that she and Patient #16 didn't get along and that Patient #16 had physically attacked her before. On 10/28/23, she was waiting in line for a group when Patient #16 came up to her and "threw boiling hot water" in her face and when she fell to the ground from the pain, Patient #16 jumped on her and started hitting her in the face and head. She stated that she was afraid when she came back from the ED that Patient #16 would attack her again. She stated that neither she nor Patient #16 had been placed on 1:1 observation. She asked staff several times to be moved to a different unit but was told no.

During an interview on 10/30/23, at 10:40 AM, Patient #16 stated that a new employee who was on orientation unlocked the closet where the water was stored. She stated she knew that the employee didn't know that staff was supposed to get the water for her so she took advantage of that and dispensed the hot water herself. She then went to Patient #3 and threw it in her face and started punching her. Afterward she went to the "reset room" for an hour. She was never put on a 1:1 observation. She was still mad at Patient #3 and that she would attack her again if "she started running her mouth."

During an interview on 11/1/23 at 10:45 AM, Staff K, Behavioral Health Associate (BHA), stated that Patient #16 asked her for a cup of water. She asked Staff G, Milleu Coordinator, if that was ok and he said yes. She didn't know she had to dispense the water for patients and she didn't know that the machine had hot water. Staff did not want Patient #16 on 1:1 observation because she was attention seeking and they didn't want to feed into that behavior. 1:1 observation was only used for patients who were a suicide (thoughts of causing one's own death) or elopement (when a patient makes an intentional, unauthorized departure from a medical facility) risk. The only education she received was instructions on the water closet and dispensing water.

During an interview on 10/31/23 at 11:40 AM, Staff F, BHA, stated that Patient #16 was upset about a "learning experience" assignment that she had been given. When she had come out of group she had asked for a cup of water. He was locking the group room door when he heard another staff yell. He turned around and saw Patient #16 on top of Patient #3 hitting her in the face. After they were separated, Patient #16 went to the reset room and Patient #3 went to the hospital, neither were placed on 1:1 observation. Patients had been placed on 1:1 observation after altercations in the past, but not always, it just "depends on how often it happens". After altercations "sometimes patients get moved to other units but it probably didn't happen with these two because it was the weekend". He had not received any education since the event.

During an interview on 10/31/23 at 12:30 PM, Staff G, Milleu Coordinator, stated that the water closet was always locked and that staff were to dispense the water for patients. He knew that the water could get really hot but he did not know the exact temperature. When Patient #3 returned from the hospital she would move closer to staff when Patient #16 would come around but she never verbalized that she didn't feel safe. Patients were moved from unit to unit at times but it was not usually because of an altercation. He had not received any education since the event.

During an interview on 10/31/23 at 10:30 AM, Staff E, BHA, stated that she heard Staff K, BHA, yelling for help around the corner and by the time she got there the patients were already separated. The two hadn't been getting along all week and that she had been asking other staff to keep a closer eye on them but no one would listen to her. She was never asked to do a 1:1 with either patient. She had not received any education since the event.

During an interview on 10/31/23 at 3:00 PM, Staff J, BHA, stated that when Patient #3 returned from the hospital they took "extra precautions" to make sure that the patients weren't near each other at meals and in groups. He was not sure why neither was placed on 1:1 but stated that nursing was responsible for escalating that. He was unsure why neither girl was moved units immediately. He had not received any education since the event.

During an interview on 11/1/23 at 1:45 PM, Staff L, Charge RN, stated that she did not witness the event but assessed Patient #3 and called for an order to send her to the ED. After altercations patients were put on LPI and that was enforced by the staff on the floor by putting distance between patients, not sharing rooms, not sitting near each other at meals and separate groups. 1:1 observations were only used for patients who were a danger to themselves or others. Providers made the decision on patient moves between units and 1:1 observations. She was unsure about what the hospital's Abuse and Neglect policy said about patient-to-patient altercations.

During an interview on 11/1/23 at 2:05 PM, Staff M, RN, stated that 1:1 observations were used after suicide gestures, severe aggression, elopement, or assaulting others. Room changes or unit changes did happen "at times" after altercations. Unsure if the abuse and neglect policy said anything about 1:1 after altercations "because those decisions are provider driven."

During an interview on 11/1/23, at 2:25 PM, Staff N, PMHNP, stated that 1:1 observations were dependent on the patient and that there was no "set rule", providers just used their "best judgement" and that they tried to be the "least restrictive while keep the patients safe." Assault Precautions were "just a warning to staff that the patient had an aggressive history and that staff needed to be extra vigilant in their observation and keeping that patient away from other patients." LPI was enforced by staff on the floor and it meant that patients on LPI were only to interact in group therapy situations. On 10/28/23, she was the provider on call but stated that she never received a call from the nursing staff regarding either of these patients.

During an interview on 11/1/23 at 3:00 PM, Staff B, Chief Nursing Officer, stated that the expectation was that nursing staff would reach out to the psychiatric provider on call after any patient to patient altercation. The decision to place a patient on 1:1 observations or make a room change was up to the provider but that they were open to recommendations. Assault Precautions meant that the patient had a history of assaultive behavior, were on checks every five or 15 minutes, and that needed to be watched closer. LPI meant that staff were to observe and ensure that patients did not have contact with another patient they were on LPI with. He was unsure how long the water machines had been in use. He thought maybe the machines had been switched while he was out on an extended leave. There were no logs that were kept to monitor the temperature of the water. The hot water was disconnected to the machines as of 10/30/23 and staff were re-educated on water dispenser instructions.

During an interview on 11/1/23 at 3:22 PM, Staff C, Chief Executive Officer, stated that nurses could place patients on LPI, take privileges away and could change observations levels but that the provider needed to be notified. The water machines had not been in used for years and that they were a replacement for old sinks that had ligature (anything which could be used for the purpose of hanging or strangulation) risks. There were switches on the back of each machine that controlled hot water to the machine and that someone must have turned the hot water switch on for the machine on 3S. All machines had been permanently disabled for hot water use as of 10/30/23.