Delta Specialty Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 33763 Based on hospital policy review, document review, medical record review, video recording review, and interview, the hospital failed to ensure all patients received care in a safe setting for 15 of 16 (Patient #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and Random Patient #1) sampled patients. The facility’s failure to ensure all patients received care in a safe setting placed all 15 patients observed on the unit with Patient #1 in an IMMEDIATE threat for their health and safety. The findings included: 1. Review of the hospital policy titled, “Scope of Service/Provision of Patient Care” revised 3/2024 revealed, “...the goal of the hospital is to provide safe and supportive environments for patients, staff and visitors...The primary goal of nursing services is to provide planned, comprehensive, therapeutic, safe, and consistent nursing care...”. Review of the hospital policy titled, “Patient Rights, ADM 01-15” revised on 2/2020 revealed, “...The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned...”. Review of the hospital policy titled, “Observations, Patient” revised 7/2021 revealed, “...In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN [Registered Nurse]...Staff documents all levels of observation on each patient’s observation form which becomes a part of the patient record. Each entry is to include the following...Level of observation...Precaution...Location...Behavior...Activity...Time...Staff Initial and Signature...Patient is placed on Q [every] 5 minutes if their behaviors is unpredictable and there is potential risk for harm to self and others yet behaviors is not at the point requiring constant 1:1 observation...Patient is monitored at minimum once in every 5-minute block of time...1:1 is the highest level of observation and is reserved for patients who are so unpredictable that without a dedicated staff member there is a risk of patient harming self or others...”. 2. Review of the hospital document titled, “Chief Nursing Officer Job Description” dated 1/1/2020 revealed, “...Recognize that patient safety is a top priority...”. Review of the hospital document titled, “RN Job Description” dated 1/1/2020 revealed, “...Recognize that patient safety is a top priority...”. Review of the hospital document titled, “Behavioral Health Associate [Behavioral Health Technician (BHT)] Job Description” dated 1/1/2020 revealed, “...Recognize that patient safety if a top priority...Responsible for conducting safety checks and ensuring that supervision is conducted at 15 minute intervals, as noted in special precaution, or in accordance with individualized supervision guidelines as needed...Document timely, accurate and appropriate clinical information in patient’s medical record...Assist in providing a safe, secure and comfortable environment for patients, significant other and staff...Interact routinely with patients, observe behaviors and communicate significant observations to nursing staff...”. Review of the hospital documents titled, “Immediately-For Your Safety, Please Follow This Process” revealed, “I attest that I understand that I am responsible for escalating situations that could lead to a significant patient or staff incident...Patient making verbal threats of physical harm, unresolved by unit staff...Patients escalating or high acuity on the unit, unresolved or uncontrolled by unit staff.” The documents were signed by BHT #2 on 3/21/2024 and by BHT #1 on 3/22/2024. Review of the hospital’s incident log revealed Patient #2 was “Injured by Other Patient” on 5/25/2024 at 7:55 PM. Review of a facility incident reported to the Survey Agency on 5/31/2024 revealed, “...On May 25, 2024...At 1955 [7:55 PM] [Patient #2 was attacked by Patient #1] unprovoked in the hallway, the attack lasted less than 30 seconds but caused significant injuries to [Patient #2]...Investigation initiated...”. 3. Medical record review for Patient #1 revealed a 34 year-old male admitted on 4/24/2024 with diagnoses which included Schizoaffective Disorder, Bipolar Type. (Schizoaffective Disorder, Bipolar Type is a mental illness characterized by symptoms such as hallucinations - seeing and/or hearing things that aren’t there, and delusions (having false or unrealistic beliefs or opinions), and symptoms of a mood disorder such as depression, mania or hypomania (periods of great excitement or euphoria, delusions, and overactivity). Review of the physician’s orders dated 5/24/2024 at 7:24 PM revealed Patient #1 was to be admitted to the hospital’s General Psychiatric Unit with Suicide Precautions and Assault Precautions and should be observed by staff every 5 minutes. Review of a Nurse Progress Note written by Registered Nurse (RN ) #1 on 5/25/2024 at 11:54 PM revealed, “[Patient #1] severely beat another patient. The fight was broken up and [Patient #1] was placed in seclusion...has no injuries or complaints of pain. [Patient #1] will be discharged and taken by [Local police department]...”. Review of a Progress Quick Note written by the Medical Director on 5/26/2024 at 3:47 PM revealed “...I was notified last night per HS [House Supervisor] pt [Patient #1] assaulted another pt [Patient #2] on the unit and left the hospital in the custody of [Local police department]...”. 4. Medical record review for Patient #2 revealed a 45 year-old male admitted on 5/24/2024 with diagnoses which included Major Depressive Disorder, Recurrent, Severe with Psychotic Features. Review of the physician’s orders dated 5/24/2024 at 10:04 AM revealed Patient #2 was to be admitted to the hospital’s Dual Diagnosis Unit (DDU). The order was changed at 10:06 AM to admit to the hospital’s General Psychiatric Unit (GPU). Further review revealed Patient #2 should be placed on assault and suicide precautions and should be observed by staff every 5 minutes. Review of a Nurse Progress Note written by RN #1 dated 5/26/2024 at 9:43 PM revealed Patient #2 was observed on the floor with Patient #1 on top of him. Patient #1 was hitting/striking Patient #2’s head. Staff intervened and pulled Patient #1 off of Patient #2. After being pulled off of Patient #2, Patient #1 was able to kick Patient #2 in the head 3 times before the incident ended. Patient #2 was unresponsive and was showing signs of damage to his brain. Staff called emergency medical services (EMS) and police. Patient #1 was taken into police custody, and Patient #2 was transported to Hospital #2 for further care. 5. Review of the Behavioral Health - Patient Observation Sheets for both Patient #1 and Patient #2 revealed BHT #2 documented both patients were asleep in their rooms during the time the incident occurred. Further review revealed both patients had orders to be observed by staff every 5 minutes; however, those observations were not completed per physician’s orders. 6. Review of the hospital’s video recording of the North hallway, dayroom, and South hallway dated 5/25/2024 from 7:49:58 PM until 8:00:51 PM revealed the cameras did not capture the incident due to the use of portable air conditioning units that were in use which obstructed the South hallway from camera view. The video recording did show both Patient #1 and #2 prior to the incident, then Patient #1 was back in view in the dayroom unsecured with a total of 14 other patients. The video recording stopped before any police or ambulance personnel arrived on scene. 7. Interviews were conducted with personnel who witnessed and/or responded to the incident. Two employees refused to be interviewed. Their written witness statements were reviewed. 8. Patient #3, #4,#5,#6, #7, #8, #9, #10, #11, #12, #13, #14, and #15’s medical records were reviewed and revealed all 13 of the patients viewed on the hospital’s video recording, were documented as being asleep in their rooms at the time of the incident although video recording showed them in the day room. Refer to A144.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 33763 Based on hospital policy review, document review, medical record review, video recording review, and interview, the hospital failed to ensure all patients received care in a safe setting for 15 of 16 (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15) sampled patients and 1 of 1 (Random Patient (RP #17) random patients reviewed. The findings included: 1. Review of the hospital policy titled, “Scope of Service/Provision of Patient Care” revised 3/2024 revealed, “...Care is provided according to an established code of ethical conduct and strict adherence to patient rights...From a facilities perspective, the goal of the hospital is to provide safe and supportive environments for patients, staff and visitors...Adult Services...Patients are admitted to one of the units based on clinical criteria...For the male population who are severely acute, demonstrating psychotic features and at risk for behavioral issues, a physician will provide an order to the patient will be admitted to GPU (General Psychiatric Unit)...Nursing Services...The primary goal of nursing services is to provide planned, comprehensive, therapeutic, safe, and consistent nursing care...Additional responsibilities of nursing staff include...providing opportunities for leaning about self and exploring patterns of interaction within a safe environment...”. Review of the hospital policy titled, “Patient Rights, ADM 01-15” revised on 2/2020 revealed, “...All personnel are responsible for adherence to the principles as outlined in the “Patient Rights.”...The patient has the right to considerate, respectful care at all times and under all circumstances...Be placed in protective privacy when considered necessary for personal safety...Personal Safety 1. The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned...”. Review of the hospital policy titled, “Observations, Patient” revised 7/2021 revealed, “...In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN [Registered Nurse]. Level of observation can be increased by the RN any time there is a concern but only a psychiatric practitioner may decrease the level...The psychiatric practitioner will order one of three levels of observation at time of admission and as the patient’s condition warrants a change: a. 15 minute b. 5 minute c. One-to-one 2. The psychiatric practitioner may also order a precaution level of observation for: a. Suicide b. Assault...f Sexual Acting Out 3. The RN may increase the level of observation if the patient’s condition changes...4. The RN may not decrease the level of observation...without an order by the psychiatric practitioner...Staff documents all levels of observation on each patient’s observation form which becomes a part of the patient record. Each entry is to include the following...Level of observation...Precaution...Location...Behavior...Activity...Time...Staff Initial and Signature...Documentation of the observation is to be completed once the patient has been observed...All patients are monitored at minimum once in every 15-minute block of time...During the rounds staff are to...Make direct visual contact; look for signs of danger or distress...Remain vigilant for specific risks for patients on Special Precautions...Q 5 Minute Rounds a. Patient is placed on Q 5 minutes if their behaviors is unpredictable and there is potential risk for harm to self and others yet behaviors is not at the point requiring constant 1:1 observation...Patient is monitored at minimum once in every 5-minute block of time...1:1 is the highest level of observation and is reserved for patients who are so unpredictable that without a dedicated staff member there is a risk of patient harming self or others...”. 2. Review of the hospital document titled, “Chief Nursing Officer Job Description” dated 1/1/2020 revealed, “...Purpose Statement: Direct, plan, coordinate, monitor and supervise the effective and efficient use of operation of nursing, other departments and the delivery of behavioral health/nursing services with a positive, empathetic, and professional attitude toward customers. Recognize that patient safety is a top priority...Demonstrates a sense of urgency related to the importance of patient safety...Oversee nursing services documentation to ensure it meets all standards...”