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Based on medical record review and interview, the hospital's governing body failed to protect each patient's right to be free from abuse and failed to provide medical care in a safe environment for 4 patients (Patients #10, #5, #2 and #11), failed to ensure medical and health risks were explained for 2 patients (Patients #12 and #13) so each patient could make informed medical decisions prior to discharging Against Medical Advice (AMA), failed to establish a process for prompt resolution and ensure an effective grievance process for 1 patient (Patient #13) and failed to provide an effect discharge planning process, consistent with the patient's goals for care and their treatment preferences, to ensure an effective transition of the patient from hospital to post-discharge care for 3 patients (#6, #12 and #13) of 15 patients reviewed. The hospital's non-compliance placed all patients in serious and immediate threat, placing them in Immediate Jeopardy (IJ).

The findings include:

Patients #10, #5, #2 and #11 were noted to be verbally and/or physically abused by the hospital's contracted security company while receiving medical care in the hospital emergency room.

Refer to A-0115 and A-0144.

Review of the hospital record for patient #12, an 82-year-old female admitted to the emergency room (ER) on 5/20/2024 at 8:40 PM, after she had fallen on the ground during a syncopal episode (sudden loss of consciousness due to a drop in blood flow to the brain), hitting her head and had abnormal blood work/lab results. Patient #12 was not provided with an explanation by the medical staff of the risks associated with leaving without treatment as per the hospital's policy.

Review of ER clinical notes for Patient #13, a 39-year-old male, showed he was admitted on 6/30/2024 with a diagnosis of Sepsis (a life-threatening reaction to infection that can damage organs and tissues). Medical record review revealed Patient #13 was not provided with the explanation by the medical staff, the risks associated with leaving without treatment as per the hospital's policy.

Refer to A-0115, A-0144 and A-0799.

Medical record review revealed Patient #6 was admitted to the ER via ambulance on 4/21/2024 at 5:53 PM, and discharged at 7:43 PM, on 4/21/2024.

Interview on 9/11/2024 at 11:05 AM, with Registered Nurse (RN) K revealed Patient #6 was homeless and unable to walk on her own, needed a wheelchair (w/c) to get around and her w/c was at the community kitchen where she lived, 8 blocks from Hospital #1. Interview revealed RN K was the discharging nurse for patient #6. He did have a chance to review patient #6's medical record, did not remember patient #6 well, but had some recollection of patient #6. He was the person who discharged Patient #6 on 4/21/2024, after being treated in the emergency room for Cellulitis. During the interview, RN K stated "...Sometimes I just push the homeless patients in the ER breezeway and let them figure out how they are going to get to where they stay..."

Interview with Officer J, with the local City Police Department on 9/11/2024 at 3:40 PM, revealed he was a supervisor with a police crisis response team which deals with social and criminal issues in the city and on 4/22/2024 at 4:30 PM, one of his officers responded to a call that a person was found crawling in the street outside on the emergency room at [Hospital #1]. The officer found Patient #6 on the street indicating that she wanted to die and that was the reason she was crawling in the street. According to the responding officer, Patient #6 explained she was seen in Hospital #1 ER the previous day (4/21/2024) and was taken by wheelchair to a bench outside the ER by a nurse and was left on a bench.

Refer to A-0144.

The Patient Experience Director confirmed the grievance for Patient #13 had not been addressed to date and the letter sent, inaccurately, assured the complainant appropriate action was taken by the unit manager when it had not been.

Refer to A-0118.

Based on facility policy review, facility documentation, medical record review and interview, the hospital failed to protect each patient's right to be free from abuse and provide medical care in a safe environment for 4 patients (Patients #10, #5, #2 and #11) and failed to ensure medical and health risks were explained prior to discharge for 2 (Patients #12 and #13) of 15 patients reviewed. The hospital's non-compliance placed all patients in a serious and immediate threat and placed them in Immediate Jeopardy (IJ).

The findings include:

Review of the hospital policy titled, "Leaving Against Medical Advice" revised 07/2023, revealed "...This policy provides guidance for [Hospital#1] in addressing situations where a patient or his or her decision maker states the desire to leave the facility against medical advice in a manner that both promotes patient safety and honors patient rights...[Hospital #1] responds appropriately to all requests for treatment. When a patient or his or her parent/legal guardian/surrogate takes action for the patient to leave Against Medical Advice (AMA), a record should be made of the circumstances. Staff members and the physician should also attempt to educate the patient/parent/legal guardian/surrogate about the consequences of leaving without approval...A. As soon as any staff member becomes aware of the patient's desire to leave the facility AMA, the attending physician should be called. The attending physician, nurse, and/or assigned patient caregiver should attempt to determine the reason(s) for the desire to leave AMA. B. The staff member should then notify the unit nurse manager and House Supervisor or designee of the desire to leave AMA. C. The patient's nurse should document the intent to leave AMA and any actions taken to leave AMA in the patient's medical record. D. If it is possible to address the concerns voiced by the patient or parent/legal guardian/surrogate, every reasonable attempt should be made to do so. If it is not possible to change the patient/parent/legal guardian/surrogate's decision to leave AMA, the charge nurse should speak to the patient/parent/legal guardian/surrogate to explain that the attending physician/designee should speak with them prior to their leaving the facility. E. The charge nurse should inform the patient/parent/legal guardian/surrogate that his/her insurance company may not pay for the hospitalization if the patient leaves AMA...G. If the attempts to discourage the patient from leaving AMA are unsuccessful, the patient's nurse or attending physician should document the following: I. The nurse and/or physician explained to the patient/parent/legal guardian/surrogate the risks associated with leaving without treatment and should document the explanation in the patient's medical record. The nurse and/or physician/designee should also document in the medical record all attempts made to address the patient/parent/legal guardian/surrogate's concerns and actions taken by the medical staff to encourage the patient/parent/legal guardian/surrogate to stay at the facility. ii. The patient/parent/legal guardian/surrogate is requested to sign the "Release of Responsibility" form (#38543). The release may be signed by the patient if 18 years of age or older without decision-making capacity. iii. A notation should be made in the nurses' notes by the nurse, stating that "the patient/parent/legal guardian/surrogate was informed about the medical concerns related to leaving AMA and has chosen to leave the hospital." iv. A notation should be made in the medical record by the attending physician indicating the events that occurred and reasons (if known) for the patient/parent/ legal guardian/surrogate deciding to leave AMA. The attending physician is also required to sign the "Release of Responsibility" section of the form. v. If the patient/parent/legal guardian/surrogate refuses to sign the "Release of Responsibility" form, the nurse or attending physician should complete and document the patient's refusal on the form and place the form in the patient's medical record. Place the "Release of Responsibility" form in the patient's chart with or without the patient/parent/legal guardian/surrogate's signature. vi. The patient's nurse completes an electronic occurrence report regarding the AMA situation. vii. The patient's nurse completes the Nursing Discharge assessment."

Review of the hospital policy titled, "Patient Related Complaint and Grievance Resolution" revised 9/2023, stated "...For grievances requiring a clinical investigation, The Patient Experience Office will send an acknowledgement letter to the complainant within 7 business days of receiving the complaint indicating that their concern(s) are under review and that they will receive follow-up within a specific time period. In those cases, a member of the Patient Experience Office will send a final written resolution response letter within the 30-day (business days) time frame. These final closure letters should also state that an investigation was performed, what steps were taken, results, the organization's contact person and date of completion...A grievance is considered resolved when the patient is satisfied with the actions taken on their behalf..."

Review of the hospital policy titled, "Patient Rights" dated 8/2024, revealed "...You, the patient, have the right to...Be safe from abuse or harassment...It is your responsibility to...Accept that bad language or bad behavior will not be tolerated..."

Review of the hospital policy titled, "Abuse Reporting" dated 11/2024, revealed "...All patients have the right to be free from all acts of violence...from staff...The hospital will ensure that patients are free from all forms of abuse...All allegations of abuse...will be investigated thoroughly and will begin immediately once the allegation has been made...If the allegation is against a...care giver for the patient, the caregiver will be removed from caring for the patient...Education is provided during new employee orientation...annual training...on abuse...including reporting requirements, prevention, intervention, and detection...The investigation will include interviews of all persons involved...Incidents of abuse...harassment will be reported...analyzed with appropriate corrective, remedial, or disciplinary actions taken in accordance with applicable local, State, or Federal law...Reports of suspected abuse...harassment shall be made to Senior Leadership or the Risk Manager immediately...The caregiver affected by the allegation will be placed on administrative leave during the investigation...If the allegations are substantiated, the employee will be terminated and the appropriate agencies will be notified..."

Review of a written statement from Staff Member B, dated 8/17/2022, revealed "...Walked into the unit @ [at] 625 am [6:25AM] Saw pt [Patient #10] in bed 8 being restrained. Offered assistance. Help [Patient Care Technician/PCT] U hold left arm to assess...IV [intravenous] was bad so we took off [specialized pressure bandage...and tried to take off the tape. While this was happening, [Staff Member B] was at the right arm of the pt. I [Staff Member B] heard the pt say, "that hurts, my arm hurts, it feels like you are going to break it!" I heard [Licensed Practical Nurse/LPN] V say, "wait his arm is at an angle, let go, that doesn't look right." I looked up and saw his [Patient #10's] arm bent at an angle toward the head of the bed. After iv [intravenous needle] was wrapped up, I left to answer call lights. I heard another commotion and came back into the room. Pt [Patient #10] was kicking his legs. I [Staff Member B] was to the foot of the bed and grabbed the pt's legs and slammed them down on the bed and yelled very loudly at the pt "STOP RIGHT NOW!" [Staff Member B] held the pt's legs down while someone else retied the leg restraints. The restraints were reassessed and found to be to [too] tight..."

Review of the facility's document titled "eSAFE" incident report dated 8/17/2022, revealed "...While multiple staff were attempting to restrain the patient [Patient #10] to allow performance of an EKG, [electrocardiogram] [Staff Member B] entered room to assist and became physically aggressive towards...[Patient #10]..."

During an interview on 9/12/2024 at 10:10 AM, Registered Nurse (RN) D stated she was working in the emergency room on 8/17/2022 when she witnessed Patient #10 being placed in 4-point (all four extremities) restraints. RN D stated she saw staff members around Patient #10. The patient started kicking his feet, Staff Member B picked up Patient #10's feet and aggressively slammed the patient's feet down on the bed and tightened the restraints too tight. Staff Member B was yelling at the patient to stop kicking. RN D stated she had never seen Staff Member B so aggressive with a patient before.

Medical record review revealed Patient #5 arrived at the facility by ambulance on 6/22/2024 for a right arm laceration. Patient #5 was treated for the right arm laceration and discharged home on 6/22/2024.

