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Based on policy review, document review, observations, video footage review, and interview, the hospital failed to ensure the physical environment was secure to prevent patients/visitors from unauthorized access when 1 of 3 (Patient #1) sampled patients breached a secure area, and fired a gun multiple times in the stairwell of the building that included the emergency department (ED), patient diagnostics, and the surgical area for obstetrics. The hospital failed to ensure 1 of 1 (Security Officer #4) security staff followed written protocols for using the metal detector to scan individuals for weapons prior to entering the ED, and failed to ensure 1 of 1 (Operator #1) operations staff followed written policies for issuing an active shooter alert.

The findings included:

1. Review of the " Phase Silver-Active Shooter" policy with revision date 11/19/2021, revealed, "Purpose- The objective of this policy is to provide guidance in the event of an individuals (or individuals) are actively shooting persons within [named hospital] or campus. Policy- It is the policy of [named hospital] to provide an emergency response plan to alert associates, patients and visitors that an active shooter appears to be engaged in killing or attempting to kill people (armed aggression) in the hospital...Definitions: For purposes of this policy an active shooter is defined as a person or persons who appear to be actively engaged in the use of deadly physical force with the intent to cause bodily harm to others in the hospital or on the hospital campus...The first employee to identify an active shooter situations will: a. Run to a safe area if possible b. Once in a safe location call the Security Emergency Number for your campus reporting the the location of the incident and description of the person (s) with the weapon...c. Evacuate patients visitors and staff is safe to do so. If not, HIDE them in a secure location...2. The Operator or Security Dispatch upon notification will...Overhead page "Phase Silver (and the location) three times..."

Review of the "Phase Silver- Active Shooter" Policy with no approval date and no formal hospital logo, utilized by the Operations department at the time of the incident on 11/26/2022, provided by the Associate Chief Financial Officer on 12/6/2022 at 2:17 PM revealed on the last page under references, "** When instructed by Security /AOC [Administrator on Call] 2) Page overhead 3 times Attention all personnel, Phase [Silver] is now in effect. **Be sure to say exact wording that you are told..."
Review of the "Proscreen Scanning Process" provided by the Manager of Security, revealed, "1. Individual enters ED and steps up to the Security check in station. 2. Security will instruct individuals to empty all pockets and place personal items into a bin. 3. Security will instruct individuals to walk past the metal detector and return. 4. If there is no detection. Security will inspect any baggage for weapons. If nothing is found, individuals are permitted to proceed. 5. If the metal detector detects something, security asks individuals to check their pockets again. 6. After checking pockets, security will instruct individuals to walk past the metal detector again and return. 7. If something is detected then security will utilize the hand held metal detector to scan individuals. 8. If something is detected then security asks individuals to check the area and determine what the scan is detecting. 9. If a weapon or illegal drugs are located individuals will be instructed to return the item to their vehicle or they can wait outside. Knives can be placed in a sharps container by individuals with the understanding that they cannot be retrieved..."

2. Review of the hospital security report submitted on 12/1/2022 at 2:24 AM, revealed on 11/26/2022 at 1:50 AM, Security Officer #1 and RN #4 discovered Patient #1 in the stairwell to the ED, firing a gun in the fourth floor stairwell. RN #4 exited the stairwell to inform ED staff and call 911. Security Officer #1 notified hospital dispatch and his Security Supervisor. Multiple hospital Security Officers responded for back up and Patient #1 was taken into custody by local police without resist.

3. Medical record review for Patient #1 revealed a 32 year old male who arrived hospital emergency department (ED) on 11/25/2022 at 10:12 PM with complaints of chest pain. Patient #1 had no identified psychiatric needs. The medical screening exam was initiated at 10:32 PM and Patient #1 reported chest pain for one week described as episodic. Patient #1's Chest Xray and electrocardiogram results were normal. Patient #1 was diagnosed with heartburn/gas, but refused the medications ordered by the ED Physican. Patient #1 was discharged from the ED in stable condition, on 11/25/2022 at 11:57 PM.

