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Based on record review, document review and staff interview it was determined the hospital failed to ensure patient care was given in a safe setting (see Tag A 144); and, failed to ensure the patient remained free from abuse (see Tag A 145).

A. An Immediate Jeopardy (IJ) to the supervision of nursing care and Abuse and Neglect. The Emergency Department staff and physician heckled and mocked a psychiatric patient and squirted her with a syringe and told the patient it was holy water. An IJ was called on 04/03/19 at 9:50 a.m.

B. Harm or Potential Harm: The patient was discharged from the hospital without any medical care and was removed by security and placed in the Emergency Room waiting room even though she was documented as having altered mental status and no family member was aware she was in the hospital.

C. Immediacy: Although the physician has been placed on a Formal Performance Improvement plan upon entrance for this survey, the other emergency personnel had not been removed from patient care until the completion of an investigation. The hospital at the time of entrance had not declared the incident to be abuse and neglect.

An immediate Plan of Correction was received and sent to the State Agency program directors. It was accepted and the facility abated the IJ on 04/03/19 at 1:20 p.m.

Based on record review, video review and staff interview it was determined the Director of the Emergency Department (ED) failed to ensure care was given in a safe setting in one (1) of one (1) patient records reviewed (patient #1). This failure has the potential for all patients who wish to receive care in the ED to receive substandard care.

Findings include:

1. Review of the medical record for patient #1 revealed the patient arrived at the ED via ambulance on 03/23/19 at 4:52 a.m. and was triaged by Charge Nurse #1; the nurse documented the patient's skin was cold to touch and heated blankets were applied. The patient's temperature upon triage was documented at 97.5 degrees Fahrenheit. Physician #1 documented: "Complaint of altered mental status that a few minutes later she stated, "Fell off a porch". EMS states the patient was running from the police...No loss of consciousness from her fall per EMS. The patient repeatedly states that she is dehydrated and "wants put on life support". Full history of present illness is unobtainable from patient secondary to altered mental status and unwillingness to talk. Full review of systems is unobtainable from patient secondary to altered mental status. History: Bipolar disorder, Post-traumatic stress disorder and Schizoaffective disorder, bipolar type. A normal head to toe assessment is completed as normal. Electrocardiogram (EKG) is documented as bradycardia. Review of old records available with a note from psychiatry...doing well. 5:24 a.m. patient is agreeable to treatment plan at this time. 5:43 a.m. Patient is refusing all evaluation and care that I was trying to offer. Does not appear to be any sign of emergent medical condition. I will let patient leave. Patient is to return here to the Emergency department if she changes her mind or if new or worsening symptoms appear. The patient is in stable condition at the time of discharge." At 5:25 p.m. registered nurse (RN) #1 documented, "patient awake and talking non sense. States she wants placed on life support... Demanding critical care because she is a critical patient. Physician is at bedside attempting to assess patient. States, she "wants on life support so she can talk to her son."...States, "She fell off porch and broken multiple bones"...Patient has stopped talking to us. Heart rate between 40-50. Walked into room to draw blood and patient keeps talking to her lord. Saying we are the devil and she will not allow us to do anything to her. Doctor in room. Patient continuous to refuse treatment. Patient is ready for discharge. 6:03 a.m. patient refuses to leave room...Security called to escort patient to waiting room. Called her father who is on her contact list unable to get in contact with him. Left a message. Patient in waiting room." There was no written documentation in the medical record of refusal of treatment from patient or patient representative.

2. When the patient arrived at 04:42 a.m. EMS gave verbal report to the Charge nurse, which included the patient had been out in the cold since 12:30 a.m., was running from the police and fell.
A review of a telephone recording on 03/23/19 of emergency medical personnel calling a report to the ED, 20 minutes after the patient's arrival, revealed she had hypothermia and suffered a two (2) story fall and was not upgraded to a P2 trauma at that time.