Review of the facility's document titled "eSAFE" incident report dated 6/27/2024, revealed an incident between a contracted security officer (Security Officer-SO Q) and Patient #5 occurred on 6/22/2024. The incident report read "...[Patient #5]...brought in on 6/22/2024 for a severe circumferential arm laceration...[Patient #5] was...held on the EMS [Emergency Medical Service] stretcher...in front of the charge desk the patient's arm was bumped the patient sat up on the stretcher and screamed in pain. When this happened...[SO Q] approached the patient grabbing him by the head and slammed him backwards and held the patient's face by under the chin pushing upwards and the top of the head pushing down so the patient could not open his mouth...[Registered Nurse-RN AA] came from the back side of the charge desk...around to where the incident was occurring [SO Q] had removed his badge and was holding it in the patient's face saying '...this is my ER [explicit language]'...[RN AA] attempted to diffuse the situation and [SO Q] would not stop...[RN AA] stepped away to ask someone to call for more help and when I [writer of the report] returned to the patient's side [SO Q] eventually let go but kept arguing with the patient...antagonizing the patient..."

Medical record review revealed Patient #2 presented to the ED on 7/5/2024 with a self-inflicted gunshot wound (GSW) to the head. Further review revealed Patient #2 was hemodynamic stable, alert and oriented, with combative behaviors. On initial evaluation, Patient #2 was extremely anxious, refused to answer questions about self-inflicted GSW, and quickly became agitated upon further questioning. Patient #2's blood alcohol level was 244 mg/dL (milligrams/deciliters-units of measure). Patient #2 was placed on suicide precautions; 1:1 observation with sitter to bedside; placed in a yellow gown; and was placed on Certificate of Need (CON-emergency psychiatric commitment) hold due to posing a potential harm or danger to self and others.

Review of the facility's document titled, "eSAFE" incident report dated 7/5/2024, revealed "...ED [Emergency Department] bed 7 was brought in as a self-inflicted GSW to the head. Shortly after arrival, pt [patient] was placed on a CON d/t [due to] SI [suicidal ideation] and attempted suicide. [Registered Nurse-RN W] responded to [Patient #2's] room after hearing screaming. Upon entry, [Patient #2] was removing bedside monitoring equipment, agitated and asking to leave. [RN W] alerted [Medical Doctor-MD Y] of [Patient #2's] behavior. [MD Y] gave a verbal order for IV [intravenous] Ativan [a sedating medication] and soft wrist restraints. [Patient #2] was placed in wrist restraints and medication was administered as prescribed. [Patient #2] was found again, out of bed, with restraints removed. [RN W] entered the room to find [Patient #2] agitated with several...security officers at bedside. [Patient #2] was visually upset and attempting to leave the ED. [RN W] alerted [MD Z] of [Patient #2] behavior and increased agitation. [MD Z] gave a verbal order for IM [intramuscular] medications and violent wrist restraints. [RN W] left the room to grab restraints, upon returning to the room, [Patient #2] was found being placed in the bed by 4 security guards. Security was attempting to move [Patient #2] in the bed when one of them verbalized being kicked. [SO X] then hit [Patient #2] with a closed fist on his chest. [RN W] was unable to reach...[Patient #2] d/t the number of security officers at the bedside. [Patient #2] was thrashing during the attempt to restrain him. During the events...[Patient #2] became agitated and was grabbing at security. [SO X] stated "I'm going to punch you if you touch my officers again." [SO X] then proceeded to hit the pt [Patient #2] several more times with a closed fist in the chest and abdomen...[SO X]...turned to [MD Z] and stated, 'I had to punch him, he grabbed my guys.'...[Patient #2] was placed in violent restraints...intermittently sat up...was agitated. IM [intramuscular] medications were administered...[Patient #2] was hit with a closed fist several more times by [SO X] after med administration..."

Medical record review of Patient #11, dated 8/28/2024 at 11:15 PM, revealed "... CO [corrections officer] attempted to put mobility chains [immobilizes upper extremities] on Patient #11 due to patient being able to move hands freely. During this encounter, Patient #11 reached for off-duty officer's gun. Security at bedside to subdue. Patient spitting blood onto security guards. Patient laughed and stated that 'it's funny because I have AIDS.' Blood is on security guard's skin and clothing. House supervisor made aware...CO requesting more officers to assist with patient..."

Review of a facility incident report for Patient #11 dated 9/11/2024, revealed "...On 09/11/24, while reviewing the combative patient report, which I [Security Director] review daily, I [Security Director] saw [Security Officer O] antagonized and bully an almost incoherent patient. PT [Patient] I [Security Director] [Patient #11] was brought into the ER [emergency room] by the...County Sheriff's Office, by Corrections Officer. The PT [Patient #11] had been violently beaten by other inmates while incarcerated and had open bleeding wounds on his face and in his mouth. [Security Officer O] reported a violent individual who was hitting and punching police officers, and at one point even trying to take officer firearm. In the footage I [Security Director] observed [Security Officer O] stalking the PT [Patient #11], who 99% of the time was sitting still and compliant. I watched the incident unfold with [Security Officer O] taking a hair net from the nurse's station, placing it over the PT's [Patient #11] head, and pulling it tight sneakily coming up behind the PT [Patient #11]. In the footage, [Security Officer O] is grinning. [Security Officer O] was not asked to assist and should have no dealings with a guarded...County Inmate. [Security Officer O] again grabbed the patient by the face, without being asked to assist, and violently shoved the patient's head down into a bed with no regard for the open wounds on his face and in his mouth and not knowing if there was a neck injury or any kind of head injury. [Security Officer O] later takes a towel, which he was constantly fixated on for some reason on the PT [Patient #11] spitting, in which the video shows he never spit on anyone and told another officer to help him with this guy who is spitting and places the towel over the PT's [Patient #11] face and holds his head immobile with heavy pressure. [Security Officer O] continues to get involved and gets into the face of the PT [Patient #11] cursing him and lunging at the PT [Patient #11], when the PT [Patient #11] leaned forward [Security Officer O] violently strikes the PT [Patient #11] again in his face, still not knowing if he could have further injury or killed the PT [Patient #11]. The...County deputy had to get between [Security Officer O] and the PT [Patient #11] and move him out of the way. [Security Officer O] stated he was spat on that was why he hit him, but video footage shows no blood coming from the PT's [Patient #11] mouth or on [Security Officer O]. [Security Officer W] witnessed the incident and stated the blood came from [Security Officer O] slapping the Pt [Patient #11] with open wounds and made the blood splatter all over everyone. The report written by [Security Officer O] has him pressing charges on the PT [Patient #11] and charging him with Aggravated Assault..."

During an interview on 9/19/2024 at 12:55 PM, the Patient Safety Quality Manager, stated she was made aware on 9/19/2024 of the events that took place involving Security Officer O and Patient #11 on 8/28/2024. The Patient Safety Quality Manager could not explain why 21 days elapsed before she was made aware of the patient abuse that occurred on 8/28/2024 until the morning of 9/19/2024. She stated she and the abuse teams reviewed the video footage of Security Officer O interacting with the Patient #11 and deemed Security Officer O's interactions were abusive. The Patient Safety Quality Manager stated she contacted the Chief of Security and asked Security Officer O be removed from the hospital and not be allowed to return.

During interview on 9/19/2024 at 1:10 PM, the Director of Security stated he was employed by the hospital's contracted security company and had been the Director of Security since 4/1/2024. The Director of Security stated Security Officer O was the night shift supervisor and he had noticed most of the aggressive behavior documented had been on the night shift and by officers supervised by Security Officer O. Security Officer O was terminated from the hospital's contracted security company because of his abusive actions taken against Patient #11.

Medical record review revealed Patient #12, an 82-year-old female, was admitted to the ER on 5/20/2024 at 8:40 PM, after she had fallen on the ground during a syncopal episode (sudden loss of consciousness due to a drop in blood flow to the brain), hitting her head. Continued record review revealed she initially had experienced mild confusion after the fall. Patient #12 had a medical history of Atrial Fibrillation (irregular and often very rapid heart rhythm), Arthritis, Asthma, Claustrophobia (fear of confined spaces) and Hypertension.

An ER review of laboratory results for Patient #12, dated 5/20/2024, revealed "Abnormal" laboratory results without defining or providing the normal and abnormal reference ranges or the specific results for Patient #12. Creatinine (blood test to measure how kidneys are performing and filtering waste)-results "Anormal"; Urea Nitrogen (blood test for a marker of kidney function)-results "Abnormal"; Glucose (blood test of a simple sugar the body uses for energy)-results "Anormal"; Hematocrit (blood test to determine the percentage of red blood cells in the blood)-results "Abnormal"; Basic Metabolic Panel (a blood test to check for kidney health, blood sugar, electrolytes and acid base balance in the blood)-results "Abnormal"; Complete Blood Count (CBC) with differential (a blood to measure red and white blood cells to test for anemia and infections, some heart diseases, autoimmune disorders)-results "Abnormal"; continued review of laboratory results on 5/21/2024 revealed Ferritin (a protein that stores iron)- results "Abnormal"; Folate (important in red blood cell formation)- results "Abnormal"; Iron (mineral vital to the proper function of hemoglobin, a protein needed to transport oxygen in the blood)- results "Abnormal"; Total Iron Binding (test to measure the blood's ability to bind to iron and carry it through the body)- results "Abnormal."

Review of hospital documentation titled, "Emergency Care (ED) Timeline" revealed Patient #12 was discharged on 5/22/2024 at 10:11 AM, with intravenous fluids (IV) discontinued at 10:12 AM. Continued record review revealed there was no documentation for Patient #12 as per the hospital's AMA policy to reflect, "...a record should be made of the circumstances, or the physician was notified or the notification of the unit nurse manager or the House Supervisor or designee" of Patient # 12 desire to leave AMA. Further record review revealed Patient #12 was not provided with an explanation by "the nurse and/or physician, the risks associated with leaving without treatment..." and no documentation "all attempts made to address the patient...concerns and actions taken by the medical staff to encourage patient...to stay at the facility" per the hospital's AMA policy after Patient #12 suffered a head injury resulting from a fall and without documented assessment and/or treatment for the noted "Abnormal" laboratory results.

