East Tennessee Behavioral Health

“COMPLIANCE WITH LAWS CFR(s): 482.11 Compliance with Federal, State and Local Laws This Condition is not met as evidenced by: 30553 Based on review of facility policy, medical record review and interviews, the facility failed to report an allegation of abuse related to an altercation between Patient #3 and Patient #4 where Registered Nurse (RN) #1 was injured and subsequently expired for 2 patients reviewed for abuse of 8 records reviewed. The findings include: Patient #3 and Patient #4 were admitted to the Facility A’s behavior unit. Both patients had known psychiatric diagnoses and behavior issues. The two patients had a previous verbal altercation on 9/19/1023. On 9/23/2023 the patients were involved in a verbal altercation where their behaviors escalated. The facility staff intervened and the patients de-escalated initially. The two patients escalated a second time. RN #1 entered the unit from another unit to assist the staff. Patient #3 pushed RN #1 to the floor resulting in injury to the RN. The unit staff took Patient #3 to the seclusion room and moved Patient #4 to another room. The RN was transported to Facility B on 9/23/2023 where the she was diagnosed with left impacted left femoral neck fracture (fracture to the femur bone). The RN required surgical intervention, she remained in the facility and subsequently expired on 10/25/2023. During the investigation, it was found the facility did not report the incident to local law enforcement or to regulatory agencies. The facility interviewed staff on 10/7/2023 (15 days after the incident occurred). An investigation had been started but not completed. Refer to A-0021”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 30553 Based on review of the Governing Body Bylaws, review of facility policy, review of a facility incident report, review of facility video footage, medical record review and interviews, the facility’s Governing Body failed to provide oversight to ensure a timely investigation and reporting for abuse related to 2 patients (#3 and #4) and Registered Nurse (RN) #1 (the alleged victim) for 2 patients of 8 records reviewed. The findings include: Patient #3 and Patient #4 were admitted to the Facility A’s behavior unit. Both patients had known psychiatric diagnoses and behavior issues. The two patients had a previous verbal altercation on 9/19/1023. On 9/23/2023 the patients were involved in a verbal altercation where their behaviors escalated. The facility staff intervened and the patients de-escalated initially. The two patients escalated a second time. RN #1 entered the unit from another unit to assist the staff. Patient #3 pushed RN #1 to the floor, resulting in injury to the RN. The unit staff took Patient #3 to the seclusion room and moved Patient #4 to another room. RN #1 was transported to Facility B on 9/23/2023 where the she was diagnosed with left impacted left femoral neck fracture (fracture to the femur bone). The RN required surgical intervention, she remained in the facility and subsequently expired on 10/25/2023. During the investigation it was found the facility did not report the incident to local law enforcement or to regulatory agencies. The facility interviewed staff on 10/7/2023 (15 days after the incident occurred). An investigation had been started but not completed. Review of the Governing Body Bylaws dated 7/2020 showed the Governing Body was “...ultimately accountable for the safety and quality of care, treatment, and services provided by the Facility. The primary function of the Governing Board is to assure that the Facility and its Medical Staff provide quality medical care that meets the needs of the community. For this purpose, the [Managing Member / Board of Directors] has delegated to the Governing Board the authority to...to oversee quality assessment and improvement, utilization review, risk management, and similar matters regarding the provision of quality patient care at the Facility, and to establish polices regarding these matters...[h] requiring that patients with comparable needs will receive the same standard of care, treatment and services at the Facility by ensuring that the Facility plans, designs, and monitors care, treatment, and services so they are consistent with the Facility’s mission, vision, and goals and ensuring the planning for care, treatment, and services addresses the following: (i) the needs and expectations of clients and, as appropriate, families, and referral sources; (ii) staff needs; (iii) the scope of care, treatment, and services needed by clients at all of the organization’s locations; (iv) resources (financial and human) for providing care and support services; (v) recruitment, retention, development, and continuing education needs of all staff; and (vi) data for measuring the performance of processes and outcomes of care...” Review of facility policy “Workplace Violence” revised 9/1/2015, showed “...[named facility] is committed to providing an environment free from all forms to violence for its employees, patients, families, and vendors. Workplace violence includes but is not limited to harassment, intimidation, threats...and acts of physical assault and other disruptive behavior. All reports of violence will be treated seriously and fully investigated. [named facility] has a Zero tolerance approach to workplace violence...in the event of an act of violence which poses an immediate threat of others...local police and/or the facility security department should be notified immediately...supervisors are responsible for observing and reporting the unusual behavior or employees or other individuals who exhibit certain circumstances which may indicative of posing a potential threat. All reported incidents of threats or violent behavior will be investigated by the appropriate individuals in Administration, Security and/or Human Resource Representative...” Review of facility policy “Patient Abuse and Neglect” revised 9/1/2015, showed “...[named facility] maintains Zero Tolerance for patient abuse or neglect...all instances of witnessed or alleged patient abuse or neglect must be immediately reported to the Risk Manager, a department head or supervisor...upon investigation and after an assessment of the findings, a final determination should be made by the Senior Facility Leader and senior management...upon the discretion of the facility and in accordance with applicable state and Federal requirements, such violations may be reported to employee state licensing agency and/or law enforcement agencies...” Review of the facility policy “Risk Management Incident Reporting Policy” reviewed 1/2023, showed “...an “incident” is an unanticipated event which results in, or nearly causes, a negative impact on patient care or visitor safety. Any harm caused can be temporary, long-term, or permanent and range in severity from no obvious or significant injury, up to death....[4.5] If the incident involves an injury to a facility employee or contracted employee the injured staff will complete an “Employee Report of Injury” and notify their immediate supervisor and the facility Human Resources Manager...[5.2] the Shift Supervisor or a Facility Designated Individual will conduct a preliminary incident review. Facility Risk Manager will investigate and will document the investigation’s findings, including determining a final severity level classification...