. Review of the hospital document titled, “RN Job Description” dated 1/1/2020 revealed, “...Purpose Statement: Responsible for providing professional nursing care to patients with a positive, empathetic, and professional attitude to foster a supportive and therapeutic environment. Recognize that patient safety is a top priority. Review of the hospital document titled, “Behavioral Health Associate [Behavioral Health Technician (BHT)] Job Description” dated 1/1/2020 revealed, “...Purpose Statement: Responsible for providing personal care services to patients at the facility under the direction of the clinical or nursing leadership...Recognize that patient safety if a top priority...Responsible for conducting safety checks and ensuring that supervision is conducted at 15 minute intervals, as noted in special precaution, or in accordance with individualized supervision guidelines as needed...Document timely, accurate and appropriate clinical information in patient’s medical record...Assist in providing a safe, secure and comfortable environment for patients, significant other and staff...Interact routinely with patients, observe behaviors and communicate significant observations to nursing staff...”. Review of the hospital documents titled, “Immediately-For Your Safety, Please Follow This Process” revealed, “I attest that I understand that I am responsible for escalating situations that could lead to a significant patient or staff incident. I understand that failure to follow the chain of command will result in disciplinary action. Examples of incident that could result in the use of this chain of command...Patient continuously antagonizing you or a peer, unresolved by unit staff...Patient making verbal threats of physical harm, unresolved by unit staff...Patients escalating or high acuity on the unit, unresolved or uncontrolled by unit staff.” The documents were signed by BHT #2 on 3/21/2024 and by BHT #1 on 3/22/2024. Review of the hospital’s incident log revealed Patient #2 was “Injured by Other Patient” on 5/25/2024 at 7:55 PM. The incident log further revealed Patient #1 was placed in “Seclusion” on 5/25/2024 at 8:00 PM. Review of a facility incident reported to the Survey Agency on 5/31/2024 revealed, “...On May 24, 2024 [Patient #2 and Patient #1] both admitted to [Hospital #1] on GPU...The history and physical for [Patient #2] acknowledges a previous gunshot wound to the head in 1994, no significant indication on the History and Physical of [Patient #1]. On May 25, 2024, up until the time of the incident, [Patient #1 and Patient #2] were both reported and documented as being calm, cooperative and as having no issues, either individually or with each other. At 1955 [7:55 PM] [Patient #2 was attacked by [Patient #1] unprovoked in the hallway, the attack lasted less than 30 seconds but caused significant injuries to [Patient #2]...Investigation initiated...”. 3. Medical record review for Patient #1 revealed a 34 year-old male admitted on 4/24/2024 with diagnoses which included Schizoaffective Disorder, Bipolar Type. (Schizoaffective Disorder, Bipolar Type is a mental illness characterized by symptoms such as hallucinations - seeing and/or hearing things that aren’t there, and delusions (having false or unrealistic beliefs or opinions), and symptoms of a mood disorder such as depression, mania or hypomania (periods of great excitement or euphoria, delusions, and overactivity). Review of the hospital’s Emergency Medical Treatment and Labor Act Medical Screening Examination (MSE) dated 5/24/2024 at 12:20 PM revealed Patient #1 had a past medical history of Hypertension (High blood pressure). The MSE further revealed the patient was exhibiting both suicidal ideations (SI) and homicidal ideations (HI) and had symptoms of extreme psychosis including auditory hallucinations to harm himself. The patient was deemed medically stable for further psychiatric evaluation. Review of the Crisis Assessment dated 5/24/2024 at 2:28 PM revealed Patient #1 presented to the assessment center on his own. The assessment further revealed, “PT [patient - Patient #1] is reporting suicidal ideation with plan and intent and access to means to starve himself...due to no access to food ..., or way to get around...PT is homicidal with plan to light unknown gas station on fire per pt due to “mistreating him” per pt. Pt is psychotic hearing AH [ auditory hallucinations] psychosis of the animals talking to him and asking him for wishers per pt. PT denying substance use...PT is depressed and anxious ongoing asking for PRN [as needed] anxiety...PT cannot safety plan and needs stabilization...”. Review of the Intake Assessment dated 5/24/2024 at 6:15 PM revealed, Patient #1 was “...experiencing SI [suicidal ideation] w [with] plan to walk into traffic ... with intent to blowup gas station...Hearing command voices to kill self and blow up gas station with people inside. Off meds [medications] for several days...Observed to be restless and fidgety...Distracted Flight of Ideas Limited Attention Span hallucinations...Legal Admission Status Voluntary...Diagnosis per Physician...Schizoaffective D/O [disorder], Bipolar Type...Acute psychiatric condition requires 24 hour skilled nursing/medical oversight Potential danger to self or others...”. Review of the physician’s orders dated 5/24/2024 at 7:24 PM revealed the patient was to be admitted to the hospital’s General Psychiatric Unit with Suicide Precautions and Assault Precautions and should be observed by staff every 5 minutes. Review of the nursing Admit Assessment dated 5/25/2024 at 12:57 AM revealed Patient #1 reported, “I’ve been hearing voices telling me to walk into traffic & [and] kill myself, & to blow up a gas station with people in in [it]... Psychiatric Assessment...calm, cooperative, anxious & restless sitting in chair, then standing waiting for nurse; flat affect, depressed mood, no eye contact...Aggression None...”. Review of the Patient #1’s Psychiatric Evaluation completed by Psychiatrist #1 on 5/25/2024 at 8:30 AM revealed, “...history of schizoaffective disorder, bipolar type and cocaine use disorder mild. Pt [patient] presents with SI with plan to walk into traffic. Reports HI [homicidal ideation] with plan to blow up a gas station. Hearing voices urging him to kill self and others in this manner. Speech is pressured, rambling with racing thoughts with illogical and disorganized thought process. paranoid and watchful of others. Sexually inappropriate speech at times...Has difficulty concentrating and following conversation. he has a history of using amphetamines, methamphetamine, cocaine...Psychomotor Behavior Agitation, Hyperactivity Attitude - Behavior Guarded, irritable...Affect irritable...Risk Factors Suicidal Ideation, Homicidal Ideation...Justification for Hospitalization - Inpatient Failure of treatment at a lower level of care, Hallucinations, delusions, agitation, anxiety, depression resulting in a significant loss of functioning, Dangerous to self, others or property with need for controlled environment...” Review of the Patient #1’s History and Physical completed by the Medical Director on 5/25/2024 at 12:19 PM revealed, “...recently discharged from the hospital, history of schizoaffective disorder, bipolar type, drug abuse, readmitted to the hospital with suicidal ideation with plan to walk into traffic. Reports homicidal ideation with plan to blow up gas station, paranoid and watchful of others, sexually inappropriate speech, at times displaying severe thought blocking. He has trauma history of being sexually abused by a sister at age 3, his mother passing in 2018, and father dying in 2021. Poor sleep and appetite. Readmitted to the hospital with a diagnosis of schizoaffective disorder. He has had many prior psychiatric hospitalizations...” Review of a Nurse Progress Note written by Registered Nurse (RN ) #1 on 5/25/2024 at 11:54 PM revealed, “[Patient #1] severely beat another patient [Patient #2]. The fight was broken up and [Patient #1] was placed in seclusion...[Patient #1] has no injuries or complaints of pain. [Patient #1] will be discharged and taken by [Local police department]...” Review of the Behavioral Health - Patient Observation Sheet dated 5/25/2024 revealed for Patient #1 revealed the following: At 7:22 PM - BHT #1 documented Patient #1 was observed in the dayroom exhibiting appropriate behaviors. At 7:37 PM, a total of 14 minutes later, BHT #2 documented Patient #1 was observed in his room and appeared to be asleep. At 7:51 PM, a total of 14 minutes later, BHT #2 again documented Patient #1 appeared to be asleep in his room. At 7:59 PM, a total of 7 minutes later, BHT #2 documented Patient #1 appeared to be asleep in his room. At 8:29 PM, a total of 30 minutes later, BHT #2 documented Patient #1 appeared to be asleep in his room. Further review of the Observation Sheet revealed Patient #1 was exhibiting appropriate behaviors and was moved to the Seclusion Room by BHT #3 at 9:06 PM. At 9:23 PM, a total of 14 minutes later, BHT #3 documented Patient #1 was observed in the seclusion room exhibiting appropriate behavior. At 9:34 PM, a total of 11 minutes later, BHT #2 documented Patient #1 appeared to be asleep in his room. Patient #1 was observed by BHT #4 in the seclusion room from 9:43 PM until 11:41 PM. At 11:51 PM, 10 minutes later, BHT #2 documented Patient #1 appeared to be asleep in his room. Facility staff failed to observe and document Patient #1’s location and behaviors every 5 minutes as ordered. BHT #2 failed to accurately document Patient #1’s location and behaviors on 5/25/2025 when she documented the patient appeared to be asleep in his room at 7:51 PM and 7:59 PM, as the patient was observed by this surveyor on video walking up and down the hallway and pacing in the dayroom. BHT #2 also failed to accurately document Patient #1’s location at 9:34 PM and 11:51 PM when the patient was actually in the seclusion room, not in his room. Review of a Progress Quick Note written by the Medical Director on 5/26/2024 at 3:47 PM revealed “...I was notified last night per HS [House Supervisor] pt [Patient #1] assaulted another pt [Patient #2] on the unit and left the hospital in the custody of [Local police department]...”. 4. Medical record review for Patient #2 revealed a 45 year-old male admitted on 5/24/2024 with diagnoses which included Major Depressive Disorder, Recurrent, Severe with Psychotic Features. Review of the Intake Assessment dated 5/24/2024 at 8:00 AM revealed Patient #2 presented to the hospital with “rambling speech and suicidal ideations w/a [with a] plan to cut his throat w/a knife...PT is endorsing depression due to minimal interaction w/ [with] family. PT is non-compliant w/ all prescribed psychotropic meds...Alcohol and Drug Use History...Cocaine...1 gram As money permits...Last Uses...Unknown...Easily agitated...Posture: tense/rigid...Mood: Anxious Manic...Motor Behavior: Restless...”. Review of the MSE dated 5/24/2024 at 8:15 AM revealed Patient #2 had a past medical history of Hypertension and arthritis. The MSE further revealed the patient was exhibiting SI with a plan of cutting his wrist, HI without any specific plan and was having auditory hallucinations with commands to hurt himself. Patient #2 was noted to be at risk of imminent harm to self/others due to psychiatric conditions...Acute psychiatric condition requires 24 hour skilled nursing/medical oversight Potential danger to self or others...”. Review of the Psychiatric Evaluation for Patient #2 completed by Psychiatrist #1 on 5/24/2024 at 9:46 AM revealed, “...admitted for depression and psychosis. Pt discharged in April. Reported SI no plan and is hearing voices to harm self. H/o [history of] at least two previous attempts. States he has been wandering the neighborhood and not realizing how he got there. H/o [history of] cocaine use but denies since dc [discharge] in April. Off meds...Unable to function...Attitude - Behavior Guarded, Irritable, Withdrawn Mood Depressed, Anxious, Irritable...Justification for Hospitalization - Inpatient...Hallucinations, delusions, agitation, anxiety, depression resulting in a significant loss of functioning. Dangerous to self, others or property with need for controlled environment...”