Review of hospital documentation titled, "Leaving the Hospital Against Medical Advice" dated 5/24/2024, revealed "Patient #12 had signed the document stating, " This will certify that I, the undersigned, [patient #12's name] A patient in the above named medical center, having requested discharge and removal from the medical center against the advices of my attending physician(s), hereby release [name of hospital], its physicians, officers and employees, severally and individually, from any and all liability of any nature whatsoever for any injury or harm or complication of any kind that may result directly or indirectly, by reason of my terminating my stay as a patient as [name of hospital] and my departure from said medical center, and hereby waive any and all rights f action I many now have or later acquire as a result of my voluntary departure from said medical center and the termination of my stay as a patient therein. This /release is made with the full knowledge of the danger that may result from the action I am taking." The document was signed by the patient and witnessed, along with the signature of the nurse. However, the physician signature was noted to not be signed and was blank where the physician was to sign.

Medical record review revealed Patient #13, a 39-year-old male, was admitted to the Emergency Room (ER) on 6/30/2024, with a diagnosis of Sepsis (a life threatening reaction to infection that can damage organs and tissues). Patient #13 had a medical history of Cervical Vertebrae (C4-C5) Spinal Injury following a fall and resulting Paraplegia complicated by neurogenic bladder, neurogenic bowel, stage IV left ischial decubitus ulcer status post (excision and flap closure in 12/2023), and Deep Vein Thrombosis (DVT).

Review of laboratory results for patient #13, dated 7/3/2024, revealed an elevated White Blood Count (CBC) (a measurement of the number of white blood cells in the body and can detect infection). The normal range for the hospital's WBC was noted to be 10*3/uL (microliters) with patient #13 results at 17.1 and flagged as being "out of range."

Review of hospital documentation titled "Progress Notes" dated 7/3/24 at 6:03 PM, revealed RN N documented, "Patient ready to leave AMA, as he feels urology, and wound care have ignored him. Pulled out his foley and is currently getting dressed. Notified MD." According to" Care Timeline" on the progress note, Patient #13 was discharged at 7:21 PM.

Review hospital documentation titled "Progress notes" dated 7/3/2024 at 6:03 PM, revealed Patient #13 was discharged AMA. Continued record review revealed no documentation for Patient #13 as per the hospital's AMA policy to reflect, "... a record should be made of the circumstances, or the physician was notified or the notification of the unit nurse manager or the House Supervisor or designee" of Patient # 13 desire to leave AMA. Further record review revealed Patient #13 was not provided with the explanation by "the nurse and/or physician, the risks associated with leaving without treatment..." and no documentation "all attempts made to address the patient...concerns and actions taken by the medical staff to encourage patient...to stay at the facility" per the hospital's AMA policy after patient #13 was diagnosed with Sepsis and an elevated WBC.

Review hospital documentation titled, "eSAFE" dated 7/5/2024, revealed a complaint/grievance was filed with the hospital for event dates 6/30/2024 on behalf of Patient #13. A follow up to the complainant was in the form of a letter dated, July 11, 2024. The letter revealed, "...An investigation was performed by the Office of Patient Experience...The nurse manager over the unit has reviewed this file and is taking appropriate action to address this. Please be assured that we are committed to identifying opportunities for improving the care delivered to our patients and taking appropriate action when necessary...Our investigation is now complete..."

During an interview on 9/11/24 at 4:01 PM, Registered Nurse (RN) M, who discharged Patient #13 on 7/3/2024 at 7:21 PM, stated he was not aware of the hospital's policy for AMA. When asked if RN M explained the risks of leaving AMA to Patient #13, he stated, "No, he [Patient #13] was very kind, but he said he felt like he was not getting the care that he needed here." Upon further interview with RN M, he revealed he was not aware of the AMA policy and had not been in-serviced on the AMA policy. RN M further stated he did not provide Patient #13 with risks to his health when he left AMA. He further stated Patient #13 left before the doctor could see the patient. Interview confirmed RN M did not provide Patient #13 with risks regarding his diagnosis of Sepsis and/or elevated WBC.

Interview on 9/12/24 at 11:25 AM, revealed RN N discharged Patient #12 on 5/22/2024, and she stated she was not aware of the hospital's policy for AMA, only that an "AMA form is provided to the patients if they want to leave, and it lets them know of their risks if they decide to leave and the patient signs the AMA form." When RN N was asked if she explained the risks of leaving AMA to Patient # 12, she stated "No." Upon further interview with RN N, it was revealed she not seen the AMA policy and had not been in-serviced on the AMA policy.

During an interview on 9/12/2024 at 11:30 AM, the hospital's attorney stated, "It's on them [patients] when they sign out AMA. They understand the risks when they sign the AMA form."

Refer to A-0144, A-0145, and A-0799.

Based on hospital policy review, medical record review and interview, the hospital failed mitigate risks and protect patients from abuse, provide a safe environment, provide appropriate discharges and ensure patient rights by not demonstrating evidence of a Quality Assurance and Performance Improvement (QAPI) associated with the provisions of the said Condition of Participation and Standards of Care for 7 of 15 patients reviewed. The hospital's non-compliance placed patients in a serious and immediate threat and placed them in an Immediate Jeopardy (IJ).

The findings include:

Patients #10, #5, #2 and #11 were noted to be verbally and/or physically abused by the hospital's contracted security company, while receiving medical care in the hospital's emergency room.

Refer to A-0115, A-0144 and A-0144.

Medical record review of Patient #12, an 82-year-old female, showed she was admitted to the emergency room (ER) on 5/20/2024 at 8:40 PM, after she had fallen on the ground during a syncopal episode (sudden loss of consciousness due to a drop in blood flow to the brain), hitting her head and has abnormal laboratory results. Patient #12 was not provided with the explanation by the medical staff, the risks associated with leaving without treatment as per the hospital's policy.

Medical record review of hospital emergency (ER) clinical notes for Patient #13, a 39-year-old male, revealed he was admitted to the ER on 6/30/2024 with a diagnosis of Sepsis (a life threatening reaction to infection that can damage organs and tissues). Interview and record review revealed Patient #13 was not provided with the explanation by the medical staff, the risks associated with leaving without treatment as per the hospital's policy.

Refer to A-0115, A-0144, and A-0799.

Medical record review revealed Patient #6 was admitted to the ER via ambulance on 4/21/2024 at 5;53 PM and discharged at 7:43 PM, on 4/21/2024.

Interview with Registered Nurse (RN) K revealed Patient #6 was homeless and unable to walk. Patient #6 explained that she was not able to walk on her own, needed a wheelchair to get around and her wheelchair was at the community kitchen where she lived 8 blocks from Hospital #1. During the interview, RN K stated "...Sometimes I just push the homeless patients in the ER breezeway and let them figure out how they are going to get to where they stay..."

Review of police records revealed Patient #6 was found the following day by the police on the sidewalk outside the hospital ER without a wheelchair. The responding officer found Patient #6 crawling on the street, indicating that she wanted to die. According to the responding officer, he stated Patient #6 explained that she had been seen in Hospital #1 ER the previous day (4/21/2024) and was taken to a bench outside the ER in a wheelchair by a nurse and was left on the bench.

Refer to A-0144.

The Patient Experience Director confirmed the grievance for Patient #13 had not been addressed to date and the letter sent inaccurately assured the complainant that appropriate action was addressed by the unit manager when it was not.

Refer to A-0118

Based on policy review, medical record review and interview, the hospital failed to have an effective discharge planning process when Patient #6, a non-ambulatory homeless patient, was discharged from the Emergency Room (ER) to a bench outside of the ER without a wheelchair and transportation to a safe location, and the hospital failed to provide the risks to the health, safety, and welfare for Patient #12 and Patient #13 when they left Against Medical Advice (AMA) of 15 patients reviewed for discharge. The hospital's non-compliance placed all discharged patients in a serious and immediate threat and placed them in Immediate Jeopardy (IJ).

The findings include:

Review of facility's policy titled, "Case Management-Transition Management, Discharge Planning, and Patient Choice," dated 6/2021, revealed "...Transition Management-the process of assessing...reassessing the patients for post-hospital needs...developing...implementing a plan to coordinate those services identified as necessary for the patient when they leave the hospital. The process includes a mechanism for a Case Management [CM] Registered Nurse [RN]or Social Worker [SW] to identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge or transfer if there is inadequate planning...as outlined in the routine nursing assessment. A discharge planning evaluation by the CM/SW may be requested...Transition management will be conducted in accordance with all legal mandates while supporting the patient's ethical and moral directives. Case Management discharge planning services are available to all patients regardless of age, sex, national origin, race, and sexual orientation...All discharge evaluations and discharge plans are recorded in [electronic medical record] by the RN/SW Case manager... results are discussed with the patient or individual acting on his or her behalf..."

Review of the facility's hospital policy titled, "Leaving Against Medical Advice [AMA]" dated 7/2023, revealed "...provides guidance...in addressing situations where a patient or...decision maker states the desire to leave the facility against medical advice in a manner that both promotes patient safety and honors patient rights...When a patient or...parent/ legal guardian/surrogate takes action for the patient to leave Against Medical Advice, a record should be made of the circumstances. Staff members and... physician should also attempt to educate...patient/parent/legal guardian/surrogate about the consequences of leaving without approval...As soon as any staff member becomes aware of the patient's desire to leave the facility AMA, the...physician should be called. The...physician, nurse...assigned patient caregiver should attempt to determine the reason(s) for the desire to leave AMA...staff member should then notify the unit nurse manager...House Supervisor or designee of the desire to leave AMA...The patient's nurse should document the intent to leave AMA...any actions taken to leave AMA in the patient's medical record...If...possible...address...concerns voiced by...patient or parent/legal guardian/surrogate, every reasonable attempt should be made to do so. If...not possible to change the patient/parent/legal guardian/surrogate's decision to leave AMA, the charge nurse should speak to the patient/parent/legal guardian/surrogate to explain that the...physician/designee should speak with them prior to their leaving the facility...The charge nurse should inform the patient/parent/legal guardian/surrogate that...insurance company may not pay for the hospitalization if the patient leaves AMA...If...attempts to discourage the patient from leaving AMA are unsuccessful, the patient's nurse or...physician should document the following:..explained...the risks associated with leaving without treatment...document the explanation in the patient's medical record...document in the medical record all attempts made to address the patient/parent/legal guardian/surrogate's concerns and actions taken by the medical staff to encourage the patient/parent/legal guardian/surrogate to stay at the facility...The patient/parent/legal guardian/surrogate is requested to sign the "Release of Responsibility" form...The release may be signed by the patient if 18 years of age or older without decision-making capacity...notation should be made in the nurses' notes by the nurse, stating...'the patient/parent/legal guardian/surrogate was informed about the medical concerns related to leaving AMA and has chosen to leave the hospital'...A notation should be made in the medical record by the...physician indicating the events that occurred...reasons (if known) for the patient/parent/ legal guardian/surrogate deciding to leave AMA. The...physician is also required to sign the "Release of Responsibility" section of the form...If the patient/parent/legal guardian/surrogate refuses to sign the "Release of Responsibility" form, the nurse or...physician should complete and document the patient's refusal on the form and place the form in the patient's medical record. Place the "Release of Responsibility" form in the patient's chart with or without the patient/parent/legal guardian/surrogate's signature...The patient's nurse completes an electronic occurrence report regarding the AMA situation...The patient's nurse completes the Nursing Discharge assessment..."

