HospitalInspections.org

Based on observation, interview and record review, the hospital failed to have an effective governing body carrying out the responsibilities of providing leadership and direction to administrative and nursing personnel when:

1. On 5/1/20, Patient (Pt) 1 was physically and sexually abused in the Emergency Department (ED) by Registered Nurse (RN) 1 who physically restrained him without following hospital policies and procedures to ensure restraints were necessary; injected Pt 1 with a chemical restraint after he refused it; used a urinary catheter (flexible, hollow tube in inserted through the penis into the body to obtain a urine specimen) to obtain a urine specimen from Pt 1 after he refused this procedure, then punched Pt 1 in his testicles after Pt 1 expressed anger about being catheterized; and the facility failed to notify Adult Protective Services (AP'S) of Pt 1's abuse within the required time frame (Refer to A145 finding 1, A386 finding 1)

2. On 4/29/20, Pt 2 was verbally and sexually abused in the ED by RN 1, whom she overheard comment she was "...another Hispanic panic," who was "faking" she needed assistance transferring from the wheelchair to the bed and pulled her t-shirt over her head, exposing her breasts, without her permission. In addition, the facility failed to notify AP'S of Pt 2's abuse within the required reporting time frame (Refer to A145 finding 2, A386 finding 2, A386 finding 2)

3. On 5/9/2020, Pt 3, a suicidal patient, attempted to hang himself with a bedsheet, which should not have been left in the room of a patient with suicidal ideations (ideas) (Refer to A145 finding 3, A 386 finding 3)

4. The hospital did not employ a full-time Infection Control Preventionist (ICP- responsible for identifying, investigating, monitoring and reporting healthcare associated infections (HAI), create, sustain infection prevention strategies, and provide feedback in the hospital) between 3/4/20 and 5/22/20 in accordance with the standards of the Association for Professionals in Infection Control and Epidemioligy (APIC) guidelines. The per diem (not a full-time employee) ICP did not conduct onsite surveillance, collect and analyze infection control (IC) data in accordance with APIC professional and practice standards and the ICP's job description. (Refer to A749 finding 1).

5. Patients arriving in the Emergency Department (ED) were not screened (questions to ask and actions to take to rapidly identify and isolate suspect COVID-19 cases) and cohorted (grouping together) in accordance with Centers for Disease Control (CDC) IC standards. Patients with respiratory symptoms were cohorted with non-respiratory symptom patients in the ED lobby. (Refer to A749 finding 2).

6. Employees were not screened prior to entering the hospital in accordance with CDC IC standards, published in the Center for Medicare and Medicaid Services (CMS) Quality Safety Oversight (QSO) letter 20-20 ALL on 3/23/20. (Refer to A749 finding 3).

7. The hospital did not develop a plan and analyze culture of safety data from the Emergency Department to educate and encourage staff to report abuse. (Refer to A273).

8. The hospital did not establish an ongoing program that contained measurable improvement indicators focused on high-risk, high-volume, or problem-prone areas that ensured patient safety in the Emergency Department (ED). The program did not collect or track data for performance improvement activities within the last year. (Refer to A283).

9. The hospital did not have an effective process for reporting adverse events (identified potential or actual harm to patient) when staff failed to use the chain of command, write an incident report (formal recording of the facts related to an incident), and complete an abuse report for two out of 21 patients reviewed (Pt 1 and Pt 2). (Refer to A286).

10. The hospital failed to ensure the nursing service was organized to deliver patient care according to the facility's policies and procedures and nationally recognized guidelines for the practice of professional nursing (refer to A386, findings 1, 2 and 3)

11. The hospital failed to ensure the emergency department was organized to deliver care according to facility policies and procedures and acceptable practice standards. (Refer to A1101 findings 1, 2,3, 4, and 5).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare for all hospitalized in a safe and responsible manner.

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Based on observation, interview, and record review, the hospital failed to ensure patients' rights were protected and care was provided in a safe setting free from abuse or harassment for three of 21 sampled patients (Patients 1, 2, and 3) when:

1. On 5/1/20, Patient (Pt) 1 was physically and sexually abused in the Emergency Department (ED) by Registered Nurse (RN) 1, the ED charge nurse, who physically restrained him without following established protocols to ensure restraints were necessary; injected Pt 1 with a chemical restraint after he refused it; inserted a urinary catheter (flexible, hollow tube inserted through the penis into the body to obtain a urine specimen in males) into Pt 1, after he refused this procedure, then punched Pt 1 in his testicles after he expressed anger about being catheterized; and the facility failed to notify Adult Protective Services (APS) of Pt 1's abuse within the required time frame (refer to A145 finding 1)

2. On 4/29/20, Pt 2 was verbally and sexually abused in the ED by RN 1, whom she overheard comment she was "...another Hispanic panic," who was "faking" she needed assistance transferring from the wheelchair to the bed and pulled her t-shirt over her head, exposing her breasts, without her permission. In addition, the facility failed to notify AP'S of Pt 2's abuse within the required reporting time frame (refer to A145 finding 2)

3. On 5/9/2020, Pt 3, a suicidal patient, attempted to hang himself with a bed sheet, which should not have been left in the room of a patient with suicidal ideations (ideas) (refer to A145 finding 3);

Because these failures resulted in serious actual harm to Pt 1, Pt 2, potential harm to Pt 3, and the serious potential harm to all patients in the hospital to suffer abuse, and unsafe care, an Immediate Jeopardy (IJ) situation was called on 5/18/20 at 5:55 p.m., for Patient Rights at 42 CFR 482.13(c)(3) [A 145] with the hospital Chief Executive Officer, Chief Nursing Officer and the Director of Quality and Risk Management.

The hospital submitted an acceptable Action Plan that addressed the IJ situation and implemented corrective actions to ensure all patients are free from abuse in a safe environment and that allegations of abuse would follow policies and procedures. The IJ was removed on 5/21/19 at 4:14 p.m., in the presence of the hospital Chief Executive Officer, Chief Nursing Officer, the Director of Quality and Risk Management.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality patient care in a safe environment.

Based on observation, interview, and record review, the hospital failed to follow their policies and procedures to ensure patients' rights were protected and care was provided in a safe setting free from abuse or harassment for three patients of 21 sampled patients (Patients 1, 2, and 3) when:

1. On 5/1/20, Patient (Pt) 1 was physically and sexually abused in the Emergency Department (ED) by Registered Nurse (RN) 1, the ED charge nurse, who physically restrained him without following the hospital's policies and procedures to ensure restraints were necessary; injected Pt 1 with a chemical restraint after he refused it; inserted a urinary catheter (flexible, hollow tube inserted through the penis into the body to obtain a urine specimen in males) into Pt 1, after he refused this procedure, then punched Pt 1 in his testicles after he expressed anger about being catheterized; and the facility failed to notify Adult Protective Services (APS) of Pt 1's abuse within the required time frame. The hospital's policies and procedures (P&P) titled, "Sentinel or Adverse Event Evaluation and Reporting", "Mandatory Reporting Requirements for Child, Elder, and Domestic Violence Abuse", "Restraints for Management of Violent and Non-Violent Behavior", "Patient's Right/Responsibilities" and "5150 Holds and Behavioral Emergencies" were not followed;

2. On 4/29/20, Pt 2 was verbally and sexually abused in the ED by RN 1, whom she overheard comment she was "...another Hispanic panic," who was "faking" she needed assistance transferring from the wheelchair to the bed and pulled her t-shirt over her head, exposing her breasts, without her permission. In addition, the facility failed to notify APS of Pt 2's abuse within the required reporting time frame. The hospital's Policies and Procedures (P&P) titled, "Sentinel or Adverse Event Evaluation and Reporting" and "Mandatory Reporting Requirements for Child, Elder, and Domestic Violence Abuse" were not followed; and

3. On 5/9/2020, Pt 3, a suicidal patient, attempted to hang himself with a bedsheet attached to a ceiling light fixture, which should not have been left in the room of a patient with suicidal ideations (ideas). The hospital's Policies and Procedures (P&P) titled, "5150 Holds and Behavioral Emergencies" and "Occurrence and Medical Error Reporting" were not followed.

Because these failures resulted in serious actual harm were not followed to Pt 1, Pt 2, potential harm to Pt 3, and the serious potential harm to all patients in the hospital to suffer abuse, and unsafe care an Immediate Jeopardy (IJ) situation was called on 5/18/20 at 5:55 p.m., for Patient Rights at 42 CFR 482.13(c)(3) [A 145] with the hospital Chief Executive Officer, Chief Nursing Officer and the Director of Quality and Risk Management.

The hospital submitted an acceptable Action Plan that addressed the IJ situation and implemented corrective actions to ensure all patients are free from abuse in a safe environment and that allegations of abuse would follow policies and procedures. The IJ was removed on 5/21/19 at 4:14 p.m., in the presence of the hospital Chief Executive Officer, Chief Nursing Officer, the Director of Quality and Risk Management.

Findings:

1. During an interview on 5/6/20 at 1:30 p.m., the Chief Nursing Officer (CNO) stated she was called at home on 5/1/20 "around 7:45 p.m." by the Director of the Contracted Security Company (DCS), who informed her one of the Security Officers (SOs) from his company reported what he just observed RN 1, the ED charge nurse, do to Pt 1 in the ED at the hospital. The CNO stated she immediately came to the hospital, met with RN 1, and asked him what happened. The CNO stated RN 1 told her, "I lost my composure" and asked if he was going to be dismissed. CNO stated she replied, "Yes but you can resign now." The CNO stated she told RN 1 his behavior was "unacceptable... he was gone in minutes." The CNO stated RN 1 left the hospital without documenting "anything that happened...the restraint changing, the security presence, the punching..."The CNO stated she did not know if Pt 1 suffered an injury to his testicles because he would not allow anyone to examine him. The CNO stated Pt 1 was still a patient in the hospital but "you can't interview him." The CNO further stated Pt 1 was "saying all kinds of things, even that he was raped."

During an interview on 5/13/20 at 9:15 a.m., SO 3 stated he was an employee with a security company that contracted to work at the hospital. The SO 3 stated, on 5/1/20, he and three other SO's from the same company (SO 1, SO 2, and SO 4) were requested by RN 1 to come to the ED to assist with transferring Pt 1 from the Emergency Medical Services (EMS) gurney (a wheeled cot) to an ED gurney when Pt 1 arrived by the Emergency Medical Services (EMS). SO 3 stated, when Pt 1 arrived, each SO held an extremity while the 4-point (one on each limb) leather restraints belonging to EMS were removed from Pt 1 and exchanged with the hospital's 4-point soft restraints by RN 1. SO 3 stated Pt 1 was cooperative throughout the exchange. SO 3 stated RN 1 gave Pt 1 a shot of medication in his thigh, after Pt 1 told RN 1 he did not want any medication. SO 3 stated RN 1 asked all four SO's to remain in Pt 1's room while he obtained a urine sample. SO 3 stated Pt 1 refused the insertion of a catheter but RN 1 pulled down Pt 1's belt, shorts and underwear, grabbed Pt 1's penis and inserted and pulled out the catheter after collecting a urine sample. SO 3 stated Pt 1 was upset and was cursing at RN 1. SO 3 stated RN 1 told Patient Care Technician (PCT) 1 to leave the room. SO 3 stated RN 1 pulled the curtain around Pt 1 to block PCT 1's view; then, SO 3 stated he observed RN 1 "punch Pt 1 in the testicles." SO 3 stated at the time of the punch, Pt 1 was in 4-point restraints secured to the gurney with a SO holding each extremity and did not have his shorts or underwear pulled up yet. SO 3 stated Patient 1 yelled in pain. SO 3 stated RN 1 asked SO 3 and the other officers, "You guys didn't see anything, did you?" SO 3 stated, after RN 1 left Pt 1's room, SO 2, the SOS supervisor, called the DCS to report the incident. SO 3 stated the four security officers gave statements to a police officer that night.

During a telephone interview on 5/13/20 at 3 p.m., SO 4 stated he was called to the ED on 5/1/20 to assist RN 1 with transferring Pt 1 from the EMS gurney to the ED gurney and assist with exchanging the leather restraints belonging to the ambulance company with the hospital restraints. SO 4 stated each SO was positioned at one of Pt 1's extremities while RN 1 removed the EMS restraints and exchanged them with the hospital restraints that RN 1 secured to Pt 1's bed. SO4 stated Pt 1 was calm during the changing of restraints and did not fight or resist. SO 4 stated Pt 1 told RN 1 he did not want medication but RN 1 gave Pt 1 an injection of medication in his leg. SO 4 stated RN 1 told him and the other three SO's to remain in Pt 1's while he collected a urine specimen. SO 4 stated Pt 1 told RN 1 he did not want a catheter to be inserted but RN 1 requested PCT 1 to go get a catheter. SO4 stated, when PCT 1 returned with a catheter, RN 1 told her to get a bigger one, which made him feel uncomfortable. SO 4 stated Pt 1 again verbalized not wanting to have a catheter inserted. SO 4 stated he observed RN 1 unbuckle Pt 1's belt, forcefully pulled down Pt 1's shorts. SO 4 stated Pt 1 said, "Don't touch my dick" and then RN 1 grabbed Pt 1's penis and stuck the catheter in quickly, got urine out and then roughly pulled it out. SO 4 stated Pt 1 was mad and cursed at RN 1. SO 4 stated RN 1 told PCT 1 to leave the room, which she did. SO 4 stated he observed RN 1 "punch [Pt 1] in the nuts," while Pt 1 who was still restrained with his shorts and underwear pulled down. SO 4 stated Pt 1 yelled in pain. SO 4 stated he and the other security officers gave statements to the police that night. SO 4 stated he did not know why RN 1 hit Pt 1 and stated Pt 1 was not a threat to any of them. SO 4 described the whole incident as feeling "raped [sexually aggressive or inappropriate in a way that causes fear or unease]."

During an interview on 5/14/20 at 3:10 p.m., the Director of Quality and Risk Management (DQR) stated "today is the first day" she became aware of Pt 1's abuse.

During an interview on 5/13/20 at 3:33 p.m., the Chief Executive Officer (CEO) confirmed Pt 1 had been abused in the ED on 5/1/20 by RN 1. The CEO stated the Risk Management Department had not been notified of the abuse incident. The CEO stated the hospital policy indicated a "serious adverse event [any event, preventable or unpreventable that caused harm to a patient]" be reported the day it occurred to the Risk Management Department. The CEO stated the CNO was notified the day the event occurred and started an investigation but no report of the event was entered into the facility's computer adverse reporting system and she "assumed the Risk Manager [RM] was informed."

During a telephone interview on 5/14/20 at 10:20 a.m., RN 4 stated she was an experienced ED nurse who had worked at this hospital for three years. RN 4 stated she was on duty the night of 5/1/20 when Pt 1 was brought in by ambulance to the ED. RN 4 stated she was assigned to be Pt 1's primary nurse and had received report and discussed the patient with PCT 1. RN 4 stated her plan was to evaluate the patient and determine if he was calm enough to be out of restraints. RN 4 stated she met the EMS staff when they arrived and accompanied Pt 1 to the room with the four SO's, PCT 1, and RN 1. Then, RN 4 stated RN 1 took over care of Pt 1 for unknown reasons and did not provide RN 4 with any explanation. RN 4 stated she did not question RN 1 because he was the charge nurse. RN 4 stated, after RN 1 exited the facility, she again resumed care of RN 1, "had a good rapport with [Pt 1] right away" and had him out of restraints "within about 35 minutes." RN 4 stated, in her experience, there is no a reason to obtain a urine specimen in a patient who has verbally refused. RN 4 stated patients have the right to refuse to have a catheter to get a urine specimen. RN 4 stated, being under a 5150 hold (involuntary confinement of a person considered to be a danger to self or others) because of being a danger to self/others or disabled, does not mean the patient gives up their rights.

During an interview on 5/14/20 at 2:40 p.m., PCT 1 stated she was working on 5/1/20 when Pt 1 came to the ED. PCT 1 stated she received report from RN 4 about Pt 1 who was, "a 5150." PCT 1 stated RN 4 told her Pt 1 had a mental illness and was off his medication. PCT 1 stated RN 4 told her Pt 1 was in restraints and, if Pt 1 was cooperative, then the restraints could be removed. PCT 1 stated, when Pt 1 arrived, he did not know why RN 1 took over the care of Pt 1 and removed RN 4 as this patient's primary nurse. PCT 1 stated, when Pt 1 arrived, he was restrained and "was upset, cussing, not abusive." PCT 1 stated there were four SO's in Pt 1's room to help transfer Pt 1 from the ambulance gurney to the ED bed and to exchange the restraints from the ambulance for the hospital restraints. PCT 1 stated Pt 1 was not fighting them and was not aggressive or abusive and the transfer was done without any difficulty. PCT 1 stated RN 1 told Pt 1, "You are stuck with me all night." PCT 1 stated RN 1 asked her to get a catheter for a urine specimen. PCT 1 stated she brought RN 1 an "in and out catheter" (one used to obtain urine that is not left inside the patient) but RN 1 told him to bring a larger, "female" catheter. The PCT 1 stated Pt 1 stated he did not want them to put the catheter in him, and he did not want to be touched. PCT 1 stated Pt 1 was in 4 point restraints (secure all four extremities) and four SO's were also holding Pt 1, one on each arm and leg. PCT 1 stated RN 1 opened Pt 1's belt and directed PCT 1 to help him pull down Pt 1's shorts and underwear. PCT 1 stated, after RN 1 inserted the catheter into Pt 1, RN 1 told her to leave the room. PCT 1 stated she left the room and pulled the privacy curtain around but left it open enough to be able to see Pt 1. PCT 1 stated RN 1 closed the curtain all of the way. PCT 1 stated she wondered at the time why RN 1 asked her to leave and pulled the curtain. PCT 1 stated she did not document what occurred with Pt 1 but "should have; I know it is important." PCT 1 stated she did not report what occurred to her supervisor because RN 1 was the charge nurse.