4. Observations of the ED on 12/6/2022 at 11:05 AM revealed security was stationed at a desk near the the walk-in entrance of the ED. The Manager of Security stated if the detector turns red at any point, the Security staff ask the person to be sure all items were removed from their person, and then direct them to return to the metal detector. The Manager of Security further stated if the light turned red a second time, the Security officer would use the hand metal detector wand prior to the patient entering the ED.

5. Review of video revealed Patient #1 entered the walk-in entrance to the ED on 11/25/2022 at 10:10 PM. Security Officer #4 did not follow written protocols for the metal detector.

Review of video for a motion detected camera near the dirty dock area on 11/26/2022 at 12:38 AM (5 minutes after leaving the ED parking lot) Patient #1 can be seen walking into the loading dock area and behind a trash compactor, into the basement of the building the includes the ED.

Patient #1 was discovered by Security Officer #1 and RN #4 on 11/26/2022 in the ED Stairwell at 1:50 AM, firing a weapon on the fourth floor stairwell. At 1:59 AM, RN #4 called the operator to report and active shooter in the ED. The Operator did not issue an overhead call for Phase Silver, according to policy.

Refer to A0057

Based on policy review, document review, observations, video review, and interview, the hospital failed to ensure the physical environment was secure to prevent patients/visitors from unauthorized access when 1 of 3 (Patient #1) sampled patients breached a secure area, and fired a gun multiple times in the stairwell of the building that included the emergency department (ED), patient diagnostics, and the surgical area for obstetrics. The hospital failed to ensure 1 of 1 (Security Officer #4) security staff followed written protocols for using the metal detector to scan individuals for weapons prior to entering the ED, and failed to ensure 1 of 1 (Operator #1) operations staff followed written policies for issuing an active shooter alert.

The findings included:

1. Review of the "Phase Silver-Active Shooter" policy with revision date 11/19/2021, revealed, "Purpose- The objective of this policy is to provide guidance in the event of an individuals (or individuals) are actively shooting persons within [named hospital] or campus. Policy- It is the policy of [named hospital] to provide an emergency response plan to alert associates, patients and visitors that an active shooter appears to be engaged in killing or attempting to kill people (armed aggression) in the hospital...Definitions: For purposes of this policy an active shooter is defined as a person or persons who appear to be actively engaged in the use of deadly physical force with the intent to cause bodily harm to others in the hospital or on the hospital campus...The first employee to identify an active shooter situations will: a. Run to a safe area if possible b. Once in a safe location call the Security Emergency Number for your campus reporting the the location of the incident and description of the person (s) with the weapon...c. Evacuate patients visitors and staff is safe to do so. If not, HIDE them in a secure location...2. The Operator or Security Dispatch upon notification will...Overhead page "Phase Silver (and the location) three times..."

Review of the "Phase Silver- Active Shooter" Policy with no approval date and no formal hospital logo, utilized by the Operations department at the time of the incident on 11/26/2022, provided by the Associate Chief Financial Officer on 12/6/2022 at 2:17 PM revealed on the last page under references, "** When instructed by Security /AOC [Administrator on Call] 2) Page overhead 3 times Attention all personnel, Phase [Silver] is now in effect. **Be sure to say exact wording that you are told..."
Review of the "Proscreen Scanning Process" provided by the Manager of Security, revealed, "1. Individual enters ED and steps up to the Security check in station. 2. Security will instruct individuals to empty all pockets and place personal items into a bin. 3. Security will instruct individuals to walk past the metal detector and return. 4. If there is no detection. Security will inspect any baggage for weapons. If nothing is found, individuals are permitted to proceed. 5. If the metal detector detects something, security asks individuals to check their pockets again. 6. After checking pockets, security will instruct individuals to walk past the metal detector again and return. 7. If something is detected then security will utilize the hand held metal detector to scan individuals. 8. If something is detected then security asks individuals to check the area and determine what the scan is detecting. 9. If a weapon or illegal drugs are located individuals will be instructed to return the item to their vehicle or they can wait outside. Knives can be placed in a sharps container by individuals with the understanding that they cannot be retrieved..."