Medical record review for Patient #6 revealed the patient was admitted to Hospital #1 on 4/21/2024 at 5:53 PM, "...Means of arrival, ambulance...66 yo [year old] F [Female] hx [history] of homelessness, Chronic Obstructive Pulmonary Disease [COPD], Diabetes Mellitus [DM], and Hypertension [HTN] presents for bilateral lower extremity pain and hip pain. Patient tearful on interview. Patient reports last Wednesday she started to notice some left hip pain as well as lower extremity pain. Patient denies any recent fever, chest pain, or shortness of breath. Patient does report some chills ..."

Review of discharge summary from Hospital #1 dated 4/21/2024 7:43 PM, [less than 2 hours after admission] "...Please continue your home medications. Continue the Doxycycline that was prescribed by previous providers to complete the course of antibiotics. There was no acute fracture of your L hip seen on your Hip Xray. Please follow up with your primary care physician. Please return to ED if you develop any new or worsening symptoms ..."

During an interview on 9/11/2024 at 11:05 AM, Registered Nurse [RN] K stated he had worked at the facility for 3.5 years and was the discharging nurse for Patient #6 on 4/21/2024, after being seen and treated in the facility's emergency department for Cellulitis. RN K stated he could not recall specifics related to Patient #6 but noted she was wheelchair bound and was not able to walk on her own. He stated the facility's emergency department has a case manager to assist patients with transportation needs during the hours of 8:00 AM-4:30 PM. When Patient #6 was discharged on 4/21/2024 at 7:43 PM, there was no case manager available. RN K further stated Patient #6 was homeless and typically, (hired transportation by private individuals) would be called for patients who do not have transportation. Patient #6 was wheelchair dependent and would have required a van with a lift. RN K stated he "...wasn't sure if [Hospital] would pay for a lift ..." RN K stated "...Sometimes I just push the homeless patients in the ER breezeway and let them figure out how they are going to get to where they stay...". RN K denied he "dumped" Patient #6 on the sidewalk outside the emergency room but could not explain how Patient #6 was found the following day on the sidewalk outside the hospital ER without a wheelchair. RN K stated patients who were discharged were transported out of the ER in a wheelchair to the breezeway and were not allowed to maintain procession of the wheelchair.

During an interview on 9/11/2024 at 3:40 PM, Officer J of the local city Police Department stated he was a supervisor with a police crisis response team which deals with social and criminal issues in the city. On 4/22/2024 at 4:30 PM, one of his officers responded to a call that a person was found crawling in the street outside of Hospital #1's ER. The responding officer found Patient #6 crawling on the street, indicating that she wanted to die. According to the responding officer, he stated Patient #6 explained that she had been seen in Hospital #1 ER the previous day (4/21/2024) and was taken to a bench outside the ER in a wheelchair by a nurse and was left on the bench. Patient #6 explained that she was not able to walk on her own, needed a wheelchair to get around and her wheelchair was at the community kitchen where she lived 8 blocks from Hospital #1). The responding officer summoned an ambulance to transport Patient #6 to Hospital #2.

Review of EMS transport records of [patient #6] revealed the following: "per police report: Patient was seen last night at [hospital #1] for hip pain and was discharged back to the community. Patient was taken across the street in a wheelchair and left in her own care. Patient did not have access to transport and her wheelchair and slept on the sidewalk. Patient is non-ambulatory and has severe cellulitis in her lower extremities. Patient has been non-compliant with all medications for at least one month. Police found patient on sidewalk and patient expressed suicidal ideation with a plan to crawl into traffic. Mobile crisis was called and volunteer behavioral placed patient on a 6404/con. Patient is going to [hospital #2] ED for medical clearance and inpatient psychiatric placement. Patients mental state is alert and oriented and answers all questions appropriately. Patient is calm and cooperative. Patient was found lying on sidewalk and had urinated and defecated on herself due to incontinence and inability to get to a restroom. Patient complained of feeling cold and uncomfortable with hip pain 5/10 from sleeping on sidewalk. Patients' respiratory effort is normal. Breath sounds clear and equal bilaterally with symmetrical chest rise and fall. Patient denies substance use. Patient admits to continued suicidal ideation. Patient admits to a suicide attempt in the past and has had previous psychiatric hospitalizations. Patient feels hopeless and complains of being a burden. Patient denies auditory and visual Hallucinations. Patient feels she is in need of skilled nursing care as she is unable to care for herself".

Review of medical record from the receiving Hospital #2 for Patient #6 dated 4/22/2024, revealed the following: "Patient is a 66-year-old white female who presents to the emergency room with complaints of suicidal ideations that are mainly of a social initiation. Patient is a morbidly obese female...confined to a wheelchair and is homeless. She was brought in by EMS with a...[psychiatric commitment order]...in place. Patient has a known history of bipolar disorder, schizoaffective disorder and supposedly was in [another psychiatric hospital] about a month ago...went to live at a local homeless shelter. Earlier this week she had a fall out of her wheelchair and went to [Hospital #1] where they evaluated her and discharged her...to the street yesterday [4/21/2024]. The patient states that she...urinated and defecated on herself. According to EMS...she was covered in urine and feces...It is of note that the patient started to crawl...going to traffic in an attempt to get help and possibly kill herself. Once again, the patient presents with suicidal ideations without plan...previously in [Hospital #1 ER] and was evaluated and was prescribed an antibiotic...continued with cellulitis and still has erythematous legs.

During an interview on 9/16/2024, at 10:30 AM, the Patient Safety and Quality Director with Hospital #1 stated that she was aware of the incident related to Patient #6's unsafe discharge on 4/21/2024 and did not investigate the discharge, do an incident report on the incident, or look for a way to prevent this type of unsafe discharge from happening in the future. When asked if Patient #6's 4/21/2024 discharge was an unsafe discharge, she confirmed "it was not an optimal discharge."

Medical record review for Patient #12, an 82 year-old female, was admitted to the ER on 5/20/2024 at 8:40 PM, after she had fallen on the ground during a syncopal episode (sudden loss of consciousness due to a drop in blood flow to the brain), hitting her head. Continued record review revealed she initially had experienced mild confusion after the fall. Patient #12 also had medical history of Atrial Fibrillation (irregular and often very rapid heart rhythm) Arthritis, Asthma, Claustrophobia (fear of confined spaces), and Hypertension.

Review of laboratory results for Patient #12 dated 5/20/2024, revealed "Abnormal" laboratory results without defining or providing the normal and abnormal reference ranges or the specific results for Patient #12. Creatinine ( blood test to measure how kidneys are performing and filtering waste)- results "Abnormal"; Urea Nitrogen ( blood test for a marker of kidney function)- results "Abnormal"; Glucose (a simple sugar the body uses for energy )- results "Abnormal"; Hematocrit (blood test to determine the percentage of red blood cells in the blood)-results "Abnormal"; Basic Metabolic Panel (a blood test that checks for kidney health, blood sugar, electrolytes and acid base balance in the blood) -results "Abnormal"; Complete Blood Count ( CBC) with differential ( a blood test that measures red and white blood cells to test for anemia and infections, some heart diseases, autoimmune disorders)- results "Abnormal"; Continued review of laboratory results on 5/21/2024 revealed, Ferritin ( a protein that stores iron) - results "Abnormal"; Folate ( important in red blood cell formation)- results "Abnormal"; Iron( mineral vital to the proper function of hemoglobin, a protein needed to transport oxygen in the blood)- results "Abnormal"; Total Iron Binding ( test that measure blood's ability to bind to iron and carry it through the body)- results "Abnormal."

Review of Hospital #1 documentation titled, "Emergency Care Timeline," revealed Patient # 12 was discharged on 5/22/2024 at 10:11 AM, with peripheral intravenous fluids (IV) discontinued at 10:12 AM. Continued record review revealed there was no documentation for Patient #12 as per the hospital's AMA policy to reflect " ... a record should be made of the circumstances, or the physician was notified or the notification of the unit nurse manager or the House Supervisor or designee..." of Patient #12 desire to leave AMA. Further record review revealed Patient #12 was not provided with the explanation by "...the nurse and/or physician, the risks associated with leaving without treatment..." and no documentation "...all attempts made to address the patient...concerns and actions taken by the medical staff to encourage patient...to stay at the facility..." per the hospital's AMA policy after Patient #12 suffered a head injury resulting from a fall and without documented treatment for the noted "Abnormal" laboratory results.

Review of Hospital #1 documentation titled, "Leaving the Hospital Against Medical Advice" dated 5/24/2024, revealed Patient #12 had signed the document stating, "...This will certify that I, the undersigned, [Patient # 12 ] A patient in the above named medical center, having requested discharge and removal from the medical center against the advices of my attending physician(s), hereby release [Hospital #1], its physicians, officers and employees, severally and individually, from any and all liability of any nature whatsoever for any injury or harm or complication of any kind that may result directly or indirectly , by reason of my terminating my stay as a patient as [Hospital #1] and my departure from said medical center, and hereby waive any and all rights action I many now have or later acquire as a result of my voluntary departure from said medical center and the termination of my stay as a patient therein. This /release is made with the full knowledge of the danger that may result from the action I am taking..." The document was signed by the patient and witnessed, along with the signature of the nurse. However, the physician signature was noted to not be signed and was blank where the physician was to sign.

During an interview on 9/12/24 at 11:25 AM, RN N who discharged Patient #12 on 5/22/2024, stated she was not aware of the hospital's policy for AMA, only that an "AMA form is provided to the patients if they want to leave, and it lets them know of their risks if they decide to leave and the patient signs the AMA form." When asked if RN N explained the risks of leaving AMA to Patient # 12, she stated, "No." Upon further interview with RN N it was revealed she not seen the AMA policy and had not been in-serviced on the AMA policy.

Medical record review for Patient #13, revealed a 39-year-old male, admitted to the ER on 6/30/2024 with a diagnosis of Sepsis (a life threatening reaction to infection that can damage organs and tissues). Patient #13 also had a medical history of Cervical Vertebrae (C4-C5) Spinal Injury following a fall and resulting Paraplegia complicated by Neurogenic Bladder, Neurogenic Bowel, Stage IV left Ischial Decubitus Ulcer status post (excision and flap closure in 12/2023), and Deep Vein Thrombosis (DVT).