During an interview on 5/21/20 at 9:55 a.m., the Medical Director (MD) of the ED stated he was on duty on 5/1/20 when Pt 1 arrived by ambulance with a diagnosis of schizophrenia, off his medication, on a 5150 hold as a danger to self/others. MD stated Pt 1 was in restraints upon arrival. MD stated Pt 1 was not combative, abusive, or violent at that time. MD stated he gave initial orders for Pt 1. MD stated he did not know anything about RN 1 taking over the care from RN 4. MD stated he was shocked when he was told Pt 1 had been punched by RN 1. MD stated something like this should never happen and he takes it seriously. MD stated he was informed, after the fact, that Pt 1 had refused the urine test. MD stated Pt 1 has the right to refuse the urine test. MD stated a urine test is used to help determine if the mental health patient can be medically cleared (process by which it is determined a patient's behavior is not caused by an underlying medical condition) so they can be transferred to psychiatric care facility, if necessary.

RN 1 was not available for interview.

During a review of Pt 1's clinical record, the document titled, "Patient Summary Report," dated 5/1/20 indicated Pt 1 was a 29 year old male who was brought in from home by ambulance to the ED at 7:14 p.m. on a 5150 hold. This form indicated RN 1 was the only RN who documented a triage assessment (initial evaluation upon a patient's arrival in the ED to determine the seriousness of the patient's illness) or documented any nurses notes related to Pt 1's care between 7:14 p.m. and 7:45 p.m. RN 1's first documentation of assessing Pt 1's behavior, at 7:39 p.m., indicated, "Behavior/Anxiety Assessment - Patient Behavior: Aggressive, Combative, Resistive to care, Mood - Angry..." The document indicated RN 1 did not enter any notes related to Pt 1's refusal for a chemical restraint (the administration of medication used for the management of acute behavioral emergencies) and Pt 1's refusal to be catheterized in addition, RN 1 did not document any notes related to punching Pt 1 in his testicles. This document indicated RN 1's last entry was at 7:39 p.m. This document indicated, at 7:45 p.m., RN 4 documented "Continuous Observation Reason - Danger to Others, Continuous Monitoring: Location - ER Bed ...Patient Behavior - Cursing, Observation Interventions - With nursing staff, private security guard... Location - ED bed, Patient Behavior - Cursing... 8 p.m.- ...Continuous Observation Reason - Danger to Others; Continuous monitoring: Patient Behavior - Lying Down, Observation Interventions - Offered fluids, offered toilet, checked vital signs, with Nursing Staff and Private Security Guard. Observation Outcome - No signs of injury, no harmful behavior...

During a review of Pt 1's clinical record, the document titled, "ED Assessment" dated 5/1/20 at 7:15 p.m., signed by MD, indicated, "[Pt 1] arrives on an involuntary 5150 hold for danger to others. [Pt 1] on arrival is aggressive...appears to be psychotic (A mental disorder characterized by disconnection from reality which results in strange behavior often accompanied by perception of voices, images, sensations and other hallucinations) and unable to verbally de-escalate requiring chemical sedation for his safety and others..."

During a review of Pt 1's clinical record, the document titled, "Orders," dated 5/1/20 at 7:16 p.m., indicated MD ordered injections (acts of forcing a fluid into a part of the body by using a needle) of "Haldol [a medication used to treat certain mental/mood disorders], 5 mg [milligrams - a unit of measurement]; Ativan [used to treat anxiety] 2 mg, and Benadryl [a medication sometimes used to treat anxiety in psychotic patients) 50 mg.

During a review of Pt 1's clinical record, the document titled, "Orders" dated 5/1/20 at 7:17 p.m., indicated, MD ordered "Drug screen, urine..."

During a review of Pt 1's clinical record, the document titled, "Patient Summary Report" dated 5/1/20 at 7:23 p.m., indicated RN 1 administered the following medications by injection: Haldol 5 mg; Ativan 2 mg.; and Benadryl 50 mg.

During a review of Pt 1's clinical record, the document titled, "Discharge Summ [Summary]" dated 5/1/20 at 8:45 p.m., indicated RN 4 removed Pt 1's 4-point restraints.

During a review of Pt 1's clinical record, the document from the local Police Department Report dated 5/1/20, indicated, "On May 1, at approximately [8:56 p.m.], I was dispatched to contact [CNO] ...regarding a staff member committing a battery against [Pt l] ...[CNO] stated [RN 1] ...punched a patient in the testicles ...[CNO] stated she spoke with [RN 1] earlier ...[CNO] stated [RN 1] admitted to the act and resigned ...INVESTIGATION: I proceeded to [Hospital Name] and spoke with the [SOs] [SO 4, SO 3, SO 1, and SO 2]. They each provided a statement ... [SO 4] stated [Pt 1] ...was already secured in four point restraints ...[SO 4] stated ...medical staff injected [Pt 1] with a sedative. [SO 4] stated medical staff requested a urine sample from [Pt 1], but he refused. [SO 4] stated [PCT 1] grabbed the requested catheter, but [RN 1] requested the 'good' catheter ...the bigger, thicker sized catheter. [SO 4] stated [RN 1] installed the catheter in an aggressive manner ...[RN 1] removed the catheter in an aggressive manner. [SO 4] stated ...[RN 1] approached [Pt 1] and used his right hand with a closed fist to punch [Pt 1] on his testicles ...I asked [SO 4] if [Pt 1] was acting erratic in any way, and [SO 4] said he was not. [SO 4] stated [Pt 1] was still restrained to the hospital bed when he was punched ...[SO 3] corroborated [SO 4]'s statement...[SO 3] stated he witnessed [RN 1] use a close fist to strike [PT 1] in his testicles. [SO 3] stated [Pt 1] ...was physically calm at the time [RN 1] punched him."

During a review of Pt 1's clinical record, the document titled, "ED Assessment Addendum" 5/1/20 at 9:08 p.m., signed by MD indicated, "There were allegations made that the patient was assaulted by a nursing staff member when the patient was being physically and chemically restrained. On re-evaluation after learning about these allegations, I have found no evidence of trauma to the patient; however, the patient refuses to allow me to examine his genitalia to evaluate for any trauma..."

During a review of Pt 1's clinical record, the document titled, "Patient Summary Report," dated 5/7/20 at 12:20 p.m. indicated, "Departure Information: Primary Impression - History of Paranoid Schizophrenia. Secondary Impressions: Psychiatric symptoms. Disposition: HOME...Condition: STABLE..." This document indicated Pt 1 remained in the ED from 5/1/20 to 5/7/20.

During a review of Pt 1's clinical record, the document titled, "[Hospital] Plan of Action," dated 5/18/20, indicated "The facility did not complete SOC 341 [a form titled, 'Report of Suspected Dependent Adult/Elder Abuse' that requires mandated reporters in health care agencies to report all forms of abuse to the California Department of Social Services within two working days] for Pt 1. This plan of action indicated the hospital planned to complete the SOC 341 for Pt 1 by 5/21/20, which was 20 days after Pt 1's abuse event.

During a review of the hospital's policy and procedure (P&P) titled, "Sentinel or Adverse Event Evaluation and reporting," dated 11/19, indicated "1. All events must be reported to the Risk Management Department immediately ...via completing of an Occurrence/Event Report ...the Risk Management Department and Administration will make the determination if a Sentinel Event has occurred and will implement [the hospital's] Sentinel Event Policy accordingly ...'Adverse Event' includes ...The sexual assault that occurs within or on the grounds. The death or significant injury of a patient or staff member resulting from a physical assault that occurs within or on the grounds."

During a review of the hospital's P&P titled, "Mandatory Reporting Requirements for Child, Elder and Domestic Violence Abuse," dated 3/20, indicated "POLICY: It is the policy of [the hospital] that health care providers as mandated reporters file both a verbal and written reports of suspected child, elder and/or domestic violence abuse and an occurrence report when encountered in clinical practice ...Protecting patients is a top priority at [the hospital] and part of our culture of patient safety. All licensed nurses and providers are mandated reporters ...Procedure ...1. All staff are mandated to report instances of suspected elder abuse ...4. A verbal report is made immediately, or as soon as practically possible, to the local Adult Protective Services 24-Hour Abuse Hotline ...5. Fill out form "Report of Suspected Dependent Adult/Elder Abuse" (Form SOC 341) and mail within two working days ...6. All suspected abuse cases must be entered into [the hospital's] occurrence reporting software."

During a review of the facility's P&P titled, "Restraints for Management of Violent and Non-Violent Behavior," dated 7/19, the P&P indicated, " ...POLICY: ...2. The decision to restrain is not driven by diagnosis, but by a comprehensive individual patient assessment ...4. Restraint may only be employed while the unsafe situation continues... 6. The use of restraint must be discontinued as soon as possible based on an individual patient assessment and re-evaluation. 7. When the use of restraint is necessary, the least restrictive method must be used to ensure patient safety. The use of restraint for the management of patient behavior should not be considered a routine part of care ...DEFINITIONS: ...11. Least restrictive interventions/Restraint Alternatives: Are to be attempted prior to initiation of restraints and rationale for not using alternatives must be documented ...

During a review of the facility's P&P titled "Patient's Rights/Responsibilities," dated 1/20, the P&P indicated, " ...1. The administration of [Hospital Name] protects and supports the rights and responsibilities of our patients ....it provides for considerate respectful care focused upon the patient's individual needs ...PATIENT RIGHTS ...14. Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment ...15. Be free from restraints and seclusion of any form used as a means of coercion, discipline, convenience or retaliation by staff.

During a review of the facility's P&P titled, "5150 Holds and Behavioral Emergencies," dated 12/19, the P&P indicated, " ...PATIENT RIGHTS 1. Patients on a 5150 hold or are here for Behavioral Emergencies have the standard patient rights. In addition: ...5. Patients have the right to accept or refuse treatment, meds, tests."

2. During a concurrent interview and record review on 5/13/20 with RN risk manager (RM) 1, Pt 2's medical record for 4/29/20 was reviewed. Review of the medical record indicated Pt 2 arrived to the ED, accompanied by her husband, at 10:40 p.m. with a chief complaint of anxiety and departed on 4/30/20 at 2:46 a.m.. The record indicated RN 1, PCT 2 and PCT 4 were the care givers.

During a telephone interview on 5/14/20 at 12:05 p.m., Pt 2 stated, on 4/29/20 her husband brought her to the ED at night because she was "feeling weird" after taking something for a bad headache. Pt 2 stated she felt like she could not talk normally and her body felt weak. Pt 2 stated as she was brought into the triage area [location in the ED where patients are initially evaluated to determine the seriousness of their illness) in a wheelchair and a male nurse (RN 1) walked up to her and said to PCT 2, "Look; it is another Hispanic panic." Pt 2 stated she and her husband were shocked to hear the nurse say that. Pt 2 stated RN 1 and PCT 2 took her to a room in the ED while her husband waited in the lobby. Pt 2 stated RN 1, PCT 2 and PCT 4 were in the room. Pt 2 stated, once in the room, she overheard RN 1 tell PCT 2 she was "faking it." Pt 2 stated RN 1 raised his voice loudly and told her several times to "get up; get on the bed" and "you don't need help." Pt 2 stated PCT 2 did not help her up but she (Pt 2) finally was able to get up from the wheelchair and onto the bed. Pt 2 stated RN 1 grabbed the t-shirt she was wearing and pulled it off, over her head. Pt 2 stated she was not wearing a bra and had tried to cover her breasts with her hands. Pt 2 stated PCT 2 did not say anything to her but draped a gown over her chest but RN 1 pulled that off of her also. Pt 2 stated RN 1 said to the other nurses "You know how you can tell if a girl is faking it, she tries to cover herself up." Pt 2 stated she told RN 1, "I can hear everything you are saying. I don't want to talk to you. I don't want you to help me." Pt 2 stated she was discharged after a couple of hours and went home. Pt 2 stated she was so upset it took her two days to talk about it. Pt 2 stated she called the hospital and spoke to the Patient Liaison (PL) and told her what happened. Pt 2 stated she cried when she told the PL what happened. Pt 2 stated she was a victim of sexual abuse years ago, and had worked hard to get past that trauma, but this incident was "all it took to put me right back there again." Pt 2 stated she called the hospital to complain because she did "not want anyone else to go through this." Pt 2 stated she had not been contacted about this complaint since she spoke with the PL on 5/1/20.

During a concurrent interview and record review on 5/14/20 at 1:15 p.m. with the PL, the Grievance Log [record of patient complaints received at the facility) was reviewed. The grievance log indicated, on 5/1/20, Pt 2 spoke to the PL about an incident that occurred on 4/29/20. PL stated she recalled this conversation with Pt 2 who was in the ED on 4/29/20 because she felt strange, weak, and couldn't move. PL stated Pt 2 described a bad experience with a RN 1 and that Pt 2 stated she wanted to report this so it won't happen to another patient. PL stated Pt 2 described how RN 1 had said Pt 2 was "faking it" and called it "Hispanic panic." PL stated Pt 2 told her RN 1 pulled off her shirt, exposing her breasts. PL stated Pt 2 cried during the telephone conversation when she described the incident. PL stated, when she finished speaking with Pt 2 on 5/1/20, Pt 2 she stayed late to file the grievance report; however due to a computer issue, it did not go through until 5/6/2020. PL stated, when the incident report is filed, an email alert goes to the director of the department. PL stated, in this case, it went to the CNO, who was also the interim ED Director, and they should start their investigation. PL stated there was a grievance meeting held on 5/13/20 and this incident was on the agenda. PL stated there was not much information presented as far as an investigation by the ED director, just that the involved "nurse [RN 1]was dismissed." PL stated this grievance is not closed because the investigation is not done.

During a telephone interview on 5/14/20 at 4 p.m., PCT 2 stated she worked at the hospital in the ED for approximately six months. PCT 2 stated she was on duty the night of 4/29/20 and remembered Pt 2 came in for anxiety and was not feeling well. PCT 2 stated Pt 2 was not really talking and was not totally alert. PCT 2 stated RN 1 said this was "Hispanic panic" and that Pt 2 was "just a faker." PCT 2 stated RN 1 told Pt 2 several times to get up on the bed. PCT 2 stated the way RN 1 talked to Pt 2 was "not right." RN 1 acted annoyed with Pt 2. PCT 2 stated once Pt 2 was up on the exam table, PCT 2 grabbed a gown to put on Pt 2 but, before she could snap the sleeves together, RN 1 pulled Pt 2's t-shirt off over her head. PCT 2 stated Pt 2 was not wearing a bra so her breasts were exposed and she tried to cover herself up with her hands. PCT 2 stated she covered PT 2's chest with the gown but RN 1 yanked the gown off of Pt 2 leaving her exposed again. PCT 2 stated RN 1 said "that's how you know a woman is faking; a woman in pain would not try to cover herself up." PCT 2 stated RN 1 was being mean. PCT 2 stated, "I feel horrible, I should have spoken up. I don't know why I didn't ...I was new and [RN 1] was in charge."

During a review of Pt 2's clinical record, the document titled, "ED Assessment" dated 4/29/20 at 10:52 p.m., indicated Pt 2 arrived in the ED complaining of "Anxiety" with a diagnosis of "Cannabis [an herbal drug containing chemicals that affect the central nervous system, which includes the brain and nerves] abuse." This document indicated Pt 2 was discharged in stable condition on 4/30/20 at 2:46 a.m.

During a review of Pt 2's clinical record, the document titled, "[Hospital] Plan of Action," dated 5/18/20, indicated "The facility did not complete SOC 341 [a form titled, 'Report of Suspected Dependent Adult/Elder Abuse' that requires mandated reporters in health care agencies to report all forms of abuse to the California Department of Social Services within two working days] for Pt 2. This plan of action indicated the hospital planned to complete the SOC 341 for Pt 2 by 5/21/20, which was 22 days after Pt 2's abuse event.

During a review of the hospital's policy and procedure (P&P) titled, "Sentinel or Adverse Event Evaluation and reporting," dated 11/19, indicated "1. All events must be reported to the Risk Management Department immediately ...via completing of an Occurrence/Event Report ...the Risk Management Department and Administration will make the determination if a Sentinel Event has occurred and will implement [the hospital's] Sentinel Event Policy accordingly ...'Adverse Event' includes ...The sexual assault that occurs within or on the grounds. The death or significant injury of a patient or staff member resulting from a physical assault that occurs within or on the grounds."