. Review of the physician orders dated 5/24/2024 at 10:04 AM revealed Patient #2 was to be admitted to the hospital’s Dual Diagnosis Unit (DDU). The order was changed at 10:06 to admit to the hospital’s General Psychiatric Unit (GPU). Further review revealed Patient #2 should be placed on assault and suicide precautions and should be observed by staff every 5 minutes. Review of the nursing Admit Assessment dated 5/24/2024 at 11:54 AM revealed Patient #2 reported, “I need to get back on my meds. I was thinking about suicide... Pt admitted to having a suicidal plan to either drive car off road or to cut wrists...Psychiatric Assessment...”[Patient #2] is irritable. Depressed with sad affect. Reports AH with commands that tell pt to harm himself...”. Review of the History and Physical for Patient #2 completed by the Medical Director on 5/24/2024 at 12:35 PM revealed, “...admitted for depression psychosis...suicidal ideation...Off medication, poor sleep...Unable to function. Diagnosis of admission is major depressive disorder...Past Medical History...noncompliance, history of smoking, drinking, using drugs, chronic pain, arthritis, renal insufficiency...”. Review of the Behavioral Health - Patient Observation Sheet for Patient #2 revealed staff documented Patient #2 was observed by staff every 5 minutes as ordered from the time of his admission on 5/24/2024 until 7:15 AM on 5/25/2024. On 5/25/2024 at 7:15 AM, staff documented they observed Patient #2 every 15 minutes from 7:15 AM until 8:00 PM on 5/25/2024. Staff documented Patient #2 was in his room asleep on 5/25/2024 at 7:30 PM, 7:45 PM and 8:00 PM. There were no physician’s orders to indicate Patient #2’s observation frequencies were changed from every 5 minutes to every 15 minutes. Observations of the hospital’s video recording revealed Patient #2 was in the dayroom on 5/25/2024 at 7:49:58 PM until 7:52:22 PM when the patient walked across the dayroom and exited camera view into the South hallway. Eyewitness testimonies revealed Patient #2 was assaulted in the South hallway at approximately 7:55 PM and he remained in the hallway until local police and EMS personnel arrived around 8:06 PM and 8:11 PM. The observations documented by BHT #2 on 5/25/2024 at 7:45 PM and 8:00 PM failed to accurately describe the Patient #2’s location and behaviors. Review of a Nurse Progress Note written by RN #1 dated 5/25/2024 at 9:43 PM revealed, “...this nurse saw [Patient #2] on the floor with [Patient #1] on top of him hitting him [Patient #2] in the head. The tech pulled [Patient #1] off of [Patient #2], but [Patient #1] ran up and stomped [Patient #2] in the head three times. [Patient #1] was removed from all of the patients and placed in seclusion. This nurse called for help and assessed the patient. EMS [emergency medical services] was immediately dispatched. patient [Patient #2] was unresponsive, with agonal and sonorous breathing, decorticate posturing, and had an obvious bloody/severe facial deformity as well as an obvious shoulder injury. [Agonal, sonorous breathing is insufficient breathing that often sounds like snoring, snorting, gasping, or labored breathing. Decorticate posturing is abnormal flexion of the arms with the extension of the legs. This pose may occur automatically because of damage to or disruptions in the brain.] Patient had a palpable pulse present and vital signs were obtained...[Patient #2] was transported off the unit with [local fire department] ALS [advanced lifesaving] unit via EMS to [Hospital #2] for a higher level of care at 2042 [8:42 PM]...” Review of the Patient #2’s Discharge Summary dated 5/25/2024 revealed Patient #2 was “...Pt was attacked by a male peer [Patient #1] while on unit. pt was transferred to [Hospital #2] for emergency care...Physical-Medical Condition on Discharge Unstable...” 5. Review of the “Incident Report” obtained from the local police department dated 5/25/2024 revealed Patient #1 was arrested for “Aggravated Assault” against Patient #2. The officers arrived at Hospital #1 at 8:06 PM in response to a “Fight call.” The report revealed, “...Officers arrived on the scene and made contact with complainant [House Supervisor (HS)]...advised that they had a patient [Patient #2] on the third floor who was unresponsive. Officers arrived on the third floor and observed a male black subject in front of room #323 on the floor The subject appeared to have a dislocated jaw, laceration above his head, and a bloody mouth. Officers then made contact with [BHT #2]...[BHT #2] advised that she witnessed the entire incident...advised that the victim/patient, [Patient #2] had a verbal altercation with [Patient #3], another patient at the facility. [BHT #2] advised that [Patient #3] made threats to harm [Patient #2]...[BHT #2] advised that [Patient #3] stated, “Imma knock you out.” [Patient #3] then stated, “They messing with me.”...[BHT #2] advised that [Patient #2 ignored [Patient #3]...[BHT #2] advised that a third patient [Patient #1]...walked from the front lobby towards [Patient#2] and struck him the face with his right closed fist...[Patient #1] repeatedly struck [Patient #2] in the face and caused [Patient #2] to fall on the ground. [BHT #2] advised that she called for help...[BHT #1] assisted with the incident. Officers made contact with [BHT #1] who advised that he had heard [BHT #2] call for help and observed [Patient #1] stomping on [Patient #2] head. [BHT #1] advised that [Patient #1] repeated the assault until he pushed him into another room and off of [Patient #2]. [BHT #2] directed the officers to room #317, where [Patient #1] was located. [Patient #1] appeared to be out of it and spaced out. Officers gave [Patient #1] commands, and [Patient #1] complied. [Patient #1] advised that he was blind and stared into the air. Officers placed [Patient #1] into the facility conclusions [seclusion] room. [EMS unit] made the scene and transported [Patient #2] to [Hospital #2] in critical condition...Officer spoke with [Psychiatrist#1], who is [Patient #1] doctor at the time. [Psychiatrist #1] advised that [Patient #1] would be discharged from the facility due to the fear of the other patient and staff safety...” 6. Review of the Prehospital Patient Record report obtained from EMS revealed the EMS unit was dispatched to the hospital for an assault on 5/25/20254 at 8:01 PM. The unit arrived at the hospital at 8:09 PM, was with Patient #2 at 8:11 PM and left the hospital with Patient #2 at 8:30 PM in route to Hospital #2. The report revealed, “...45 y/o male [Patient #2] lying unresponsive in the hallway after being assaulted by another pt [Patient #1]. The nurses on scene stated the pt’s [Patient #2] head was stomped on several times very hard before they could break up the fight. The pt [Patient #2] did lose consciousness before opening his eyes a few moments later...The pt [Pateint #2] was responsive to pain only and had decorticate posturing. pt [Patient #2] was breathing rapidly with blood in his airway. Pt [Patient #2] had massive facial trauma with swelling and deformity all over his face and he had several teeth knocked out. No other obvious injuries were noted anywhere else on the pt. Pt’s [Patient #2] pupils were equal and unresponsive to light, skin warm/diaphoretic, and BS [breath sounds] had bilateral stridor due to blood in the airway. Pt had a GCS [Glasco Coma Scale] of 9 [The Glasco coma scale is a clinical scale used to reliably measure a person’s level of consciousness after a brain injury. It is the summation of scores for eye, verbal and motor responses. The minimum score is 3 which indicates deep coma or a brain dead state. the maximum is 15 which indicates a fully awake patient.]...a c-collar [cervical spine collar] was placed on pt, vitals taken...pt’s airway was suctioned multiple times due to bleeding, 3 lead EKG [electrocardiogram] performed (sinus tach[tachycardia]) [An EKG measures the electrical activity of the heart]. Sinus tach is an abnormally rapid heart rate usually in excess of 100 beats per minute.]...IV [intravenous catheter] was placed...a bolus of LR’s [lactated ringers, an IV fluid solution] was hung wide open...transported to [Hospital #2] in critical condition...pt [Patient #2] was sent to shock trauma and care transferred...” 7. Review of Patient #2’s History and Physical Report obtained from Hospital #2 dated 5/25/2024 at 9:08 PM revealed Patient #2 was as assault victim and his “...face stomped. On arrival to trauma bay, he was GCS 6...and hypertensive. He was also posturing on arrival. He began desatting [desaturating] to the 70s so he was bag masked and prepared for intubation. [Desatting refers to oxygen levels in the blood are dropping.] He was then intubated. [Intubation is a procedure used to place a tube in the patient’s mouth or nose down through into the trachea (windpipe). The tube keeps the patient’s airway open so air can get to the lungs.] OGT [NGT (nasogastric tube)] [A naso-gastric tube is a procedure in which a tube is inserted into the patient’s nose down through the back of the throat, esophagus (food tube) and into the stomach.]...and foley [indwelling urinary catheter] placed He was taken to CT [computerized tomography] scanner...Physical Examination...Eyes: 4 mm [millimeters] and sluggish b/l [bilaterally] Face/Neck...peri-orbital edema [swelling] encompassing the right side of the face. blood in mouth and missing teeth...Neurologic & Psych [psychiatric] GCS 6...Posturing...” The patient had CT scans of the head, cervical spine, chest, abdomen, pelvis and maxillofacial areas as well as a CT angiogram of the brain and neck, and x-rays of the chest and pelvis. The report revealed “...Impression and Plan Assessment: Assault...Injuries: 6 mm R [right] SDH [Subdural Hematoma, trapped blood that develops between the inner layers and the tough outer covering of the brain called the dura] 8 mm L [left] SDH 5 mm parafalcine SDH [A parafalcine subdural hematoma is a rare subtype of intracranial hematoma, or brain hemorrhage that can occur in the brain or within the three layers that cover the brain.] 8 mm R frontal SDH b/l [bilateral] SAH [subarachnoid hemorrhage. A subarachnoid hemorrhage is bleeding into the subarachnoid space, the area between the arachnoid membrane and the pia mater surrounding the brain.] R zygomatic arch fx [fracture The zygomatic arch or cheekbone is the arch of bone that extends along the front or side of the head around to the maxilla (upper jawbone).] small L PTX [pneumothorax A pneumothorax is the presence of gas (often air) in the cavity between the lungs and underneath the chest wall].” Review of a Patient #2’s Palliative Care Progress Note obtained from Hospital #2 dated 6/3/2024 revealed, “...admitted with TBI [Traumatic Brain Injury] and various injuries after an assault...Pt is s/p [status post] tracheostomy. current level of consciousness is consistent with unresponsive wakefulness syndrome (UWS) [Unresponsive wakefulness syndrome, formerly known as vegetative state, is one of the most dramatic outcomes of acquired brain injury. Patients with UWS open their eyes spontaneously but demonstrate only reflexive behaviors; there are no signs of consciousness.]...” 