Review of laboratory results for Patient #13 dated 7/3/2024, revealed elevated White Blood Count (WBC) a measurement of the number of white blood cells in the body and can detect infection). The normal range for the hospital's WBC was noted to be 10*3/uL (microliters) with Patient #13 results at 17.1 and flagged as being out of range.

Review of hospital documentation for Patient #13 titled, "Progress Notes," dated 7/03/24 at 6:03 PM, revealed RN N documented, " ...Patient ready to leave AMA, as he feels urology, and wound care have ignored him. Pulled out his foley and is currently getting dressed. Notified MD [Medical Doctor]..." According to Care Timeline on the progress note, Patient #13 was discharged at 7:21 PM.
Review hospital documentation titled, "Progress notes" dates 7/3/2024 at 6:03 PM, revealed Patient #13 was discharged AMA. Continued record revealed there was no documentation for Patient #13 as per the hospital's AMA policy to reflect, "... a record should be made of the circumstances, or the physician was notified or the notification of the unit nurse manager or the House Supervisor or designee..." of Patient's #13 desire to leave AMA. Further record review revealed Patient #13 was not provided with the explanation by "...the nurse and/or physician, the risks associated with leaving without treatment..." and no documentation "...all attempts made to address the patient...concerns and actions taken by the medical staff to encourage patient...to stay at the facility..." per the hospital's AMA policy after patient #13 was diagnosed with Sepsis and with an elevated WBC.

Review of the Physician's Progress Note dated 7/3/2024 at 7:21 PM, the physician documented, "Went to PM round on patient [Patient #13], patient not in room. Informed that he has left AMA."

During an interview on 9/11/24 at 4:01 PM, RN M discharged Patient #13 on 7/3/2024 at 7:21 PM, stated he was not aware of the hospital's policy for AMA. When asked if RN M explained the risks of leaving AMA to Patient #13, he stated, " ...No, he [Patient #13] was very kind, but he said he felt like he was not getting the care that he needed there..." RN M confirmed he was not aware of the AMA policy and had not been in-serviced on the AMA policy. RN M further confirmed he did not provide Patient #13 with risks to his health when he left AMA. He further stated Patient #13 left before the doctor could see Patient #13. RN M confirmed he had not provided Patient #13 with the risks regarding his diagnosis of Sepsis and/or elevated WBC.

During an interview on 9/12/2024 at 11:30 AM, the hospital's attorney stated, "...It's on them [patients] when they sign out AMA. They understand the risks when they sign the AMA form ..."

Based on facility policy review, medical record review and interview, the hospital failed to establish a process for prompt resolution of patient grievances and to ensure effective operation of the grievance process for 1 (Patient #13) of 15 patients reviewed.

The findings include:

Review of the hospital policy titled, "Patient Related Complaint and Grievance Resolution, revised 9/2023, stated " ...For grievances requiring a clinical investigation, The Patient Experience Office will send an acknowledgement letter to the complainant within 7 business days of receiving the complaint indicating that their concern(s) are under review and that they will receive follow-up within a specific time period. In those cases, a member of the Patient Experience Office will send a final written resolution response letter within the 30-day (business days) time frame. These final closure letters should also state that an investigation was performed, what steps were taken, results, the organization's contact person and date of completion...A grievance is considered resolved when the patient is satisfied with the actions taken on their behalf..."

Review hospital documentation titled, "eSAFE" dated 7/5/2024, revealed a complaint/grievance was filed with the hospital for event dates 6/30/2024 on behalf of Patient #13. A follow up to the complainant was in form of a letter dated, July 11, 2024. The letter revealed, "...An investigation was performed by the Office of Patient Experience...The nurse manager over the unit has reviewed this file and is taking appropriate action to address this. Please be assured that we are committed to identifying opportunities for improving the care delivered to our patients and taking appropriate action when necessary...Our investigation is now complete..."

During an interview on 9/11/2024 at 12:16 PM, the Patient Experience Director stated the nurse manager over the unit did not review or address the concern. The Patient Experience Director stated, "It was an assumption since I saw she [unit manager] was in the system and she would address it." The Patient Experience Director confirmed the grievance had not been addressed to date and the letter sent, inaccurately assured the complainant that appropriate action was addressed by the unit manager and when it was not.

Refer to A-0115.

Based on facility policy review, medical record review and interview, the hospital failed to protect each patient's right to be free from abuse and provide medical care in a safe environment for 4 patients (Patients #10, #5, #2, and #11), and failed to be provide medical care in a safe environment for 1 patient (#6) who was wheelchair bound and homeless, without a wheelchair upon discharge, whereby Patient #6 was found by police approximately 24 hours later outside the hospital emergency room, attempting to crawl onto the road, the hospital failed to ensure medical and health risks were explained so that the individual patients could make informed medical decisions prior to discharging Against Medical Advice (AMA) for 2 patients (Patients #12 and #13) of 15 patients reviewed.

The findings include:

Review of hospital policy titled, "Patient Related Complaint and Grievance Resolution" revised 9/2023, stated "...For grievances requiring a clinical investigation, The Patient Experience Office will send an acknowledgement letter to the complainant within 7 business days of receiving the complaint indicating that their concern(s) are under review and that they will receive follow-up within a specific time period. In those cases, a member of the Patient Experience Office will send a final written resolution response letter within the 30-day (business days) time frame. These final closure letters should also state that an investigation was performed, what steps were taken, results, the organization's contact person and date of completion...A grievance is considered resolved when the patient is satisfied with the actions taken on their behalf..."

Review of the facility policy titled, "Patient Rights" dated 8/2024, revealed "...You, the patient, have the right to...Be safe from abuse or harassment...It is your responsibility to...Accept that bad language or bad behavior will not be tolerated..."

Review of the facility policy titled, "Abuse Reporting," dated 11/2024, revealed "...All patients have the right to be free from all acts of violence...from staff...The hospital will ensure that patients are free from all forms of abuse...All allegations of abuse...will be investigated thoroughly and will begin immediately once the allegation has been made...If the allegation is against a...care giver for the patient, the caregiver will be removed from caring for the patient...Education is provided during new employee orientation...annual training...on abuse...including reporting requirements, prevention, intervention, and detection...The investigation will include interviews of all persons involved...Incidents of abuse...harassment will be reported...analyzed with appropriate corrective, remedial, or disciplinary actions taken in accordance with applicable local, State, or Federal law...Reports of suspected abuse...harassment shall be made to Senior Leadership or the Risk Manager immediately...The caregiver affected by the allegation will be placed on administrative leave during the investigation...If the allegations are substantiated, the employee will be terminated and the appropriate agencies will be notified..."

Review of a written statement from Staff Member B dated 8/17/2022, revealed "...Walked into the unit @ [at] 625 am [6:25 AM] Saw pt [Patient #10] in bed 8 being restrained. Offered assistance. Help [Patient Care Technician/PCT] U hold left arm to assess...IV [intravenous] was bad so we took off ...[specialized pressure bandage]...and tried to take off the tape. While this was happening, [Staff Member B] was at the right arm of the pt [Patient #10]. I [Staff Member B] heard the pt [Patient #10] say, "that hurts, my arm hurts, it feels like you are going to break it!" I heard [Licensed Practical Nurse/LPN] V say, "wait his arm is at an angle, let go, that doesn't look right." I looked up and saw his [Patient #10] arm bent at an angle toward the head of the bed...After iv [intravenous needle] was wrapped up, I left to answer call lights. I heard another commotion and came back into the room. Pt [Patient #10] was kicking his legs. [Staff Member B] was to the foot of the bed and grabbed the pts [Patient #10's] legs and slammed them down on the bed and yelled very loudly at the pt [patient] "STOP RIGHT NOW!" [Staff Member B] held the pt's [Patient #10] legs down while someone else retied the leg restraints. The restraints were reassessed and found to be to [too] tight..."

Review of the facility's document titled, "eSAFE" incident report dated 8/17/2022, revealed "...While multiple staff were attempting to restrain the patient [Patient #10] to allow performance of an EKG, [electrocardiogram] [Staff Member B] entered room to assist and became physically aggressive towards...[Patient #10]..."

During an interview on 9/12/2024 at 10:10 AM, Registered Nurse (RN) D stated she was working in the emergency room on 8/17/2022, when she witnessed Patient #10 being placed in 4-point (all four extremities) restraints. RN D stated she saw staff members around Patient #10. The patient started kicking his feet, Staff Member B picked up Patient #10's feet and aggressively slammed the patient's feet down on the bed and tightened the restraints too tight. Staff Member B was yelling at the patient to stop kicking. RN D stated she had never seen Staff Member B so aggressive with a patient before.

Medical record review of Patient #5 revealed he arrived at the facility by ambulance on 6/22/2024, for a right arm laceration. Patient #5 was treated for the right arm laceration and was discharged home on 6/22/2024.

Review of the facility's document titled, "eSAFE" incident report dated 6/27/2024, revealed an incident between a contracted security officer (Security Officer-SO Q) and Patient #5 occurred on 6/22/2024. The incident report read "...[Patient #5] ...brought in on 6/22/2024 for a severe circumferential arm laceration...[Patient #5] was...held on the EMS [Emergency Medical Service] stretcher...in front of the charge desk the patient's arm was bumped the patient sat up on the stretcher and screamed in pain. When this happened...[SO Q] approached the patient grabbing him by the head and slammed him backwards and held the patient's face by under the chin pushing upwards and the top of the head pushing down so the patient could not open his mouth...[Registered Nurse-RN AA] came from the back side of the charge desk...around to where the incident was occurring [SO Q] had removed his badge and was holding it in the patients face saying '...this is my ER [explicit language]'...[RN AA] attempted to diffuse the situation and [SO Q] would not stop...[RN AA] stepped away to ask someone to call for more help and when I returned to the patients side [SO Q] eventually let go but kept arguing with the patient...antagonizing the patient..."

Medical record review revealed Patient #2 presented to the ED on 7/5/2024, with a self-inflicted gunshot wound (GSW) to the head. Further review revealed Patient #2 was hemodynamically stable, alert and oriented, with combative behaviors. On initial evaluation, Patient #2 was extremely anxious, refused to answer questions about self-inflicted GSW, and quickly became agitated upon further questioning. Patient #2's blood alcohol level was 244 mg/dL (milligrams/deciliters-units of measure). The patient was placed on suicide precautions; 1:1 observation with sitter to bedside; placed in a yellow gown; and was placed on Certificate of Need (CON-emergency psychiatric commitment) hold due to the potential harm or danger to self and others.