[5.3] The facility Risk Manager will notify Corporate Risk Management of all Initial “Level I” and “Level II” incidents within 24 hours...Sentinel Event: Identifies a patient safety-related incident (not primarily related to the natural course of an illness or underlying condition of an individual served) that reaches an individual served and results in death, severe harm, or permanent harm where intervention was required to sustain life. Workplace Violence Event: Identifies an incident that specifically involved a person(s) who commits assault, engages in harassing or intimidating behaviors, or credibly threatens the personal safety of employees (including contracted/agency staff), patients, visitors, or vendors...” The Severity Level Classification was as follows: Level I (Major): Incidents which are considered serious events This may include sentinel events. Level II (Moderate): Injury or impairment in which the patient or visitor’s function is altered requiring outside medical intervention. Level III (Minor): Injury or impairment in which a patient or visitor’s function may be altered with treatment limited to first aid. Level IV (Inconsequential): Events which do not otherwise qualify as a Level I, II, or III and where no injury or outcome alters a patient or visitor’s function. Review of a facility investigation report dated 9/23/2023 at 2:48 PM, showed an altercation occurred between 2 patients and (Patient #3) pushed an RN. The summary of the event showed Patient #3 walked behind Patient #4 and a verbal altercation occurred between the two patients. Both patients ripped off their shirts, they started yelling at each other and attempted to approach each other. The facility staff intervened and stood between the 2 patients trying to “stop their behaviors with words.” RN #1 arrived on the unit to assist and Patient #3 pushed the RN onto floor. The ‘severity level’ was a 2 indicating a moderate classification. Review of facility video footage of the Unit 4 for 9/23/2023 showed the following: The times were only in seconds for real time, not the actual time of the incident: 00:04 seconds: Patient #3 was pacing in the hallway. Patient #4 was at the medication room door. 00:41 seconds: the patients were walking towards each other and appeared verbally aggressive with each other. 00:47 seconds: both patients took their shirts off and appeared verbally aggressive with each other. The staff members were in the nurses station and a Behavioral Health Assistant (BHA) was standing in front of Patient #3. 1:27 seconds: The RN (the victim) entered the hallway from the Nurses Station 1:29 seconds: Patient #3 ran toward Patient #4. Patient #3 pushed the RN to the floor. The RN was laying in the floor up against the wall. She appeared to be holding her hip and in pain. Medical record review showed Patient #3 was admitted on 9/5/2023 with diagnoses including chronic schizophrenia (mental disorder with psychosis) and depressive disorder. The patient was admitted under an involuntary commitment related to a change in his mental status, disorganized thought processes, speech with agitation, aggressive threatening behaviors and psychosis. Medical record review of a Seclusion Patient Debriefing for Patient #3 dated 9/23/2023 at 8:50 AM showed “...[Patient #3] was walking behind [Patient #4] who became very agitated at patient. [Patient #3] began cussing at [Patient#4] and took his shirt off to fight the other patient. He was unable to be redirected. As he lunged for [Patient #4], he hit an RN...and shoved her to the ground. She landed on her hip...” Medical record review of a Psychiatry Progress Note for Patient #3 dated 9/23/2023 at 10:40 AM showed “...the patient is a 33-year-old male presenting to the hospital for psychosis. Per nursing staff, pt. was involved in a confrontation with another patient...” Medical record review of a Psychiatry Progress Note for Patient #3 dated 10/1/2023 at 11:30 AM showed the patient continued to isolate himself in his room. He remained delusional with impaired insight and judgement. The patient had required Haldol Decanoate 200 milligrams (mg) intramuscular (IM) on 9/29/2023. Medical record review showed Patient #4 was admitted on 9/15/2023 under an involuntary admission related to suicidal ideations [SI], Schizophrenia related to substance abuse psychosis related to amphetamines and cannabis use, visual hallucinations and delusional thoughts. The patient had previous history of bipolar, schizophrenia, and multiple personality disorder. Medical record review of a Restraint Progress Note for Patient #4 dated 9/19/2023 at 9:20 AM showed the patient had a verbal altercation with Patient #3 with threatening behaviors with the other patient. The patient required a physical hold at 8:53 AM related to aggressive behaviors. The patient required IM PRN [as needed] for agitation. He was given Zyprexa [medication used to treat schizophrenia] 10 mg IM at 9:15 AM. The care plan for the patient was to be updated related to anger and aggression. The care plan was not updated. Medical record review of a Psychiatry Progress Note dated 9/23/2023 at 8:45 AM showed “...pt. [patient] at med window getting meds and another patient was in the hallway waiting. Pt. asked the other pt. to ‘stop walking behind him and talking shit’. The other patient quickly escalated and was shouting. Both pt’s. had shirts off by the time I was able to come to the hall from the med room, both pt’s. were verbally threatening each other and staff separated them after the other patient pushed a staff to the floor. Pt. took PRN Zydis [Zyprexa] and was apologetic for the incident...” Medical record review of a restraint Progress Note for Patient #4 dated 9/23/2023 at 11:38 AM showed “...pt. at med window getting meds and another patient was in the hallway. Pt. asked the other pt to ‘stop walking behind him and talking shit’. The other patient quickly escalated and shouting. Both pts. had shirts off by the time I was able to come to hall from med room, both patients were verbally threatening each other and staff separated them after the other patient pushed a staff to the floor. Pt. took Zydis and was apologetic for the incident...” Medical record review showed RN #1 was admitted to Facility B on 9/23/2023. Medical record review of an ED Physicians Record dated 9/23/2023 at 11:07 AM showed the patient was admitted after two patients had gotten in a fight and she was pushed where she fell on her left hip. Radiology diagnostic testing showed an impacted left femoral neck fracture. Orthopedics was consulted and the patient was admitted to the facility. Medical record review of an admission H&P dated 9/23/2023 at 12:44 PM showed the patient was a Behavioral Health Nurse and got pushed by a patient during an altercation between two patients. Orthopedics was consulted. Medical record review of a Discharge Summary dated 10/25/2023 at 3:38 PM showed the patient (the RN) expired. The patient’s diagnoses included Fracture of the Left Femoral Neck (part of the hip joint), Acute Respiratory Failure, Enterobacter Cloacae (infection) Pneumonia, Aspiration Pneumonia, Septic Shock, Type 2 Myocardial Infarction with Takostubo Cardiomyopathy (a weakening of the left ventricle, the heart’s main pumping chamber), Deep Vein Thrombosis (blood clot) right upper extremity, and Acute Tubular Necrosis (acute kidney injury). During an interview on 11/6/2023 at 9:30 AM, the Risk Manager, stated the incident occurred on 9/23/2023. The incident report showed the incident was prioritized at a lower level. The employee was transferred to Facility B for treatment. The Corporate HR was aware and were handling the incident as a Workman’s Compensation concern. The facility’s corporate Human Resource Department informed the facility of the need of an investigation once the facility was made aware of the extent of the employee’s injuries and status. Interviews with the staff were completed on 10/7/2023 (15 days after the incident). She confirmed the Root Cause Analysis (RCA) was due next week but had not been completed and the facility “would look at the RCA and see what interventions, if any, needed to be performed.” During an interview on 11/6/2023 at 9:40 AM, Behavioral