During a review of the hospital's P&P titled, "Mandatory Reporting Requirements for Child, Elder and Domestic Violence Abuse," dated 3/20, indicated "POLICY: It is the policy of [the hospital] that health care providers as mandated reporters file both a verbal and written reports of suspected child, elder and/or domestic violence abuse and an occurrence report when encountered in clinical practice ...Protecting patients is a top priority at [the hospital] and part of our culture of patient safety. All licensed nurses and providers are mandated reporters ...Procedure ...1. All staff are mandated to report instances of suspected elder abuse ...4. A verbal report is made immediately, or as soon as practically possible, to the local Adult Protective Services 24-Hour Abuse Hotline ...5. Fill out form "Report of Suspected Dependent Adult/Elder Abuse" (Form SOC 341) and mail within two working days ...6. All suspected abuse cases must be entered into [the hospital's] occurrence reporting software."

3. During a concurrent observation and interview on 5/21/20 at 12:20 p.m., a tour of the ED was completed with the Clinical Coordinator (CC). During the tour, the CC identified two rooms (rooms 105 and 112) that were used for patients with a 5150 hold. Inside room 112, there was a large low hanging light fixture extending from the ceiling several feet down with a moveable arm extending laterally a couple of feet above a gurney. The CC stated most of the rooms were set up in the same manner and have the same light fixture. The CC stated, if a patient was suicidal, she would remove objects from the room that a patient may use to hurt themselves. The CC stated she " ...definitely could see how it [the light fixture] could be a risk ..." since a patient could reach the light fixture if they got up on the gurney.

During an interview on 5/21/20 at 2:05 p.m., RN 8 stated she was on duty on 5/9/20 in the ED and was the primary nurse for Pt 3, who was located in room 112 on the day shift. RN 8 stated Pt 3 was brought in to the ED on 5/8/20 with a chief complaint of suicidal ideation and was under a 5150 hold because he was determined to be a danger to himself. RN 8 stated she was aware that Pt 3 talked about wanting to hang himself. RN 8 stated on 5/9/20 in the afternoon, she was busy with another

Based on interview and administrative record review, the hospital failed to implement and maintain an on-going, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program to improve both quality of care and patient safety when:

1. The hospital did not develop a plan and analyze culture of safety (the core values and behaviors that come about when there is a collective and continuous commitment by organizational leadership, managers and health care workers to emphasize safety) data from the Emergency Department to educate and encourage staff to report abuse. (Refer to A273).

2. The hospital did not establish an ongoing program that contained measurable improvement indicators focused on high-risk, high-volume, or problem-prone areas that ensured patient safety in the Emergency Department (ED). The program did not collect or track data for performance improvement activities within the last year. (Refer to A283).

3. The hospital did not have an effective process for reporting adverse events (identified potential or actual harm to patient) when staff failed to use the chain of command, write an incident report (formal recording of the facts related to an incident), and complete an abuse report for two out of 21 patients reviewed (Pt 1 and Pt 2). (Refer to A286).

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality patient care in a safe environment.

40644

Based on interview and record review, the hospital failed to develop a Quality Assurance and Performance Improvement (QAPI) plan and analyze culture of safety data (core values and behaviors that come about when there is a collective and continuous commitment by organizational leadership, managers and health care workers to emphasize safety) from the Emergency Department to educate and encourage staff to report abuse when no data had been submitted to the quality department from the Emergency Department since prior to July 1, 2019.

This failure resulted in Patient Care Technician (PCT) 1 and PCT 2 did not follow the hospital's procedure when they did not report witnessed the actions of Registered Nurse 1.

Findings:

During a concurrent interview and review on 5/21/20 at 10:30 a.m , with the Director of Quality and Risk Management (DQR), the hospital document titled "Quality Assurance and Performance Improvement (QAPI) 2020 Plan dated 7/1/19 and signed 10/15/19 was reviewed. The QAPI Plan indicated, "Priorities for 2017 - 2018 ...4. Expansion of Culture of Safety Program - Implementation of Just Culture principles and AHRQ's Culture of Safety Survey. Service specific results will be analyzed with action plans." The DQR stated, "I'm thinking we don't have for the Emergency Department." The DQR stated the ED has not turned in any reports or any data for at least a year. The DQR stated "Culture of Safety" included ensuring staff felt safe enough to bring concerns to leadership and to not be afraid of getting in trouble if they bring up something that seemed wrong.

During an interview on 5/14/20 at 2:51 p.m., with PCT 1) she stated Registered Nurse 1 (RN 1) had a "demeaning manner" and "I have told multiple people." PCT 1 stated that RN 1 was often the charge nurse on the night shifts.

During an interview on 5/14/20 at 4:09 p.m., with PCT 2, she stated, RN 1 was the charge nurse for the night. PCT 2 stated RN 1 was "being mean" when RN 1 yanked (a sudden vigorous pull or jerk) Patient 2's (Pt 2) gown off. PCT 2 stated, "I feel horrible, I should have spoken up". PCT 2 stated she was new, trying to build trust and her chain of command was the charge nurse.

During a concurrent interview and record review, on 5/22/20 at 8:15 a.m., with the Chief Executive Officer (CEO), the "Survey on Patient Safety" dated August 2019 was reviewed. The CEO validated the Emergency Room's score for nonpunitive response to error was 19% (81 out of 100 staff would not report adverse events for fear of getting in trouble). The CEO stated the 19% score "Definitely could have contributed" to staff not reporting when they saw a problem.

During a review of the hospital's policy and procedure (P & P) titled, "...Chain of Command for the Emergency Department, the P & P indicated "PROCEDURE: Events, problems or concerns that occur and are made aware by ER [Emergency Room] staff must be immediately reported to the ER charge nurse. The ER charge nurse will discuss the concern with the ER Director, Medical Director or designee..."

During a review of the hospital document titled "Culture of safety - Pulse Check" dated 2019, indicated, "Organizational culture refers to the beliefs, values, norms, shared by staff throughout the organization that influence their actions and behaviors. Patient safety culture is the extent to which these beliefs, values, and norms support and promote patient safety. Patient safety culture can be measured by determining what is rewarded, supported, expected, and accepted in an organization as it relates to patient safety," and the purpose of the plan was to "...raise staff awareness about patient safety; Assess patient safety culture; Identify strengths and areas for improvement; Evaluate trends over time; Evaluate the impact of patient safety initiatives." The results for the Emergency Department indicated, "Frequency of events reported - 58%, and non-punitive response to error - 45%." The "Culture of safety - Pulse Check" dated 2019 indicated, "....What's next? Action Planning for Improvement: Communicate Action Plan - Meeting with Dept. Directors - Staff Meetings/Monthly Safety Meeting - Continuous Monitoring - PI/PEPST Reporting..."

During a review of the hospital document titled "[The Hospital] QAPI for FY 2020, the checklist indicated no data had been submitted from the Emergency Room since prior to July 1, 2019.

Based on interview and record review, the hospital failed to establish an ongoing program that contained measurable improvement indicators focused on high-risk, high-volume, or problem-prone areas that ensured patient safety in the Emergency Department (ED) when the program did not collect or track data for performance improvement activities within the last year.

This failure resulted in the hospitals inability to track the ED's performance improvement activities.

Findings:

1. During a concurrent interview and record review on 5/21/20, at 10:31 a.m., with the Director of Quality and Risk Management (DQR), the hospital's "Quality Assurance and Performance Improvement Plan (QAPI Plan)" dated 7/1/19 and signed 10/15/19 was reviewed. The QAPI Plan indicated, "Priorities for 2017 - 2018 ...4. Expansion of Culture of Safety Program - Implementation of Just Culture principles and AHRQ's Culture of Safety Survey. Service specific results would be analyzed with action plans (is a plan that contains enough detail to achieve an objective or goal) for the Emergency Department. The DQR stated the ED has not turned in any reports or any data for at least a year. The DQR stated she followed up with the Chief Nursing Officer (CNO), who told the DQR she did not have the data ready during a direct report meeting. The DQR stated the next step was informing the Chief Executive Officer (CEO) and the Chief Financial Officer about department's lack of submission of quality data.

During a concurrent interview and record review on 5/22/20, at 7:57 a.m., with the DQR, the hospital document titled "Survey on Patient Safety (SOPS)," dated August 2019 was reviewed. The DQR stated the SOPS data was shared on 10/23/19 and the directive was to turn in a department specific performance improvement plan for the lowest three scores. The SOPS indicated the lowest three scores for the ED were non-punitive response to error, staffing level and teamwork across hospital units but no performance improvement plan was submitted for the ED. The DQR stated the ED did not follow through on the Culture of Safety plan for their department.

During a concurrent interview and record review, on 5/22/20, at 8:15 a.m., with the CEO, the "Survey on Patient Safety" dated August 2019 was reviewed. The CEO validated the Emergency Room's score for nonpunitive response to error was 19% (81 out of 100 staff would not report adverse events for fear of getting in trouble).The CEO stated the 19% score "Definitely could have contributed" to staff not reporting when they saw a problem.

During a review of the hospital document titled "[The Hospital] QAPI for FY 2020, the checklist indicated no data had been submitted from the Emergency Room since prior to July 1, 2019.

Based on interview and record review, the hospital failed to have an effective process for reporting adverse patient events (identified potential or actual harm to patient) when staff failed to use the chain of command, write an incident report (formal recording of the facts related to an incident), and complete an abuse report for two out of 21 patients reviewed (Pt 1 and Pt 2).

This failure resulted in actual harm to Pt 1 with the potential to affect all patient's health and well-being.

Findings:

During an interview on 5/13/20, at 3:33 p.m., with the Chief Executive Officer (CEO), the CEO stated a root cause analysis (RCA- systematic process for identifying problems or events and an approach for responding to them) had not been initiated for Pt 1's abuse event because documentation had not been provided to the Risk Management Department. The CEO stated the hospital policy indicated a serious adverse event be reported the day it occurred to risk management. The CEO validated the Chief Nursing Officer (CNO) was notified the day the event occurred. The CEO validated no report was typed into the computer adverse reporting system. The CEO state she "Assumed the risk manager was informed".

During an interview on 5/13/20, at 3:10 p.m., with the Director of Quality and Risk Management (DQR), the DQR stated the hospital had not conducted a RCA because "Today is the first day I heard about the event". The DQR stated when the survey team arrived she had to ask the CNO why surveyors were at the hospital. The DQR stated she had worked the previous week and was unaware a surveyor came for a complaint investigation the previous week.

During a review of the hospital's policy and procedure (P&P) titled, "Sentinel or Adverse Event Evaluation and reporting," dated 11/19, the P&P indicated "1. All events must be reported to the Risk Management Department immediately ...via completing of an Occurrence/Event Report ...the Risk Management Department and Administration will make the determination if a Sentinel Event has occurred and will implement [The Hospital] Sentinel Event Policy accordingly ...'Adverse Event' includes ...The sexual assault that occurs within or on the grounds. The death or significant injury of a patient or staff member resulting from a physical assault that occurs within or on the grounds."

During a review of the hospital's policy and procedure (P&P) titled, "Mandatory Reporting Requirements for Child, Elder and Domestic Violence Abuse," dated 3/20, the P&P indicated "POLICY: It is the policy of [The Hospital] that health care providers as mandated reporters file both a verbal and written reports of suspected child, elder and/or domestic violence abuse and an occurrence report when encountered in clinical practice ...Protecting patients is a top priority at [The Hospital] and part of our culture of patient safety. All licensed nurses and providers are mandated reporters ...Procedure ...1. All staff are mandated to report instances of suspected elder abuse ...4. A verbal report is made immediately, or as soon as practically possible, to the local Adult Protective Services 24-Hour Abuse Hotline ...5. Fill out form "Report of Suspected Dependent Adult/Elder Abuse" (Form SOC 341) and mail within two working days ...6. All suspected abuse cases must be entered into [brand name] our occurrence reporting software."

Based on observation, interview, and record review, the hospital failed to ensure the nursing service was organized to ensure the provision of patient care according to its policies and procedures and nationally recognized guidelines for the practice of professional nursing for three Emergency Department (ED) patients (Patients 1, 2 and 3) when:

1. On 5/1/20, Patient (Pt) 1 was physically and sexually abused in the Emergency Department (ED) by Registered Nurse (RN) 1, the ED charge nurse, who physically restrained him without following established protocols to ensure restraints were necessary; injected Pt 1 with a chemical restraint after he refused it; inserted a urinary catheter (flexible, hollow tube inserted through the penis into the body to obtain a urine specimen in males) into Pt 1, after he refused this procedure, then punched Pt 1 in his testicles after he expressed anger about being catheterized (refer to A386 finding 1)

2. On 4/29/20, Pt 2 was verbally and sexually abused in the ED by RN 1, whom she overheard comment she was "...another Hispanic panic," who was "faking" she needed assistance transferring from the wheelchair to the bed and pulled her t-shirt over her head, exposing her breasts, without her permission (refer to A386 finding 2); and

3. On 5/9/20, Pt 3, a suicidal patient, attempted to hang himself with a bedsheet attached to a ceiling light fixture, which should not have been left in the room of a patient with suicidal ideations (ideas) (refer to A386, finding 3).

The cumulative effect of these systematic problems resulted in the facility's inability to ensure the provision of quality patient care in a safe environment.



42118

Based on observation, interview, and record review, the hospital failed to ensure the provision of nursing care according to the facility's policies and procedures and nationally recognized guidelines for the practice of professional nursing for three Emergency Department (ED) patients (Patients 1, 2 and 3) when:

1. On 5/1/20, Patient (Pt) 1 was physically and sexually abused in the Emergency Department (ED) by Registered Nurse (RN) 1, the ED charge nurse, who physically restrained him without following established policies and procedures to ensure restraints were necessary; injected Pt 1 with a chemical restraint after he refused it; inserted a urinary catheter (flexible, hollow tube inserted through the penis into the body to obtain a urine specimen in males) into Pt 1, after he refused this procedure, then punched Pt 1 in his testicles after he expressed anger about being catheterized. The hospital's policies and procedures (P&P) titled, "Clinical Director Emergency Services," "Care of the Patient in the Emergency Department: Triage to Discharge," "Restraints for Management of Violent and Non-Violent Behavior," "Patient's Rights/Responsibilities," and "5150 Holds and Behavioral Emergencies" were not followed;

2. On 4/29/20, Pt 2 was verbally and sexually abused in the ED by RN 1, whom she overheard comment she was "...another Hispanic panic," who was "faking" she needed assistance transferring from the wheelchair to the bed and pulled her t-shirt over her head, exposing her breasts, without her permission. The hospital's P&P titled, "Care of the Patient in the Emergency Department: Triage to Discharge" and "Clinical Director Emergency Services" were not followed; and

3. On 5/9/2020, Pt 3, a suicidal patient, attempted to hang himself with a bedsheet attached to a ceiling light fixture, which should not have been left in the room of a patient with suicidal ideations (ideas). The hospital's P&P titled, "Clinical Director Emergency Services" and "515 Holds and Behavioral Emergencies" were not followed.

These failures resulted in actual harm to Pt 1, Pt 2, the potential for harm to Pt 3, and the inability of the facility to ensure the provision of safe patient care for all patients receiving care in the ED.

Findings:

1. During an interview on 5/6/20 at 1:30 p.m., the Chief Nursing Officer (CNO) stated she was called at home on 5/1/20 "around 7:45 p.m." by the Director of the Contracted Security Company (DCS), who informed her one of the Security Officers (SOs) from his company reported what he just observed RN 1, the ED charge nurse, do to Pt 1 in the ED at the hospital. The CNO stated she immediately came to the hospital, met with RN 1, and asked him what happened. The CNO stated RN 1 told her, "I lost my composure" and asked if he was going to be dismissed. CNO stated she replied, "Yes but you can resign now." The CNO stated she told RN 1 his behavior was "unacceptable... he was gone in minutes." The CNO stated RN 1 left the hospital without documenting "anything that happened...the restraint changing, the security presence, the punching..." The CNO stated she did not know if Pt 1 suffered an injury to his testicles because he would not allow anyone to examine him. The CNO stated Pt 1 was still a patient in the hospital but "you can't interview him." The CNO further stated Pt 1 was "saying all kinds of things, even that he was raped."