Review of the facility's document titled, "eSAFE" incident report dated 7/5/2024, revealed "...ED [Emergency Department] bed 7 was brought in as a self-inflicted GSW to the head. Shortly after arrival, pt [patient] was placed on a CON d/t [due to] SI [suicidal ideation] and attempted suicide. [Registered Nurse-RN W] responded to [Patient #2] room after hearing screaming. Upon entry, [Patient #2] was removing bedside monitoring equipment, agitated, and asking to leave. [RN W] alerted [Medical Doctor-MD Y] of [Patient #2] behavior. [MD Y] gave a verbal order for IV [intravenous] Ativan [a sedating medication] and soft wrist restraints. [Patient #2] was placed in wrist restraints and medication was administered as prescribed. [Patient #2] was found again, out of bed, with restraints removed. [RN W] entered the room to find [Patient #2] agitated with several...security officers at bedside. [Patient #2] was visually upset and attempting to leave the ED. [RN W] alerted [MD Z] of [Patient #2] behavior and increased agitation. [MD Z] gave a verbal order for IM [intramuscular] medications and violent wrist restraints. [RN W] left the room to grab restraints, upon returning to the room, [Patient #2] was found being placed in the bed by 4 security guards. Security was attempting to move [Patient #2] in the bed when one of them verbalized being kicked. [SO, X] then hit [Patient #2] with a closed fist on his chest. [RN W] was unable to reach...[Patient #2] d/t the number of security officers at the bedside. [Patient #2] was thrashing during the attempt to restrain him. During the events...[Patient #2] became agitated and was grabbing at security. [SO X] stated 'I'm going to punch you if you touch my officers again.' [SO X] then proceeded to hit the pt [Patient #2] several more times with a closed fist in the chest and abdomen...[SO X]...turned to [MD Z] and stated, "I had to punch him, he grabbed my guys."...[Patient #2] was placed in violent restraints...intermittently sat up...was agitated. IM [intramuscular] medications were administered...[Patient #2] was hit with a closed fist several more times by [SO X] after medication administration..."

Medical record review revealed Patient #11 was a patient in the ER on 8/28/2024 at 11:15 PM, and revealed "... CO [corrections officer] attempted to put mobility chains [immobilizes upper extremities] on Patient #11 due to patient being able to move hands freely. During this encounter, Patient #11 reached for off-duty officer's gun. Security at bedside to subdue. Patient spitting blood onto security guards. Patient laughed and stated that 'it's funny because I have AIDS.' Blood is on security guard's skin and clothing. House supervisor made aware...CO requesting more officers to assist with patient..."

Review of a facility incident report for Patient #11 dated 9/11/2024, revealed "...On 09/11/24, while reviewing the combative patient report, which I [Security Director] review daily, I [Security Director] saw [Security Officer O] antagonized and bully an almost incoherent patient. PT [Patient] I [Security Director] [Patient #11] was brought into the ER [emergency room] by the...County Sheriff's Office, by Corrections Officer. The PT [Patient #11] had been violently beaten by other inmates while incarcerated and had open bleeding wounds on his face and in his mouth. [Security Officer O] reported a violent individual who was hitting and punching Police Officers, and at one point even trying to take officer firearm. In the footage I [Security Director] observed [Security Officer O] stalking the PT [Patient #11], who 99% of the time was sitting still and compliant. I watched the incident unfold with [Security Officer O] taking a hair net from the nurse's station, placing it over the PT's [Patient #11] head, and pulling it tight sneakily coming up behind the PT [Patient #11]. In the footage, [Security Officer O] is grinning. [Security Officer O] was not asked to assist and should have no dealings with a guarded...County Inmate. [Security Officer O] again grabbed the patient by the face, without being asked to assist, and violently shoved the patient's head down into a bed with no regard for the open wounds on his face and in his mouth and not knowing if there was a neck injury or any kind of head injury. [Security Officer O] later takes a towel, which he was constantly fixated on for some reason on the PT [Patient #11] spitting, in which the video shows he never spit on anyone and told another officer to help him with this guy who is spitting and places the towel over the PT's [Patient #11] face and holds his head immobile with heavy pressure. [Security Officer O] continues to get involved and gets into the face of the PT [Patient #11] cursing him and lunging at the PT [Patient #11], when the PT [Patient #11] leaned forward [Security Officer O] violently strikes the PT [Patient #11] again in his face, still not knowing if he could have further injured or killed the PT [Patient #11]. The...County deputy had to get between [Security Officer O] and the PT [Patient #11] and move him out of the way. [Security Officer O] stated he was spat on that was why he hit him, but video footage shows no blood coming from the PT's [Patient #11] mouth or on [Security Officer O]. [Security Officer W] witnessed the incident and stated the blood came from [Security Officer O] slapping the Pt [Patient #11] with open wounds and made the blood splatter all over everyone. The report written by [Security Officer O] has him pressing charges on the PT [Patient #11] and charging him with Aggravated assault..."

During an interview on 9/19/ 2024, at 12:55 PM, the Patient Safety Quality Manager stated she was made aware on 9/19/2024 of the events that took place involving Security Officer O and Patient #11 on 8/28/2024. The Patient Safety Quality Manager could not explain why it took 21 days for her to be made aware of the patient abuse that occurred on 8/28/2024. She stated she and the abuse teams reviewed the video footage of Security Officer O interacting with [Patient #11] and deemed Security Officer O's interactions were abusive. The Patient Safety Quality Manager stated she contacted the Chief of Security and asked Security Officer O to be removed from the hospital and not be allowed to return, 21 days after the abuse.

During interview on 9/19/2024 at 1:10 PM, the Director of Security stated he was employed by the hospital's contracted security company and had been the Director of Security since 4/1/2024. The Director of Security stated Security Officer O was the night shift supervisor, and he had noticed that most of the aggressive behavior documented had been on the night shift and by officers supervised by Security Officer O. Security Officer O was terminated from the hospital's contracted security company because of his abusive actions taken against the emergency room Patient #11.

Medical record review of Patient #6 revealed the patient was admitted on 4/21/2024, at 5:53 PM, "Means of arrival, ambulance...hx [history] of homelessness, COPD [Congestive Obstructive Pulmonary Disease], DM [Diabetes Mellitus], and HTN [Hypertension] presents for bilateral lower extremity pain and hip pain. Patient tearful on interview. Patient reports last Wednesday she started to notice some left hip pain as well as lower extremity pain. Patient denies any recent fever, chest pain, or shortness of breath...does report some chills."

Review of the discharge summary dated 4/21/2024 7:43 PM [less than 2 hours after admission] "Please continue your home medications. Continue the Doxycycline that was prescribed by previous providers to complete the course of antibiotics. There was no acute fracture of your L [left] hip seen on your Hip Xray. Please follow up with your primary care physician. Please return to ED if you develop any new or worsening symptoms."

Interview with RN K, on 9/11/2024 at 11:05 AM, revealed RN K was the discharging nurse for patient #6 on 4/21/2024. He reviewed Patient #6's medical record, did not remember patient #6 well, but had some recollection of Patient #6 from 4/21/2024. He discharged Patient #6 on 4/21/2024, after being treated in the emergency room for Cellulitis. Patient #6 was wheelchair bound and was not able to walk on her own. Interview revealed from 8:00 AM to 4:30 PM, there was a case manager who assists patient with transportation if the patient does not have transportation. The case manager was not on duty when Patient #6 was discharged at 7:43 PM, on 4/21/2024. He remembered Patient #6 was homeless. He stated "typically would call for a [name of taxi] if a patient does not have transportation," but patients who are wheelchair bound would require a van with a lift and "he wasn't sure if [Hospital #1] would pay for a lift van....Sometimes I just push the homeless patients in the ER breezeway and let them figure out how they are going to get to where they stay."

Interview continued and he denied he "dumped" Patient #6 on the sidewalk outside the emergency room, but he could not explain how Patient #6 was found the following day on the sidewalk, outside the Hospital #1's emergency room, with no wheelchair. He state that patients are taken out of the emergency room in a wheelchair when being discharged, but do not get to keep a wheelchair from the emergency room.

Interview with staff member L, on 9/11/2024 at 9:25 AM, revealed she was an ER Clinical Staff Leader and stated if a patient does not have transportation [Hospital #1] will always try to get the patient transportation to their place of residence. She stated there was a case manager available during the day to arrange transportation and the house supervisor can arrange transportation for patients after hours and [Hospital #1] will arrange transportation for patients that are wheelchair bound.

Interview with Officer J, with the local City Police Department on 9/11/2024 at 3:40 PM, revealed he was a supervisor with a police crisis response team which deals with social and criminal issues in the city. On 4/22/2024 at 4:30 PM, one of his officers responded to a call that a person was found crawling in the street outside on the emergency room at [Hospital #1]. The officer found Patient #6 on the street, indicating that she wanted to die and that was the reason she was crawling in the street. Continued interview revealed Patient #6 explained she had been seen in the emergency room the previous day and was taken to a bench outside the emergency room, in a wheelchair by a nurse, and was left on a bench. Patient #6 explained she was not able to walk on her own, needed a wheelchair to get around and her wheelchair was at the community kitchen where she lived on 11th street. An ambulance was called and Patient #6 was transported to Hospital #2.

Review of emergency medical services (EMS) transport records of patient #6 dated April 22, 2024, revealed, the following: "...per police report: patient [patient #6] was seen last night [4/21/2024] at [hospital #1] ...for hip pain... and was discharged back to the community. Patient was taken across the street in a wheelchair... and left in... her own care.... patient did not have access to transport or... her wheelchair and slept on the sidewalk. Patient is non-ambulatory... and has severe cellulitis in... her lower extremities. patient has been non-compliant with all medications for at least one month. Police found patient on sidewalk... and patient expressed suicidal ideation with a plan to crawl into traffic. Mobile crisis was called and volunteer behavioral placed patient on a [involuntary psychiatric commitment]. Patient is going to ... [hospital #2] ... ED for medical clearance and inpatient psychiatric placement. Patients mental state... is alert... and oriented... and answers all questions appropriately. Patient is calm and cooperative. Patient was found lying on sidewalk... and had urinated and defecated on herself due to incontinence and inability to get to a restroom. Patient complained of feeling cold and uncomfortable with hip pain ...from sleeping on sidewalk ...patient admits to continued suicidal ideation... patient admits to a suicide attempts in the past... and has had previous psychiatric hospitalizations. Patient feels hopeless... and complains of being a burden...patient feels she is in need of skilled nursing care... as she is unable to care for herself...".