3. A review of video of 03/23/19 from 4:42 a.m. through 5:15 a.m., in the presence of security who is also explaining the hospital personnel when asked, revealed in part: The patient can be seen being taken to an ED room at 4:42 a.m. Charge Nurse #1 can be seen going into the room with the emergency medical personnel. At 4:46 p.m. Physician #1 can be seen going into the room and then exiting and going down the hallway. He returns from the hallway and appears to have a syringe in his hand that he is showing to the staff at the nursing station. He re-enters the patient's room and nine (9) staff members surround the patient's room, looking into the room, and appear to be laughing while observing the inside of the patient's room. The physician comes out of the room and appears to be laughing, then sits down and continues to appear to laugh. Employees can be seen going to the patient's room doorway and their mouths moving and what appears to be laughing as other personnel are at the nurse's station laughing. The patient is discharged at 6:05 a.m. and escorted by wheelchair to the ED waiting room by security.

4. A telephone interview was conducted on 04/02/19 at 7:43 a.m. with Charge Nurse #1. When asked if she remembered patient #1 and her interaction with the patient, and if so please describe, she stated in part, "We got her in and I am the nurse who triaged her. She didn't say anything and wouldn't answer my questions. She did eventually tell us her medications with dosages." When asked if she was present for the physician squirting holy water on the patient, she stated in part, "A few people were standing around when he squirted her and they were laughing and he was laughing; I just walked away." When asked if she knew the patient had a second story fall, she stated in part, "No, I would have made her a trauma if I knew she fell from a 2nd story deck."

5. A telephone interview was conducted with Physician #1 on 04/02/19 at 9:44 a.m. The Chairman of the ED was present for the interview. When asked to explain his interaction with patient #1, he stated in part, "She came in after running from the police and bizarre behavior. She was reluctant to talk to me. She felt her primary issues were dehydration, life support and she hurt everywhere. She couldn't say where she hurt though. Her vital signs were normal and she did allow us to do labs and they were normal. An EKG did show a low heart rate but, she refused care and she didn't want to be there. She was hyper-religious and was calling the techs the devil. She kept escalating and I was afraid I was keeping her against her will. She was determined to leave. I felt she had capacity because when she would talk she answered my questions. I feel like I did an adequate medical screening before she was discharged." When asked if he squirted the patient with a syringe and told her it was holy water, he stated in part, "I did take a syringe in her room and squirted some water on her chest and told her it was holy water and she calmed down. I didn't do it for any mean reason, but in hindsight it was a poor decision. I've already been called in and this was discussed with me." When asked if he had been placed on an action plan for the care of patient #1, he stated in part, "Yes, I am on a focal performance improvement plan."

6. An interview was conducted with the Chairman of the ED on 04/02/19 immediately following the interview with physician #1. When asked if physician #1 was on a performance improvement plan, he stated in part, "He is on a focal performance improvement plan that has three (3) parts to it and it includes compliance and a course on sensitivity for psychiatric patients."

7. An interview was conducted on 04/02/19 at 12:13 p.m. with Registration Clerk #1. When asked to describe her interaction with patient #1, she stated in part, "Well, I was in the ER [Emergency Room] when they brought the patient in and the nurses were laughing at her because she kept talking about Satan and wanting to be intubated to talk to her son. The physician walked into the room and squirted her with holy water from a syringe and everyone stood at the door and laughed at her. I thought it was horrible. They discharged her and put her in the waiting room. I was in the main registration at that point and the patient was talking about religion and scaring the other patients and we called back into the ER and asked for her to be seen and I was told by the charge nurse she isn't coming back here again. She's discharged, call the police. So, I contacted the police and when the police officer came, he demanded the patient to be seen again and was told she was discharged. He demanded to talk to the charge nurse and even said he'd arrest the patient so she could get medical clearance if necessary, but it was clear to him the patient needed medical care. The charge nurse came out, talked to the police and then we registered her to be seen. The night shift nurses laughed at her and made fun of her. They stood outside of her door and would yell 'Hallelujah' and 'Praise God'. That is not right, and I tried to report it but they told me I was blowing it out of proportion."