During an interview on 5/13/20 at 9:15 a.m., SO 3 stated he was an employee with a security company that contracted to work at the hospital. The SO 3 stated, on 5/1/20, he and three other SOs from the same company (SO 1, SO 2, and SO 4) were requested by RN 1 to come to the ED to assist with transferring Pt 1 from the Emergency Medical Services (EMS) gurney (a wheeled cot) to an ED gurney when Pt 1 arrived by the Emergency Medical Services (EMS). SO 3 stated, when Pt 1 arrived, each SO held an extremity while the 4-point (one on each limb) leather restraints belonging to EMS were removed from Pt 1 and exchanged with hospital restraints by RN 1. SO 3 stated Pt 1 was cooperative throughout the exchange. SO 3 stated RN 1 gave Pt 1 a shot of medication in his thigh, after Pt 1 told RN 1 he did not want any medication. SO 3 stated RN 1 asked all four SOs to remain in Pt 1's room while he obtained a urine sample. SO 3 stated Pt 1 refused the insertion of a catheter but RN 1 pulled down Pt 1's belt, shorts and underwear, grabbed Pt 1's penis and inserted and pulled out the catheter after collecting a urine sample. SO 3 stated Pt 1 was upset and was cursing at RN 1. SO 3 stated RN 1 told Patient Care Technician (PCT) 1 to leave the room. SO 3 stated RN 1 pulled the curtain around Pt 1 to block PCT 1's view; then, SO 3 stated he observed RN 1 "punch Pt 1 in the testicles." SO 3 stated at the time of the punch, Pt 1 was in 4-point restraints secured to the gurney with a SO holding each extremity and did not have his shorts or underwear pulled up yet. SO 3 stated Patient 1 yelled in pain. SO 3 stated RN 1 asked SO 3 and the other officers, "You guys didn't see anything, did you?" SO 3 stated, after RN 1 left Pt 1's room, SO 2, the SOs' supervisor, called the DCS to report the incident. SO 3 stated the four security officers gave statements to a police officer that night.

During a telephone interview on 5/13/20 at 3 p.m., SO 4 stated he was called to the ED on 5/1/20 to assist RN 1 with transferring Pt 1 from the EMS gurney to the ED gurney and assist with exchanging the leather restraints belonging to the ambulance company with the hospital restraints. SO 4 stated each SO was positioned at one of Pt 1's extremities while RN 1 removed the EMS restraints and exchanged them with the hospital restraints that RN 1 secured to Pt 1's bed. SO4 stated Pt 1 was calm during the changing of restraints and did not fight or resist. SO 4 stated Pt 1 told RN 1 he did not want medication but RN 1 gave Pt 1 an injection of medication in his leg. SO 4 stated RN 1 told him and the other three SO's to remain in Pt 1's room while he collected a urine specimen. SO 4 stated Pt 1 told RN 1 he did not want a catheter to be inserted but RN 1 requested PCT 1 to go get a catheter. SO4 stated, when PCT 1 returned with a catheter, RN 1 told her to get a bigger one, which made him feel uncomfortable. SO 4 stated Pt 1 again verbalized not wanting to have a catheter inserted. SO 4 stated he observed RN 1 unbuckle Pt 1's belt and forcefully pull down Pt 1's shorts. SO 4 stated Pt 1 said, "Don't touch my dick" and then RN 1 grabbed Pt 1's penis and stuck the catheter in quickly, got urine out and then roughly pulled it out. SO 4 stated Pt 1 was mad and cursed at RN 1. SO 4 stated RN 1 told PCT 1 to leave the room, which she did. SO 4 stated he observed RN 1 "punch [Pt 1] in the nuts," while Pt 1 who was still restrained with his shorts and underwear pulled down. SO 4 stated Pt 1 yelled in pain. SO 4 stated he and the other security officers gave statements to the police that night. SO 4 stated he did not know why RN 1 hit Pt 1 and stated Pt 1 was not a threat to any of them. SO 4 described the whole incident as feeling "rapey [sexually aggressive or inappropriate in a way that causes fear or unease]."

During an interview on 5/13/20 at 3:33 p.m., the Chief Executive Officer (CEO) confirmed Pt 1 had been abused in the ED on 5/1/20 by RN 1. The CEO stated the Risk Management Department had not been notified of the abuse incident. The CEO stated the hospital policy indicated a "serious adverse event [any event, preventable or unpreventable that caused harm to a patient]" be reported the day it occurred to the Risk Management Department. The CEO stated the CNO was notified the day the event occurred and started an investigation but no report of the event was entered into the facility's computer adverse reporting system and she "assumed the Risk Manager [RM] was informed."

During a concurrent interview and record review, on 5/14/20, at 9:30 a.m., with the Director of Human Resources (DHR) and the CNO in attendance, the DHR and CNO validated the CNO was also the Interim ED Director (IERD). RN 1's Personnel File was reviewed. The DHR and CNO validated RN 1's was hired 11/4/20 hire and there was no evidence RN 1 was oriented to the ED night shift relief charge position and there was no evidence he had leadership training for the charge nurse position. The DHR validated RN 1's timesheets indicated he was the ED charge nurse for 26 shifts, since hire. The DHR stated there should be orientation to each new role with documentation that the individual was competent to function in the role.

During a telephone interview on 5/14/20 at 10:20 a.m., RN 4 stated she was an experienced ED nurse who had worked at this hospital for three years. RN 4 stated she was on duty the night of 5/1/20 when Pt 1 was brought in by ambulance to the ED. RN 4 stated she was assigned to be Pt 1's primary nurse and had received report and discussed the patient with PCT 1. RN 4 stated her plan was to evaluate the patient and determine if he was calm enough to be out of restraints. RN 4 stated she met the EMS staff when they arrived and accompanied Pt 1 to the room with the four SOs, PCT 1, and RN 1. Then, RN 4 stated RN 1 took over care of Pt 1 for unknown reasons and did not provide RN 4 with any explanation. RN 4 stated she did not question RN 1 because he was the charge nurse. RN 4 stated, after RN 1 exited the facility, she again resumed care of RN 1, "had a good rapport with [Pt 1] right away" and had him out of restraints "within about 35 minutes." RN 4 stated, in her experience, there is no a reason to obtain a urine specimen in a patient who has verbally refused. RN 4 stated patients have the right to refuse to have a catheter to get a urine specimen. RN 4 stated, being under a 5150 hold (involuntary confinement of a person considered to be a danger to self or others) because of being a danger to self/others or disabled, does not mean the patient gives up their rights.

During an interview on 5/14/20 at 2:40 p.m., PCT 1 stated she was working on 5/1/20 when Pt 1 came to the ED. PCT 1 stated she received report from RN 4 about Pt 1 who was, "a 5150." PCT 1 stated RN 4 told her Pt 1 had a mental illness and was off his medication. PCT 1 stated RN 4 told her Pt 1 was in restraints and, if Pt 1 was cooperative, then the restraints could be removed. PCT 1 stated, when Pt 1 arrived, he did not know why RN 1 took over the care of Pt 1 and removed RN 4 as this patient's primary nurse. PCT 1 stated, when Pt 1 arrived, he was restrained and "was upset, cussing, not abusive." PCT 1 stated there were four SOs in Pt 1's room to help transfer Pt 1 from the ambulance gurney to the ED bed and to exchange the restraints from the ambulance for the hospital restraints. PCT 1 stated Pt 1 was not fighting them and was not aggressive or abusive and the transfer was done without any difficulty. PCT 1 stated RN 1 told Pt 1, "You are stuck with me all night." PCT 1 stated RN 1 asked her to get a catheter for a urine specimen. PCT 1 stated she brought RN 1 an "in and out catheter" (one used to obtain urine that is not left inside the patient) but RN 1 told her to bring a larger, "female" catheter. The PCT 1 stated Pt 1 stated he did not want them to put the catheter in him, and he did not want to be touched. PCT 1 stated Pt 1 was in 4 point restraints (secure all four extremities) and four SOs were also holding Pt 1, one on each arm and leg. PCT 1 stated RN 1 opened Pt 1's belt and directed PCT 1 to help him pull down Pt 1's shorts and underwear. PCT 1 stated, after RN 1 inserted the catheter into Pt 1, RN 1 told her to leave the room. PCT 1 stated she left the room and pulled the privacy curtain around but left it open enough to be able to see Pt 1. PCT 1 stated RN 1 closed the curtain all of the way. PCT 1 stated she wondered at the time why RN 1 asked her to leave and pulled the curtain. PCT 1 stated she did not document what occurred with Pt 1 but "should have; I know it is important." PCT 1 stated she did not report what occurred to her supervisor because RN 1 was the charge nurse.

During an interview on 5/15/20 at 10:02 a.m., with the Nurse Educator (NE), she stated each department has a competency checklist to complete before completing orientation. The NE stated the charge nurse role is a different role and additional training is required.

During an interview on 5/21/20 at 9:55 a.m., the Medical Director (MD) of the ED stated he was on duty on 5/1/20 when Pt 1 arrived by ambulance with a diagnosis of schizophrenia, off his medication, on a 5150 hold as a danger to self/others. MD stated Pt 1 was in restraints upon arrival. MD stated Pt 1 was not combative, abusive, or violent at that time. MD stated he gave initial orders for Pt 1. MD stated he did not know anything about RN 1 taking over the care from RN 4. MD stated he was shocked when he was told Pt 1 had been punched by RN 1. MD stated something like this should never happen and he takes it seriously. MD stated he was informed, after the fact, that Pt 1 had refused the urine test. MD stated Pt 1 has the right to refuse the urine test. MD stated a urine test is used to help determine if the mental health patient can be medically cleared (process by which it is determined a patient's behavior is not caused by an underlying medical condition) so they can be transferred to a psychiatric care facility, if necessary.

RN 1 was not available for interview.

During a review of Pt 1's clinical record, the document titled, "Patient Summary Report," dated 5/1/20 indicated Pt 1 was a 29 year old male who was brought in from home by ambulance to the ED at 7:14 p.m. on a 5150 hold. This form indicated RN 1 was the only RN who documented a triage assessment (initial evaluation upon a patient's arrival in the ED to determine the seriousness of the patient's illness) or documented any nurses notes related to Pt 1's care between 7:14 p.m. and 7:45 p.m. RN 1's first documentation of assessing Pt 1's behavior, at 7:39 p.m., indicated, "Behavior/Anxiety Assessment - Patient Behavior: Aggressive, Combative, Resistive to care, Mood - Angry..." The document indicated RN 1 did not enter any notes related to Pt 1's refusal for a chemical restraint (the administration of medication used for the management of acute behavioral emergencies) and Pt 1's refusal to be catheterized; in addition, RN 1 did not document any notes related to punching Pt 1 in his testicles. This document indicated RN 1's last entry was at 7:39 p.m. This document indicated RN 4's first documentation related to assessing Pt 1's behavior was at 7:45 p.m. when RN 4 documented, "Continuous Observation Reason - Danger to Others, Continuous Monitoring: Location - ER Bed ...Patient Behavior - Cursing, Observation Interventions - With nursing staff, private security guard... Location - ED bed, Patient Behavior - Cursing... 8 p.m.- ...Continuous Observation Reason - Danger to Others; Continuous monitoring: Patient Behavior - Lying Down, Observation Interventions - Offered fluids, offered toilet, checked vital signs, with Nursing Staff and Private Security Guard. Observation Outcome - No signs of injury, no harmful behavior...

During a review of Pt 1's clinical record, the document titled, "Orders," dated 5/1/20 at 7:16 p.m., indicated MD ordered injections (acts of forcing a fluid into a part of the body by using a needle) of "Haldol [a medication used to treat certain mental/mood disorders], 5 mg [milligrams - a unit of measurement]; Ativan [used to treat anxiety] 2 mg, and Benadryl [a medication sometimes used to treat anxiety in psychotic patients) 50 mg.

During a review of Pt 1's clinical record, the document titled, "Orders" dated 5/1/20 at 7:17 p.m., indicated, MD ordered "Drug screen, urine..."

During a review of Pt 1's clinical record, the document titled, "Patient Summary Report" dated 5/1/20 at 7:23 p.m., indicated RN 1 administered the following medications by injection: Haldol 5 mg; Ativan 2 mg.; and Benadryl 50 mg.

During a review of Pt 1's clinical record, the document titled, "Discharge Summ [Summary]" dated 5/1/20 at 8:45 p.m., indicated RN 4 removed Pt 1's 4-point restraints.

During a review of Pt 1's clinical record, the document from the local Police Department Report dated 5/1/20, indicated, "On May 1, at approximately [8:56 p.m.], I was dispatched to contact [CNO] ...regarding a staff member committing a battery against [Pt l] ...[CNO] stated [RN 1] ...punched a patient in the testicles ...[CNO] stated she spoke with [RN 1] earlier ...[CNO] stated [RN 1] admitted to the act and resigned ...INVESTIGATION: I proceeded to [Hospital Name] and spoke with the [SOs] [SO 4, SO 3, SO 1, and SO 2]. They each provided a statement ... [SO 4] stated [Pt 1] ...was already secured in four point restraints ...[SO 4] stated ...medical staff injected [Pt 1] with a sedative. [SO 4] stated medical staff requested a urine sample from [Pt 1], but he refused. [SO 4] stated [PCT 1] grabbed the requested catheter, but [RN 1] requested the 'good' catheter ...the bigger, thicker sized catheter. [SO 4] stated [RN 1] installed the catheter in an aggressive manner ...[RN 1] removed the catheter in an aggressive manner. [SO 4] stated ...[RN 1] approached [Pt 1] and used his right hand with a closed fist to punch [Pt 1] on his testicles ...I asked [SO 4] if [Pt 1] was acting erratic in any way, and [SO 4] said he was not. [SO 4] stated [Pt 1] was still restrained to the hospital bed when he was punched ...[SO 3] corroborated [SO 4]'s statement...[SO 3] stated he witnessed [RN 1] use a close fist to strike [PT 1] in his testicles. [SO 3] stated [Pt 1] ...was physically calm at the time [RN 1] punched him."

During a review of Pt 1's clinical record, the document titled, "ED Assessment Addendum" 5/1/20 at 9:08 p.m., signed by MD indicated, "There were allegations made that the patient was assaulted by a nursing staff member when the patient was being physically and chemically restrained. On re-evaluation after learning about these allegations, I have found no evidence of trauma to the patient; however, the patient refuses to allow me to examine his genitalia to evaluate for any trauma..."

During a review of Pt 1's clinical record, the document titled, "Patient Summary Report," dated 5/7/20 at 12:20 p.m. indicated, "Departure Information: Primary Impression - History of Paranoid Schizophrenia. Secondary Impressions: Psychiatric symptoms. Disposition: HOME...Condition: STABLE..." This document indicated Pt 1 remained in the ED from 5/1/20 to 5/7/20.

During a review of the facility's P & P titled, "Clinical Director Emergency Services, dated 9/15, the P & P indicated, "REPORTS TO: Vice President, Patient Care Services. SUPERVISES Emergency ... Professional staff members... POSITION SUMMARY: Performs the primary functions of a professional nurse leader in assessing, planning, directing, and evaluating Emergency Service patient care on a 24-hour basis. Is responsible for meeting Approved Accrediting Agency Standards of Nursing Practice for Emergency Services... 1. Administrative Responsibilities: a. Maintains knowledge of and adheres to... Federal and state standards governing the delivery of healthcare services; e. Insures department is adequately staffed...to deliver safe, quality care which meets the needs of the patients..."

During a review of the facility's document titled, "Vice President - Chief Nursing Officer" dated 11/15, this document indicated, "REPORTS TO: Chief Executive Officer... SUPERVISES: Clinical Directors:...Emergency Services... POSITION SUMMARY: ...Ensures ...competent patient care/nursing staff and nursing leadership at all levels...

During a review of the facility document titled, "VP - Chief Nursing Officer 2019 Annual Evaluation" dated 8/14/19, signed by the Chief Executive Office, the document indicated, "...POSITION SUMMARY: Plans, organizes, directs, and leads the departmental functions and activities for the nursing/patient care service department... Responsible for the establishment of standards of nursing/patient care practices...in accordance with... professional stands [standards] of practice. Ensures... competent patient care/nursing staff... Evaluator Comments - Patient Care Services has not had adequate and competent staffing and this has been a continual problem for some time... Needs to work on monitoring safety in nursing areas... [CNO] does promote our mission but we are still struggling with our quality and safety in patient care services..."

During a review of the facility's P & P titled, "Care of the Patient in the Emergency Department: Triage to Discharge" dated 3/17, the P & P indicated, "Purpose: To provide nursing care guidelines in evaluating patients on arrival to the Emergency Department, providing on going high quality care and assessment of the patient during their ED stay... Policy:... 7. Nursing staff will deliver/facilitate any medical treatment... rendering care to the patient that is within their scope of practice... Procedure: 2. Nursing staff will deliver care/treatments ordered by the ED provider... They will document the care/treatments given... 3. Basic nursing care will be provided to the patient, as needed..."

During a review of the facility's P&P titled, "Restraints for Management of Violent and Non-Violent Behavior," dated 7/19, the P&P indicated, " ...POLICY: ...2. The decision to restrain is not driven by diagnosis, but by a comprehensive individual patient assessment ...4. Restraint may only be employed while the unsafe situation continues... 6. The use of restraint must be discontinued as soon as possible based on an individual patient assessment and re-evaluation. 7. When the use of restraint is necessary, the least restrictive method must be used to ensure patient safety. The use of restraint for the management of patient behavior should not be considered a routine part of care ...DEFINITIONS: ...11. Least restrictive interventions/Restraint Alternatives: Are to be attempted prior to initiation of restraints and rationale for not using alternatives must be documented..."