Health Associate (BHA) #1 stated the two patients become verbally aggressive with each other in the hallway. Patient #3 took his shirt off and walked toward Patient #4 who then took his shirt off and the two patients started walking toward each other. The nursing staff attempted to de-escalate and separate the patients. Patient #3 initially walked away but the patients remained verbally aggressive. RN #1 was on the other unit and heard the yelling and came to the unit to assist. She stated “...when I turned around, [Patient 3] was charging toward Patient #4. The next thing I saw, [RN #1] was in the floor and she stated her hip was hurt and she could not get up...” During a telephone interview on 11/6/2023 at 9:55 AM, RN #2 stated she was giving medications to Patient #4. Patient #3 was pacing the hallway, talking to himself and had walked behind Patient #4. A verbal altercation occurred between the two patients. She came out of med room and saw the two patients had taken their shirts off and were trying to fight each other, but the staff were in between them. She had yelled for help. RN #1 came from the other unit to assist. Patient #4 had walked away toward the opposite end of the hall, but then turned around and started charging toward Patient #4. RN #1 grabbed [Patient #3’s] arm to try to stop him and [Patient #3] shoved the nurse to the ground. During a telephone interview on 11/6/2023 at 10:45 AM, RN #3 stated she was the primary nurse for Patient #3 who had anger issues and rambled a lot. She heard the two patients yelling in the hallway and when she came to the hallway, other staff members were standing in between the patients. Both patients had taken their shirts off and were verbally aggressive with each other, but there were no hands on between the patients. She stated “...[RN #1] came from the other unit to help. [Patient #3] turned around and started charging toward [Patient #4]. [RN #1] tried to grab [Patient #3’s] arm and when she did...he pushed her and she landed in the floor...we were able to separate the patients and no hands-on occurred between the patients...” During an interview on 11/6/2023 at 11:00 AM the Human Resource Director stated the process for reporting an employee injury included reporting the injury to the 24-hour hot line and filling out the appropriate paperwork. The employee normally filled the paperwork out, but since the employee was injured, the House Supervisor would have completed the paperwork to send to Workman’s Compensation. Corporate HR normally takes the lead after an employee workman’s compensation claim. During a telephone interview on 11/6/2023 at 1:25 PM RN #4 stated the two patients were verbally aggressive in the hallway towards each other. Both patients were very angry. She stated “...[RN #1] heard the call for help and came to the unit. At that point, [Patient #3] had walked away but then turned around and started to charge towards [Patient #4]. [RN #1] reached out to grab [Patient #3’s] arm and he pushed the nurse to the floor...” During an interview on 11/6/2023 at 4:10 PM the Chief Executive Officer stated she was made aware of the incident on 9/23/2023. On Monday (9/25/2023) the video footage was reviewed by the administrative staff. Interviews were completed with the staff involved on 10/7/2023 [15 days after the incident occurred]. On 10/17/2023 (25 days after the incident occurred) the facility provided training related to safety and de-escalating agitated psychiatric patients was provided during a staff meeting. The CEO confirmed the facility had not reported the incident to the local enforcement or regulatory agencies. During an interview on 11/9/2023 at 2:15 PM, RN #5 stated the two patients (#3 and #4) had a verbal altercation on 9/19/2023 where the staff had to intervene. There was no hands-on between the patients. Patient #4 required an as needed antipsychotic medication related to his behaviors. She had documented the need to update the care plan for Patient #4 for anger and aggression but had failed to update the care plan.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 30553 Based on review of facility policy, review of a facility incident report, review of facility video footage, medical record review and interviews, the facility failed to ensure the safety of two behavioral health patients (#3 and #4) and the Registered Nurse (RN) #1 (the victim) who were involved in a verbal and physical altercation, for 2 patients reviewed of 8 records reviewed. The findings include: Patient #3 and Patient #4 were admitted to the Facility A’s behavior unit. Both patient’s had known psychiatric diagnoses and behavior issues. The two patients had a previous verbal altercation on 9/19/1023. On 9/23/2023 the patients were involved in a verbal altercation where their behaviors escalated. The facility staff intervened and the patients de-escalated initially. The two patients escalated a second time. RN #1 entered the unit from another unit to assist the staff. Patient #3 pushed RN #1 to the floor resulting in injury to the RN. The unit staff took Patient #3 to the seclusion room and moved Patient #4 to another room. The RN was transported to Facility B on 9/23/2023 where the she was diagnosed with left impacted left femoral neck fracture (fracture to the femur bone). The RN required surgical intervention, she remained in the facility and subsequently expired on 10/25/2023. During the investigation, it was found the facility did not report the incident to local law enforcement or to regulatory agencies. The facility interviewed staff on 10/7/2023 (15 days after the incident occurred). An investigation had been started but not completed. Refer to A-0145”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 30553 Based on review of facility policy, review of a facility incident report, review of facility video footage, medical record review, and interview, the facility’s Quality Assurance Performance Committee (QAPI) failed to identify and recognize verbal abuse and potential physical abuse for 2 patients (#3 and #4) resulting in Registered Nurse (RN) #1 (the victim) being injured with subsequent death. The facility’s QAPI failure placed potential or likelihood to create an Immediate Jeopardy situation for all 14 patients on the unit. The findings included: Patient #3 and Patient #4 were admitted to Facility A’s behavior unit. Both patients had known psychiatric diagnoses and behavior issues. The two patients had a previous verbal altercation on 9/19/1023. On 9/23/2023 the patients were involved in a verbal altercation where their behaviors escalated. The facility staff intervened and the patients de-escalated initially. The two patients escalated a second time. RN #1 entered the unit from another unit to assist the staff. Patient #3 pushed RN #1 to the floor resulting in injury to the RN. The unit staff took Patient #3 to the seclusion room and moved Patient #4 to another room. The RN was transported to Facility B on 9/23/2023 where the she was diagnosed with left impacted left femoral neck fracture (fracture to the femur bone). The RN required surgical intervention, she remained in the facility and subsequently expired on 10/25/2023. During the investigation it was found the facility did not report the incident to local law enforcement or to regulatory agencies. The facility interviewed staff on 10/7/2023 (15 days after the incident occurred). An investigation had been started but not completed. Refer to A-0021”