2. Medical record review for Patient #1 revealed a 32 year old male who arrived via private car at the hospital ED on 11/25/2022 at 10:12 PM with complaints of chest pain. Triage was initiated at 10:18 PM with vital signs recorded as Blood Pressure- 129/88, Pulse-77, respiratory rate 16 and Oxygen Saturation-98%. Electrocardiogram (EKG) initiated during triage revealed a normal EKG. Patient #1 was screened during triage for psychiatric needs with the Columbia Suicide Severity Rating Scale with no concerns reported by Patient #1. The Medical screening exam was initiated at 10:32 PM and Patient #1 reported chest pain for one week described as episodic. Patient #1 reported he was under a lot of stress due to his dog boarding business going bankrupt. The physician ordered a chest Xray and results were normal. The ED physician ordered Aluminum Hydroxide, Magnesium Hydroxide, and Simethicone 30 milliliters (mL) Suspension, Pepcid 40 milligrams (mg) and Lidocaine 15 mL solution for heartburn/gas. Patient #1 refused the medications. Patient #1 was discharged from the ED in stable condition, on 11/25/2022 at 11:57 PM, with a prescription for Pepcid 20 mg.

Interviews with all ED clinical staff who provided care to Patient #1 revealed they had no concerns about Patient #1's behavior. The ED staff reported Patient #1 showed no aggression or red flags during his ED visit on 11/25/2022 and he was discharged in stable condition.

3. Review of the hospital video footage revealed Patient #1 entered the walk-in entrance to the hospital's ED on 11/25/2022 at 10:10 PM. At 10:11 PM Patient #1 can be seen removing items from his coat pockets into a tray at the security desk and stepping back to stand and turn in front of the metal detector. The metal detector light can be seen lighting up green and red as Patient #1 was scanning himself. Patient #1 can be seen then retrieving his items from the plastic bin and entering the ED. Security Officer #4 did not instruct Patient #1 to ensure his pockets were empty and return to the metal detector for a second scan when the detector turned red. Security Officer #4 did not use the handheld metal detector to scan Patient #1 before he entered the ED, as required by written protocols.

The video revealed while Patient #1 was in the ED waiting room and in the ED receiving treatment revealed no erratic or aggressive behaviors. Patient #1 appeared cooperative. At 10:47 PM, Patient #1 can be seen walking down an ED hallway with a plastic pan in his hand to go water his dog. At 10:50 PM Patient #1 exited the ED walk in entrance with water for his dog. At 10:52 PM, Patient #1 can be seen entering the ED walk in entrance, emptying his pockets into the tray at the security desk and stepping back to stand and turn in front of the metal detector. The metal detector can be seen lighting up green only. Patient #1 then retrieved his items from the plastic bin and entered the ED. At 10:54 PM Patient #1 can be seen returning to his exam room. At 10:54 PM Patient #1 can be seen walking from his ED exam room with hospital staff into the Radiology area. At 11:59 PM Patient #1 can be seen walking from his ED exam room holding his discharge paperwork. On 11/26/2022 at 12:00 AM Patient #1 can be seen exiting the ED proper and returning to the ED waiting room area, where he enters a bathroom. At 12:02 AM Patient #1 can be seen exiting the bathroom and taking a seat in a bank of chairs in the ED waiting room and appears to be talking on his cellular phone. At 12:05 AM, Patient #1 can be seen exiting the ED past the Security desk at the walk-in entrance.