Medical record review of Patient #6 after admitted to Hospital #2's ER on 4/22/2024, revealed the following: "Patient is a 66-year-old white female who presents to the emergency room with complaints of suicidal ideations that are mainly of a social initiation. Patient is a morbidly obese female that is confined to a wheelchair and is homeless. She was brought in by EMS with a CON in place. Patient has a known history of bipolar disorder, Schizoaffective disorder and supposedly was in [Hospital #3] about a month ago. It is of note that patient was supposed to discharge from [Hospital #2] and went to live at a local homeless shelter. Earlier this week she had a fall out of her wheelchair and went to [Hospital #1] where they evaluated her and discharged her...to the street yesterday. The patient states...urinated and defecated on herself. According to EMS, she was...covered in urine and feces...It is of note that the patient started to crawl...going to traffic in an attempt to get help and possibly kill herself. Once again, the patient presents with suicidal ideations without plan. Patient was seen 4 days ago in the emergency room ...Patient still has erythematous legs.."

Review of hospital policy Case Management-Transition Management, Discharge Planning, and Patient Choice, last revised 6, 2021, stated..."Transition Management" -the process of assessing and reassessing the patients for post-hospital needs and then developing and implementing a plan to coordinate those services identified as necessary for the patient when they leave the hospital. The process includes a mechanism for a Case Management Registered Nurse or Social Worker to identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge or transfer if there is inadequate planning... as outlined in the routine nursing assessment. A discharge planning evaluation by the CM/SW may be requested...Transition management will be conducted in accordance with all legal mandates while supporting the patient's ethical and moral directives. Case Management discharge planning services are available to all patients regardless of age, sex, national origin, race, and sexual orientation...All discharge evaluations and discharge plans are recorded in EPIC by the RN/SW Case manager and the results are discussed with the patient or individual acting on his or her behalf..."

During an interview with the Patient Safety and Quality Director, on 9/16/2024, at 10:30 AM, she stated that she was aware of the incident related to Patient #6's unsafe discharge on 4/21/2024 and did not investigate the discharge, do an incident report on the incident, or look for a way to prevent this type of unsafe discharge from happening in the future. When asked if Patient #6's 4/21/2024 was an unsafe discharge, she stated "it was not an optimal discharge."

Review of hospital documentation titled, "Leaving Against Medical Advice" revised 07/2023, revealed "This policy provides guidance for [Hospital #1] in addressing situations where a patient or his or her decision maker states the desire to leave the facility against medical advice in a manner that both promotes patient safety and honors patient rights ... [Hospital #1] responds appropriately to all requests for treatment. When a patient or his or her parent/ legal guardian/surrogate takes action for the patient to leave Against Medical Advice (AMA), a record should be made of the circumstances. Staff members and the physician should also attempt to educate the patient/parent/ legal guardian/surrogate about the consequences of leaving without approval ... A. As soon as any staff member becomes aware of the patient's desire to leave the facility AMA, the attending physician should be called. The attending physician, nurse, and/or assigned patient caregiver should attempt to determine the reason(s) for the desire to leave AMA.
B. The staff member should then notify the unit nurse manager and House Supervisor or designee of the desire to leave AMA. C. The patient's nurse should document the intent to leave AMA and any actions taken to leave AMA in the patient's medical record. D. If it is possible to address the concerns voiced by the patient or parent/legal guardian/surrogate, every reasonable attempt should be made to do so. If it is not possible to change the patient/parent/legal guardian/surrogate's decision to leave AMA, the charge nurse should speak to the patient/parent/legal guardian/surrogate to explain that the attending physician/designee should speak with them prior to their leaving the facility. E. The charge nurse should inform the patient/parent/legal guardian/surrogate that his/her insurance company may not pay for the hospitalization if the patient leaves AMA...G. If the attempts to discourage the patient from leaving AMA are unsuccessful, the patient's nurse or attending physician should document the following: I. The nurse and/or physician explained to the patient/parent/legal guardian/surrogate the risks associated with leaving without treatment and should document the explanation in the patient's medical record. The nurse and/or physician/designee should also document in the medical record all attempts made to address the patient/parent/legal guardian/surrogate's concerns and actions taken by the medical staff to encourage the patient/parent/legal guardian/surrogate to stay at the facility. ii. The patient/parent/legal guardian/surrogate is requested to sign the "Release of Responsibility" form (#38543). The release may be signed by the patient if 18 years of age or older without decision-making capacity. iii. A notation should be made in the nurses' notes by the nurse, stating that "the patient/parent/legal guardian/surrogate was informed about the medical concerns related to leaving AMA and has chosen to leave the hospital." iv. A notation should be made in the medical record by the attending physician indicating the events that occurred and reasons (if known) for the patient/parent/ legal guardian/surrogate deciding to leave AMA. The attending physician is also required to sign the "Release of Responsibility" section of the form. v. If the patient/parent/legal guardian/surrogate refuses to sign the "Release of Responsibility" form, the nurse or attending physician should complete and document the patient's refusal on the form and place the form in the patient's medical record. Place the "Release of Responsibility" form in the patient's chart with or without the patient/parent/legal guardian/surrogate's signature. vi. The patient's nurse completes an electronic occurrence report regarding the AMA situation. vii. The patient's nurse completes the Nursing Discharge assessment."

Review of hospital record review for Patient #12, an 82-year-old female was admitted to the emergency room (ER) on 5/20/2024 at 20:40 (8:40 PM EST) after she had fallen on the ground during a syncopal episode (sudden loss of consciousness due to a drop in blood flow to the brain), hitting her head. Continued record review revealed she initially had experienced mild confusion after the fall. Patient #12 also had medical history of Atrial Fibrillation (irregular and often very rapid heart rhythm) arthritis, asthma, claustrophobia (fear of confined spaces), and hypertension.

Review of laboratory results for patient #12, dated 5/20/2024 revealed "Abnormal" laboratory results without defining or providing the normal and abnormal reference ranges or the specific results for Patient #12. Creatinine ( blood test to measure how kidneys are performing and filtering waste)- results "Abnormal"; Urea Nitrogen ( blood test for a marker of kidney function)- results "Abnormal"; Glucose ( a simple sugar the body uses for energy )- results "Abnormal"; Hematocrit ( blood test to determine the percentage of red blood cells in the blood)-results "Abnormal"; Basic Metabolic Panel ( a blood test that checks for kidney health, blood sugar, electrolytes and acid base balance in the blood) -results "Abnormal"; Complete Blood Count ( CBC) with differential( a blood test that measures red and white blood cells to test for anemia and infections, some heart diseases, autoimmune disorders)- results "Abnormal"; Continued review of laboratory results on 5/21/2024 revealed, Ferritin ( a protein that stores iron) - results "Abnormal"; Folate ( important in red blood cell formation)- results "Abnormal"; Iron( mineral vital to the proper function of hemoglobin, a protein needed to transport oxygen in the blood)- results "Abnormal"; Total Iron Binding ( test that measure blood's ability to bind to iron and carry it through the body)- results "Abnormal."

Review hospital documentation titled, "Emergency Care (ED) Timeline" revealed Patient #12 was discharged on 5/22/2024 at 10:11 AM with peripheral intravenous fluids (IV) discontinued at 10:12 AM. Continued record revealed there was no documentation for Patient #12 as per the hospital's AMA policy to reflect, "... a record should be made of the circumstances, or the physician was notified or the notification of the unit nurse manager or the House Supervisor or designee" of Patient # 12 desire to leave AMA. Further record review revealed Patient #12 was not provided with the explanation by "the nurse and/or physician, the risks associated with leaving without treatment..." and no documentation "all attempts made to address the patient...concerns and actions taken by the medical staff to encourage patient...to stay at the facility" per the hospital's AMA policy after Patient #12 suffered a head injury resulting from a fall and without documented treatment for the noted "Abnormal" laboratory results.

Review of hospital documentation titled, "Leaving the Hospital Against Medical Advice" dated 5/24/2024, revealed Patient #12 had signed the document stating, " This will certify that I, the undersigned, [patient # 12 name] A patient in the above named medical center, having requested discharge and removal from the medical center against the advices of my attending physician(s), hereby release [name of hospital], its physicians, officers and employees, severally and individually, from any and all liability of any nature whatsoever for any injury or harm or complication of any kind that may result directly or indirectly , by reason of my terminating my stay as a patient as [name of hospital] and my departure from said medical center, and hereby waive any and all rights f action I many now have or later acquire as a result of my voluntary departure from said medical center and the termination of my stay as a patient therein. This /release is made with the full knowledge of the danger that may result from the action I am taking." The document was signed by the patient and witnessed, along with the signature of the nurse. However, the physician signature was noted to not be signed and was blank where the physician was to sign.

Medical record review revealed Patient #13, a 39-year-old male, was admitted to the Emergency Room (ER) on 6/30/2024 with a diagnosis of Sepsis (a life threatening reaction to infection that can damage organs and tissues). Patient #13 also had a medical history of Cervical Vertebrae (C4-C5) Spinal Injury following a fall and resulting Paraplegia complicated by neurogenic bladder, neurogenic bowel, stage IV left Ischial decubitus ulcer status post (excision and flap closure in 12/2023) and Deep Vein Thrombosis (DVT).

Review of laboratory results for patient #13, dated 7/3/2024, revealed elevated White Blood Count (CBC) (a measurement of the number of white blood cells in the body and can detect infection). The normal range for the hospital's WBC was noted to be 10*3/uL with patient #13 results at 17.1 and flagged as being out of range.

Review of hospital documentation titled, "Progress Notes" dated 7/03/24 at 6:03 PM, revealed RN N documented, "Patient ready to leave AMA, as he feels urology, and wound care have ignored him. Pulled out his foley and is currently getting dressed. Notified MD." According to" Care Timeline" on the progress note, Patient #13 was discharged 7:21 PM.

Review hospital documentation titled, "Progress notes" dates 7/3/2024 at 6:03 PM, revealed Patient #13 was discharged AMA. Continued record revealed there was no documentation for Patient #13 as per the hospital's AMA policy to reflect, "... a record should be made of the circumstances, or the physician was notified or the notification of the unit nurse manager or the House Supervisor or designee" of Patient #13 desire to leave AMA. Further record review revealed Patient #13 was not provided with the explanation by "the nurse and/or physician, the risk

Based on facility policy review, medical record review and interview, the hospital failed to protect each patient's right to be free from abuse for 4 patients (Patients #10, #5, #2, and #11) of 15 patients reviewed for abuse.

The findings include:

Review of the facility policy titled, "Patient Rights," dated 8/2024, revealed "...You, the patient, have the right to...Be safe from abuse or harassment...It is your responsibility to...Accept that bad language or bad behavior will not be tolerated..."