“COMPLIANCE WITH LAWS CFR(s): 482.11(a) The hospital must be in compliance with applicable Federal laws related to the health and safety of patients. This Standard is not met as evidenced by: 30553 Based on review of facility policy, review of a facility incident report, medical record review and interviews, the facility failed to investigate and report and allegation of patient to staff abuse related to Patient #3 and Patient #4 and Registered Nurse (RN) #1 (the victim) which resulted in RN #1 being hospitalized with required surgical intervention, and subsequent death, for 2 patients (#3 and #4) of 8 records reviewed. The findings included: Review of facility policy “Workplace Violence” revised 9/1/2015, showed “...[named facility] is committed to providing an environment free from all forms to violence for its employees, patients, families, and vendors. Workplace violence includes but is not limited to harassment, intimidation, threats...and acts of physical assault and other disruptive behavior. All reports of violence will be treated seriously and fully investigated. [named facility] has a Zero tolerance approach to workplace violence...in the event of an act of violence which poses an immediate threat of others...local police and/or the facility security department should be notified immediately...supervisors are responsible for observing and reporting the unusual behavior or employees or other individuals who exhibit certain circumstances which may indicative of posing a potential threat. All reported incidents of threats or violent behavior will be investigated by the appropriate individuals in Administration, Security and/or Human Resource Representative...” Review of facility policy “Patient Abuse and Neglect” revised 9/1/2015, showed “...[named facility] maintains Zero Tolerance for patient abuse or neglect...all instances of witnessed or alleged patient abuse or neglect must be immediately reported to the Risk Manager, a department head or supervisor...upon investigation and after an assessment of the findings, a final determination should be made by the Senior Facility Leader and senior management...upon the discretion of the facility and in accordance with applicable state and Federal requirements, such violations may be reported to employee state licensing agency and/or law enforcement agencies...” Review of facility policy “Risk Management Incident Reporting Policy” reviewed 1/2023, showed “...an “incident” is an unanticipated event which results in, or nearly causes, a negative impact on patient care or visitor safety. Any harm caused can be temporary, long-term, or permanent and range in severity from no obvious or significant injury, up to death....[4.5] If the incident involves an injury to a facility employee or contracted employee the injured staff will complete an “Employee Report of Injury” and notify their immediate supervisor and the facility Human Resources Manager...[5.2] the Shift Supervisor or a Facility Designated Individual will conduct a preliminary incident review. Facility Risk Manager will investigate and will document the investigation’s findings, including determining a final severity level classification...[5.3] The facility Risk Manager will notify Corporate Risk Management of all Initial “Level I” and “Level II” incidents within 24 hours...Sentinel Event: Identifies a patient safety-related incident (not primarily related to the natural course of an illness or underlying condition of an individual served) that reaches an individual served and results in death, severe harm, or permanent harm where intervention was required to sustain life. Workplace Violence Event: Identifies an incident that specifically involved a person(s) who commits assault, engages in harassing or intimidating behaviors, or credibly threatens the personal safety of employees (including contracted/agency staff), patients, visitors, or vendors...” The Severity Level Classification was as follows: Level I (Major): Incidents which are considered serious events This may include sentinel events. Level II (Moderate): Injury or impairment in which the patient or visitor’s function is altered requiring outside medical intervention. Level III (Minor): Injury or impairment in which a patient or visitor’s function may be altered with treatment limited to first aid. Level IV (Inconsequential): Events which do not otherwise qualify as a Level I, II, or III and where no injury or outcome alters a patient or visitor’s function. Review of a facility investigation report dated 9/23/2023 at 2:48 PM showed an altercation occurred between 2 patients and [patient #3] pushed an RN. The summary of event showed Patient #3 walked behind Patient #4 and a verbal altercation occurred between the two patients. Both patients ripped off their shirts, they started yelling at each other and attempted to approach each other. The facility staff intervened and stood between the 2 patients trying to ‘stop their behaviors with words’. RN #1 arrived on the unit to assist and Patient #3 pushed the RN onto floor. The ‘severity level’ was a 2 indicating a moderate classification. Medical record review showed Patient #3 was admitted on 9/5/2023 with diagnoses including chronic schizophrenia (mental disorder with psychosis) and depressive disorder. The patient was admitted under an involuntary commitment related to a change in his mental status. He presented with disorganized thought processes and speech with agitation, aggressive threatening behaviors and psychosis. Medical record review showed Patient #4 was admitted on 9/15/2023 under an involuntary admission with diagnoses including Suicidal Ideations, Schizophrenia related to substance abuse psychosis related to amphetamines and cannabis use. The patient had previous history of bipolar, schizophrenia, and multiple personality disorder. He had visual hallucinations and delusional thoughts. Medical record review of a Restraint Progress Note dated 9/19/2023 at 9:20 AM, showed a verbal altercation occurred between Patient #3 and Patient #4. Patient #4 required a physical hold and he was given Zyprexa (medication used to treat schizophrenia) 10 milligrams (mg) IM (intramuscular) at 9:15 AM. The patient’s care plan was to be updated related to anger and aggression but the care plan was not updated. Medical record review of a Seclusion Patient Debriefing dated 9/23/2023 at 8:50 AM, showed “...Patient #3 was walking behind Patient #4 who became very agitated at patient. Patient #3 began cussing at Patient #4 and both patients took their shirts off and a verbal altercation occurred. Initially the patients were able to be redirected. Patient #3 lunged for Patient #4 and during the incident, Patient #3 shoved RN #1 to the ground where the nurse landed on her hip. Medical record review showed RN #1 was admitted to Facility B on 9/23/2023. Two patients had gotten in a fight and she was pushed where she fell on her left hip. She was unable to walk and had received 100 mcg (micromilligrams) of Fentanyl by EMS. Radiology diagnostic testing showed an impacted left femoral neck fracture. Orthopedics was consulted and the patient was admitted to the facility. The nurse required surgical intervention. The diagnoses included a Fracture of the left femoral neck (of the hip joint), Acute Respiratory Failure, Enterobacter Cloacae (infection) Pneumonia, Aspiration Pneumonia, Septic Shock, Type 2 Myocardial Infarction with Takostubo Cardiomyopathy (a weakening of the left ventricle, the heart’s main pumping chamber), Deep Vein Thrombosis (blood clot) of the right upper extremity, and Acute Tubular Necrosis (acute kidney injury). The RN expired at Facility B on 10/25/2023 at 3:38 PM. During an interview on 11/6/2023 at 9:30 AM, the Risk Manager stated the incident occurred on 9/23/2023. The incident report showed the incident was prioritized at a lower level. The employee was transferred to Facility B for treatment. The facility’s corporate Human Resource Department informed the facility of the need of an investigation once the facility was made aware of the extent of the employee’s injuries and status. Interviews with the staff were completed on 10/7/2023 (15 days after the incident). She confirmed the Root Cause Analysis (RCA) was due next week but had not been completed. The facility did not report the incident to local law enforcement or regulatory agencies. During an interview on 11/6/2023 at 4:10 PM, the Chief Executive Officer stated she was made aware of the incident on 9/23/2023. On Monday (9/25/2023) the video footage was reviewed by the administrative staff. Interviews were completed with the staff involved on 10/7/2023 [15 days after the incident occurred]. She confirmed the facility had not reported the incident to the local enforcement or regulatory agencies.