A review of video footage for 11/26/2022 with time beginning at 12:04 AM was done. The video revealed Patient #1 walked outside into the parking lot near a white truck at 12:05 AM. At 12:06 PM, Patient #1 can be seen getting his white dog from his truck (parked near the Emergency Services entrance) and walking the dog around the parking lot on a leash. Patient #1 continued to walk his dog in the ED parking lot until approximately 12:15 AM. At 12:20 AM Security Officer #2 and #3 can be seen standing near the Emergency Services (EMS) entrance. At 12:29 AM Patient #1 can be seen backing his truck out of the parking space and then driving back into the same parking space. At 12:31 AM Patient #1 can be seen standing in front of his parked truck and walking along the side of the building. At 12:32 AM Patient #1 can be seen walking away from his parked truck and up the ramp at the EMS entrance to the ED. At 12:34 AM Patient #1 can be seen walking back down the ramp at the EMS entrance and Security Officer #3 can be seen speaking with Patient #1 briefly. At 12:35 AM Patient #1 can be seen entering his truck and driving out of the ED parking lot.

Review of video from a motion detected camera near the dirty dock area on 11/26/2022 at 12:38 AM (5 minutes after leaving the ED parking lot) Patient #1 can be seen walking into the loading dock area and behind a trash compactor. The loading dock area was identified as the basement of the building that houses the hospital ED. Video from inside the basement of the building at 12:39 AM and 12:40 AM revealed Patient #1 walking in the basement level of the hospital building that housed the ED.

Review of video of the ED on 11/26/2022 at 1:48 AM, revealed RN #4 seated at the nursing station talking with Security Officer #1 who was standing near the desk. At 1:49 AM RN #4 and Security Officer #1 can be seen turning to look towards the other end of ED. At 1:49 AM RN #4 and Security Officer #1 walk towards the stairwell door and appear to open the door. At 1:50 AM RN #4 is seen jogging back toward the front of the ED. At 1:51 AM staff are no longer visible and no patients are visible in the video. At 1:54 AM- staff can be seen rolling hospital beds and a large warming blanket cart in front of the stairwell door. At 1:55 AM RN #4 walks into camera view and appears to be talking on a cellular phone. At 1:57 AM 3 police department officers can be seen entering the back of the ED through the EMS entrance. At 1:58 AM- RN #4 can be seen picking up the desk telephone and making several different calls, she also appears to be using her cellular phone simultaneously. At 2:01 AM the local police (multiple officers) can be seen entering the ED. At 2:04 AM Patient #1 can be seen in handcuffs being escorted out of the ED EMS entrance in the custody of local police department. Patient #1 was not injured.

Review of the audio call to Operator #1 from RN #4 on 11/26/2022 at 1:59 AM revealed,"Hey its [named RN #4] over here at [named hospital campus] ED- I'm letting you know we have an active shooter within the hospital on the floor, [named police department] and security is aware and are on scene and we want you guys to be safe..." The Operator #1 responded "Okay bye."

4. Review of the hospital security report submitted on 12/1/2022 at 2:24 AM, revealed "on 11/26/2022 at approx. [approximately] 0150 [1:50 AM] I [named Security Officer #1] along with several ER [emergency room] staff heard loud noises coming from the stairwell near Chest Pain area. Once opening stairwell door and walking up, the charge nurse [RN #4] yells out for a response. I looked up the stairwell and seen a male figure yelling back and stated 'help help don't come up', then two loud bangs went off I then went through the 2nd floor stairwell door and called dispatch. Once notifying dispatch, I notified [named Security Supervisor #1] of the situation. [Security Supervisor #1] and I proceeded to the elevators to the 3rd floor, then proceed towards the stairwell. Once we arrived, [Security Supervisor #1] opened the door [to stairwell] and called out for any responses. Subject yells 'don't come up active shooter, I need help I need the FBI'. Then [Security Supervisor #1] and I drew our firearms. Subject was stuck at the top stairwell which is the 4th floor and we secured the 3rd floor stairwell. That's when [named police department] arrived on scene and made contact with the subject. [named Security Officer #2 and Security Officer #3] followed up the stairwell behind [police department]... subject was arrested taken by [police department]. Dispatch was notified. Upon further investigation with the use of cameras, the subject was identified [named Patient #1]... was discharged at approximately 11:55 PM. [Patient #1] was seen lingering around the ambulance bay near his vehicle. [Patient #1] then made contact [spoke] with [named Security Officer #3] at 12:36 AM at the ambulance entrance door. [Patient #1] then left in his white truck off the premises. [Patient #1] then parked in the North tower parking lot, then proceeded towards the B dock. He maneuvered through the laundry room and then entered the stairwell near the ER. All doors were card accessed, so [Patient #1] couldn't get into any doors... was stuck at the 4th floor door where he was trying to shoot the lock off with his firearm..."