8. An interview was conducted on 04/02/19 at 12:17 p.m. with RN #3. When asked to explain her interaction with patient #1, she became tearful and stated in part, "During report we were told about the physician squirting water on the patient and telling her it was holy water and that she was healed and that the staff was laughing at her and yelling 'Praise to God' and 'Hallelujah' into her room. It is terrible what they did to this patient. No patient should be treated the way she was treated." When asked if the patient was denied to be re-evaluated in the emergency room after her arrival to work at 7:00 a.m., she stated in part, "Yes, I came into work and we were told she had been seen on nightshift and she was still sitting in the lobby. The triage nurse called back and insisted the patient be re-seen and the dayshift charge nurse told her she had already been seen and she wasn't coming back." When asked if she heard that for herself or was told that information, she stated in part, "I was standing right beside of her when she told the triage nurse she had 'already been evaluated and discharged, she's not coming back here'. The triage nurse called back again and asked the charge nurse to go to the waiting room and talk to the police."

9. An interview was conducted on 04/02/19 at 4:20 p.m. with Corporal #1 of the Martinsburg Police Department. When asked if he remembered the patient, and if he did could he explain his contact with the patient, he stated in part, "Yes, I got a call to come pick up the patient for disturbance. I was going to take her home. When I arrived at the ED, I initially went to see where the patient was and when I went to the patient, she was cold to touch and unresponsive to me touching to her and talking to her. I remember thinking this patient has died in their emergency room and no one even knows. I went to the desk and asked for the patient to be seen; they said they were told she refused to be examined and they won't let her back in the ED. I took the patient outside to put her in my car to take her home and another officer helped me stand her up and she screamed "I am broken". I looked at her body and her left hip was bulged. I took her back into the ED and demanded she been seen; the nurse called back to the ED and was told the patient was already discharged and that she wasn't getting re-seen. I told them if I had to arrest her to get medical clearance I would because something was clearly wrong with the patient and she needed medical treatment. I asked to speak to the charge nurse and when she came out I told her the patient was going to be examined and she initially told me she had already been discharged and wasn't going to be seen. I then told her the patient had a two (2) story fall in the presence of another officer and she needs at least X-rays because she clearly has a medical problem. The nurse stated they didn't know it was a two (2) story fall and then took the patient back into the ED.

10. Review of a body cam video of Corporal #1 revealed the officer arrived at the hospital at approximately 9:40 a.m. and went to the triage station (this part of the video has no voice recording). He then went to the patient and tried to talk to her, but the patient does not move. He continues to talk to the patient and takes the wheelchair outside to his police car. The patient begins to talk in religious overtones. Eleven (11) minutes and nine (9) seconds into the video the officer, with the help of another officer, stands the patient up and she screams "My leg is broken" and she will not move. He sits the patient back down and takes her back into the ED waiting room. He tells the people at the desk that the patient needs to be re-seen and he is told they have tried, and they refuse to see her. The triage nurse picks up the phone and makes a phone call and then tells the officer that they say she has already been seen and discharged. Thirteen (13) minutes and forty (40) seconds into the video the Corporal tells the desk staff, "You either check her in as a patient or as a prisoner, but one way or another she is going to be seen. She obviously needs medical attention." The staff still are telling him there is nothing they can do and the ED refuses to see her. He then asks for the charge nurse. The charge nurse arrives in the waiting room at seventeen (17) minutes into the video. She is telling the Corporal the patient has already been seen and discharged. The officer tells the nurse, "When I arrived, she was cool to touch and unresponsive; I thought she was dead in your ED and you didn't even know it. She had a two (2) story fall last night that was visualized by another officer. She needs medical attention and if I have to handcuff her to a bed we aren't leaving until she gets it." The patient is taken into the ED at eighteen (18) minutes into the video.

11. An interview was conducted on 04/02/19 at approximately 2:00 p.m. with the Director of Compliance. Although she was not present for the interviews, she concurred that her understanding is the physician did squirt the patient with a syringe and tell her it was holy water and that the staff did laugh at the patient.