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 30553 Based on review of facility policy, review of a facility incident report, review of facility video footage, medical record review and interview, the facility failed to protect Registered Nurse (RN) #1 from abuse, which had the potential to effect other staff members and patients, failed to follow facility policy regarding a timely investigation, and failed to provide immediate education to ensure the safety of two behavioral health patients (#3, #4) and RN #1 (the victim) who were involved in a verbal and physical altercation, for 2 patients reviewed of 8 patient records reviewed. The findings include: Review of facility policy “Workplace Violence” revised 9/1/2015, showed “...[named facility] is committed to providing an environment free from all forms to violence for its employees, patients, families, and vendors. Workplace violence includes but is not limited to harassment, intimidation, threats...and acts of physical assault and other disruptive behavior. All reports of violence will be treated seriously and fully investigated. [named facility] has a Zero tolerance approach to workplace violence...in the event of an act of violence which poses an immediate threat of others...local police and/or the facility security department should be notified immediately...supervisors are responsible for observing and reporting the unusual behavior or employees or other individuals who exhibit certain circumstances which may indicative of posing a potential threat. All reported incidents of threats or violent behavior will be investigated by the appropriate individuals in Administration, Security and/or Human Resource Representative...” Review of facility policy “Patient Abuse and Neglect” revised 9/1/2015, showed “...[named facility] maintains Zero Tolerance for patient abuse or neglect...all instances of witnessed or alleged patient abuse or neglect must be immediately reported to the Risk Manager, a department head or supervisor...upon investigation and after an assessment of the findings, a final determination should be made by the Senior Facility Leader and senior management...upon the discretion of the facility and in accordance with applicable state and Federal requirements, such violations may be reported to employee state licensing agency and/or law enforcement agencies...” Review of facility policy “Risk Management Incident Reporting Policy” reviewed 1/2023, showed “...an “incident” is an unanticipated event which results in, or nearly causes, a negative impact on patient care or visitor safety. Any harm caused can be temporary, long-term, or permanent and range in severity from no obvious or significant injury, up to death....[4.5] If the incident involves an injury to a facility employee or contracted employee the injured staff will complete an “Employee Report of Injury” and notify their immediate supervisor and the facility Human Resources Manager...[5.2] the Shift Supervisor or a Facility Designated Individual will conduct a preliminary incident review. Facility Risk Manager will investigate and will document the investigation’s findings, including determining a final severity level classification...[5.3] The facility Risk Manager will notify Corporate Risk Management of all Initial “Level I” and “Level II” incidents within 24 hours...Sentinel Event: Identifies a patient safety-related incident (not primarily related to the natural course of an illness or underlying condition of an individual served) that reaches an individual served and results in death, severe harm, or permanent harm where intervention was required to sustain life. Workplace Violence Event: Identifies an incident that specifically involved a person(s) who commits assault, engages in harassing or intimidating behaviors, or credibly threatens the personal safety of employees (including contracted/agency staff), patients, visitors, or vendors...” The Severity Level Classification was as follows: Level I (Major): Incidents which are considered serious events This may include sentinel events. Level II (Moderate): Injury or impairment in which the patient or visitor’s function is altered requiring outside medical intervention. Level III (Minor): Injury or impairment in which a patient or visitor’s function may be altered with treatment limited to first aid. Level IV (Inconsequential): Events which do not otherwise qualify as a Level I, II, or III and where no injury or outcome alters a patient or visitor’s function. Review of a facility investigation report dated 9/23/2023 at 2:48 PM, showed an altercation occurred between 2 patients and [patient #3] pushed an RN. The summary of event showed Patient #3 walked behind Patient #4 and a verbal altercation occurred between the two patients. Both patients ripped off their shirts, they started yelling at each other and attempted to approach each other. The facility staff intervened and stood between the 2 patients trying to ‘stop their behaviors with words’. RN #1 arrived on the unit to assist and Patient #3 pushed the RN onto floor. The ‘severity level’ was a 2 indicating a moderate classification. Review of facility video footage of Unit 4 for 9/23/2023 showed the following: The times were only in seconds not the actual time of the incident: 00:04 seconds: Patient #3 was pacing in the hallway. Patient #4 was at the medication room door 00:41 seconds: Patient #4 walked down the hallway towards Patient #3. Both patients were talking to each other 00:47 seconds: Patient #3 took his shirt off and threw in the floor. Patient #4 took his shirt off. Staff members were in the nurse’s station. Facility staff were in the hallway with the patients. 1:03 seconds: The nursing staff were in the hallway with the patients talking to the patients. 1:07 seconds: Mr. Easley walked away from the staff towards the other end of the hall. 1:26 seconds: RN supervisor talking with Patient #3. 1:27 seconds: The RN (the victim) entered the hallway from the Nurses Station 1:29 seconds: Patient #3 ran toward Patient #4. Patient #3 pushed the RN to the floor. 