5. In an interview on 12/6/2022 at 9:08 AM the hospital Chief Operating Officer (COO) stated Patient #1 gained access to the hospital building (where ED is located) at the dirty loading dock (basement level) because the third rolling door in front of the trash compactor was left open. The COO stated the hospital learned how patient #1 gained access after the shooting incident. When asked if the door should have been left open, he stated, "No it should not have." The COO stated the building had 4 floors: Floor one- ED, Floor two- CT/Diagnostic area, Floor three- surgical area for Obstetrics caesarian sections, Floor four- roof access. The COO verified Patient #1 gained access from the basement level/loading docks of the Building, entered the stairwell and climbed to the fourth floor level (roof access). The COO stated there was no way to enter the hospital from the stairwell with out badge access.

In an interview on 12/6/2022 at 9:33 AM the Risk Manager (RM) stated Patient #1 gave a alias when he registered with the ED on 12/25/2022 and the hospital did not know it was an alias until the police located his identity when he was apprehended

In an interview on 12/6/2022 at 9:38 AM, the Manager of Security stated after the incident, his staff reviewed all camera footage on the exterior of the ED to determine where Patient #1 breached the hospital premises. The Manager of Security stated Patient #1 was seen on camera on the back exterior corridor of the ED at approximately 12:31 AM. The Manager of Security stated this was the back side of the ED and only maintenance, security or facilities staff would be in this area. He verified this was not a staff entrance area. The Manager of Security stated the next time Patient #1 was identified in camera review was at 12:38 AM on the motion activated camera in the dirty dock area of the Ford building. The Manager of Security stated, "EVS [environmental services] goes in and out constantly and we found out they have been leaving it [doors] open..." The Manager of Security stated they determined Patient #1 was in the basement area approximately 45 minutes, based on the time the shots were initially fired. The Manager of Security stated Patient #1 somehow found his way to the stairwell. The Manager of Security verified there was no video footage of the stairwell. The Manager of Security stated Patient #1 made his way to the fourth floor in the stairwell, the roof access, but was unable to open the door because it required badge access. The Manager of Security stated the ED staff heard a gunshot sound and the ED Charge nurse (RN #4) and Security Officer #1 opened the ED door to the stairwell and yelled up to see what was happening. The Manager of Security stated Patient #1 yelled back "Help me, help me, active shooter". The Manager of Security stated RN #4 then backed out of the doorway and went to secure and keep safe everyone in ED, called the local police- 911 and "called all the floors when didn't hear the Code Silver go out." When the surveyor asked why a Code Silver was not issued for the hospital property, the Manager of Security stated the policy at the time of the incident required an Administrator on call (AOC) or Security to issue a Code Silver. The COO who was also present in this interview stated, "that policy has since been changed." When asked how his security staff responded to the incident, the Manager of Security stated Security Officer #1 stayed in the stairwell with his weapon drawn. He stated when Security Supervisor #1 arrived in the stairwell, Security Officer #1 and Security Supervisor #1 moved to the third level of the stair well with their weapons drawn and waited in the local police to arrive. The Manager of Security stated his security staff did not engage with Patient #1 because that is what they have been trained to do. The Manager of Security stated 2 other Security Officers responded (Security Officer #2 and #3) but remained on the first-floor level of stairwell near the ED. The Manager of Security stated the police department responded quickly and all clear was called 6 minutes later because Patient #1 was in custody. The Manager of Security verified the rolling door should not have been open where Patient #1 gained access to the hospital.