During a review of the facility's P&P titled "Patient's Rights/Responsibilities," dated 1/20, the P&P indicated, " ...1. The administration of [Hospital Name] protects and supports the rights and responsibilities of our patients ....it provides for considerate respectful care focused upon the patient's individual needs ...PATIENT RIGHTS ...14. Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment ...15. Be free from restraints and seclusion of any form used as a means of coercion, discipline, convenience or retaliation by staff..."

During a review of the facility's P&P titled, "5150 Holds and Behavioral Emergencies," dated 12/19, the P&P indicated, " ...PATIENT RIGHTS 1. Patients on a 5150 hold or are here for Behavioral Emergencies have the standard patient rights. In addition: ...5. Patients have the right to accept or refuse treatment, meds, tests."

During a review of Professional reference from https://www.nursingworld.org/ana/about-ana/standards/ titled, "Code of Ethics for Nurses with Interpretive Statements" dated 2015, indicated, "Provision 1 - The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person ... Provision 2 - The nurse's primary commitment is to the patient ... Provision 3 - The nurse promotes, advocates for, and protects the rights, health, and safety of the patient ... Provision 4 - The nurse has ... accountability, and responsibility for nursing practice: makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care ... Provision 6 - The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care ... Provision 7 - The nurse, in all roles and settings, advances the profession through ... professional standards development ..."

2. During a concurrent interview and record review on 5/13/20 with RN risk manager (RM) 1, Pt 2's medical record for 4/29/20 was reviewed. Review of the medical record indicated Pt 2 arrived to the ED, accompanied by her husband, at 10:40 p.m. with a chief complaint of anxiety and departed on 4/30/20 at 2:46 a.m.. The record indicated RN 1, PCT 2 and PCT 4 were the care givers.

During a concurrent interview and record review, on 5/14/20, at 9:30 a.m., with the Director of Human Resources (DHR) and the CNO in attendance, the DHR and CNO validated the CNO was also the Interim ED Director (IERD). RN 1's Personnel File was reviewed. The DHR and CNO validated RN 1's was hired 11/4/20 and there was no evidence RN 1 was oriented to the ED night shift relief charge position and there was no evidence he had leadership training for the charge nurse position. The DHR validated RN 1's timesheets indicated he was the ED charge nurse for 26 shifts, since hire. The DHR stated there should be orientation to each new role with documentation that the individual was competent to function in the role.

During a telephone interview on 5/14/20 at 12:05 p.m., Pt 2 stated, on 4/29/20 her husband brought her to the ED at night because she was "feeling weird" after taking something for a bad headache. Pt 2 stated she felt like she could not talk normally and her body felt weak. Pt 2 stated, as she was brought into the triage area [location in the ED where patients are initially evaluated to determine the seriousness of their illness) in a wheelchair and a male nurse (RN 1) walked up to her and said to PCT 2, "Look; it is another Hispanic panic." Pt 2 stated she and her husband were shocked to hear the nurse say that. Pt 2 stated RN 1 and PCT 2 took her to a room in the ED while her husband waited in the lobby. Pt 2 stated RN 1, PCT 2 and PCT 4 were in the room. Pt 2 stated, once in the room, she overheard RN 1 tell PCT 2 she was "faking it." Pt 2 stated RN 1 raised his voice loudly and told her several times to "get up; get on the bed" and "you don't need help." Pt 2 stated PCT 2 did not help her up but she finally was able to get up from the wheelchair and onto the bed. Pt 2 stated RN 1 grabbed the t-shirt she was wearing and pulled it off, over her head. Pt 2 stated she was not wearing a bra and had tried to cover her breasts with her hands. Pt 2 stated PCT 2 did not say anything to her but draped a gown over her chest but RN 1 pulled that off of her also. Pt 2 stated RN 1 said to the other nurses "You know how you can tell if a girl is faking it, she tries to cover herself up." Pt 2 stated she told RN 1, "I can hear everything you are saying. I don't want to talk to you. I don't want you to help me." Pt 2 stated she was discharged after a couple of hours and went home. Pt 2 stated she was so upset it took her two days to talk about it. Pt 2 stated she called the hospital and spoke to the Patient Liaison (PL) and told her what happened. Pt 2 stated she cried when she told the PL what happened. Pt 2 stated she was a victim of sexual abuse years ago, and had worked hard to get past that trauma, but this incident was "all it took to put me right back there again." Pt 2 stated she called the hospital to complain because she did "not want anyone else to go through this." Pt 2 stated she had not been contacted about this complaint since she spoke with the PL on 5/1/20.

During a concurrent interview and record review on 5/14/20 at 1:15 p.m. with the PL, the Grievance Log [record of patient complaints received at the facility) was reviewed. The grievance log indicated, on 5/1/20, Pt 2 spoke to the PL about an incident that occurred on 4/29/20. PL stated she recalled this conversation with Pt 2 who was in the ED on 4/29/20 because she felt strange, weak, and couldn't move. PL stated Pt 2 described a bad experience with RN 1 and that Pt 2 stated she wanted to report this so it won't happen to another patient. PL stated Pt 2 described how RN 1 had said she was "faking it" and called it "Hispanic panic." PL stated Pt 2 told her RN 1 pulled off her shirt, exposing her breasts. PL stated Pt 2 cried during the telephone conversation when she described the incident. PL stated, when she finished speaking with Pt 2 on 5/1/20, she stayed late to file the grievance report; however due to a computer issue, it did not go through until 5/6/2020. PL stated, when the incident report is filed, an email alert goes to the director of the department. PL stated, in this case, it went to the CNO, who was also the interim ED Director, and they should start their investigation. PL stated there was a grievance meeting held on 5/13/20 and this incident was on the agenda. PL stated there was not much information presented as far as an investigation by the ED director, just that the involved "nurse [RN 1] was dismissed." PL stated this grievance is not closed because the investigation is not done.

During a telephone interview on 5/14/20 at 4 p.m., PCT 2 stated she worked at the hospital in the ED for approximately six months. PCT 2 stated she was on duty the night of 4/29/20 and remembered Pt 2 came in for anxiety and was not feeling well. PCT 2 stated Pt 2 was not really talking and was not totally alert. PCT 2 stated RN 1 said this was "Hispanic panic" and that Pt 2 was "just a faker." PCT 2 stated RN 1 told Pt 2 several times to get up on the bed. PCT 2 stated the way RN 1 talked to Pt 2 was "not right... RN 1 acted annoyed with Pt 2." PCT 2 stated, once Pt 2 was up on the exam table, PCT 2 grabbed a gown to put on Pt 2 but, before she could snap the sleeves together, RN 1 pulled Pt 2's t-shirt off over her head. PCT 2 stated Pt 2 was not wearing a bra so her breasts were exposed and she tried to cover herself up with her hands. PCT 2 stated she covered PT 2's chest with the gown but RN 1 yanked the gown off of Pt 2 leaving her exposed again. PCT 2 stated RN 1 said "that's how you know a woman is faking; a woman in pain would not try to cover herself up." PCT 2 stated RN 1 was being mean. PCT 2 stated, "I feel horrible, I should have spoken up. I don't know why I didn't ...I was new and [RN 1] was in charge."

During an interview on 5/15/20 at 10:02 a.m., with the Nurse Educator (NE), she stated each department has a competency checklist to complete before completing orientation. The NE stated the charge nurse role is a different role and additional training is required.

During a review of Pt 2's clinical record, the document titled, "ED Assessment" dated 4/29/20 at 10:52 p.m., indicated Pt 2 arrived in the ED complaining of "Anxiety" with a diagnosis of "Cannabis [an herbal drug containing chemicals that affect the central nervous system, which includes the brain and nerves] abuse." This document indicated Pt 2 was discharged in stable condition on 4/30/20 at 2:46 a.m.

During a review of the facility's P & P titled, "Care of the Patient in the Emergency Department: Triage to Discharge" dated 3/17, the P & P indicated, "Purpose: To provide nursing care guidelines in evaluating patients on arrival to the Emergency Department, providing on going high quality care and assessment of the patient during their ED stay... Policy:... 7. Nursing staff will deliver/facilitate any medical treatment... rendering care to the patient that is within their scope of practice... Procedure: 2. Nursing staff will deliver care/treatments ordered by the ED provider... They will document the care/treatments given... 3. Basic nursing care will be provided to the patient, as needed..."

During a review of the facility's P & P titled, "Clinical Director Emergency Services, dated 9/15, the P & P indicated, "REPORTS TO: Vice President, Patient Care Services. SUPERVISES Emergency ... Profe

Based on observations, interviews, and record reviews, the hospital failed to ensure that there was an active infection control surveillance program for the prevention, control and investigation of infections and communicable diseases for when:

1. The hospital did not employ a full time Infection Control Preventionist (ICP responsible for identifying, investigating, monitoring and reporting healthcare associated infections (HAI), create, sustain infection prevention strategies, and provide feedback in the hospital) between 3/4/20 and 5/22/20 in accordance with the standards of the Association for Professionals in Infection Control and Epidemiology (APIC). The per diem (not a full time employee) ICP did not conduct onsite surveillance, collect and analyze infection control (IC) data in accordance with APIC professional and practice standards and the ICP's job description. (Refer to A749 finding 1).

2. Patients arriving in the Emergency Department (ED) were not screened (questions to ask and actions to take to rapidly identify and isolate suspect corona virus (COVID-19-a respiratory illness caused by a virus, that spreads from person to person) cases and cohorted (grouping together) in accordance with Centers for Disease Control (CDC) IC standards. Patients with respiratory symptoms were cohorted with non respiratory symptom patients in the ED lobby. (Refer to A749 finding 2).

3. Employees were not screened prior to entering the hospital in accordance with CDC IC standards, published in the Center for Medicare and Medicaid Services (CMS) Quality Safety Oversight (QSO) letter 20 20 ALL on 3/23/20. (Refer to A749 finding 3).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality patient care in a safe environment.



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Based on observation, interview, and record review, the hospital failed to ensure a system was in place for screening, preventing and controlling of transmission of COVID 19 and ensuring a sanitary environment, in accordance with nationally recognized infection control standards and regulations when:

1. The hospital did not employ a full time Infection Control Preventionist (ICP responsible for identifying, investigating, monitoring and reporting healthcare associated infections (HAI), create, sustain infection prevention strategies, and provide feedback in the hospital) between 3/4/20 and 5/22/20 in accordance with the standards of the Association for Professionals in Infection Control and Epidemiology (APIC). The per diem (not a full time employee) ICP did not conduct onsite surveillance, collect and analyze infection control (IC) data in accordance with APIC professional and practice standards and the ICP's job description;

2. Patients arriving in the Emergency Department (ED) were not screened (questions to ask and actions to take to rapidly identify and isolate suspect COVID-19-a respiratory illness caused by a virus, that spreads from person to person) cases and cohorted (grouping together) in accordance with Centers for Disease Control (CDC) IC standards. Patients with respiratory symptoms were cohorted with non respiratory symptom patients in the ED lobby;

3. Employees were not screened prior to entering the hospital in accordance with CDC IC standards, published in the Center for Medicare and Medicaid Services (CMS) Quality Safety Oversight (QSO) letter 20 20 ALL on 3/23/20;

4. Three Registered Nurses (RN's 9, 10, and 11) did not disinfect glucometers (instrument used for measuring the concentration of sugar in the blood) according to the manufacturer's recommendations of a two minute dwell (contact time the disinfectant is required to remain on the target surface to effectively kill bacteria and germs) time;

5. The refrigerator in the Intensive Care Unit (ICU) was observed to have a white powder stain and was not clean. Staff were unaware of a cleaning schedule for the refrigerator; and

6. RN 12 stored her eye shield and N- 95 (a respiratory protective device designed to achieve a very close facial fit and provide efficient filtration of airborne particles) mask in the same paper bag after she cared for a suspected COVID-19 patient in the ED and was not in accordance with the hospital's policy and procedure and the Centers for Disease Control (CDC) standards.

These failures resulted in the potential harm of not identifying sources of infection and the potential risk of transmitting COVID 19 to patients and employees.

Findings:

1. During a telephone interview on 5/13/20, at 2:12 p.m. with the ICP, the ICP stated, she retired on 3/4/2020 and moved out of state. The ICP stated, she was working per diem in the Acute Care Hospital (ACH). The ICP stated, she visited the ACH once a month since 3/2020 and was there for a few days. The ICP stated, the Chief Nursing Officer (CNO) and Chief Executive Officer (CEO) called her after her retirement and asked her to work as a per diem ICP due to the COVID 19 pandemic. The ICP stated, the ACH had one ICP and it was her. The ICP stated, the ACH did not have a full time ICP to conduct surveillance onsite.

During a telephone interview on 5/13/20, at 3:30 p.m., with the Risk Manager (RM), the CNO, and the ICP, the RM, the CNO and the ICP stated, they were not aware of the CMS QSO letter 20 20 which addressed the "COVID-19 Focused Infection Control Survey for Acute and Continuing Care" (a survey tool which provides a focused review of the critical elements associated with the transmission of COVID-19). The RM stated, the ACH bed capacity was 106. The RM stated, they would need a copy of the QSO 20 20 letter to review and prepare the hospital employees in one day.

During an interview on 5/15/20, at 1:31 p.m., with the CNO, the CNO stated, the ICP lived out of state and came onsite to the ACH once a month for a week since 3/2020. The CNO stated, the ICP last visited the ACH on 5/5/2020. The CNO stated, the ICP was not onsite in the hospital and worked out of state. The ICP stated, the Clinical Educator (CE) assisted the ICP in gathering surveillance data and would send it to the ICP.

During a concurrent interview on 5/15/20, at 4:30 p.m., with the CNO and CEO, the CNO and CEO stated, they were aware the ACH did not have a full time ICP onsite. The CEO stated, she was actively looking for a full time ICP, but had challenges hiring a full time ICP. The CEO and CNO stated, they were aware the ACH required a full time ICP onsite especially during the COVID 19 pandemic.

During an interview on 5/20/20, at 11:57 a.m., with the ICP, the ICP stated, she notified the CNO her last day as the ICP would be 3/4/2020. The ICP stated, on 3/9/2020 the CNO called her and asked her if she would be able to work per diem to review and submit data to National Healthcare Safety Network (NHSN the nation's most widely used healthcare associated infection tracking system. NHSN provides facilities, states, regions, and the nation with data needed to identify problem areas, measure progress of prevention efforts, and ultimately eliminate healthcare associated infections). The ICP stated, she agreed to work per diem. The ICP stated, while in the hospital she reviewed and submitted data on surgical site infections, positive blood cultures, central line cultures, blood cultures and ventilator related infections to NHSN. The ICP stated, while in the hospital she conducted observations in the different departments to observe for correct placement and labeling of intravenous (a thin, flexible, plastic that goes into the vein to deliver fluids and medications) lines. The ICP stated, when she was not onsite in the ACH, she assigned a licensed vocational nurse (LVN a nurse who cares the for sick, injured, convalescing, or disabled patients under the supervision of a registered nurses or physician) to collect data and review the data to determine what could be considered an HAI. The ICP stated, she did not collect the infection control surveillance data but would review the data collected by the LVN, such as surgical site infections and submit the data to NHSN. The ICP stated, every department head in the ACH was responsible to conduct surveillance and observe for hand washing, putting on and removing personal protective equipment (PPE). The ICP stated, the department heads would meet once a month or every two months to communicate the results of the observations to her and she would attempt to provide in service training but she had a challenge with staff not attending the in service. The ICP stated, she worked from 3/10/2020 to 3/13/2020 but did not work full days. The ICP stated, she returned between 4/5/2020 to 4/8/2020, 4/29/2020 to 5/2/2020 and from 5/4/2020 to 5/5/2020. The ICP stated, she returned onsite again on 5/17/2020 when she was called by the CEO and CNO to return to the ACH. The ICP stated, she was not aware of the QSO 20 20 letter for "COVID-19 Focused Infection Control Survey for Acute and Continuing Care" because she was not working full time in the ACH. The ICP stated, she was not aware who was responsible to receive the QSO 20 20 letters. The ICP stated, she had not reviewed the QSO 20 20 letter but had glanced at it. The ICP stated, she was aware of the hospital's practice of not screening employees prior to entering the hospital. The ICP stated, she made a recommendation to the CNO and CEO that employee screening should be done prior to entering the hospital and was not implemented. The ICP stated, she had not been involved in the COVID-19 processes that were put into place by the ICP committee because she was not onsite in the hospital.

During a review of the Professional reference from https://www.ajicjournal.org/action/showPdf?pii=S0196 6553%2817%2931230 0 titled, "A systematic approach to quantifying infection prevention staffing and coverage needs," dated 2018, indicated, " ...the average staffing ratio necessary to support an effective infection prevention program was 1.0 infection prevention full time equivalent per 69 beds ... having an IPC presence on each inpatient unit at least 5 [days per week], even for as few as 5 10 minutes, was of great value to the program ..."