Review of the facility policy titled, "Abuse Reporting" dated 11/2024, revealed "...All patients have the right to be free from all acts of violence...from staff...The hospital will ensure that patients are free from all forms of abuse...All allegations of abuse...will be investigated thoroughly and will begin immediately once the allegation has been made...If the allegation is against a...care giver for the patient, the caregiver will be removed from caring for the patient...Education is provided during new employee orientation...annual training...on abuse...including reporting requirements, prevention, intervention, and detection...The investigation will include interviews of all persons involved...Incidents of abuse...harassment will be reported...analyzed with appropriate corrective, remedial, or disciplinary actions taken in accordance with applicable local, State, or Federal law...Reports of suspected abuse...harassment shall be made to Senior Leadership or the Risk Manager immediately...The caregiver affected by the allegation will be placed on administrative leave during the investigation...If the allegations are substantiated, the employee will be terminated and the appropriate agencies will be notified..."

Review of a written statement from Staff Member B dated 8/17/2022, revealed " ...Walked into the unit @ [at] 625 am [6:25 AM] Saw pt [Patient #10] in bed 8 being restrained. Offered assistance. Help [Patient Care Technician/PCT]...hold left arm to assess the...IV [intravenous] was bad so we took off...[specialized pressure bandage]...and tried to take off the tape. While this was happening, [Staff Member B] was at the right arm of the pt [Patient #10]. I [Staff Member B] heard the pt [Patient #10] say, "that hurts, my arm hurts, it feels like you are going to break it!" I heard [Licensed Practical Nurse/LPN] V say, "wait his arm is at an angle, let go, that doesn't look right." I looked up and saw his [Patient #10's] arm bent at an angle toward the head of the bed. After IV was wrapped up, I left to answer call lights. I heard another commotion and came back into the room. Pt [Patient #10] was kicking his legs. [Staff Member B] was to the foot of the bed and grabbed the pts [Patient #10's] legs and slammed them down on the bed and yelled very loudly at the pt "STOP RIGHT NOW!" [Staff Member B] held the pts [Patient #10] legs down while someone else retied the leg restraints. The restraints were reassessed and found to be to [too] tight ..."

Review of the facility's document titled, "eSAFE" incident report dated 8/17/2022, revealed "...While multiple staff were attempting to restrain the patient [Patient #10] to allow performance of an EKG, [electrocardiogram] [Staff Member B] entered room to assist and became physically aggressive towards...[Patient #10]..."

During an interview on 9/12/2024 at 10:10 AM, Registered Nurse (RN) D stated she was working in the emergency room on 8/17/2022 when she witnessed Patient #10 being placed in 4-point (all four extremities) restraints. RN D stated she saw staff members around Patient #10. The patient started kicking his feet, Staff Member B picked up Patient #10's feet and aggressively slammed the patient's feet down on the bed and tightened the restraints too tight. Staff Member B was yelling at the patient to stop kicking. RN D stated she had never seen Staff Member B so aggressive with a patient before.

Medical record review revealed Patient #5 arrived at the facility by ambulance on 6/22/2024 for a right arm laceration. Patient #5 was treated for the right arm laceration and was discharged home on 6/22/2024.

Review of the facility's document titled, "eSAFE," incident report dated 6/27/2024, revealed an incident between a contracted security officer (Security Officer-SO Q) and Patient #5 occurred on 6/22/2024. The incident report revealed, "...[Patient #5] ...brought in on 6/22/2024 for a severe circumferential arm laceration...[Patient #5] was...held on the EMS [Emergency Medical Service] stretcher...in front of the charge desk the patient's arm was bumped the patient sat up on the stretcher and screamed in pain. When this happened...[SO Q] approached the patient grabbing him by the head and slammed him backwards and held the patients face by under the chin pushing upwards and the top of the head pushing down so the patient could not open his mouth...[Registered Nurse-RN AA] came from the back side of the charge desk...around to where the incident was occurring [SO Q] had removed his badge and was holding it in the patients face saying " this is my ER [explicit language]"...[RN AA] attempted to diffuse the situation and [SO Q] would not stop...[RN AA] stepped away to ask someone to call for more help and when I returned to the patient's side [SO Q] eventually let go but kept arguing with the patient stating he could have his name and badge...antagonizing the patient..."

Medical record review revealed Patient #2 was admitted on 7/5/2024, to the ED with a self-inflicted gunshot wound (GSW) to the head. Further review reveled Patient #2 was hemodynamically stable, alert and oriented, with combative behaviors. On initial evaluation, Patient #2 was extremely anxious, refused to answer questions about self-inflicted GSW, and quickly became agitated upon further questioning. Patient #2's blood alcohol level was 244 mg/dL (milligrams/deciliters-units of measure). The patient was placed on suicide precautions; 1:1 observation with sitter to bedside; placed in a yellow gown; and was placed on Certificate of Need (CON-emergency psychiatric commitment) hold due to the potential of harm or danger to self and others.

Review of the facility's document titled, "eSAFE" incident report dated 7/5/2024, revealed "...ED [Emergency Department] bed 7 was brought in as a self-inflicted GSW [gunshot wound] to the head. Shortly after arrival, pt was placed on a CON d/t [due to] SI [suicidal ideation]and attempted suicide. [Registered Nurse-RN W] responded to [Patient #2] room after hearing screaming. Upon entry, [Patient #2] was removing bedside monitoring equipment, agitated, and asking to leave. [RN W] alerted [Medical Doctor-MD Y] of [Patient #2] behavior. [MD Y] gave a verbal order for IV [intravenous] Ativan [a sedating medication] and soft wrist restraints. [Patient #2] was placed in wrist restraints and medication was administered as prescribed. [Patient #2] was found again, out of bed, with restraints removed. [RN W] entered the room to find the [Patient #2] agitated with several...Security officers at bedside. [Patient #2] was visually upset and attempting to leave the ED. [RN W] alerted [MD Z] of [Patient #2] behavior and increased agitation. [MD Z] gave a verbal order for IM [intramuscular] medications and violent wrist restraints. [RN W] left the room to grab restraints, upon returning to the room, the [Patient #2] was found being placed in the bed by 4 security guards. Security was attempting to move the [Patient #2] in the bed when one of them verbalized being kicked. [SO X] then hit the [Patient #2] with a closed fist on his chest. [RN W] was unable to reach... [Patient #2] d/t the number of security officers at the bedside. [Patient #2] was thrashing during the attempt to restrain him. During the events...[Patient #2] became agitated and was grabbing at security. [SO X] stated "I'm going to punch you if you touch my officers again." [SO X] then proceeded to hit the pt [Patient #2] several more times with a closed fist in the chest and abdomen...[SO X]...turned to [MD Z] and stated, 'I had to punch him, he grabbed my guys.'...[Patient #2] was placed in violent restraints...intermittently sat up...was agitated. IM [intramuscular] medications were administered...[Patient #2] was hit with a closed fist several more times by [SO X] after med administration..."

Medical record review of Patient #11's medical record, dated 8/28/2024 at 11:15 PM, revealed "...CO [corrections officer] attempted to put mobility chains [immobilizes upper extremities] on Patient #11 due to patient being able to move hands freely. During this encounter, Patient #11 reached for off-duty officer's gun. Security at bedside to subdue. Patient spitting blood onto security guards. Patient laughed and stated that 'it's funny because I have AIDS.' Blood is on security guard's skin and clothing. House supervisor made aware...CO requesting more officers to assist with patient..."

Review of a facility incident report for Patient #11, dated 9/11/2024, revealed "...On 09/11/24, while reviewing the combative patient report, which I [Security Director] review daily, I [Security Director] saw [Security Officer O] antagonized and bully an almost incoherent patient. PT [Patient] I [Security Director] [Patient #11] was brought into the ER by the...County Sheriff's Office, by Corrections Officer. The PT [Patient #11] had been violently beaten by other inmates while incarcerated and had open bleeding wounds on his face and in his mouth. [Security Officer O] reported a violent individual who was hitting and punching Police Officers, and at one point even trying to take officer firearm. In the footage I [Security Director] observed [Security Officer O] stalking the PT [Patient #11], who 99% of the time was sitting still and compliant. I watched the incident unfold with [Security Officer O] taking a hair net from the nurse's station, placing it over the PT's [Patient #11] head, and pulling it tight sneakily coming up behind the PT [Patient #11]. In the footage, [Security Officer O] is grinning. [Security Officer O] was not asked to assist and should have no dealings with a guarded...County Inmate. [Security Officer O] again grabbed the patient by the face, without being asked to assist, and violently shoved the patient's head down into a bed with no regard for the open wounds on his face and in his mouth and not knowing if there was a neck injury or any kind of head injury. [Security Officer O] later takes a towel, which he was constantly fixated on for some reason on the PT [Patient #11] spitting, in which the video shows he never spit on anyone and told another officer to help him with this guy who is spitting and places the towel over the PT's [Patient #11] face and holds his head immobile with heavy pressure. [Security Officer O] continues to get involved and gets into the face of the PT [Patient #11] cursing him and lunging at the PT [Patient #11], when the PT [Patient #11] leaned forward [Security Officer O] violently strikes the PT [Patient #11] again in his face, still not knowing if he could have further injured or killed the PT [Patient #11]. The...County deputy had to get between [Security Officer O] and the PT [Patient #11] and move him out of the way. [Security Officer O] stated he was spat on that was why he hit him, but video footage shows no blood coming from the PT's [Patient #11] mouth or on [Security Officer O]. [Security Officer W] witnessed the incident and stated the blood came from [Security Officer O] slapping the Pt [Patient #11] with open wounds and made the blood splatter all over everyone. The report written by [Security Officer O] has him pressing charges on the PT [Patient #11] and charging him with Aggravated assault..."

During an interview on 9/19/2024, at 12:55 PM, the Patient Safety Quality Manager, stated she was made aware on 9/19/2024 of the events that took place involving Security Officer O and Patient #11 on 8/28/2024. The Patient Safety Quality Manager could not explain why it took so long for her to be made aware of the patient abuse that occurred on 8/28/2024 until the morning of 9/19/2024, a period of 21 days. She stated that she and the abuse teams reviewed the video footage of Security officer O interacting with the Patient #11, and deemed Security Officer O's interaction was abusive. The Patient Safety Quality Manager stated she contacted the Chief of Security and asked Security officer O to be removed from the hospital and not be allowed to return.

During interview on 9/19/2024, at 1:10 PM, the Director of Security stated he was employed by the hospital's contracted security company and has been the Director of Security since 4/1/ 2024. The Director of Security stated Security Officer O was the night shift supervisor, and he has noticed that most of the aggressive behavior documented had been on the night shift and by officers supervised by Security Officer O. Security officer O was terminated from the hospital's contracted security company because of his abusive actions taken against the emergency room Patient #11.

Refer to A-0115 and A-0144.