In an interview on 12/6/2022 at 9:45 AM, the COO stated when he rounded the hospital property, after the incident with Patient #1, between 3:15 AM to 3:30 AM, the third rolling door at the dirty dock door was still open.

6. Observations of the ED on 12/6/2022 at 11:05 AM revealed security was stationed at a desk near the the walk-in entrance of the ED. The Manager of Security stated all visitors and patients were required to empty their pockets and stand in front of the metal detector and slowly rotate in a circle. The Manager of Security demonstrated the process and the light feature turned red as he was turning. The Manager of Security stated if the detector turns red at any point, the Security staff ask the person to be sure all items were removed from their person, and then direct them to return to the metal detector. The Manager of Security further stated if the light turned red a second time, the Security officer would use the hand metal detector wand prior to the patient entering the ED.

Observations of the building where Patient #1 gained access on 12/6/2022 at 11:10 AM revealed the loading dock area gave access to a stair well with 5 floors (Basement level to Level 4). There was a door at the mezzanine level of the stairwell that could be exited to the outside only. Observations of Levels 1-4 revealed the doors were locked and only Security, Maintenance or Senior Leadership had access to those areas. Observations on floor 4 revealed damage to the door where Patient #1 had fired shots, but the door had been repaired.

7. In an interview on 12/6/2022 at 12:10 PM, while reviewing changes to the Silver Phase policy, the Facilities Director stated there had been an internal policy with Operations (PBX the communication system within the hospital) that required an AOC or Supervisor to initiate a Phase Silver and that was why the Phase Silver was not sent out on 11/26/2022 when the shooter was discovered. The surveyor asked to speak to the Director of Operations/ PBX.

In an interview on 12/6/2022 at 12:15 PM the Associate Chief Financial Officer (ACFO) stated the PBX/ Operations department was under his direction. The ACFO stated in the internal PBX/ Operations policy for Phase Silver had an amendment that documented an AOC had to approve the call for Phase Silver. When asked who made the amendment, the ACFO stated he was unable to determine who made the addendum to the policy. When asked if the amendment to this policy was approved by hospital administration/governing body, the Performance Improvement Manager stated the amended policy was not approved and the policy should not have been changed. The surveyor verified that because an AOC did not nitrify the Operator on 11/26/2022 of an active shooter situation, the Operator did not issue a Phase Silver for the hospital over the intercom system. The CFO verified because a Phase Silver was not issued over the intercom system, other area of the hospital were not aware of the potential danger of the active shooter. In a subsequent interview with the CFO at 2:17 PM, he stated the amended policy had been in place for at least 15 years, before he was employed by the hospital. The CFO stated that had been the procedure for Operators to follow- only call a Phase Silver if instructed to by an AOC or Security, but since this incident all Operations staff had been trained on the appropriate Phase Silver procedure.

In an interview on 12/6/2022 at 3:25 PM, the surveyor viewed the video footage from Patient #1 entering the ED at 10:10 PM, with the Manager of Security and the COO present. The surveyor asked why Patient #1 was not prompted to empty his pockets a second time, scanned a second time by the standup detector and then wanded by Security Officer #4 if the metal detector light turned red. The Manager of Security verified Security Officer #4 did not follow the appropriate protocol. The Manager of Security stated he had only reviewed the video earlier in the day after the surveyor requested to watch all video from Patient #1's 11/25/2022 ED visit. The Manager of Security stated, "oversight on our part...we were focused on the shooting incident...didn't review the footage of Patient #1 [in ED]..." The Security Manager stated Security Officer #4 employment had been terminated after reviewing the video.