2:04 seconds: Male RN came into the hallway and immediately took Patient #3 into the seclusion room. Patient #4 was escorted into the activity room with staff. Medical record review of an admission Psychiatric Evaluation dated 9/5/2023 11:45 AM, showed Patient #3 was admitted under an involuntary commitment related to a change in his mental status and schizophrenia (mental disorder with psychosis). The patient presented with disorganized thought processes and speech with agitation, aggressive threatening behaviors and psychosis. The patient had religious preoccupations. He had sadness, depression, and agitation. Medical record review of a Seclusion Patient Debriefing for Patient #3 dated 9/23/2023 at 8:50 AM, showed “...Patient was walking behind patient [#4] who became very agitated at patient. [Patient #3] began cussing at [Patient #4] and took his shirt off to fight the other patient. He was unable to be redirected. As he lunged for [Patient #4] he hit an RN [#1 and the victim] and shoved her to the ground. She landed on her hip. Patient was brought to the seclusion room for patient and staff safety...” Medical record review of a Psychiatry Progress Note for Patient #3 dated 9/23/2023 at 10:40 AM, showed “...the patient [pt.] is a 33-year-old male presenting to the hospital for psychosis. Per nursing staff, pt. was involved in a confrontation with another patient. Two were separated and the other patient was moved to another unit...difficult to understand most of the time. Unsure if cultural or dysarthric [slurred speech]...does appear hypervigilant [abnormally alert to potential danger] and spending majority of the time on the unit as far end looking at activities in the hallway...” Medical record review of a Psychiatry Progress Note for Patient #3 dated 9/25/2023 at 10:30 AM, showed “...the patient reports there being a misunderstanding about an incident that occurred yesterday [9/23/2023] in which he was accused of being the aggressor in an altercation between himself and another patient. Patient reports the other patient was verbally aggressive towards him and he was simply trying to defend himself. The patient reports this resulted in him being placed in seclusion and given an injection of as needed medications which has contributed to elevate levels on anxiety and depression which he continues to persist today...” Medical record review of a Psychiatry Progress Note for Patient #3 dated 10/1/2023 at 11:30 AM, showed the patient continued to isolate himself in his room. He had refused to take some of his home medications, refused to participate in the interview for the psychiatric examination and remained delusional with impaired insight and judgement. The patient had required Haldol Decanoate (antipsychotic medication) 200 milligrams (mg) intramuscular (IM) on 9/29/2023. Medical record review of an admission Psychiatric History and Physical (H&P) for Patient #4 dated 9/16/2023 at 8:43 AM, showed the patient had previous history of bipolar, schizophrenia and multiple personality disorder. The patient was admitted under an involuntary admission related to suicidal ideations [SI]. He had visual hallucinations and delusional thoughts. He had multiple SI attempts. Medical record review of a Restraint Progress Note for Patient #4 dated 9/19/2023 at 9:20 AM, showed the patient became agitated with Patient #3 and shouted obscenities at Patient #4. A verbal altercation occurred between the two patients and both patients threatened physical harm to peer. Patient #3 was making ‘gang signs and gesturing with his hands as if peer was holding a pointed gun at Patient #4. The staff separated the two patients but both patients were attempting to emptying to push past staff and attack peer. Patient #4 was placed in a physical hold at 8:53 AM for pt. and unit safety. Patient #4 was given (medication used to treat schizophrenia) 10 milligrams (mg) IM at 9:15 AM. The Care Plan was to be updated to include Anger and Aggression. Medical record review of the Care Plan for Patient #4 dated 9/19/2023, showed the Care Plan was not updated for anger and aggression. Medical record review of a Psychiatry Progress Note for Patient #4 dated 9/23/2023 at 8:45 AM, showed “...pt. at med window getting meds and another patient was in the hallway waiting. Pt. asked the other pt. to ‘stop walking behind him and talking shit’. The other patient quickly escalated and was shouting. Both pt’s. had shirts off by the time I was able to come to the from the med room, both pt’s. were verbally threatening each other and staff separated them after the other patient pushed a staff to the floor. Pt. took PRN Zydis [Zyprexa, antipsychotic medication] and was apologetic for the incident...[11:41 AM] pt. was moved to unit 3 without incident...” Medical record review of a restraint Progress Noted for Patient #4 dated 9/23/2023 at 11:38 AM, showed “...pt. at med window getting meds and another patient was in the hallway. Pt. asked the other pt to ‘stop walking behind him and talking shit’. The other patient quickly escalated and shouting. Both pts. had shirts off by the time I was able to come to hall from med room, both patients were verbally threatening each other and staff separated them after the other patient pushed a staff to the floor. Pt. took Zydis and was apologetic for the incident...” Medical record review showed RN #1 was admitted to Facility B on 9/23/2023. Medical record review of an ED Physicians Record dated 9/23/2023 at 11:07 AM, showed the patient was admitted after two patients had gotten in a fight and she was pushed where she fell on her left hip. She was unable to walk and had received 100 micrograms (mcg) of Fentanyl (pain medication) by Emergency Medical Service (EMS). Radiology diagnostic testing showed an impacted left femoral neck fracture. Orthopedics was consulted and the patient was admitted to the facility. Medical record review of an admission H&P dated 9/23/2023 at 12:44 PM, showed the patient (RN #1) had previous history of Type 1 DM (diabetes), Hyperlipidemia (elevated blood lipids), Hyperthyroidism (elevated thyroid levels), Depression and Anxiety. The patient was a Behavioral Health Nurse and got pushed by a patient during an altercation between two patients. Orthopedics was consulted. The patients EKG (electrocardiogram) showed T wave inversions in V2 and V3 (indicating cardiac ischemia) which was thought not to be related to current cardiac injury. Lovenox (blood thinner) was held related to an impending surgical procedure. Medical record review of a Discharge Summary dated 10/25/2023 at 3:38 PM, showed the patient expired. The patient’s diagnoses included Fracture of the left femoral neck (part of the hip joint), Acute Respiratory Failure, Enterobacter Cloacae (infection) Pneumonia, Aspiration Pneumonia, Septic Shock, Type 2 Myocardial Infarction with Takostubo Cardiomyopathy (a weakening of the left ventricle, the heart’s main pumping chamber), Deep Vein Thrombosis (blood clot) right upper extremity, and Acute Tubular Necrosis (acute kidney injury). The patient had a prolonged hospital course and “...despite aggressive measures including but not limited to vasopressor support, mechanical ventilation, multiple medications patient’s condition continued to deteriorate. During an interview on 11/6/2023 at 9:30 AM, the Risk Manager stated the incident occurred on 9/23/2023. The staff had intervened and handled the situation per facility policy using appropriate de-escalation techniques. The incident report showed the incident was prioritized at a lower level. The employee was transferred to Facility B for treatment. The Corporate HR was aware and were handling the incident as a Workman’s Compensation concern. The facility’s corporate Human Resource Department informed the facility of the need of an investigation once the facility was made aware of the extent of the employee’s injuries and status. Interviews with the staff were completed on 10/7/2023 (15 days after the incident). She confirmed the Root Cause Analysis (RCA) was due next week but had not been completed. The facility “...would look at the RCA and see what interventions, if any, needed to be performed.” During an interview on 11/6/2023 at 9:40 AM, Behavioral Health Associate (BHA) #1 stated the two patients become verbally aggressive with each other in the hallway. Patient #3 took his shirt off and walked toward Patient #4 who then took his shirt off and the two patients started walking toward each other. The nursing staff came from the nurse’s station and attempted to de-escalate and separate the patients. Patient #3 initially walked away but the patients remained verbally aggressive. RN #1 was on the other unit and heard the yelling and came to the unit to assist. She stated “...when I turned around, [Patient 3] was charging toward Patient #4. The next thing I saw, [RN #1] was in the floor and she