During a review of Professional reference from https://apic.org/wp content/uploads/2019/04/PPS.pdf titled, "The "American Journal of Infection Control," dated 2016, indicated, " ... The need for a well informed and versatile [Infection Preventionist] who can respond to rapidly changing circumstances and evolving priorities. The field of IPC has grown over time from a primary focus on surveillance and reporting to complex program and project management, including the use of performance improvement methodologies and multidisciplinary collaboration. IP's are also responsible for the execution of comprehensive, multisystem surveillance plans; reporting to regulatory agencies; and providing expert guidance on the maintenance of health care environments that are safe for patients, visitors, and staff ... in their day to day responsibilities ..."

During a review of the facility's document titled, "Job Description of Infection Control Coordinator", dated 10/2014, indicated, " ... Supervises hospital personnel utilizing infection control techniques ... The Infection Control Nurse is assigned the responsibility of developing, coordinating and implementing the hospital wide Infection Control Program. Specializes in identifying, controlling and preventing outbreaks of infection in healthcare settings and the community. Activities include the collection and analysis of infection control data; the planning implementation and evaluation of infection prevention and control; the development and revision of infection control policies and procedures, the investigation of suspected outbreaks of infection and the provision of consultation on infection risk assessment, prevention and control strategies ... Position Roles & Responsibilities ... a. Planning, organizing, developing and implementing Infection Control Prevention Standards of Practice and providing surveillance, education and training to [ACH] employees and Medical Staff ... c.Recognizing and preventing disease outbreaks ... analyze data, and determine appropriate infection control measures in coordination with the Medical Staff ... Principle duties ... b. Collaborates with Department Directors, Administration, Employees and the Medical Staff ... f. Periodically conducts surveillance rounds of patient care areas for the purpose of adherence by hospital staff to infection control and safety policies and practices ... l. Maintains current knowledge on and accurately collects and records all ongoing epidemiological programs and surveys ..."

2. During a concurrent observation and interview on 5/15/20, at 1:35 p.m., with Certified Nursing Assistant (CNA) 1, in the Emergency Department Admitting Tent Unit (EDATU), CNA 1 was observed screening staff and patients for signs and symptoms COVID-19. CNA 1 stated, when a patient arrived in a severe condition with fever and cough, the patient entered the EDATU and walked to the ambulance bay entrance. CNA 1 stated, all other patients would enter through the main ED entrance.

During a concurrent observation and interview on 5/15/20, at 2:30 p.m., with the CNO and the RM, in the ED lobby, multiple patients were observed sitting in the ED lobby. The ED lobby was observed with a mobile divider (a curtain to absorb sound between patient beds, provides privacy for patient overflow and creates patient treatment centers on the spot) between respiratory and non respiratory patients. The CNO stated, patients in the ED lobby were wearing face masks and the hospital had placed a High Efficiency Particulate Air (HEPA a type of a mechanical air filter which forces air though a fine mesh that traps harmful particles such as pollen, dust mites and tobacco smoke) filter and a mobile privacy divider to separate respiratory and non respiratory patients.

During a concurrent observation and interview on 5/15/20, at 3:35 p.m., with the CNO, in the ED lobby, the ED lobby was observed to be divided by a mobile privacy divider. The CNO stated, the process for screening patients for COVID-19 was initiated in the EDATU. The CNO stated, when patients arrived in the EDATU and answered yes to a cough or sore throat and did not have severe symptoms (fever), the patient would enter the main ED entrance, into the lobby and sit on the right side of the mobile privacy divider. The CNO stated, patients who answered no to any COVID-19 signs and symptoms would enter the main ED entrance, into the lobby and sit on the left side of the mobile privacy divider. The CNO stated, the ACH made the decision to separate the patients by using a mobile privacy divider and a HEPA filter because there was no other location to isolate patients with COVID-19 signs and symptoms. The CNO stated, patients would then go to one of the three triage rooms to be examined and then taken to one of the ED rooms.

During an interview on 5/15/20, at 4:35 p.m., with RN 13, RN 13 stated, the process to identify and isolate a suspected COVID-19 patient was initiated in the EDATU upon being screened. RN 13 stated, when a patient presented to the EDATU with signs and symptoms of fever, shortness of breath or cough, the staff screening the patient would provide the patient a mask. RN 13 stated, ED staff were made aware by a telephone call from the employee who screened the patient. RN 13 stated, if he received the call, he would put on an N-95 mask, a gown, a shield, and gloves before meeting with the patient in the EDATU. RN 13 stated, he would walk out through the ambulance bay and enter the EDATU and walk back in through the ambulance bay with the patient and walk down the common hallway used by non COVID-19 patients and employees. RN 13 stated, he would walk with the patient to the back of the ED and placed the patient in rooms 112, 114, 115, or 116.

During an interview on 5/18/20, at 2:14 p.m., with Charge Nurse (CN), CN stated, she was the triage nurse for the ED extension room. CN stated, a patient with respiratory symptoms was instructed to come to the ED extension room. CN stated, she would conduct an assessment of the patient in the triage room and would notify the physician of the assessment conducted. CN stated, if the patient required treatment, she would call a work clerk to locate a clean room in the ED. CN stated, a patient under investigation for COVID-19 was placed in a negative air pressure room (rooms 115 or 116). CN stated, if rooms 115 or 116 were not available, she would find an empty single room, or she could move patients around and put the patient on isolation. CN stated, there was no physical barrier in the ED department to distinguish a COVID-19 unit and non COVID-19 unit.

During a concurrent observation and interview on 5/20/20, at 7:15 a.m., with Patient Care Technician (PCT) 5, PCT 5 was observed standing in the EDATU screening employees and patients for COVID-19 symptoms. PCT 5 was observed taking temperature and documenting the temperature but did not ask the questions on the screening log. PCT 5 stated, "Today is my first day here. I have not been trained to screen, my supervisor asked me to come and cover." PCT 5 stated, she was not familiar and did not know the screening process for employees or patients before they entered the hospital.

During a concurrent observation and interview on 5/20/20, at 7:18 a.m., with RN 14, in the EDATU, RN 14 was observed screening employees and patients for COVID-19 symptoms. RN 14 stated, she had not been trained on the screening process and was not familiar with the process. RN 14 stated, the Director of Surgical Services (DSS) notified her she would be trained by the Director of Medical Surgical (DMS) prior to her assignment in the EDATU. RN 14 stated, the DMS should have trained her before she arrived to the EDATU and did not.

During an interview on 5/20/20, at 7:20 a.m., with the DMS, the DMS stated, the night shift staff who were assigned in the EDATU should not have left the screening area in the EDATU because PCT 5 and RN 14 had not been trained on the screening process.

During an interview on 5/21/20, at 8:04 a.m., with PCT 5, PCT 5 stated, her supervisor from Director of Surgical Services (DSS) called her and notified her she would be screening in the EDATU. PCT 5 stated, the DSS notified her she would be trained by the DMS prior to her assignment in the EDATU. PCT 5 stated, she had not been trained on the screening process for COVID-19. PCT 5 stated, it was important for her to be provided training on screening patients and employees prior to assigning her in the EDATU so she would have the knowledge to conduct patient and employee screening competently.

During an interview on 5/21/20, at 10:05 a.m., with the DSS, the DSS stated, over the weekend of 5/16/20 and 5/17/20, she notified PCT 5, she would be in the EDATU for patient and employee screening on 5/20/20. The DSS stated, she notified PCT 5 she would be trained by the DMS. The DSS stated, it was important for employees to be trained prior to being assigned in the EDATU because they would be conducting the patient and employee screening. The DSS stated, the DMS should have trained PCT 5 and RN 14 before they started their screening assignment in the EDATU. The DSS stated, it was important for employees assigned in the EDATU to be knowledgeable in screening employees and patients for COVID-19 signs and symptoms.

During a concurrent interview on 5/21/20, at 10:31 a.m., with the CEO and CNO, the CEO stated, she was not aware of the CMS QSO 20 20 letter dated 3/23/2020, "COVID-19 Focused Infection Control Survey for Acute and Continuing Care" and had not read it. The CEO stated, the CNO and the RM were responsible to receive the CMS QSO letters and had not received them. The CNO stated, the ACH had not seen an increase in the influx of COVID-19 patients in the ACH. The CNO stated, the ACH had a COVID 19 team which involved eight physicians, the CEO, CNO and the ICP. The CNO stated, the ACH worked with the local county public health medical director and had made the decision to put a mobile privacy divider and HEPA filter in the ED lobby to separate respiratory and non respiratory patients. The CEO stated, she initially believed the ACH was taking the appropriate precautions on screening and isolating patients but were not. The CEO stated, the ACH used CDC guidance to put processes in place. The CNO stated, on 5/15/20 while doing rounds in the ACH she realized patients in the ED lobby needed to be separated from respiratory to non respiratory and the ACH had not followed CDC guidance on screening and isolating patients.

During an interview on 5/21/20, at 1:32 p.m., with the DMS, the DMS stated, PCT 5 and RN 14 should have been trained and checked off as competent before screening employees and patient for COVID-19 and it was not done.

During a review of the CDC Infection Control Guidance titled, "Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings," dated 4/11/20, indicated, " ... 1. Minimize Chance for Exposure ... Patients and Visitors ... Upon Arrival and During the Visit ... Limit and monitor points of entry to the facility. Advise patients and visitors entering the facility, regardless of symptoms, to put on a cloth face covering or facemask before entering the building and await screening for fever and symptoms of COVID-19 ... Consider establishing triage stations outside the facility to screen individuals before they enter. Ensure rapid, safe triage and isolation of patients with symptoms of suspected COVID-19 or other respiratory infection (e.g., fever, cough). Ensure triage personnel who will be taking vitals and assessing patients wear a respirator (or facemask if respirators are not available), eye protection, and gloves for the primary evaluation of all patients presenting for care until COVID-19 is deemed unlikely. Prioritize triage of patients with symptoms of suspected COVID-19 ... Ensure that, at the time of patient check in, all patients are asked about the presence of fever, symptoms of COVID-19, or contact with patients with possible COVID-19. Isolate patients with symptoms of COVID-19 in an examination room with the door closed. If an examination room is not readily available, ensure the patient is not allowed to wait among other patients seeking care. Identify a separate, well ventilated space that allows waiting patients to be separated by 6 or more feet, with easy access to respiratory hygiene supplies ... 3. Patient Placement ... As a measure to limit [Health care Personnel] exposure and conserve PPE, facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with known or suspected COVID 19. Dedicated means that HCP are assigned to care only for these patients during their shift ... It might not be possible to distinguish patients who have COVID-19 from patients with other respiratory viruses. As such, patients with different respiratory pathogens might be housed on the same unit. However, only patients with the same respiratory pathogen may be housed in the same room ..."

During a review of the facility's P&P titled, "Employee/Visitor/Vendor Screening" dated, 5/17/20, the P&P indicated, " ... Policy ... All patients ... presenting to [ACH] will be greeted at the entrance of the facility by designated personnel. They will conduct screening procedures at facility entrance. Designated personnel will direct patients to put on a mask and sanitize their hands before checking for COVID-19 related symptoms, checking their temperature, and other symptoms. There will be a criteria checklist that will state ... patient name, date and time of visit, temperature, yes or no to any symptoms such as cough, shortness of breath, chills, sore throat, muscle pain, and new loss of taste or smell, if answer yes to any symptoms or have a fever, they will be instructed to return to car and given number to Rapid care remaining in car for further follow up ... Staff Responsibilities ... For patients coming to [ACH Emergency Department] ... 1. Patients who exhibit fever over 100 degrees or state yes to any symptoms will be treated as a Respiratory patient. 2. If the patient has any positive COVID-19 respiratory symptoms and are deemed clinically stable by the Screening RN, they will be transported to the Respiratory Illness waiting room in the [ACH] Alternative Care Area (ACA) as outlined by red arrows. 3. The patient will have a red paper attached with documented symptoms to alert the staff or possible COVID 19 exposure. 4. If the patient is identified to be critically ill with potential COVID-19 illness, they will be transported through the ambulance bay to preferentially bed 4, 5, or 6. Secondarily, they will be placed in beds 1, 2 or 3 if needed. 5. Patients in the Respiratory Illness waiting room will be triaged by our triage nurse and provider to screen for COVID-19 related illness. Patients identified with concern for COVID 19 from the Respiratory Illness waiting room will be taken directly to beds 15 and 16 (negative pressure rooms). Patients who require more intensive monitoring will be placed in beds 14, 12, 6, 5 or 4."

3. During a concurrent observation and interview on 5/15/20, at 1:30 p.m., with CNA 1, in the EDATU, CNA 1 was observed taking a patient's temperature with a touchless thermometer and asked the patient questions on signs and symptoms of COVID-19. CNA 1 then proceeded to take the surveyor's temperature with the thermometer several times and was unable to. A security guard was observed standing beside the surveyor and he took the thermometer from CNA 1 and did not disinfect the thermometer between patient's and visitor's use. CNA 1 stated, she screened patients going inside the ED and hospital employees were not screened prior to entering the ACH. CNA 1 stated, employees had several entrances to come in to work and were not screened prior to entering the hospital.

During an interview on 5/15/20, at 3 p.m., with RN 3, in the ED, RN 3 stated hospital employees were not being screened prior to entering the hospital and would get screened once they arrived to their department.

During a concurrent interview and record review on 5/15/20, at 3:15 p.m., with RN 3, the "Employee Screening Log (ESL)," dated 5/15/20 was reviewed. The ESL indicated, "Time In, Name, Temperature, Cough, Chills, Shortness of Breath, Sore Throat, Muscle Pain, New Loss of Taste or Smell and Department". The ESL indicated, a box to document the temperature taken and a yes or no to the signs and symptoms. RN 3 stated, she was responsible to screen employees in the ED for signs and symptoms of COVID 19. RN 3 stated, the ED employees were screened in the ED break room after the employees had entered the ACH. RN 3 stated, when an employee answered yes to one of the signs and symptoms on the ESL, they would be sent home. RN 3 stated, the break room did not allow for staff to practice social distancing measures (the practice of keeping space of six feet between yourself and others to reduce the chance of contact with those who knowingly or unknowingly carry an illness).

During an interview on 5/15/2020, at 3:40 p.m., with RN 2, in the ICU, RN 2 stated, the ACH did not screen employees prior to entering the ACH. RN 2 stated, the process of screening employees at their department was implemented since the start of the COVID-19 pandemic.

During an interview on 5/15/20, at 4 p.m., with the RM, the RM stated, ACH employees were not screened prior to entering the ACH and were screened once they arrived at their department. The RM stated, all employees should have been screened prior to entering the ACH in order to determine if an employee exhibited signs and symptoms of COVID-19 such as fever, shortness of breath and should have been sent home prior to entering the ACH. The RM stated, the ACH did not implement the screening process of employees for COVID-19 in accordance with CDC recommendations to actively screen employees at the beginning of their shift.

During a concurrent interview and record review on 5/15/20, at 4:50 p.m., with RN 2, the facility document titled, "ESL," dated 5/15/20 was reviewed. The ESL indicated, " ... Time In, Name, Temperature, Cough, Chills, Shortness of Breath, Sore Throat, Muscle Pain, New Loss of Taste or Smell and Department ...". The ESL indicated, a box to document the temperature taken and yes or no to the signs and symptoms of COVID 19. RN 2 stated, she was responsible to screen employees in the nurse's station in the ICU department after employees had entered the ACH, for signs and symptoms of COVID 19. RN 2 stated, when an employee answered yes to a sign and symptom of COVID 9 they
would be sent home.

During an interview on 5/20/20 at 11:57 a.m., with the ICP, the ICP stated, she was unsure of the exact date she made a recommendation to the COVID-19 committee to screen employees prior to entering the hospital building, based on the CDC guidelines. The ICP stated, the COVID-19 committee decided to screen staff after they had entered the ACH. The ICP stated, she was notified by the CEO and CNO, the county officer notified the ACH, they could screen
employees inside the ACH. The ICP stated, she was unsure of the exact date when the county officer made the recommendations to the COVID-19 committee to screen employees inside the ACH. The ICP stated, not screening employees prior to entering the ACH placed patients and other employees at risk to acquire COVID-19. The ICP stated, the ACH would not be able to identify employees who exhibited COVID-19 active signs and symptoms
prior to entering the ACH. The ICP stated, the hospital used CDC guidelines to screen employees. The ICP stated, the process of screening employees inside ACH changed over the weekend. The ICP stated, she was not part of the screening changes for COVID 19 and was unaware of the changes made to screen employees entering the ACH.

During a review of the CDC Infection Control Guidance titled, "Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings," dated 4/11/20, indicated, " ... 8. Monitor and Manage Healthcare Personnel ... Screen all [Health Care Personnel] at the beginning of their shift for fever and symptoms consistent with COVID-19 ... Actively take their temperature and document absence of symptoms consistent with COVID-19 ..."