8. Review of the hospital’s video recording of the dayroom and North hallway was completed with the hospital’s Chief Operating Officer (COO) on 6/6/2024 beginning at 12:17 PM. The video started on 5/25/2024 at 7:49:58 PM . The video showed the entire dayroom, the entire North hallway, and the entrance to the South hallway where Patient #1’s and #2’s rooms were located. The South hallway itself, was not visible in the video. Patient #2 was sitting in a chair in front of the nurse’s station wrapped in a blanket. Patient #4, #5, #6, #7, #8 and Random Patient (RP #17) are in the dayroom and Patient #9 is visible at the far end of the North hallway, and BHT #1 was in the dayroom. At 7:50:21 PM, Patient #2 stood up, turned and faced the nurse’s station and appears to be knocking on the window. At 7:50:35 PM, BHT #1 exited the dayroom leaving Patients #4, #5, #6, #7, #8, #9, and RP #17 in view. Patient #2 is still standing at the window to the nurse’s station. At 7:50:45 PM, Patient #3 walked into the dayroom, across the dayroom, then back out of the dayroom into the South hallway and out of view of the camera. Patient #2 continues to stand at the nurse’s station window. At 7:51:09 PM, Patient #9 exited the dayroom and entered the South hallway out of view of the camera. Patient #2 is still standing at the nurse’s station window. At 7:51:16 PM, Patient #3 re-entered the dayroom from the South hallway. BHT #2 is visible in the North hallway holding a tablet and entering patient rooms. At 7:51:24, BHT #2 exited the North hallway and walked into the dayroom. Patient #2 is still standing at the nurse’s station and Patient #3, #4, #5, #6, #7, #8, and RP #17 were still visible. At 7:51:34, BHT #2 exited the dayroom and entered the South hallway out of view of the camera. Patient #2 is still standing at the nurse’s station window. Patient #3, #4, #5, #6,#7, #8, and RP #17 are still visible. At 7:51:58 PM, Patient #3 exited the dayroom and entered the South hallway out of view of the camera. Patient #2 is still at the nurse’s station window. Patient #4, #5,#6, #7, #8, and RP #17 are still visible. At 7:52:00 PM, BHT #2 was visible at the entrance of the South hallway, Patient #6 exited view at the top of the video near the medication room. Patient #4, #5, #7 ,#8, and RP #17 are still visible. At 7:52:05 PM, BHT #2 moved out of view of the camera into the South hallway. At 7:52:22, Patient #2 walked out of the dayroom into the South hallway out of view of the camera. At 7:52:29: PM, BHT #1 re-entered the dayroom where Patient #4, #5,#6, #7, #8, and RP #17 were still visible. At 7:52:38, BHT #2 is back in view of the camera at the entrance to the South hallway. At 7:52:51 PM, BHT #2 was out of view in the South hallway. . At 7:53:02, BHT #1 exited the dayroom leaving 5 patients in view. Patient #4, #5, #6, #7, #8, and RP #17 were still visible. At 7:53:21 PM, Patient # 10 followed by Patient #9 entered the dayroom from the South hallway. At 7:53:22, BHT #1 re-entered the dayroom where Patient #4, #5, #7, #8, #9,#10, and RP #17 were still visible. At 7:53:35 PM Patient #1 entered the dayroom dressed in an orange and white outfit similar to a basketball uniform. The patient is seen walking back and forth in a pacing motion. Patient #9 has started walking down the North hallway. All other patients are still present; however, Patient #4 is now standing near the entrance to the South hallway. BHT #1 is still in the dayroom. At 7:54:12 PM, Patient #1 continues to pace and began swinging his arms back and forth. BHT #1 is visible across the room from Patient #1 and is talking to Patient #9. BHT #1 was facing away from Patient #1. At 7:54:19 PM, Patient #7 exited the dayroom into the South hallway out of view of the camera. Patient #1, #4, #5, #6, #9, #10, and RP #17 are still in view. At 7:54:33 PM, Patient #1 exited the dayroom out of view of the camera into the South hallway. Patient #4, #5, #6, #7, #9, #10, RP #17, BHT #1 and RN #1 were visible in the dayroom. At 7:54:35 PM, Patient #4 was looking down the South hallway and jumped backwards away from the South hallway. Both BHT #1 and RN #1 were still in view. RN #1 is facing Patient #4 and BHT #1 has his back toward Patient #4. At 7:54:36 PM, Patient #4 continues to move in a fleeing motion away from the South hallway further into the dayroom. BHT #1 and RN #1 were still in the dayroom along with Patient #5, #6, #9, #10, and RP #17. At 7:54:37 PM, Patient #4 began pointing down the South hallway alerting RN #1 and BHT #1 who turned toward the South hallway. At 7:54:38 PM, RN #1 and BHT #1 walk across the dayroom toward the South hallway. The remaining patients began standing up and walking toward the South hallway. At 7:54:41 PM, RN #1 got to the entrance of the South hallway, where she stopped and appeared to be looking down the hallway. BHT #1 is right behind the RN but doesn’t stop. At 7:54:44 PM, BHT #1 entered the South hallway out of view of the camera. RN #1 continued to stand at the entrance of the South hallway but did not enter. At 7:54:50 PM, RN #2 entered the dayroom running toward the South hallway. At 7:54:52 PM, RN #2 entered the South hallway out of view of the camera. RN #1 was still standing at the entrance of the South hallway. At 7:54:56 PM, Patient #1 re-entered the dayroom from the South hallway. RN #1 was still standing at the entrance of the South hallway. Patient #4, #5, #6, #7, #8, #9, #10, #11, and RP #17 were still present in the dayroom. The doorway into the dayroom was open, but no staff entered at that time. At 7:55:02 PM, RN #2 re-entered the dayroom from the South hallway. Both RN #1 and RN #2 began walking toward the exit. At 7:55:10 PM, RN #2 exited the day room. RN #1 walked across the day room toward the opposite side. Patient #1, #4, #5, #6, #7, #8, #9, #10, #11, and RP #17 were still in the dayroom. Patient #1 is walking around the dayroom in a pacing motion. At 7:55:11 PM, RN #2 exited the dayroom out of view of the camera. At 7:55:15 PM, BHT #1 re-entered the dayroom from the South hallway. At 7:55:20 PM, BHT #1 began walking through the dayroom toward the exit door, but he did not exit the room. Patient #3, #4, #7, #8, #9, #10, #12, #14, and RP #17 were in the dayroom along with Patient #1. At 7:55:27 PM, BHT #2 re-entered the dayroom from the South hallway. At 7:55:30 PM, BHT #1 re-entered the South hallway out of view of the camera. BHT #2 was still present along with the other patients. At 7:55:54 PM, BHT #1 re-entered the dayroom from the South hallway running toward the exit door. At 7:55:57 PM, BHT #1 is seen at the exit door and appeared to be motioning for help. At 7:56:03 PM, BHT #4 entered the day room and began walking toward the South hallway. BHT #2. AT 7:56:10 PM, BHT #4 entered the South hallway out of view of the camera. At 7:56:11 PM, BHT #4 re-entered the dayroom from the South hallway; BHT #2 is visible by the exit door. . At 7:56:17 PM, BHT #4 exited the dayroom. BHT #1 and Patient #1 BHT #1 is no longer in view of the camera. At 7:56:28 PM, BHT #1 and RN #1 re-enter the dayroom. At 7:56:31 PM, BHT #4 re-entered the dayroom. At 7:56:33 PM, RN #4 entered the dayroom. At 7:56:37 PM, BHT #1, BHT #4, RN #1, and RN #4 entered the South hallway out of view of the camera. BHT #2 remained in the dayroom with Patient #1, #3, #4, #6, #8, #9, #12, #13, #14, and RP #17. At 7:56:40 PM, RN #3 re-entered the dayroom from the South hallway running toward the exit door then exited. At 7:56:42 PM, BHT #4 re-entered the dayroom from the South hallway. BHT #2 still in view in the dayroom along with the other patients. At 7:56:43 PM, BHT #4 exited the dayroom. BHT #1 and RN #3 re-entered the dayroom from the South hallway walking toward the exit door. At 7:56:48 PM, BHT#1 and RN #3 exited the dayroom. BHT #2, the other patients and Patient #1 were still in view in the dayroom. At 7:56:52 PM, Patient #11 re-entered the dayroom from the North Hallway. At 7:56:56 PM, Patient #15 entered the dayroom from the North hallway and Patient #13 exited the dayroom into the North hallway. At 7:57:09 PM, BHT #1 and BHT #4 re-entered the dayroom. BHT #1 re-entered the South hallway out of view of the camera. BHT #2 and BHT #4 were still in dayroom. At 7:57:19 PM, BHT #1 re-entered the dayroom from the South hallway. At 7:57:28 PM, BHT #1 begins motioning patients to leave the area toward their rooms. At 7:57:29 PM, Patient #6 and #13 were still visible in the North hallway. Patient #1 was still present in the dayroom. At 7:58:11 PM, BHT #4 exited the dayroom. BHT #1 was following behind. Patient #1 was still present in the dayroom. BHT #2 was also present. At 7:58:13 PM, both BHT #1 and BHT #4 exited the dayroom. Patient #1 was still present in the dayroom along with BHT #2. At 7:58:23 PM, Patient #1 was still in the dayroom and held out his left hand and appeared to open and close his fist while looking at it. BHT #1 is visible walking down the North hallway with her tablet. At 7:58:27 PM, RN #3 re-entered the dayroom followed by the House Supervisor, BHT #1 and BHT #4. At 7:58:49 PM, RN #3, the House Supervisor, BHT #1 and BHT #4 entered the South hallway out of view of the camera. At 7:58:54 PM, the House Supervisor re-entered the day room and walked toward the exit door. At 7:58:57 PM, BHT #1 re-entered the dayroom and appeared to be pointing at Patient #1. Patient #6 was still present in the dayroom. At 7:59:03 PM, RN #3 re-entered the dayroom from the South hallway. At 7:59:07 PM, the House Supervisor entered the South hallway out of view of the camera. At 7:59:14 PM, BHT #4 re-entered the day room from the South hallway just as Patient #1 entered the South hallway out of view of the camera. At 7:59:20 PM, BHT #4 exited the dayroom, and the House Supervisor re-entered the dayroom from the South hallway. BHT #5 entered the dayroom from the nurse’s station. At 7:59:31 PM, BHT #5 entered the South hallway out of view of the camera followed by BHT #1 and the House Supervisor. At 7:59:34 PM, BHT #1 and the House Supervisor entered the South hallway of view of the camera and BHT #4 re-entered the dayroom pulling a vital signs machine toward the South hallway. At 7:59:39 PM, BHT #4 entered the South hallway out of view of the camera. At 7:59:49 PM, BHT #1 re-entered the dayroom from the South hallway. At 7:59:58 PM, the House Supervisor and BHT #4 re-entered the dayroom from the South hallway. At 7:59:59 PM, the video ends with BHT #1, BHT #4, and the House Supervisor in the dayroom. Patient #1, who had just brutally assaulted Patient #2, was visible in the dayroom with other patients from 7:54:56 PM until 7:59:14 PM, a total of 4 minutes and 18 seconds before he exited into the South hallway out of view of the camera. 9. Review of the hospital’s video recording of the South hallway where Patient #1 and #2 were housed was completed with the facility’s COO on 6/6/2024 beginning at 2:10 PM. The video shows the South hallway from the far end of the hall looking toward the entrance to the dayroom. The video begins on May 25, 2024, at 7:49:59 PM. There is a portable air conditioning (AC) unit in the center of the hallway with a flex pipe extending up into the ceiling obstructing the camera’s full view of the South hallway. BHT #2 is visible in the hallway with her tablet making patient rounds. At 7:50:06 PM, BHT #2 entered Patient #1’s room out of view of the camera. At 7:70:08 PM, Patient #3 appeared from behind the AC unit in the hallway walking toward the camera. At 7:50:11 PM, BHT #2 exited Patient #1’s room and Patient #3 walked past her in the hallway. At 7:50:19 PM, Patient #3 walked back down the hallway behind the AC unit out of view of the camera. At 7:50:21 PM, BHT #2 exited the hallway via the walk-through access to the North hallway out of view of the camera. At 7:50:59 PM, Patient #3 appeared behind the AC unit, then turned back toward the South hallway entrance out of view of the camera. At 7:51:04 PM, Patient #1 appeared from behind the AC unit walking toward his room at the end of the hallway. Patient #1 continued walking to the end of the hallway, turned around and started walking back toward the entrance of the South hallway away from the camera. At 7:51:38 PM, Patient #1 walked around the AC unit and out of view of the camera. At the same time, Patient #9 is seen walking toward the AC unit. This patient continued walking to the end of the hallway, turned around and walked by down the hallway toward the entrance to the South hallway and out of view of the camera. At 7:51:56 PM, Patient #1 is back in view in the hallway behind the AC unit walking toward the camera. Patient #1 continued walking toward the end of the hallway and appeared to be rubbing his hand together in a back and forth motion. Patient #3 appeared from behind the AC unit walking briskly toward the end of the hallway where Patient #3 was headed. At 7:51:20, both Patient #1 and Patient #3 are at the end of the hallway where they turn around and start walking back toward the AC unit and the entrance to the South hallway. At 7:52:42 PM, Patient #1 is out of view behind the AC unit. At 7:52:45 PM, Patient #1 is visible behind the AC unit walking toward the end of the South hallway toward the camera. At 7:52:55 PM, Patient #1 stepped from behind the AC toward the end of the hallway and Patient #3 is visible following him down the hallway. At 7:52:01 PM, Patient #1 and Patient #3 are at the end of the hallway and Patient #3 appeared to be talking. At 7:53:14 PM, Patient #1 is back out of view of the camera behind the AC unit. Patient #3 is still visible walking behind the AC unit toward the South hall entrance. At 7:53:17 PM, Patient #1 is still not visible, but Patient #3’s leg is visible behind the AC unit. NOTE: The video stopped at this point and jumps to 7:57:59 PM when Random Patient #17 was seen walking toward the end of the hall toward the camera. At 7:58:02 PM, RP #17 entered a room on the left side of the hallway out of view of the camera. At 7:58:06 PM, the video stopped and restarted at 7:59:25 PM when RP #17 exited the room wrapped in a blanket and walked back into the hallway heading toward the South hallway entrance. At 7:59:29 PM, Patient #1 reappeared in the hallway walking toward the camera at the end of the hallway. At 7:59:40 PM, Patient #1 entered his room out of view of the camera. At 7:59:52, PM, RP #1 re-entered his room and exited camera view. At 8:00:28 PM, Patient #1 exited his room into the hallway wiping his hands on a towel and appeared to be looking back toward the entrance of the South hallway. At 8:00:42 PM, Patient #1 re-entered his room. At 8:00:51 PM, the video ended. There was no video footage of the assault provided and no video footage of the police and EMS arrival or departures. 10. During an interview on 6/6/2024 at 2:35 PM, the COO confirmed there was no video footage of the assault and no video footage of the police and/or ambulance arrival or departure. The COO was unable to state why they had no footage. The COO was asked why the video of the South hallway skipped from 7:57:59 PM until 7:59:25 PM, the COO stated she would let their computer technician explain it. During an interview on 6/6/2024 at 2:28 PM, the Field Service Operator stated the time lapse in the video happens when there is no motion detected by the camera; however there were staff and patients walking in the hallways. During an interview on 6/10/2024 at 3:58 PM, the Chief Executive Officer (CEO) verified hospital staff failed to acurrately document Patient #1 and #2’s location and behaviors during when the incident occurred. The CEO further stated there were no physician orders to indicate Patient #1 and Patient #2 were no longer on every 5 minute observations. During a telephone interview on 6/11/2024 at 9:56 AM, RN #1 was asked what she could recall regarding the assault of Patient #2 by Patient #1. RN #1 stated she was on the unit with another patient, heard the commotion, and walked over and saw Patient #2 on the ground with Patient #1 on top of Patient #2 punching him. The RN stated she called for help and BHT #1 ran and tried to get Patient #1 off of Patient #2. The RN continued and stated Patient #1 still managed to kick Patient #2 in the head 2 or 3 times before BHT #1 was able to redirect him out of the hallway. RN #1 stated she assessed Patient #1, then left Patient #1 to go get help, then returned to Patient #1 and stayed with the patient until EMS arrived and took over. The RN stated Patient #1 stayed in his room until the police arrived and took Patient #1 to the seclusion room. RN #1 was asked if Patient #1 and Patient #2 had appeared to be upset or volatile before the assault. The RN stated “No.” RN #1 was asked why patients were put on Assault precautions. The RN stated, “They have a history of aggressive behaviors, and we have to be extra careful around them and other patients and watch for them getting upset due to a history of violence.” During a telephone interview on 6/11/2024 at 10:08 AM, the House Supervisor (HS) was asked what she could recall regarding the assault on Patient #2. The HS stated she had been on another unit making rounds and when she got in the elevator, she got a call from the 3rd floor (GPU) stating “We need you now!” The HS stated when she saw Patient #2, he was “in the floor and had been beaten very badly.” The HS then stated Patient #2 was “unresponsive” and respirations were agonal, and the patient was decorticate posturing. The HS was asked if anyone called report to Hospital #2. The HS stated, “No, I don’t think so, just EMS. They got a front sheet and a list of meds; he was too critical for a lot of paperwork. They [EMS] basically loaded and left with him.” The HS was asked if there was anything that could have prevented the assault. The HS stated, “It happened so fast; 1 good kick. Maybe if we could have picked up on the escalation of behaviors; I don’t know. I didn’t see the tape [video] review and I didn’t actually witness the event. They [staff] said it happened really fast and he [Patient #1] deteriorated rapidly. He was pretty messed up.” The HS was asked how the hospital ensured the other patients were safe following the assault. The HS stated they immediately started sending the other patients to their rooms, but “they don’t always listen. Once the police arrived, we felt safer.” The HS continued and stated Patient #1 was pacing and then in a chair close to the dayroom until the police arrived. During a telephone interview on 6/11/2024 at 10:22 AM, RN #3 was asked what she could recall regarding the assault on Patient #2. The RN stated she was the on-coming nurse for the night shift and had just gotten report and was in the medication room when she heard a shout from the unit. The RN stated she ran out of the med room and saw Patient #2 laying on the floor with Patient #1 jumping on him. The RN stated, “Someone pulled him [Patient #1]off... [Patient #2] wasn’t responding. I ran back to the room to page the support team, but it had already been done.” RN #3 stated, “I stayed with the patient until 911 would arrive.” RN #3 was asked what was done to protect the other patients from Patient #1. The RN stated, “We put him in seclusion until the police department arrived and took him.” RN #1 was asked if the hospital had implemented any changes or provided any in-services since the assault occurred. The RN stated, “I really don’t know because I’m prn [as needed] and I don’t work that often. They did some stress relief with us.” During a telephone interview on 6/11/2024 at 10:28 AM, BHT #4 was asked what she could recall regarding the assault on Patient #2. BHT #4 stated she was off her unit when she heard a loud beating type noise. The BHT stated she heard someone say, “Beat his [slang for buttocks]...!”. BHT #4 stated she ran over to the door and looked in and saw a patient [Patient #1] beating a patient [Patient #2] severely. BHT #4 then stated, “I heard [RN #4] yell, “[BHT #1] stop him! Somebody help! I think [BHT #1] might have been in shock.” BHT #4 stated, “There was so much blood, and the other patients were egging it on [encouraging the beating].” BHT #4 was asked where the staff were during the incident. BHT #4 stated, ...” the young lady [BHT #3] was still doing rounds in the other hall and BHT #1 was right there, but he didn’t move until RN #4 started yelling.” BHT #4 was asked where Patient #1 went after the assault. The BHT stated Patient #1 “went to the other side of the room.” BHT #4 was asked where the assault occurred. The BHT stated “right in front of the activity room [dayroom] on the right side, the 3rd door down on the right side. I’ve never worked GPU but he [Patient #2] was in front of the AC unit they had over there.” BHT #4 was asked how they ensured the other patients were safe. BHT #4 stated, BHT #1 was yelling telling the other patients to go to their rooms. The BHT was asked if the hospital had implemented any changes or provided any in-services since the assault occurred. BHT #4 stated, “Yes, but it was on day shift. I got a briefing on it via text messages about how to handle a situation like that and offered us counseling.” During a telephone interview on 6/11/2024 at 10:40 AM, BHT #1 was asked what he could recall regarding the assault on Patient #2. BHT #1 stated one of the other techs, “called me around there [South hallway] and said they [Patient #1 and Patient #2] was fighting. When I ran over there [Patient #1] was already on top of him [Patient #2] beating him. There was blood everywhere! I’m not sure how long; he beat up real bad. I pushed [Patient #1] off of him [Patient #2] and I re-directed him to go to his room. He didn’t go right then so I was telling everybody [other patients] to go to their rooms.” BHT #1 stated he told Patient #1 to go to his room about 3 times and the patient finally went into his room. BHT #1 stated Patient #1 “had no emotions on his face; he was scary.” BHT #1 was asked if Patient #1 had seem agitated or upset before the assault. The BHT stated, “No, he was very quiet. The female tech [BHT #2] was telling me that they [Patient #1 and Patient #3] said they were going to fight. She told me about 7:30 or 7:45. We walked up to them, and I told them to stop talking about fight and they said they weren’t going to fight so I thought we had it solved. The BHT said Patient #1 and Patient #3 said “we ain’t fixin to fight nobody”. The BHT stated Patient #1 and Patient #3 waited for him to go around the corner and was with another patient when it happened. BHT#1 was asked if the hospital had implemented any changes or provided any in-services since the assault occurred. BHT #1 was asked if he or BHT #2 informed any of the nursing staff that Patient #1 and Patient #3 had said they were going to fight. BHT #1 stated, “I don’t think we did. They do that kind of talking all the time. They were just talking.” BHT #1 stated, “If I would have known who they [Patient #1 and Patient #3] were going to attack, I would have sent him [Patient #2] to his room.” The BHT stated the assault occurred during shift change and there was a lot going on on the unit. BHT #1 stated, “The problem before the fight we had a patient very confused; we were distracted trying to re-direct the patient and keep him from trying to get out of the door. The patients [Patient #1 and Patient #3] took the opportunity to fight; just 1 guy [Patient #1] fought. [BHT #1] said she saw it all.” BHT #1 was asked if BHT #3 tried to separate the patients. The BHT stated, “No, I don’t think so. This guy [Patient #1] was very big and scary and had a history of hurting other patients. I think she was scared and probably would have gotten hurt. I’m thankful I didn’t get hurt; it was very scary to me, but I had to do something.” During a telephone interview on 6/11/2024 at 11:00 AM RN #4 was asked what she could recall regarding the assault. The RN stated she had already given her statement and spoken to a lawyer, and she couldn’t think of anything to say. Review of a witness statement written by RN #4 on 5/30/2024 at 7:02 PM revealed, “While I was in the medication room, I heard people screaming and recognized [BHT #4] voice saying, ‘They’re fighting.’ I immediately ran towards the GPU and saw [Patient #1] stomping on a man, who was later identified as [Patient #2], laying on the floor. As I approached them, I screamed ’[BHT #1] stop him!’ I heard a staff member say ‘He [Patient #2] is bleeding and can’t stand up.’ At that time [Patient #1] already was led away. I quickly ran back to the nursing station and called the house supervisor...while [RN #2] called 911... I then went to where [Patient #2] was lying on the floor but saw a large group of people around him, so I decided to check the nursing station for any updates on the Medic [EMS]. There was a lot of activity going on at this point because we had two new patients just admitted... The medics arrived and took [Patient #2] out...” During an interview on 6/11/2024 at 3:00 PM, the CEO verified the hospital’s security camera view on the South hallway was obstructed by a portable air conditioning unit. The CEO further verified hosptal staff failed to secure Patient #1 to protect the other patients immediately following the incident. During a telephone interview on 6/12/2024 at 12:33 PM, BHT #2 was asked what she could recall regarding the assault on Patient #2. The BHT stated “I was doing rounds then I sat back down [just inside the South hallway near one of two AC units]. He [Patient #2] came up to me and said he should go home because we had given his room away. I explained to him his transfer to DDU [dual diagnosis unit] was a better floor. Another patient [Patient #3] came and said he was going to knock [Patient #2] out. [Patient #3] was getting riled up saying he was going to take him [Patient #2] out. I was talking to [Patient #3] and [Patient #1] came from the TV area [dayroom] and punched him [Patient #2] twice and he [Patient #2] hit the ground. I’m calling for help. By then [Patient #1] got on top of him [Patient #2] punching his face. BHT #1 got him [Patient #1] off of him [Patient #2]. [Patient #1] kicked him [Patient #2] in the head. The nurses came and helped [Patient #2] and then EMS came.” BHT #2 was asked what were Patient #1 and Patient #3’s behaviors were prior to the assault. The BHT stated, “They [Patient #1 and Patient #3] were pacing up like they were going to do something. [BHT #1] asked them if they were up to something and told them no fighting. I had never seen [Patient #1] and [Patient #2] until that day. I knew [Patient #3].” BHT #2 was asked if she was aware she had documented every patient was asleep in their room between 7:30 PM and 8:00 PM. The BHT stated, “No ma’am but they [leadership] said I did that.” When asked if what was documented accurately reflected the patients’ locations and behaviors, BHT #2 verified the documentation was incorrect. BHT #2 was asked if she could recall when BHT #1 spoke to Patient #1 and #3. The BHT stated she couldn’t recall the exact time, but she knew it was sometime before the assault occurred. BHT #2 stated, “ they [Patient #1 and Patient #3] were in the quiet room earlier and [BHT #1] went in there and talked to them and I went in behind him. [BHT #1] was saying something like ‘what’s going on and there wasn’t going to be no fighting on the unit.’ “ BHT #2 was asked if she or BHT #1 reported their concerns to any of the nursing staff. BHT #2 stated, “No.” BHT #2 was asked where she was sitting at the time of the assault. The BHT stated she was “sitting by the AC unit at the front of the hallway.” The BHT was asked if there were any other staff members in the hallway with her. BHT #2 stated, “No.” BHT #2 was asked what she did after the nurses started caring for Patient #2. The BHT stated she made sure the other patients got in their rooms. The BHT was asked where Patient #1 went after the assault. The BHT stated, “I think he was in his room down the hallway.” This surveyor was scheduled to interview RN #2 via telephone on 6/13/2024 at 11:30 AM in the presence of the COO. When the interview was attempted, RN #2 did not answer the phone call. Review of a witness statement written by RN #2 on 5/30/2024 at 12:16 PM revealed, “...As I was leaving at around 7:55 PM, I was in the med room. We [RN #4, RN #3, and RN #4] heard a noise outside. We hurried outside to see [Patient #1] stomping on [Patient #2]’s head. One of the techs [BHT #1] was on the other side 2 or 3 feet away telling him to stop and trying to deescalate [de-escalate]. Within seconds of us being outside, [Patient #1] stopped stomping and left, I don’t remember to where, but I remember seeing blood from the patient’s [Patient #2] head that he [Patient #1] was originally covering and him [Patient #2] being unresponsive...asked someone to call 911. I saw nobody doing so. I went back into the office to call 911, I tried to call [CNO] but hung up when I saw the supervisors on the floor, we called a medical code and a support team over the speaker. [RN #1] and [RN #3] stayed with the patient [Patient #2]. I was on the call with 911... I asked for an ambulance at least a few times I stressed how grave the situation was but the responder kept asking questions ...When the ambulance people came, they asked for a suction...went to get the crash cart and pulled it to the floor. After that, I went back to the office wrote a witness statement which I left on the table. While I was leaving, the newly arrived admission was in the hallway screaming...I don’t know why I am being interrogated, or why everyone keeps insisting I be the one writing either a witness statement or incident reports about things that I have no responsibilities doing but I will not be taking any blame for what happened that day if that is what [hospital’s parent company] is currently trying to do. I clearly remember this incident happening on the second shift because a few [minutes] after I looked at the clock when it was 7:53 pm that incident happened. I remember telling [CEO] one day that [Hospital] needed to hire security, people who specialize in PRT [pivotal response training], for when this types of incidents happen because it is not safe for both staff and patient and that this precautions has been taking [taken] in a previous facility I have worked...She [CEO] then told me the techs were trained in PRT and that’s why special security don’t need to be hired, and subsequently telling me ‘ok we need more trainings’. I remember having told numerous people about this type of safety issues multiple times and I remember even writing a letter about it. I was also told this patient [Patient #1] punched out an eyeball on another patient before, and hit another staff that quit right after, but he was still admitted. Let me be clear. I want nothing to do with this horrifying incident that probably killed someone...”. 11. Review of the hospital’s Framework For Root Cause Analysis and Corrective Actions revealed, “...A patient interview revealed that there were no precipitating factors that led to the event except [Patient #1] sporadically, without any provocation calling [Patient #2] a ‘bitch’ moments before the event. Patients did not appear fearful of [Patient #1] prior to or immediately after the event which could mean that [Patient #1] never displayed aggression before the incident on the unit. On May 25, 2025 @ [at] approximately 7:55 PM, unprovoked, [Patient #1] attacked [Patient #2] knocking him to the floor. BHTs and Nurse immediately responded, pulling and pushing [Patient #1] away from [Patient #2]. [Patient #1] still managed to kick [Patient #2] approximately 3 times in the head before final redirection/separation with immediate first aid being provided to [Patient #2]. EMS and [local police department] was also activated...2000 [8:00 PM] Leadership (CEO, CNO, ACNO [assistant chief nursing officer], COO) received notification and begin the route to hospital, arriving within 30 minutes. [Patient #1] placed in seclusion. 2010 [8:10 PM] [local police department] onsite. 2015 EMS arrived onsite. 2017 [8:17 PM] EMS left with [Patient #2] in route to [Hospital #2] 2020 - 0200 [8:00 PM - 2:00 AM] [local police department] remained onsite speaking with employees, reviewing video, collecting evidence. 2100 [9:00 PM] Emergency contact, mother notified of incident by CNO and CEO. 2450 [12:40 AM] [Patient #1 taken out of seclusion/arrested and taken from facility...0107 [1:07 AM] - Police/Investigators exited the building...On June 5, 2024 @ 8:30 am...attempted to get a copy of the police Report ...and was denied a copy...Past Medical/Psychiatric History: [Patient #2] Twice admitted to [Hospital] with previous admission 4/24 [4/24/2024]. [Patient #1]- History of many admissions to [Hospital] and other psychiatric facilities with most recent prior admission to [Hospital] on 5/4/24. [Patient #1] has specifically had 26 admissions to [Hospital] and there were only 2 previous incidents that involved him assaulting others (nurse, peer). Those incidents occurred in March 2020 and during the same admission. Since the 2020 admission there have been 9 other admissions with no incidents of aggression...Analysis Findings...Patients admitted with suicidal ideations are placed on Q [every] 5 [minutes] and if deemed appropriate, Q5 is downgraded to Q 15 when psych [psychiatric] evaluation is completed. Though staff report both patients were on Q15- verbal orders received were not entered...During rounding the actual location/activity/behaviors of patients are entered into ObservSmart. Location and activity in ObservSmart were not accurate on either patient. Securing the aggressor immediately. 2 minutes post incident, patients sent to their room. 5 minutes post incident - aggressor sent to his room. Though no other patients injured, there was potential...Though rounds occurred, the actual location and activity of patients was incorrect...failure to enter verbal orders. Failure to document appropriate location and activity of patient when rounding...Staff have competencies on utilizing ObservSmart. Staff were trained on verbal orders and the requirements to enter verbal orders into the EMR [electronic medical record]...”. The hospital failed to identify BHT #1 and BHT #2 who had knowledge that Patient #1 and Patient #3 had been talking about fighting another patient, failed to escalate their concerns to nursing staff and failed to increase the frequency of observations of the patients. Additionally, the hospital failed to identify the inherent safety risks posed by the portable AC units placed in the hallways which obstructed the camera view. The cameras were implemented to be an additional observation tool to help ensure the safety of patients and staff. With the camera view obstructed, there was no way for security and/or nursing staff to view the patients in the South hallway where the incident occurred. 12. Medical record review for Patient #3 revealed a 25 year-old male admitted on 5/8/2024 with diagnoses which included Schizoaffective Disorder, Bipolar Type. Review of the Intake Assessment dated 5/8/2024 at 10:30 AM revealed Patient #3 had a history of “Bipolar and opioid use. Per parent, pt has had incremental sleeping pattern and opioid use. pt is walking through the neighborhood pulling on doors and is endorsing homicidal ideation towards parties unknown ‘Just to hurt somebody.’...hostility/aggression...HI towards strangers...paranoid...disoriented Due to non-compliance w/ psychotropic medication ‘I wanna hurt/kill somebody.’...Easily angered...Legal Admission Status Voluntary...Potential danger to self or others...” Review of the physician’s orders dated 5/8/2024 at 6:01 to 6:02 PM revealed the patient was to be admitted to GPU and was to be observed by staff every 15 minutes. There were no special precautions ordered for Patient #3 upon admission. Review of the Psychiatric Evaluation completed by Psychiatrist #1 on 5/9/2024 at 6:53 AM revealed Patient #3 was “...admitted for psychosis and behavioral disturbance. Pt has been found walking the neighborhood, pulling on doors wearing a black mask and a BB gun, endorsing homicidal ideations against persons unknown: ‘Just to hurt somebody’. Believes people are after his family and trying to kill them. Reports AH [auditory hallucinations] of voices telling him this and to hurt self/others...States he has difficulty controlling his tempter. Unable to function...Justification for Hospitalization...Hallucinations delusions, agitation, anxiety, depression resulting in a significant loss of functioning. Dangerous to self, others or property with need for controlled environment...” Review of a Nurse Progress Note dated 5/20/2024 at 8:58 PM revealed Patient #3 “...is anxious, angry and labile. He is pacing and agitated. He was seen fighting with another peer on the unit at approximately 2045 [8:25 PM] and the BHT staff was eventually able to separate them. No injures noted...”