In an interview on 12/7/2022 at 8:30 AM, the surveyor asked the RM if the hospital had determined who in Environmental services left the door open at the dirty dock on 11/26/2022 when Patient #1 breached the building. The RM stated, "I haven ' t gotten a timeline from EVS [environmental services]...so I haven't interviewed EVS yet." The surveyor requested to speak with the EVS employee who was working in the basement area when Patient #1 accessed the building through the unsecure rolling door.
In an interview with the use of an Arabic translator on 12/7/2022 at 8:36 AM, EVS Trash Technician #1 verified he was working 11 PM on 11/25/2022 through 7 AM on 11/26/2022 and he had been employed for 2 years. EVS Trash Technician #1 stated his job duties were to take trash to the compactor [just outside the dirty dock in front of the third rolling door], organize boxes and in early morning collect trash from the ED. EVS Trash Technician stated he had been instructed since he worked here to close the doors after use, and further stated he did not leave the door open. He stated, "Whenever I see open door, I close it..." When asked what time he went to the trash compactor during his shift beginning 11/25/2022, he stated he did not recall. When asked if he ever found the rolling doors open/unsecure, he stated, "Maybe at daytime, but not at night." EVS Trash Technician #1 further stated he did not use the rolling doors to take trash to the compactor he used the walk-through door. When asked again if he recalled the rolling door left open on 11/26/2022, he stated "I don't remember."

In an interview on 12/7/2022 at 9:03 AM with the Manager of EVS stated the Trash Technicians collect all the trash and take it to the basement. When asked if he had determined who left the third rolling door open on 11/26/2022, he stated, "No, but we've trained them [to keep doors secure] now." The surveyor asked to see documentation of the EVS training. The Manager of EVS stated the training would be completed 12/8/2022 and 12/9/2022.

In a telephone interview on 12/7/2022 at 12:40 PM, ED Physician #1 verified he provided care to Patient #1 on 11/25/2022. Physician #1 stated Patient #1 had no identified psychiatric concerns and had presented with chest pain which the physician attributed to heartburn after EKG and Chest Xray were normal. Physician #1 stated the patient did ask to go out and water his dog but came immediately back to the ED. Physician #1 stated Patient #1 was discharged without incident. Physician #1 stated "Next thing I know I was at desk, and I hear gunshots 25 feet away ..." Physician #1 stated RN #4 immediately started making calls and securing patients.

In a telephone interview on 12/7/2022 at 12:48 PM, Security Officer #4 stated she had worked with the Security at ED entrance/Metal Detector for 10 months. Security Officer #4 verified on 11/25/2022, when Patient #1 entered the ED, she did not she did not ask Patient #1 to be sure his pockets were empty and send him back to the standing metal detector after the detector turned red to indicate a problem. Security Officer #4 verified she did not use the handheld wand on Patient #1 before he entered the ED. When asked why she did not follow the protocols, Security Officer #1 stated "I was not informed you need to wand...I wasn't given a lot of information...not fully trained..." The surveyor requested Security Officer #4's orientation and training for the metal detector. On 12/12/2022 at 11:05 AM the Manager of Security and Cooperate Director of Security for the hospital stated there was no documentation Security Officer #4 had been trained on the "Metal Detector/Wanding Procedures."

8. The surveyor requested the police report for the incident leading to Patient #1's arrest via email on 12/9/2022. On 12/12/2022 at 7:40 AM the request was denied via email. The denial reason listed: Open case/charges pending: Report is not releasable at this time.

9. In an interview on 12/12/2022 at 9:30 AM the surveyor listened to the audio call from RN #4 to Operator #1, with the Manager of Performance Improvement (PI) and RM present. The RM verified RN #4 called the Operator at 1:59 AM. Patient #1 was initially discovered in the stairwell on 11/26/2022 at 1:49 AM, according to the video footage provided by the hospital. The Manager of PI and RM verified there was a delay in RN #4 calling the Operator to report the active shooter.