stated her hip was hurt and she could not get up...” During a telephone interview on 11/6/2023 at 9:55 AM, RN #2 stated she was giving medications to Patient #4. Patient #3 was pacing the hallway, talking to himself and had walked behind Patient #4. Mr. A verbal altercation occurred between the two patients. The nursing staff in the nurse’s station came into the hallway and stood between the two patients. She came out of med room and saw the two patients had taken their shirts off and were trying to fight each other, but the staff were in between them. She had yelled for help. RN #1 came from the other unit to assist. Patient #4 had walked away toward the opposite end of the hall, but then turned around and started charging toward Patient #4. RN #1 grabbed [Patient #3’s] arm to try to stop him and [Patient #3] shoved the nurse to the ground. During a telephone interview on 11/6/2023 at 10:45 AM, RN #3 stated she was the primary nurse for Patient #3 who had anger issues and rambled a lot. She heard the two patients yelling in the hallway and when she came to the hallway, other staff members were standing in between the patients. Both patients had taken their shirts off and were verbally aggressive with each other, but there were no hands on between the patients. She stated “...[RN #1] came from the other unit to help. [Patient #3] turned around and started charging toward [Patient #4]. [RN #1] tried to grab [Patient #3’s] arm and when she did...he pushed her and she landed in the floor...we were able to separate the patients and no hands-on occurred between the patients...” During an interview on 11/6/2023 at 11:00 AM, the Human Resource Director stated the process for reporting an employee injury included reporting the injury to the 24-hour hot line and filling out the appropriate paperwork. The employee normally filled the paperwork out, but since the employee was injured, the House Supervisor would have completed the paperwork to send to Workman’s Compensation. Corporate HR normally takes the lead after an employee workman’s compensation claim. The corporate HR notified OSHA of the incident on 9/27/2023. During a telephone interview on 11/6/2023 at 1:25 PM, RN #4 stated the two patients were verbally aggressive in the hallway towards each other. Both patients were very angry. Patient #3 had been walking down the hallway and Patient #4 was at the medication window. The staff had intervened, and verbal de-escalation was attempted. The BHA and another nurse arrived and were able to keep the patients separated. She stated “...[RN #1] heard the call for help and came to the unit. At that point, [Patient #3] had walked away but then turned around and started to charge towards [Patient #4]. [RN #1] reached out to grab [Patient #3’s] arm and he pushed the nurse to the floor...” She had called 911 and informed them of the situation and told them RN #1 was injured. During an interview on 11/6/2023 at 4:10 PM, the Chief Executive Officer stated she was made aware of the incident on 9/23/2023. On Monday (9/25/2023) the video footage was reviewed by the administrative staff. Interviews were completed with the staff involved on 10/7/2023 [15 days after the incident occurred]. The facility had not reported the incident to the local enforcement or regulatory agencies and the investigation had not been completed. During an interview on 11/9/2023 at 2:15 PM, RN #5 stated the two patients (#3 and #4) had a verbal altercation on 9/19/2023 where the staff had to intervene. There was no hands-on between the patient. Patient #4 required an as needed antipsychotic medication related to his behaviors. She had documented the need to update the care plan for Patient #4 for anger and aggression but had failed to update the care plan.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 30553 Based on review of the Governing Body Bylaws, review of facility policy, review of a facility incident report, review of facility video footage, medical record review and interviews, the facility’s Quality Assurance Performance Committee (QAPI) failed to identify, recognize, and provide a timely investigation related to verbal abuse and potential physical abuse for 2 patients (#3 and #4) resulting in Registered Nurse (RN) #1 (the victim) being injured with subsequent death. The findings include: Review of the Governing Body Bylaws dated 7/2020, showed the Governing Body was “...ultimately accountable for the safety and quality of care, treatment, and services provided by the Facility. The primary function of the Governing Board is to assure that the Facility and its Medical Staff provide quality medical care that meets the needs of the community. For this purpose, the [Managing Member / Board of Directors] has delegated to the Governing Board...to oversee quality assessment and improvement, utilization review, risk management, and similar matters regarding the provision of quality patient care at the Facility, and to establish polices regarding these matters...” Review of facility policy “Workplace Violence” revised 9/1/2015, showed “...[named facility] is committed to providing an environment free from all forms to violence for its employees, patients, families, and vendors. Workplace violence includes but is not limited to harassment, intimidation, threats...and acts of physical assault and other disruptive behavior. All reports of violence will be treated seriously and fully investigated. [named facility] has a Zero tolerance approach to workplace violence...in the event of an act of violence which poses an immediate threat of others...local police and/or the facility security department should be notified immediately...supervisors are responsible for observing and reporting the unusual behavior or employees or other individuals who exhibit certain circumstances which may indicative of posing a potential threat. All reported incidents of threats or violent behavior will be investigated by the appropriate individuals in Administration, Security and/or Human Resource Representative...” Review of facility policy “Patient Abuse and Neglect” revised 9/1/2015, showed “...[named facility] maintains Zero Tolerance for patient abuse or neglect...all instances of witnessed or alleged patient abuse or neglect must be immediately reported to the Risk Manager, a department head or supervisor...upon investigation and after an assessment of the findings, a final determination should be made by the Senior Facility Leader and senior management...upon the discretion of the facility and in accordance with applicable state and Federal requirements, such violations may be reported to employee state licensing agency and/or law enforcement agencies...” Review of facility policy “Risk Management Incident Reporting Policy” reviewed 1/2023, showed “...an “incident” is an unanticipated event which results in, or nearly causes, a negative impact on patient care or visitor safety. Any harm caused can be temporary, long-term, or permanent and range in severity from no obvious or significant injury, up to death....[4.5] If the incident involves an injury to a facility employee or contracted employee the injured staff will complete an “Employee Report of Injury” and notify their immediate supervisor and the facility Human Resources Manager...[5.2] the Shift Supervisor or a Facility Designated Individual will conduct a preliminary incident review. Facility Risk Manager will investigate and will document the investigation’s findings, including determining a final severity level classification...