. There was no documentation in the medical record to indicate Patient #3 was placed on assault precautions following the incident of him fighting. Review of a Behavioral Health (BH) Progress Note written by Psychiatrist #1 on 5/21/2024 at 6:58 AM revealed, Patient #3 was seen “...In dayroom sitting by self. Mood is anxious, irritable...Very guarded...Body language can be hostile at times...Yesterday, seen fighting with another peer on the unit at approximately ...Tolerating current meds...”. Review of the Behavioral Health-Patient Observation Sheet dated 5/25/2024 revealed BHT #2 documented Patient #3 was asleep in his room at 7:45 PM; however, the Patient was observed by this surveyor on video pacing up and down the hall and in the day room. There was no documentation of Patient #3’s location and/or behavior until 8:15 PM, 30 minutes later, when BHT #2 documented the patient was asleep in his bedroom. During an interview on 6/13/2024 at 12:06 PM, the COO confirmed the hospital failed to place Patient #3 on assault precautions following the incident on 5/20/2024. 13. Medical record review for Patient #4 revealed a 42 year-old male admitted on 5/21/2024 with diagnosis of Schizophrenia. [Schizophrenia is a mental disorder characterized by reoccurring episodes of psychosis that are correlated with a general misconception of reality.] Review of the Intake Assessment dated 5/21/2024 at 9:10 PM revealed, Patient #4 was experiencing “...AH of deceased mother’s voice telling him she is disappointed...paranoid disorient Due to non-compliant w/psychotropic medication...Racing thought/flight of idea thought insertion/broadcasting Rambling Speech...High anxiety due to unfamiliar surroundings...Easily angered...Legal Admission Status: Voluntary...Potential danger to self or others...” Review of the Psychiatric Evaluation completed by Psychiatrist #2 on 5/21/2024 at 12:58 PM revealed, Patient #4 had a “...history of treatment for schizophrenia referred...due to having suicidal and homicidal ideations. He is alert and oriented...he reports he was having a history of a suicide gesture in which he shot bullet while under a bridge to show someone that he was serious about wanting to end his life 4 days ago. He is reporting bizarre delusions which include auditory and visual hallucinations in which he hears his deceased mother talking to him and he also saw her at a local grocery store...Paranoid and watchful of others...Preoccupied with internal stimuli...Mood is up and down...Justification for Hospitalization - Inpatient...Hallucinations, delusions, agitation, anxiety , depression resulting in a significant loss of functioning, Dangerous to self, others, or property with need for controlled environment...” Review of the physician’s orders dated 5/21/2024 at 1:08 PM revealed the patient was to be admitted to the GPU under suicide and assault precautions and should be observed by staff every 5 minutes. Review of a physician’s order dated 5/21/2024 at 5:29 PM, revealed the patient was changed to every 15 minute observations by staff. Review of the Behavioral Health-Patient Observation Sheet dated 5/25/2024 revealed BHT #2 documented Patient #4 was asleep in his room at 7:45 PM and 8:00 PM. Review of the hospital’s video recording of the dayroom and North hallway dated 5/25/2024 revealed Patient #4 was in the dayroom from 7:49:58 PM until 7:54:31 PM, when he entered another patient’s room. 14. Medical record review for Patient #5 revealed a 21 year-old male admitted on 5/22/2024 with diagnosis of Schizoaffective disorder, bipolar type. Review of the Intake Assessment dated 5/22/2024 at 8:45 PM, revealed Patient #5 “...reports hear voices and being paranoid all the time. Pt. is having auditory & visual hallucinations, but can’t make out the voices or images. pt reports being verbally abusive toward his mother. Pt is non-compliant with medications...reports hard to re-direct...Legal Admission Status: Voluntary...Potential danger to self or others...”. Review of the physician’s orders dated 5/22/2024 at 9:25 PM revealed the patient was to be admitted to the BHU (Behavioral health unit also known as GPU) under Q 15 minute observations by staff. Review of the Psychiatric Evaluation completed by Psychiatrist #2 on 5/23/2024 at 9:31 AM revealed Patient #5 had a history of “...schizoaffective disorder bipolar type, ADHD [attention deficit disorder] and conduct disorder...hearing voices and feeling paranoid...auditory and visual hallucinations all the time...verbally abusive towards his mother because of the voices...Pressured speech, rambling with racing thoughts with flight of ideas...Pt is unable to sit still jumping and laughing inappropriately...responding to internal stimuli...smokes a gram of Cannabis daily...Not sleeping or eating. pts mood is manic...unable to contract for safety...Justification for Hospitalization - Inpatient...hallucinations, delusions, agitation anxiety, depression resulting in a significant loss of functioning, Dangerous to self, others or property with need for controlled environment...”. Review of the Behavioral Health-Patient Observation Sheet dated 5/25/2024 revealed BHT #2 documented Patient #5 was asleep in his room at 7:45 PM and 8:00 PM. There was no documentation of the patient’s activity and location at 8:15 PM. Review of the hospital’s video recording of the dayroom and North hallway dated 5/25/2024 revealed Patient #5 was in the dayroom from 7:49:58 PM until 7:54:31 PM, then re-entered the dayroom at 7:55:22 PM and remained there until 7:55:27 PM when he exited. 15. Medical record review for Patient #6 revealed a 20 year-old male admitted on 5/25/2024 with diagnosis of Unspecified psychosis not due to a substance. Review of the Intake Assessment dated 5/25/2024 at 4:08 PM revealed Patient #6 had a history of Schizophrenia and “...presents w/HI towards neighbor by waving a knife at them and threatening to kill them. Pt is off meds. Pt is easily agitated and aggressive w/others. Pt is displaying extreme anxiety and elopement behaviors. Pt denies psychosis...Past or present medical conditions...Seizure d/o...Legal Admission Status: Involuntary...Acute psychiatric condition requires 24 hour skilled nursing/medical oversight Potential danger to self or others...”. Review of the physician’s orders dated 5/25/2024 at 7:23 PM revealed Patient #6 was to be observed by staff every 15 minutes with seizure and assault precautions. Patient #6 was brought up to the unit and was seen on video in the dayroom off and on from 7:49:58 PM until 7:59:59 PM when the video ended. 16. Medical record review for Patient #7 revealed a 38 year-old male admitted on 5/18/2024 with diagnosis of Schizoaffective Disorder, Bipolar Type. Review of the Intake Assessment dated 5/18/2024 at 3:00 AM revealed Patient #7 presented with suicidal ideations and a plan “...to jump off bridge...Has been taking more than prescribed medications. Experiencing command auditory hallucinations and started taking more meds than prescribed along with smoking THC [Tetrahydrocannabinol, the psychoactive constituent of cannabis (marijuana)]to calm voices...paranoid, delusional though content, racing thoughts/flight of ideas, anxiety/worry/panic...Legal Admission Status: Involuntary...Acute psychiatric condition requires 24 hour skilled nursing/medical oversight...”. Review of the physician’s orders dated 5/18/2024 at 3:23 AM revealed Patient #7 was to be admitted to the GPU with elopement and suicide precautions. Review of the physician’s orders dated 5/18/2024 at 6:29 AM, revealed Patient #7 was placed under 1 to 1 observation. Review of the Psychiatric Evaluation completed by Psychiatrist #3 on 5/18/2024 at 8:52 AM revealed Patient #7 was “...admitted with increased psychosis and mood lability. + [positive] Suicidal ideation with plan to ‘Hurt myself’. Angry and delusional...Telling MD [medical doctor] that he does not need to be here. Has been noncompliant with medications...Justification for Hospitalization - Inpatient...Hallucinations, delusions, agitation, anxiety, depression resulting in a significant loss of functioning. Dangerous to self, others or property with need for controlled environment...”. Review of the physician’s orders dated 5/18/2024 at 10:53 AM, revealed Patient #7 should be observed by staff every 15 minutes. Review of the Behavioral Health-Patient Observation Sheet dated 5/25/2024 revealed BHT #2 documented Patient #7 was asleep in his room at 7:45 PM and 8:00 PM. Review of the hospital’s video recording of the dayroom and North hallway dated 5/25/2024 revealed Patient #7 was in the dayroom from 7:49:58 PM until 7:54:19 PM, then re-entered the dayroom at 7:55:15 PM and remained there until 7:56:35 PM when he exited. 17. Medical record review for Patient #8 revealed a 44 year-old male admitted on 5/19/2024 with diagnosis of Schizoaffective Disorder, Bipolar Type. Review of the Intake Assessment dated 5/19/2024 at 11:00 PM revealed Patient #8 reported “...started hearing voices to harm self & others. Pressured speech, rambling c [with] racing thoughts...states seeing people that aren’t there. AH...medical conditions...Seizures...Psychotic Symptoms auditory or command hallucinations...voices screaming loudly to him. Paranoid & watchful of others Disorient to time and place...Depressed...mood swings...Restless frequent pacing irritable easily agitated...Legal Admission Status: Voluntary...”. Review of the physician’s orders dated 5/19/2024 at 11:18 PM revealed Patient #8 was to be admitted to the GPU under seizure, and assault precautions and should be observed by staff every 15 minutes...” Review of the Psychiatric Evaluation completed by Psychiatrist #2 on 5/20/2024 at 9:09 AM revealed Patient #8 presented “...due to auditory and visual command hallucinations demanding self harm...Pressured speech, rambling with racing thoughts with flight of ideas...Irritable and easily agitated...talking to self and laughing inappropriately. States people are inside his body beating him up...States he is unable to get along with staff and peers at the group home...Justification for Hospitalization - Inpatient...Hallucinations, delusions, agitation, anxiety, depression resulting in a significant loss of functioning. Dangerous to self, others or property with need for controlled environment...”. Review of the physician’s orders dated 5/20/204 at 7:15 PM revealed Patient #8 should be placed under suicide precautions. Review of the Behavioral Health-Patient Observation Sheet dated 5/25/2024 revealed BHT #2 documented Patient #8 was asleep in his room at 7:45 PM and 8:00 PM. Review of the hospital’s video recording of the dayroom and North hallway dated 5/25/2024 revealed Patient #8 was in the dayroom from 7:49:58 PM until 7:57:59 PM when he exited into the South hallway. 18. Medical record review for Patient #9 revealed a 32 year-old male admitted on 5/19/2024 with diagnosis of Bipolar Disorder, Current episode Manic Severe with Psychosis. Review of the Intake Assessment dated 5/19/2024 at 5:47 AM revealed Patient #9’s wife stated the patient “...has been having some acute mental health disturbance over the last week or two. Pt was observed running in the middle of the interstate throwing heavy curb rocks. A citizen flagged down police...The police observed the pt. present w bizarre behaviors & change in demeanor & personality. Pt has flight of ideas x random talk about unrelated topics...Noncompliant...Legal Admission Status: Involuntary...Acute psychiatric condition requires 24 hour skilled nursing/medical oversight Potential danger to self or others...”. Review of the physician’s orders dated 5/19/2024 at 6:19 AM revealed Patient #9 was to be admitted to the GPU and should be observed by staff every 15 minutes. Review of the Psychiatric Evaluation completed by Psychiatrist #3 on 5/19/2024 at 9:19 AM revealed Patient #9 was “...admitted with increased psychosis and mood lability. per report, patient was found wandering on the interstate throwing rocks and heavy objects at moving vehicles. Patient is denying this saying he was at home minding his own business...Has been off medications for years...Justification for Hospitalization - Inpatient...Hallucinations, delusions, agitation, anxiety, depression resulting in a significant loss of functioning. Dangerous to self, others or property with need for controlled environment...”