During a review of the facility's policy and procedure (P&P) titled, "COVID 19 Employee/Visitor/Vendor Screening" dated 5/17/20, the P&P indicated, " ... Purpose ... to assure that all employees, vendors, patients are screened for COVID- 19 symptoms upon entering [ACH]. Infection control prevention and staff safety ... Policy ... All patients/employees or vendors presenting to [ACH] will be greeted at the entrance of facility by designated personnel. They will conduct screening procedures at facility entrance ..."

4. During a concurrent observation and interview on 5/18/20, at 2:47 p.m., with RN 9, in the ED, RN 9 was observed cleaning a glucometer. RN 9 performed hand hygiene, applied gloves, obtained a disinfecting wipe from a purple container, took the glucometer, wiped the glucometer on all sides. RN 9 used a timer (time clock on the wall) and stated the glucometer should stay wet from 2:47 p.m. to 2:49 p.m. RN 9 stated, the glucometer was not wet for two minutes because it dried in 30 seconds. RN 9 placed the glucometer back on charging station. RN 9 stated, she should have kept wiping the glucometer for two minutes to ensure she was following manufacturers recommendations for using the disinfecting wipes. RN 9 stated, it was important to follow manufacturer's recommendations because the two minutes was the amount of time it took to kill viruses and bacteria.

During a concurrent observation and interview on 5/19/20, at 2:53 p.m., with RN 11, in the ICU, RN 11 was observed cleaning a glucometer. RN 11 performed hand hygiene, applied gloves, obtained a disinfecting wipe from a purple container, took the glucometer, wiped the glucometer on all sides, top to bottom and left to right. RN 11 observed the time on her watch to be 2:55 p.m. and stated the glucometer should stay wet for two minutes. RN 11, verified on the purple wipe container, the manufactures recommendations indicated a wet time of two minutes. RN 11 stated, the glucometer dried before the two minutes. RN 11 stated, it was important to follow manufacturer' recommendations to avoid transmission of blood borne pathogens between patients.

During a concurrent observation and interview on 5/20/20, at 9:50 a.m., with RN 10, in the Medical Surgical Unit (MSU), RN 10 was observed cleaning a glucometer. RN 10 performed hand hygiene, applied gloves, obtained a disinfecting wipe from a purple container and wiped down all sides of the glucometer. RN 10 placed the glucometer on a clean paper towel under a fan. RN 10 observed the time on his watch to be 9:55 a.m. and stated the glucometer should stay wet for two minutes. RN 10 stated, the glucometer was not wet for two minutes. RN 10 stated, it was important to follow manufacturers recommendations on the disinfectant wipes to prevent transmission of blood borne pathogens. RN 10 stated, he should read the manufacturer's recommendations on the disinfecting wipes and become familiar with the products he used.

During an interview on 5/20/20, at 12:28 p.m., with the ICP, the ICP stated, she did not provide training on glucometer disinfection. The ICP stated, the Clinical Educator (CE) and laboratory provided education to employees on glucometer disinfection. The ICP stated, she attended the in service training for glucometer disinfection. The ICP stated, the process for disinfecting the glucometer was to use the disinfecting wipes from the purple container and scrub all sides three times and let it dry. The ICP stated, the glucometer should stay wet for two minutes. The ICP stated, if the glucometer was not wet for two minutes the expectation was for employees to wipe down the glucometer for two minutes. The ICP stated, staff were trained multiple times and it was the expectation for licensed staff to follow the manufacturers. The ICP stated, the importance of following manufacturers recomme

Based on observation, interview, and record review, the facility failed to ensure the emergency needs of patients in the Emergency Department (ED) were met according to hospital policies and procedures and acceptable practice standards when:

1. On 5/1/20, Patient (Pt) 1 was physically and sexually abused in the Emergency Department (ED) by Registered Nurse (RN) 1, the ED charge nurse, who physically restrained him without following established protocols to ensure restraints were necessary; injected Pt 1 with a chemical restraint after he refused it; inserted a urinary catheter (flexible, hollow tube inserted through the penis into the body to obtain a urine specimen in males) into Pt 1, after he refused this procedure, then punched Pt 1 in his testicles after he expressed anger about being catheterized (refer to A1101 finding 1);

2. On 4/29/20, Pt 2 was verbally and sexually abused in the ED by RN 1, whom she overheard comment she was "...another Hispanic panic," who was "faking" she needed assistance transferring from the wheelchair to the bed and pulled her t-shirt over her head, exposing her breasts, without her permission (refer to A1101 finding 2);

3. On 5/9/2020, Pt 3, a suicidal patient, attempted to hang himself with a bedsheet attached to a ceiling light fixture, which should not have been left in the room of a patient with suicidal ideations (ideas) (refer to A1101 finding 3)

4. The hospital failed to develop a plan and analyze culture of safety data from the Emergency Department to educate and encourage staff to report abuse when no data had been submitted to the quality department from the Emergency Department since prior to July 1, 2019 (refer to A1101 finding 4); and

5. Patients arriving in the Emergency Department (ED) were not screened (questions to ask and actions to take to rapidly identify and isolate suspect COVID-19 cases) and cohorted (grouping together) in accordance with Centers for Disease Control (CDC) IC standards. Patients with respiratory symptoms were cohorted with non-respiratory symptom patients in the ED lobby (refer to A1101 finding 5).

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality patient care in a safe environment for all patients receiving care in the ED.

Based on observation, interview, and record review, the hospital failed to ensure the emergency department was organized to ensure the delivery of safe patient care when:

1. On 5/1/20, Patient (Pt) 1 was physically and sexually abused in the Emergency Department (ED) by Registered Nurse (RN) 1, the ED charge nurse, who physically restrained him without following established policies and procedures to ensure restraints were necessary; injected Pt 1 with a chemical restraint after he refused it; inserted a urinary catheter (flexible, hollow tube inserted through the penis into the body to obtain a urine specimen in males) into Pt 1, after he refused this procedure, then punched Pt 1 in his testicles after he expressed anger about being catheterized;

2. On 4/29/20, Pt 2 was verbally and sexually abused in the ED by RN 1, whom she overheard comment she was "...another Hispanic panic," who was "faking" she needed assistance transferring from the wheelchair to the bed and pulled her t-shirt over her head, exposing her breasts, without her permission;

3. On 5/9/2020, Pt 3, a suicidal patient, attempted to hang himself with a bedsheet attached to a ceiling light fixture, which should not have been left in the room of a patient with suicidal ideations (ideas);

4. The hospital failed to develop a plan and analyze culture of safety data from the Emergency Department to educate and encourage staff to report abuse when no data had been submitted to the quality department from the Emergency Department since prior to July 1, 2019; and

5. Patients arriving in the Emergency Department (ED) were not screened (questions to ask and actions to take to rapidly identify and isolate suspect COVID-19 cases) and cohorted (grouping together) in accordance with Centers for Disease Control (CDC) IC standards. Patients with respiratory symptoms were cohorted with non-respiratory symptom patients in the ED lobby.

These failures resulted in actual harm to Pt 1, Pt 2, the potential for harm to Pt 3, and the inability of the facility to ensure the provision of safe patient care for all patients receiving care in the ED.

Findings:

1. During an interview on 5/6/20 at 1:30 p.m., the Chief Nursing Officer (CNO) stated she was called at home on 5/1/20 "around 7:45 p.m." by the Director of the Contracted Security Company (DCS), who informed her one of the Security Officers (SO's) from his company reported what he just observed RN 1, the ED charge nurse, do to Pt 1 in the ED at the hospital. The CNO stated she immediately came to the hospital, met with RN 1, and asked him what happened. The CNO stated RN 1 told her, "I lost my composure" and asked if he was going to be dismissed. CNO stated she replied, "Yes but you can resign now." The CNO stated she told RN 1 his behavior was "unacceptable... he was gone in minutes." The CNO stated RN 1 left the hospital without documenting "anything that happened...the restraint changing, the security presence, the punching..." The CNO stated she did not know if Pt 1 suffered an injury to his testicles because he would not allow anyone to examine him. The CNO stated Pt 1 was still a patient in the hospital but "you can't interview him." The CNO further stated Pt 1 was "saying all kinds of things, even that he was raped."

During an interview on 5/13/20 at 9:15 a.m., SO 3 stated he was an employee with a security company that contracted to work at the hospital. The SO 3 stated, on 5/1/20, he and three other SO's from the same company (SO 1, SO 2, and SO 4) were requested by RN 1 to come to the ED to assist with transferring Pt 1 from the Emergency Medical Services (EMS) gurney (a wheeled cot) to an ED gurney when Pt 1 arrived by the Emergency Medical Services (EMS). SO 3 stated, when Pt 1 arrived, each SO held an extremity while the 4-point (one on each limb) leather restraints belonging to EMS were removed from Pt 1 and exchanged with hospital restraints by RN 1. SO 3 stated Pt 1 was cooperative throughout the exchange. SO 3 stated RN 1 gave Pt 1 a shot of medication in his thigh, after Pt 1 told RN 1 he did not want any medication. SO 3 stated RN 1 asked all four SO's to remain in Pt 1's room while he obtained a urine sample. SO 3 stated Pt 1 refused the insertion of a catheter but RN 1 pulled down Pt 1's belt, shorts and underwear, grabbed Pt 1's penis and inserted and pulled out the catheter after collecting a urine sample. SO 3 stated Pt 1 was upset and was cursing at RN 1. SO 3 stated RN 1 told Patient Care Technician (PCT) 1 to leave the room. SO 3 stated RN 1 pulled the curtain around Pt 1 to block PCT 1's view; then, SO 3 stated he observed RN 1 "punch Pt 1 in the testicles." SO 3 stated at the time of the punch, Pt 1 was in 4-point restraints secured to the gurney with a SO holding each extremity and did not have his shorts or underwear pulled up yet. SO 3 stated Patient 1 yelled in pain. SO 3 stated RN 1 asked SO 3 and the other officers, "You guys didn't see anything, did you?" SO 3 stated, after RN 1 left Pt 1's room, SO 2, the SOs' supervisor, called the DCS to report the incident. SO 3 stated the four security officers gave statements to a police officer that night.

During a telephone interview on 5/13/20 at 3 p.m., SO 4 stated he was called to the ED on 5/1/20 to assist RN 1 with transferring Pt 1 from the EMS gurney to the ED gurney and assist with exchanging the leather restraints belonging to the ambulance company with the hospital restraints. SO 4 stated each SO was positioned at one of Pt 1's extremities while RN 1 removed the EMS restraints and exchanged them with the hospital restraints that RN 1 secured to Pt 1's bed. SO4 stated Pt 1 was calm during the changing of restraints and did not fight or resist. SO 4 stated Pt 1 told RN 1 he did not want medication but RN 1 gave Pt 1 an injection of medication in his leg. SO 4 stated RN 1 told him and the other three SO's to remain in Pt 1's room while he collected a urine specimen. SO 4 stated Pt 1 told RN 1 he did not want a catheter to be inserted but RN 1 requested PCT 1 to go get a catheter. SO 4 stated, when PCT 1 returned with a catheter, RN 1 told her to get a bigger one, which made him feel uncomfortable. SO 4 stated Pt 1 again verbalized not wanting to have a catheter inserted. SO 4 stated he observed RN 1 unbuckle Pt 1's belt and forcefully pull down Pt 1's shorts. SO 4 stated Pt 1 said, "Don't touch my dick" and then RN 1 grabbed Pt 1's penis and stuck the catheter in quickly, got urine out and then roughly pulled it out. SO 4 stated Pt 1 was mad and cursed at RN 1. SO 4 stated RN 1 told PCT 1 to leave the room, which she did. SO 4 stated he observed RN 1 "punch [Pt 1] in the nuts," while Pt 1 who was still restrained with his shorts and underwear pulled down. SO 4 stated Pt 1 yelled in pain. SO 4 stated he and the other security officers gave statements to the police that night. SO 4 stated he did not know why RN 1 hit Pt 1 and stated Pt 1 was not a threat to any of them. SO 4 described the whole incident as feeling "raped [sexually aggressive or inappropriate in a way that causes fear or unease]."

During an interview on 5/13/20 at 3:33 p.m., the Chief Executive Officer (CEO) confirmed Pt 1 had been abused in the ED on 5/1/20 by RN 1. The CEO stated the Risk Management Department had not been notified of the abuse incident. The CEO stated the hospital policy indicated a "serious adverse event [any event, preventable or unpreventable that caused harm to a patient]" be reported the day it occurred to the Risk Management Department. The CEO stated the CNO was notified the day the event occurred and started an investigation but no report of the event was entered into the facility's computer adverse reporting system and she "assumed the Risk Manager [RM] was informed."

During a concurrent interview and record review, on 5/14/20, at 9:30 a.m., with the Director of Human Resources (DHR) and the CNO in attendance, the DHR and CNO validated the CNO was also the Interim ED Director (IERD). RN 1's Personnel File was reviewed. The DHR and CNO validated RN 1's was hired 11/4/20 hire and there was no evidence RN 1 was oriented to the ED night shift relief charge position and there was no evidence he had leadership training for the charge nurse position. The DHR validated RN 1's timesheets indicated he was the ED charge nurse for 26 shifts, since hire. The DHR stated there should be orientation to each new role with documentation that the individual was competent to function in the role.

During a telephone interview on 5/14/20 at 10:20 a.m., RN 4 stated she was an experienced ED nurse who had worked at this hospital for three years. RN 4 stated she was on duty the night of 5/1/20 when Pt 1 was brought in by ambulance to the ED. RN 4 stated she was assigned to be Pt 1's primary nurse and had received report and discussed the patient with PCT 1. RN 4 stated her plan was to evaluate the patient and determine if he was calm enough to be out of restraints. RN 4 stated she met the EMS staff when they arrived and accompanied Pt 1 to the room with the four SO's, PCT 1, and RN 1. Then, RN 4 stated RN 1 took over care of Pt 1 for unknown reasons and did not provide RN 4 with any explanation. RN 4 stated she did not question RN 1 because he was the charge nurse. RN 4 stated, after RN 1 exited the facility, she again resumed care of RN 1, "had a good rapport with [Pt 1] right away" and had him out of restraints "within about 35 minutes." RN 4 stated, in her experience, there is no a reason to obtain a urine specimen in a patient who has verbally refused. RN 4 stated patients have the right to refuse to have a catheter to get a urine specimen. RN 4 stated, being under a 5150 hold (involuntary confinement of a person considered to be a danger to self or others) because of being a danger to self/others or disabled, does not mean the patient gives up their rights.

During an interview on 5/14/20 at 2:40 p.m., PCT 1 stated she was working on 5/1/20 when Pt 1 came to the ED. PCT 1 stated she received report from RN 4 about Pt 1 who was, "a 5150." PCT 1 stated RN 4 told her Pt 1 had a mental illness and was off his medication. PCT 1 stated RN 4 told her Pt 1 was in restraints and, if Pt 1 was cooperative, then the restraints could be removed. PCT 1 stated, when Pt 1 arrived, he did not know why RN 1 took over the care of Pt 1 and removed RN 4 as this patient's primary nurse. PCT 1 stated, when Pt 1 arrived, he was restrained and "was upset, cussing, not abusive." PCT 1 stated there were four SO's in Pt 1's room to help transfer Pt 1 from the ambulance gurney to the ED bed and to exchange the restraints from the ambulance for the hospital restraints. PCT 1 stated Pt 1 was not fighting them and was not aggressive or abusive and the transfer was done without any difficulty. PCT 1 stated RN 1 told Pt 1, "You are stuck with me all night." PCT 1 stated RN 1 asked her to get a catheter for a urine specimen. PCT 1 stated she brought RN 1 an "in and out catheter" (one used to obtain urine that is not left inside the patient) but RN 1 told her to bring a larger, "female" catheter. The PCT 1 stated Pt 1 stated he did not want them to put the catheter in him, and he did not want to be touched. PCT 1 stated Pt 1 was in 4 point restraints (secure all four extremities) and four SO's were also holding Pt 1, one on each arm and leg. PCT 1 stated RN 1 opened Pt 1's belt and directed PCT 1 to help him pull down Pt 1's shorts and underwear. PCT 1 stated, after RN 1 inserted the catheter into Pt 1, RN 1 told her to leave the room. PCT 1 stated she left the room and pulled the privacy curtain around but left it open enough to be able to see Pt 1. PCT 1 stated RN 1 closed the curtain all of the way. PCT 1 stated she wondered at the time why RN 1 asked her to leave and pulled the curtain. PCT 1 stated she did not document what occurred with Pt 1 but "should have; I know it is important." PCT 1 stated she did not report what occurred to her supervisor because RN 1 was the charge nurse.

During an interview on 5/15/20 at 10:02 a.m., with the Nurse Educator (NE), she stated each department has a competency checklist to complete before completing orientation. The NE stated the charge nurse role is a different role and additional training is required.