Based on record review, policy review, video review and staff interview it was determined Charge Nurse #1, failed to ensure a patient remained free from mental abuse in (1) of one (1) records reviewed.(Patient #1) This failure has the potential for all patients who wish to receive care in the emergency department may be mentally abused by the emergency department staff.

A. An immediate jeopardy to the emergency department (ED) staff and physician, heckled and mocked a psychiatric patient and squirted her with a syringe and told the patient it was holy water. An immediate Jeopardy was called on 04/03/19 at 9:50 a.m.

B. Harm or Potential Harm: The patient was discharged from the hospital without any medical care and was removed by security and placed in the Emergency Room waiting room even though she was documented as having altered mental status and no family member was aware she was in the hospital.

C. Immediacy: Although the physician has been placed on a Formal Performance Improvement plan upon entrance for this survey the other emergency personnel had not been removed from patient care until the completion of an investigation. The hospital at the time of entrance had not declared the incident to be abuse and neglect.

An immediate plan of correction was received and sent to the state agency program directors. It was accepted and the facility abated on 04/03/19 at 1:20 p.m.

Based on record review, video review and staff interview it was determined the Director of the Emergency room failed to ensure care was given in a safe setting in one (1) of one (1) patient #1 records reviewed. This failure has the potential for all patients who wish to receive care in the emergency department to receive substandard care.

A. An immediate jeopardy to the emergency department (ED) staff and physician, heckled and mocked a psychiatric patient and squirted her with a syringe and told the patient it was holy water. An immediate Jeopardy was called on 04/03/19 at 9:50 a.m.

B. Harm or Potential Harm: The patient was discharged from the hospital without any medical care and was removed by security and placed in the Emergency Room waiting room even though she was documented as having altered mental status and no family member was aware she was in the hospital.

C. Immediacy: Although the physician has been placed on a Formal Performance Improvement plan upon entrance for this survey the other emergency personnel had not been removed from patient care until the completion of an investigation. The hospital at the time of entrance had not declared the incident to be abuse and neglect.

An immediate plan of correction was received and sent to the state agency program directors. It was accepted and the facility abated on 04/03/19 at 1:20 p.m.

1. . Review of the medical record for patient #1, revealed the patient arrived at the Emergency Department via ambulance on 03/23/19 at 4:52 a.m. was triaged by charge nurse #1, with documentation patient skin cold to touch heated blankets applied. Temperature upon triage is documented at 97.5 degrees Fahrenheit. Documentation by physician #1, is as follows: Complaint of altered mental status that a few minutes later she stated, "Fell off a porch". EMS states the patient was running from the police...No loss of consciousness from her fall per EMS. The patient repeatedly states that she is dehydrated and "wants put on life support". Full history of present illness is unobtainable from patient secondary to altered mental status and unwillingness to talk. Full review of systems is unobtainable from patient secondary to altered mental status. History: Bipolar disorder, Post-traumatic stress disorder and Schizoaffective disorder, bipolar type. A normal head to toe assessment is completed as normal. Electrocardiogram (EKG) is documented as bradycardia. Review of old records available with a note from psychiatry...doing well. 5:24 a.m. patient is agreeable to treatment plan at this time. 5:43 a.m. Patient is refusing all evaluation and care that I was trying to offer. Does not appear to be any sign of emergent medical condition. I will let patient leave. Patient is to return here to the Emergency department if she changes her mind or if new or worsening symptoms appear. The patient is in stable condition at the time of discharge. 5:25 p.m. Registered Nurse #1 documented, patient awake and talking none sense. States she wants "placed on life support... Demanding critical care because she is a critical patient. Physician is at bedside attempting to assess patient. States, she "wants on life support so she can talk to her son."...States, "She fell off porch and broken multiple bones"...Patient has stopped talking to us. Heart rate between 40-50. Walked into room to draw blood and patient keeps talking to her lord. Saying we are the devil and she will not allow us to do anything to her. Doctor in room. Patient continuous to refuse treatment. Patient is ready for discharge. 6:03 a.m. patient refuses to leave room...Security called to escort patient to waiting room. Called her father who is on her contact list unable to get in contact with him. Left a message. Patient in waiting room. No written documentation in the medical record of refusal of treatment from patient or patient representative.