. Review of the Behavioral Health-Patient Observation Sheet dated 5/25/2024 revealed BHT #2 documented Patient #9 was asleep in his room at 7:45 PM and 8:00 PM. Review of the hospital’s video recording of the dayroom and North hallway and of the South hallway dated 5/25/2024 revealed Patient #9 was in the dayroom, North hallway or South hallway from 7:50:32 PM until 7:57:59 PM when he exited view. 19. Medical record for Patient #10 revealed an 18 year-old male admitted on 5/10/2024 with diagnosis of Schizophrenia. Review of the Intake Assessment dated 5/10/2024 at 10:41 PM revealed Patient #10 “...was seen walking in and out of the street into oncoming traffic. pt has been off his medication and has been feeling agitated & irritable...Legal Admission Status: Involuntary...”. Review of the physician’s orders dated 5/10/2024 at 11:14 PM revealed Patient #10 should be observed by staff every 15 minutes. Review of the Psychiatric Evaluation completed by Psychiatrist #2 on 5/12/2024 at 5:29 PM revealed Patient #10 “...presents at risk of harm to self and others as evidenced by walking in and out of the street into oncoming traffic. He presents with threats of harming violence towards others as evidenced by becoming physically/combative and aggressive towards the police...States he needs medication...Bizarre avoiding all eye contact asking to leave AMA [against medical advice]...Paranoid and preoccupied with internal stimuli...history of destroying property in the home and becoming physically aggressive with his mother. He currently presents at risk of harming danger to self and others as evidenced by suicidal ideations threats of harm on and violence toward others...unable to contract for safety...Justification for Hospitalization - Inpatient...Hallucinations, delusions, agitation, anxiety, depression resulting in a significant loss of functioning. Dangerous to self, others or property with need for controlled environment...”. Review of the Behavioral Health-Patient Observation Sheet dated 5/25/2024 revealed BHT #2 documented Patient #10 was asleep in his room at 7:45 PM. There was no documentation of the patient’s location and behaviors at 8:00 PM. Review of the hospital’s video recording of the dayroom and North hallway dated 5/25/2024 revealed Patient #10 was in the dayroom from 7:53:18 PM until 7:56:35 PM when he exited into the South hallway. 20. Medical record review for Patient #11 revealed a 41 year-old male admitted on 5/21/2024 with diagnosis of Schizoaffective Disorder, Bipolar Type. Review of the Intake Assessment dated 5/21/2024 at 8:23 AM revealed Patient #11 “...presented w rambling speech and endorsing homicidal ideations towards family member and harm self (plan not divulged) pt is non-compliant w/ psychotropic medication...Talks of harming himself...Legal Admission Status: Voluntary...Potential danger to self or others...”. Review of the Psychiatric Evaluation completed by Psychiatrist #2 on 5/21/2024 at 12:43 PM revealed Patient #11 had a “...presented...after reporting that he was having homicidal and suicidal ideations. He reported that the voices are telling him to do negative things ‘kill them, shoot them to people he speaks to on the street.’ He reports that the voices have become unbearable...has been off his meds for the past 6 months...unable to contract for safety for self or others...Justification for Hospitalization - Inpatient...Hallucinations, delusions, agitation, anxiety, depression resulting in a significant loss of functioning. Dangerous to self, others or property with need for controlled environment...”. Review of the physician’s orders dated 5/21/2024 at 1:10 PM revealed Patient #11 should be observed by staff every 15 minutes under assault precautions. Review of the Behavioral Health-Patient Observation Sheet dated 5/25/2024 revealed BHT #2 documented Patient #11 was asleep in his room at 7:45 PM. There was no documentation of the patient’s location and behaviors at 8:00 PM or 8:15 PM. Review of the hospital’s video recording of the dayroom and North hallway dated 5/25/2024 revealed Patient #11 was in the dayroom at 7:54:46 PM. 21. Medical record review for Patient #12 revealed a 65 year old male admitted on 5/20/2024 with diagnosis of Schizoaffective Disorder, Depressive Type. The Intake Assessment provided was for a previous admission; therefore, it is not included in this patient account. Review of the physician’s orders dated 5/21/2024 at 12:27 AM revealed the patient was placed on suicide precautions and should be monitored by staff every 5 minutes. Review of the Psychiatric Evaluation completed by Psychiatrist #1 on 5/21/2024 at 6:12 AM revealed Patient #12 was “...admitted for depression and medication stabilization. Reports feelings of depression and worthlessness due to being homeless and having verbal altercation with girlfriend. Reports AH of command voices telling him to kill himself and his girlfriend. H/o [history of] cocaine use but denies since last dc [discharge]. Off medications since recent dc 5/17/24. pt is noncompliant with meds, OP [outpatient] and medical appts [appointment]...Justification for Hospitalization - Inpatient...Hallucinations, delusions, agitation, anxiety, depression resulting in a significant loss of functioning. Dangerous to self, others or property with need for controlled environment...”. Review of a physician’s order dated 5/24/2024 at 6:33 PM revealed Patient #12 was placed under elopement precautions. Review of a physician’s order dated 5/24/2024 at 7:48 PM revealed the patient was to be observed by staff every 15 minutes. Review of the Behavioral Health-Patient Observation Sheet dated 5/25/2024 revealed BHT #2 documented Patient #12 was asleep in his room at 7:45 PM and 8:00 PM. Review of the hospital’s video recording of the dayroom and North hallway dated 5/25/2024 revealed Patient #12 was in the dayroom at 7:54:48 PM until 7:57:59 PM when he exited. 22. Medical record review for Patient #13 revealed a 46 year-old male admitted on 5/22/2024 with diagnosis of Unspecified Psychosis due a Substance Known. Review of the Intake Assessment dated 5/22/2024 at 2:21 AM revealed Patient #13 “...was sitting outside of a neighbors apartment for a long period of time for an unknown reason. Pt also ran into traffic on a busy st [street] on two separate occasions, trying to flag down cars for unknown reasons. pt experiencing delusions thinking that people are trying to steal the person’s identity, someone it trying to get the person’s money to file their own taxes, and people are wanting to know what he is doing at all times...Denies SI/SA [suicidal ideations/suicide attempt]...Pt angry/agitated...Legal Admission Status: Involuntary...Acute psychiatric condition requires 24 hour skilled nursing/medical oversight Potential danger to self or others...”. Review of the physician’s orders dated 5/22/2024 at 3:23 AM revealed Patient #13 should be admitted to the GPU under assault and elopement precautions and should be observed by staff every 15 minutes. Review of the Psychiatric Evaluation completed by Psychiatrist #3 on 5/22/2024 at 9:10 AM revealed Patient #13 was “...admitted with increased psychosis and mood lability. Responding to internal stimuli during initial assessment. Labile and agitated. Does not want to be here. Paranoid and argumentative. Believes he is being held ‘Hostage’...long history of noncompliance with treatment...Justification for Hospitalization - Inpatient...Hallucinations, delusions, agitation, anxiety, depression resulting in a significant loss of functioning. Dangerous to self, others or property with need for controlled environment...”. Review of the Behavioral Health-Patient Observation Sheet dated 5/25/2024 revealed BHT #2 documented Patient #13 was asleep in his room at 7:45 PM and 8:00 PM. Review of the hospital’s video recording of the dayroom and North hallway dated 5/25/2024 revealed Patient #13 was in the North hallway at 7:55:06 PM. The patient entered the dayroom at 7:56;35 PM where he remained until 7:56:56 PM when he exited into his room in the North hallway. At 7:58:12 PM, Patient #14 was back in view of the camera where he remained visible until the video ended at 7:59:59 PM. 23. Medical record review for Patient #14 revealed a 62 year-old male admitted on 5/23/2024 with diagnosis of Bipolar Disorder, Current Episode Depression, Severe with Psychotic Features. Review of the Intake Assessment dated 5/23/2024 at 8:00 AM revealed Patient #14 presented with “...suicidal ideation via being shot by law enforcement. Pt endorses depression and alcoholism. pt is non-compliant w/ psychotropic medications (hx [history] of Bipolar). pt is exhibiting high anxiety due to pending homelessness...Acute psychiatric condition requires 24 hour skilled nursing/medical oversight Potential danger to self or others...” Review of the physician’s orders dated 5/23/2024 at 11:42 AM revealed Patient #14 should be observed by staff every 5 minutes under suicide precautions. Review of the Psychiatric Evaluation completed by Psychiatrist #3 on 5/23/2024 at 10:42 AM revealed Patient #14 was “...admitted with increased depression and psychosis. States ‘My mental is worse than my physical’. Reporting hearing voices telling him ‘Bad things’. + Suicidal ideation due to chronic health issues including cancer diagnosis. Has been off medications...Justification for Hospitalization - Inpatient...Hallucinations, delusions, agitation, anxiety, depression resulting in a significant loss of functioning. Dangerous to self, others or property with need for controlled environment...”. Review of the physician’s orders dated 5/24/2024 at 7:16 AM revealed Patient #14 should be observed by staff every 15 minutes. Review of the Behavioral Health-Patient Observation Sheet dated 5/25/2024 revealed BHT #2 documented Patient #14 was asleep in his room at 7:45 PM and 8:00 PM. Review of the hospital’s video recording of the dayroom and North hallway dated 5/25/2024 revealed Patient #14 was in the dayroom just outside his room at 7:55:06 PM where he remained until The patient entered the dayroom at 7:56:35 PM where he remained until 7:56:57 PM when he and Patient #4 entered his room out of view of the camera. 24. Medical record review for Patient #15 revealed a 45 year-old male admitted on 5/17/2024 with diagnosis of Bipolar Disorder, Current Episode Depression, Severe with Psychotic Features. Review of the Intake Assessment dated 5/17/2024 at 1:26 PM revealed Patient #15 presented with “...suicidal ideation w/o [without] plan. Pt exhibiting high anxiety due to pending homelessness non-compliant w/psychotropic medication...hearing voices...paranoid...Rambling speech...Legal Admission Status: Voluntary...”. Review of the physician’s orders dated 5/17/2024 at 1:31 PM revealed Patient #15 was placed under suicide precautions. Review of the Psychiatric Evaluation completed by Psychiatrist #3 on 5/17/2024 at 2:05 PM revealed Patient #15 was “...admitted with increased depression, psychosis, and substance abuse. +Suicidal ideation with plan to walk into traffic. +Auditory hallucinations. hearing voices telling him to ‘Do it’. Has been drinking and abusing crack cocaine daily ‘When I had the money’. Off medications...Justification for Hospitalization - Inpatient...Hallucinations, delusions, agitation, anxiety, depression resulting in a significant loss of functioning. Dangerous to self, others or property with need for controlled environment...”. Review of the physician’s orders dated 5/17/2024 at 2:05 PM revealed Patient #15 was to be observed by staff every 15 minutes. Review of the Behavioral Health-Patient Observation Sheet dated 5/25/2024 revealed BHT #2 documented Patient #15 was asleep in his room at 7:45 PM and 8:00 PM. Review of the hospital’s video recording of the dayroom and North hallway dated 5/25/2024 revealed Patient #15 entered the dayroom at 7:56:56 PM where he remained until 7:57:59 PM when he exited. 25. In a telephone interview on 6/12/2024 at 12:33 PM BHT #2 verified she failed to accurately document the Patients’ locations and behaviors on 5/26/2024 at 7:45 PM through 8:15 PM.”