In a telephone interview on 12/12/2022 at 10:00 AM, RN #4 stated she was the ED Charge Nurse on 11/26/2022. RN #4 stated she initially heard a loud noise from the stairwell that sounded like metal hitting metal. RN #4 verified she and Security Officer #1 walked to the stairwell and opened the door. RN #4 stated she heard someone say, "Active shooter". RN #4 stated she never saw Patient #1. RN #4 stated she stepped out of the stairwell and informed staff. RN #4 stated ED staff started to barricade doors and secure patients because she was unsure if there was more than one shooter, and she started making phone calls. RN #4 stated as best she could recall, she called 911 first, called her House Supervisor second and called the Operator third. RN #4 could not recall the time she called the Operator. When asked if the Operator called a Phase Silver over the intercom, RN #4 stated she did not recall hearing it- and she does not know if it was paged. RN #4 stated she and her nursing staff started calling all the hospital floors to be sure they were aware of the active shooter.

In an interview on 12/12/2022 at 10:30 AM, Security Officer #1 stated he had been employed with hospital security since July 2022. He verified he was working security in the ED on 11/26/2022. Security Officer #1 stated he heard 3 loud noises from the stairwell area which sounded like something loud falling. He stated he and RN #4 went to the stairwell and when he entered the stairwell he walked from the first level up to the second level and he saw a figure looking down at him from above. He stated the figure said, "I need help please, don't come up" and he heard 2 more loud noises. He stated RN #4 left the stairwell and returned to the ED. Security Officer #1 stated he reported to his Supervisor and Dispatch the situation. Security Officer #1 stated Security Supervisor #1 came to assist. Security Officer #1 stated they could smell smoke from the firearm, and he and Security Supervisor #1 upholstered their weapons and remained at the door of the stairwell on the third floor level, until the local police department arrived and took Patient #1 into custody without incident.

In an interview on 12/12/2022 at 10:40 AM, Security Supervisor #1 stated he had been employed with hospital security for one year. Security Supervisor #1 stated when he arrived to assist Security Officer #1 in the stairwell, he called up to announce himself and he heard Patient #1 reply "I need the FBI." Security Supervisor #1 stated he could smell gunpowder when he entered the stairwell. Security Supervisor #1 stated Patient #1 attempted to start walking down the stairs and Security Supervisor #1 directed him to stay upstairs, and Patient #1 complied. Security Supervisor #1 stated 3 local police department officers arrived and the proceeded up to the fourth-floor level where Patient #1 surrendered without a fight.

In an interview on 12/12/2022 at 10:44 AM, Security Officer #2 stated the dispatcher alerted over the radio of a potential shooter near the ED. Security Officer #2 stated he and Security Officer #3 made their way to the ED. Security Officer #2 verified Security Officer #3 was in orientation and Security Officer #2 was showing him around the hospital grounds on 11/26/2022. Security Officer #2 stated he and Security Officer #3 remained on the second level stairwell and the local police arrived and took lead to apprehend Patient #1. Security Officer #2 verified he had seen Patient #1 lingering in the ED parking lot near his truck, earlier in his shift, and he monitored Patient #1 but did not approach him.

In an interview on 12/12/2022 at 10:51 AM Security Officer #3 stated that 11/25/2022 was his second day of employment with hospital security. Security Officer #3 stated Patient #1 lingered in the ED parking lot after his discharge from the ED and he and Security Officer #2 monitored the area. Security Officer #3 stated Patient #1 walked up to the EMS entrance area and appeared to be on his cellular phone. Security Officer #3 stated he told Patient #1 he had been discharged from the ED and he could not remain on the property. Security Officer #3 stated Patient #1 then got in his truck and "sped off like he was mad" (Review of the video footage did not reveal Patient #1 speeding from the ED parking lot). Security Officer #3 stated he and Security Officer #2 responded to the dispatch call for a possible shooter in the ED. Security Officer #3 stated he did not engage with Patient #1 in the stairwell and the local police arrived and took the lead.