During an interview on 5/21/20 at 9:55 a.m., the Medical Director (MD) of the ED stated he was on duty on 5/1/20 when Pt 1 arrived by ambulance with a diagnosis of schizophrenia, off his medication, on a 5150 hold as a danger to self/others. MD stated Pt 1 was in restraints upon arrival. MD stated Pt 1 was not combative, abusive, or violent at that time. MD stated he gave initial orders for Pt 1. MD stated he did not know anything about RN 1 taking over the care from RN 4. MD stated he was shocked when he was told Pt 1 had been punched by RN 1. MD stated something like this should never happen and he takes it seriously. MD stated he was informed, after the fact, that Pt 1 had refused the urine test. MD stated Pt 1 has the right to refuse the urine test. MD stated a urine test is used to help determine if the mental health patient can be medically cleared (process by which it is determined a patient's behavior is not caused by an underlying medical condition) so they can be transferred to a psychiatric care facility, if necessary.

RN 1 was not available for interview.

During a review of Pt 1's clinical record, the document titled, "Patient Summary Report," dated 5/1/20 indicated Pt 1 was a 29 year old male who was brought in from home by ambulance to the ED at 7:14 p.m. on a 5150 hold. This form indicated RN 1 was the only RN who documented a triage assessment (initial evaluation upon a patient's arrival in the ED to determine the seriousness of the patient's illness) or documented any nurses notes related to Pt 1's care between 7:14 p.m. and 7:45 p.m. RN 1's first documentation of assessing Pt 1's behavior, at 7:39 p.m., indicated, "Behavior/Anxiety Assessment - Patient Behavior: Aggressive, Combative, Resistive to care, Mood - Angry..." The document indicated RN 1 did not enter any notes related to Pt 1's refusal for a chemical restraint (the administration of medication used for the management of acute behavioral emergencies) and Pt 1's refusal to be catheterized; in addition, RN 1 did not document any notes related to punching Pt 1 in his testicles. This document indicated RN 1's last entry was at 7:39 p.m. This document indicated RN 4's first documentation related to assessing Pt 1's behavior was at 7:45 p.m. when RN 4 documented, "Continuous Observation Reason - Danger to Others, Continuous Monitoring: Location - ER Bed ...Patient Behavior - Cursing, Observation Interventions - With nursing staff, private security guard... Location - ED bed, Patient Behavior - Cursing... 8 p.m.- ...Continuous Observation Reason - Danger to Others; Continuous monitoring: Patient Behavior - Lying Down, Observation Interventions - Offered fluids, offered toilet, checked vital signs, with Nursing Staff and Private Security Guard. Observation Outcome - No signs of injury, no harmful behavior...

During a review of Pt 1's clinical record, the document titled, "Orders," dated 5/1/20 at 7:16 p.m., indicated MD ordered injections (acts of forcing a fluid into a part of the body by using a needle) of "Haldol [a medication used to treat certain mental/mood disorders], 5 mg [milligrams - a unit of measurement]; Ativan [used to treat anxiety] 2 mg, and Benadryl [a medication sometimes used to treat anxiety in psychotic patients) 50 mg.

During a review of Pt 1's clinical record, the document titled, "Orders" dated 5/1/20 at 7:17 p.m., indicated, MD ordered "Drug screen, urine..."

During a review of Pt 1's clinical record, the document titled, "Patient Summary Report" dated 5/1/20 at 7:23 p.m., indicated RN 1 administered the following medications by injection: Haldol 5 mg; Ativan 2 mg.; and Benadryl 50 mg.

During a review of Pt 1's clinical record, the document titled, "Discharge Summ [Summary]" dated 5/1/20 at 8:45 p.m., indicated RN 4 removed Pt 1's 4-point restraints.

During a review of Pt 1's clinical record, the document from the local Police Department Report dated 5/1/20, indicated, "On May 1, at approximately [8:56 p.m.], I was dispatched to contact [CNO] ...regarding a staff member committing a battery against [Pt l] ...[CNO] stated [RN 1] ...punched a patient in the testicles ...[CNO] stated she spoke with [RN 1] earlier ...[CNO] stated [RN 1] admitted to the act and resigned ...INVESTIGATION: I proceeded to [Hospital Name] and spoke with the [SO's] [SO 4, SO 3, SO 1, and SO 2]. They each provided a statement ... [SO 4] stated [Pt 1] ...was already secured in four point restraints ...[SO 4] stated ...medical staff injected [Pt 1] with a sedative. [SO 4] stated medical staff requested a urine sample from [Pt 1], but he refused. [SO 4] stated [PCT 1] grabbed the requested catheter, but [RN 1] requested the 'good' catheter ...the bigger, thicker sized catheter. [SO 4] stated [RN 1] installed the catheter in an aggressive manner ...[RN 1] removed the catheter in an aggressive manner. [SO 4] stated ...[RN 1] approached [Pt 1] and used his right hand with a closed fist to punch [Pt 1] on his testicles ...I asked [SO 4] if [Pt 1] was acting erratic in any way, and [SO 4] said he was not. [SO 4] stated [Pt 1] was still restrained to the hospital bed when he was punched ...[SO 3] corroborated [SO 4]'s statement...[SO 3] stated he witnessed [RN 1] use a close fist to strike [PT 1] in his testicles. [SO 3] stated [Pt 1] ...was physically calm at the time [RN 1] punched him."

During a review of Pt 1's clinical record, the document titled, "ED Assessment Addendum" 5/1/20 at 9:08 p.m., signed by MD indicated, "There were allegations made that the patient was assaulted by a nursing staff member when the patient was being physically and chemically restrained. On re-evaluation after learning about these allegations, I have found no evidence of trauma to the patient; however, the patient refuses to allow me to examine his genitalia to evaluate for any trauma..."

During a review of Pt 1's clinical record, the document titled, "Patient Summary Report," dated 5/7/20 at 12:20 p.m. indicated, "Departure Information: Primary Impression - History of Paranoid Schizophrenia. Secondary Impressions: Psychiatric symptoms. Disposition: HOME...Condition: STABLE..." This document indicated Pt 1 remained in the ED from 5/1/20 to 5/7/20.

During a review of the facility's P & P titled, "Clinical Director Emergency Services, dated 9/15, the P & P indicated, "REPORTS TO: Vice President, Patient Care Services. SUPERVISES Emergency ... Professional staff members... POSITION SUMMARY: Performs the primary functions of a professional nurse leader in assessing, planning, directing, and evaluating Emergency Service patient care on a 24-hour basis. Is responsible for meeting Approved Accrediting Agency Standards of Nursing Practice for Emergency Services... 1. Administrative Responsibilities: a. Maintains knowledge of and adheres to... Federal and state standards governing the delivery of healthcare services; e. Insures department is adequately staffed...to deliver safe, quality care which meets the needs of the patients..."

During a review of the facility's document titled, "Vice President - Chief Nursing Officer" dated 11/15, this document indicated, "REPORTS TO: Chief Executive Officer... SUPERVISES: Clinical Directors:...Emergency Services... POSITION SUMMARY: ...Ensures ...competent patient care/nursing staff and nursing leadership at all levels...

During a review of the facility document titled, "VP - Chief Nursing Officer 2019 Annual Evaluation" dated 8/14/19, signed by the Chief Executive Office, the document indicated, "...POSITION SUMMARY: Plans, organizes, directs, and leads the departmental functions and activities for the nursing/patient care service department... Responsible for the establishment of standards of nursing/patient care practices...in accordance with... professional stands [standards] of practice. Ensures... competent patient care/nursing staff... Evaluator Comments - Patient Care Services has not had adequate and competent staffing and this has been a continual problem for some time... Needs to work on monitoring safety in nursing areas... [CNO] does promote our mission but we are still struggling with our quality and safety in patient care services..."

During a review of the facility's P & P titled, "Care of the Patient in the Emergency Department: Triage to Discharge" dated 3/17, the P & P indicated, "Purpose: To provide nursing care guidelines in evaluating patients on arrival to the Emergency Department, providing on going high quality care and assessment of the patient during their ED stay... Policy:... 7. Nursing staff will deliver/facilitate any medical treatment... rendering care to the patient that is within their scope of practice... Procedure: 2. Nursing staff will deliver care/treatments ordered by the ED provider... They will document the care/treatments given... 3. Basic nursing care will be provided to the patient, as needed..."

During a review of the facility's P&P titled, "Restraints for Management of Violent and Non-Violent Behavior," dated 7/19, the P&P indicated, " ...POLICY: ...2. The decision to restrain is not driven by diagnosis, but by a comprehensive individual patient assessment ...4. Restraint may only be employed while the unsafe situation continues... 6. The use of restraint must be discontinued as soon as possible based on an individual patient assessment and re-evaluation. 7. When the use of restraint is necessary, the least restrictive method must be used to ensure patient safety. The use of restraint for the management of patient behavior should not be considered a routine part of care ...DEFINITIONS: ...11. Least restrictive interventions/Restraint Alternatives: Are to be attempted prior to initiation of restraints and rationale for not using alternatives must be documented..."

During a review of the facility's P&P titled "Patient's Rights/Responsibilities," dated 1/20, the P&P indicated, " ...1. The administration of [Hospital Name] protects and supports the rights and responsibilities of our patients ....it provides for considerate respectful care focused upon the patient's individual needs ...PATIENT RIGHTS ...14. Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment ...15. Be free from restraints and seclusion of any form used as a means of coercion, discipline, convenience or retaliation by staff..."

During a review of the facility's P&P titled, "5150 Holds and Behavioral Emergencies," dated 12/19, the P&P indicated, " ...PATIENT RIGHTS 1. Patients on a 5150 hold or are here for Behavioral Emergencies have the standard patient rights. In addition: ...5. Patients have the right to accept or refuse treatment, meds, tests."

During a review of Professional reference from https://www.nursingworld.org/ana/about-ana/standards/ titled, "Code of Ethics for Nurses with Interpretive Statements" dated 2015, indicated, "Provision 1 - The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person ... Provision 2 - The nurse's primary commitment is to the patient ... Provision 3 - The nurse promotes, advocates for, and protects the rights, health, and safety of the patient ... Provision 4 - The nurse has ... accountability, and responsibility for nursing practice: makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care ... Provision 6 - The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care ... Provision 7 - The nurse, in all roles and settings, advances the profession through ... professional standards development ..."

2. During a concurrent interview and record review on 5/13/20 with RN risk manager (RM) 1, Pt 2's medical record for 4/29/20 was reviewed. Review of the medical record indicated Pt 2 arrived to the ED, accompanied by her husband, at 10:40 p.m. with a chief complaint of anxiety and departed on 4/30/20 at 2:46 a.m.. The record indicated RN 1, PCT 2 and PCT 4 were the care givers.

During a concurrent interview and record review, on 5/14/20, at 9:30 a.m., with the Director of Human Resources (DHR) and the CNO in attendance, the DHR and CNO validated the CNO was also the Interim ED Director (IERD). RN 1's Personnel File was reviewed. The DHR and CNO validated RN 1's was hired 11/4/20 and there was no evidence RN 1 was oriented to the ED night shift relief charge position and there was no evidence he had leadership training for the charge nurse position. The DHR validated RN 1's timesheets indicated he was the ED charge nurse for 26 shifts, since hire. The DHR stated there should be orientation to each new role with documentation that the individual was competent to function in the role.

During a telephone interview on 5/14/20 at 12:05 p.m., Pt 2 stated, on 4/29/20 her husband brought her to the ED at night because she was "feeling weird" after taking something for a bad headache. Pt 2 stated she felt like she could not talk normally and her body felt weak. Pt 2 stated, as she was brought into the triage area [location in the ED where patients are initially evaluated to determine the seriousness of their illness) in a wheelchair and a male nurse (RN 1) walked up to her and said to PCT 2, "Look; it is another Hispanic panic." Pt 2 stated she and her husband were shocked to hear the nurse say that. Pt 2 stated RN 1 and PCT 2 took her to a room in the ED while her husband waited in the lobby. Pt 2 stated RN 1, PCT 2 and PCT 4 were in the room. Pt 2 stated, once in the room, she overheard RN 1 tell PCT 2 she was "faking it." Pt 2 stated RN 1 raised his voice loudly and told her several times to "get up; get on the bed" and "you don't need help." Pt 2 stated PCT 2 did not help her up but she finally was able to get up from the wheelchair and onto the bed. Pt 2 stated RN 1 grabbed the t-shirt she was wearing and pulled it off, over her head. Pt 2 stated she was not wearing a bra and had tried to cover her breasts with her hands. Pt 2 stated PCT 2 did not say anything to her but draped a gown over her chest but RN 1 pulled that off of her also. Pt 2 stated RN 1 said to the other nurses "You know how you can tell if a girl is faking it, she tries to cover herself up." Pt 2 stated she told RN 1, "I can hear everything you are saying. I don't want to talk to you. I don't want you to help me." Pt 2 stated she was discharged after a couple of hours and went home. Pt 2 stated she was so upset it took her two days to talk about it. Pt 2 stated she called the hospital and spoke to the Patient Liaison (PL) and told her what happened. Pt 2 stated she cried when she told the PL what happened. Pt 2 stated she was a victim of sexual abuse years ago, and had worked hard to get past that trauma, but this incident was "all it took to put me right back there again." Pt 2 stated she called the hospital to complain because she did "not want anyone else to go through this." Pt 2 stated she had not been contacted about this complaint since she spoke with the PL on 5/1/20.

During a concurrent interview and record review on 5/14/20 at 1:15 p.m. with the PL, the Grievance Log [record of patient complaints received at the facility) was reviewed. The grievance log indicated, on 5/1/20, Pt 2 spoke to the PL about an incident that occurred on 4/29/20. PL stated she recalled this conversation with Pt 2 who was in the ED on 4/29/20 because she felt strange, weak, and couldn't move. PL stated Pt 2 described a bad experience with RN 1 and that Pt 2 stated she wanted to report this so it won't happen to another patient. PL stated Pt 2 described how RN 1 had said she was "faking it" and called it "Hispanic panic." PL stated Pt 2 told her RN 1 pulled off her shirt, exposing her breasts. PL stated Pt 2 cried during the telephone conversation when she described the incident. PL stated, when she finished speaking with Pt 2 on 5/1/20, she stayed late to file the grievance report; however due to a computer issue, it did not go through until 5/6/2020. PL stated, when the incident report is filed, an email alert goes to the director of the department. PL stated, in this case, it went to the CNO, who was also the interim ED Director, and they should start their investigation. PL stated there was a grievance meeting held on 5/13/20 and this incident was on the agenda. PL stated there was not much information presented as far as an investigation by the ED director, just that the involved "nurse [RN 1] was dismissed." PL stated this grievance is not closed because the investigation is not done.

During a telephone interview on 5/14/20 at 4 p.m., PCT 2 stated she worked at the hospital in the ED for approximately six months. PCT 2 stated she was on duty the night of 4/29/20 and remembered Pt 2 came in for anxiety and was not feeling well. PCT 2 stated Pt 2 was not really talking and was not totally alert. PCT 2 stated RN 1 said this was "Hispanic panic" and that Pt 2 was "just a faker." PCT 2 stated RN 1 told Pt 2 several times to get up on the bed. PCT 2 stated the way RN 1 talked to Pt 2 was "not right... RN 1 acted annoyed with Pt 2." PCT 2 stated, once Pt 2 was up on the exam table, PCT 2 grabbed a gown to put on Pt 2 but, before she could snap the sleeves together, RN 1 pulled Pt 2's t-shirt off over her head. PCT 2 stated Pt 2 was not wearing a bra so her breasts were exposed and she tried to cover herself up with her hands. PCT 2 stated she covered PT 2's chest with the gown but RN 1 yanked the gown off of Pt 2 leaving her exposed again. PCT 2 stated RN 1 said "that's how you know a woman is faking; a woman in pain would not try to cover herself up." PCT 2 stated RN 1 was being mean. PCT 2 stated, "I feel horrible, I should have spoken up. I don't know why I didn't ...I was new and [RN 1] was in charge."

During an interview on 5/15/20 at 10:02 a.m., with the Nurse Educator (NE), she stated each department has a competency checklist to complete before completing orientation. The NE stated the charge nurse role is a different role and additional training is required.

During a review of Pt 2's clinical record, the document titled, "ED Assessment" dated 4/29/20 at 10:52 p.m., indicated Pt 2 arrived in the ED complaining of "Anxiety" with a diagnosis of "Cannabis [an herbal drug containing chemicals that affect the central nervous system, which includes the brain and nerves] abuse." This document indicated Pt 2 was discharged in stable condition on 4/30/20 at 2:46 a.m.

During a review of the facility's P & P titled, "Care of the Patient in the Emergency Department: Triage to Discharge" dated 3/17, the P & P indicated, "Purpose: To provide nursing care guidelines in evaluating patients on arrival to the Emergency Department, providing on going high quality care and assessment of the patient during their ED stay... Policy:... 7. Nursing staff will deliver/facilitate any medical treatment... rendering care to the patient that is within their scope of practice... Procedure: 2. Nursing staff will deliver care/treatments ordered by the ED provider... They will document the care/treatments given... 3. Basic nursing care will be provided to the patient, as needed..."

During a review of the facility's P & P titled, "Clinical Director Emergency Services, dated 9/15, the P & P indicated, "REPORTS TO: Vice President, Patient Care Services. SUPERVISES Emergency ... Professional staff members... POSITION SUMMARY: Performs the primary functions of a professional nurse leader in