[5.3] The facility Risk Manager will notify Corporate Risk Management of all Initial “Level I” and “Level II” incidents within 24 hours...Sentinel Event: Identifies a patient safety-related incident (not primarily related to the natural course of an illness or underlying condition of an individual served) that reaches an individual served and results in death, severe harm, or permanent harm where intervention was required to sustain life. Workplace Violence Event: Identifies an incident that specifically involved a person(s) who commits assault, engages in harassing or intimidating behaviors, or credibly threatens the personal safety of employees (including contracted/agency staff), patients, visitors, or vendors...” The Severity Level Classification was as follows: Level I (Major): Incidents which are considered serious events This may include sentinel events. Level II (Moderate): Injury or impairment in which the patient or visitor’s function is altered requiring outside medical intervention. Level III (Minor): Injury or impairment in which a patient or visitor’s function may be altered with treatment limited to first aid. Level IV (Inconsequential): Events which do not otherwise qualify as a Level I, II, or III and where no injury or outcome alters a patient or visitor’s function. Review of a facility investigation report dated 9/23/2023 at 2:48 PM, showed an altercation occurred between 2 patients and (Patient #3) pushed an RN. The summary of event showed Patient #3 walked behind Patient #4 and a verbal altercation occurred between the two patients. Both patients ripped off their shirts, they started yelling at each other and attempted to approach each other. The facility staff intervened and stood between the 2 patients trying to “...stop their behaviors with words.” RN #1 arrived on the unit to assist and Patient #3 pushed RN #1 onto floor. The ‘severity level’ was a 2 indicating a moderate classification. Review of facility video footage of Unit 4 for 9/23/2023 showed the following: The times were only in seconds not the actual time of the incident: 00:04 seconds: Patient #3 was pacing in the hallway. Patient #4 was at the medication room door 00:41 seconds: Patient #4 walked down the hallway towards Patient #3. Both patients were talking to each other 00:47 seconds: Patient #3 took his shirt off and threw in the floor. Patient #4 took his shirt off. Staff members were in the nurse’s station. Facility staff were in the hallway with the patients. 1:03 seconds: The nursing staff were in the hallway with the patients talking to the patients. 1:07 seconds: Patient #3 walked away from the staff towards the other end of the hall. 1:26 seconds: RN supervisor talking with Patient #3. 1:27 seconds: The RN (the victim) entered the hallway from the Nurses Station 1:29 seconds: Patient #3 ran toward Patient #4. Patient #3 pushed the RN to the floor. Medical record review showed Patient #3 was admitted on 9/5/2023 with diagnoses including chronic schizophrenia [mental disorder with psychosis] and depressive disorder under an involuntary commitment related to a change in his mental status. The patient had previous history of psychiatric inpatient admissions. He presented with disorganized thought processes and speech with agitation, aggressive threatening behaviors and psychosis. Medical record review of a Seclusion Patient Debriefing for Patient #3 dated 9/23/2023 at 8:50 AM showed “...[Patient #3] was walking behind Patient #4 who became very agitated at patient. [Patient #3] began cussing at [Patient#4] and took his shirt off to fight the other patient. He was unable to be redirected. As he lunged for [Patient #4], he hit an RN...and shoved her to the ground. She landed on her hip...” Medical record review of a Psychiatry Progress Note dated 10/1/2023 at 11:30 AM, showed the patient continued to isolate himself in his room. He remained delusional with impaired insight and judgement. The patient had required Haldol Decanoate 200 milligrams (mg) intramuscular (IM) on 9/29/2023. Medical record review showed Patient #4 was admitted on 9/15/2023 with diagnoses including Schizophrenia related to substance abuse psychosis related to amphetamines and cannabis use. The patient had previous history of bipolar, schizophrenia, and multiple personality disorder. The patient was admitted under an involuntary admission related to suicidal ideations [SI]. He had visual hallucinations and delusional thoughts. He had multiple SI attempts. Medical record review of a Restraint Progress Note for Patient #4 dated 9/19/2023 at 9:20 AM, showed the patient had a verbal altercation with Patient #3 with threatening behaviors with the other patient. The patient required a physical hold at 8:53 AM related to aggressive behaviors. The patient required IM PRN (as needed) for agitation. He was given Zyprexa (medication used to treat schizophrenia) 10 mg IM at 9:15 AM. The patients care plan was to be updated related to anger and aggressive behaviors which was not completed. Medical record review of a Psychiatry Progress Note for Patient #4 dated 9/23/2023 at 8:45 AM showed “...pt. [patient] at med window getting meds and another patient was in the hallway waiting. Pt. asked the other pt. to ‘stop walking behind him and talking shit’. The other patient quickly escalated and was shouting. Both pt’s. had shirts off by the time I was able to come to the hall from the med room, both pt’s. were verbally threatening each other and staff separated them after the other patient pushed a staff to the floor. Pt. took PRN Zydis [Zyprexa] and was apologetic for the incident...” Medical record review of a restraint Progress Noted for Patient #4 dated 9/23/2023 at 11:38 AM showed “...pt. at med window getting meds and another patient was in the hallway. Pt. asked the other pt to ‘stop walking behind him and talking shit’. The other patient quickly escalated and shouting. Both pts. had shirts off by the time I was able to come to hall from med room, both patients were verbally threatening each other and staff separated them after the other patient pushed a staff to the floor. Pt. took Zydis and was apologetic for the incident...” Medical record review showed RN #1 was admitted to Facility B on 9/23/2023 after two patients had gotten into a fight and the nurse was pushed to the floor injuring her left hip. Radiology diagnostic testing showed an impacted left femoral neck fracture. Orthopedics was consulted and the patient was admitted to the facility. Review of the discharge summary showed the nurse expired on 10/25/2023 at 3:38 PM with the following diagnoses: Fracture of the Left Femoral Neck (part of the hip joint), Acute Respiratory Failure, Enterobacter Cloacae (infection) Pneumonia, Aspiration Pneumonia, Septic Shock, Type 2 Myocardial Infarction with Takostubo Cardiomyopathy (a weakening of the left ventricle, the heart’s main pumping chamber), Deep vein thrombosis (blood clot) right upper extremity, and acute tubular necrosis (acute kidney injury). During an interview on 11/6/2023 at 9:30 AM, the Risk Manager, stated the incident occurred on 9/23/2023. The incident report showed the incident was prioritized at a lower level. The facility’s corporate Human Resource Department informed the facility of the need of an investigation once the facility was made aware of the extent of the employes injuries and status. Interviews with the staff were completed on 10/7/2023 (15 days after the incident). She confirmed the Root Cause Analysis (RCA) was due next week but had not been completed. The facility did not report the incident to local law enforcement or regulatory agencies. During an interview on 11/6/2023 at 4:10 PM the Chief Executive Officer stated she was made aware of the incident on 9/23/2023. On Monday (9/25/2023) the video footage was reviewed by the administrative staff. Interviews were completed with the staff involved on 10/7/2023 [15 days after the incident occurred]. She confirmed the facility had not reported the incident to the local enforcement or regulatory agencies and the investigation had not been completed.”