2. Review of the policy titled "Abuse and Neglect" with a last revision date 7/18 states in part, Definition "Mental Abuse: Includes humiliation, harassment, and threats of punishment or deprivation... All patients identified as an alleged or suspected victim of abuse will be referred to the DHHR by the person with firsthand information.

3. When the patient arrived at 04:42 a.m. EMS gave verbal report to the Charge nurse, which included the patient had been out in the cold since 12:30 a.m., was running from the police and fell.
A review of a telephone recording on 03/23/19 of emergency medical personnel calling a report to the ED, 20 minutes after the patient's arrival, revealed she had hypothermia and suffered a two (2) story fall and was not upgraded to a P2 trauma at that time.

4. A review of video of 03/23/19 from 4:42 a.m. through 5:15 a.m. in the presence of security who is also explaining the hospital personnel when asked revealed in part. The patient can be seen being taken to an Emergency Department (ED) room at 4:42 a.m. Charge nurse #1, can be seen going into the room with the emergency medical personnel. At 4:46 p.m. Physician #1 can be seen going into the room and then exiting and going down the hallway. He returns from the hallway and appears to have a syringe in his hand that he is showing to the staff at the nursing station. He re-enters the patient's room and nine (9) staff members surround the patients room looking into the room and appear to be laughing while observing the inside of the patients room the physician comes out of the room and appears to be laughing, he then sits down and continues to appear to laugh. Employees can be seen going to the patients room doorway and their mouths moving and what appears to be laughing as other personnel are at the nurses station laughing. The patient is discharged at 6:05 a.m. and escorted by wheelchair to the ED waiting room by security.

5. A telephone interview was conducted on 04/02/19 at 7:43 a.m. with Charge nurse #1. When asked if she remembered patient #1 and her interaction with the patient and if so please describe she stated in part, "We got her in and I am the nurse who triaged her. she didn't say anything and wouldn't answer my questions. She did eventually tell us her medications with dosages. When asked if she was present for the physician squirting holy water on the patient she stated in part, "A few people were standing around when he squirted her and they were laughing and he was laughing I just walked away." When asked if she knew the patient had a second story fall she stated in part, "No, I would have made her a trauma if I knew she fell from a 2nd story deck."

6. A telephone interview was conducted with physician #1 on 04/02/19 at 9:44 a.m. the Chairman of the ED was present for the interview. When asked to explain his interaction with patient #1 he stated in part, "She came in after running from the police and bizarre behavior. She was reluctant to talk to me. She felt her primary issues were dehydration, life support and she hurt everywhere. She couldn't say where she hurt though. Her vital signs were normal and she did allow us to do labs and they were normal. An EKG did show a low heart rate but, she refused care and she didn't want to be there. She was hyper-religious and was calling the techs the devil. She kept escalating and I was afraid I was keeping her against her will. She was determined to leave. I felt she had capacity because when she would talk she answered my questions. I feel like I did an adequate medical screening before she was discharged." When asked if he squirted the patient with a syringe and told her it was holy water he stated in part, "I did take a syringe in her room and squirted some water on her chest and told her it was holy water and she calmed down. I didn't do it for any mean reason but, in hindsight it was a poor decision. I've already been called in and this discussed with me." When asked if he has been placed on an action plan for the care of patient #1 he stated in part, "Yes, I am on a focal performance improvement plan.

7. An interview was conducted with the Chairman of the ED on 04/02/19 immediately following the interview with physician #1. When asked if physician #1 was on a performance improvement plan, he stated in part, "He is on a focal performance improvement plan that has three parts to it and it includes compliance and a course on sensitively for psychiatric patients.

8. An interview was conducted on 04/02/19 at 12:13 p.m. with registration clerk #1. When asked to describe her interaction with patient #1 she stated in part, "Well. I was in the ER when they brought the patient in and the nurses were laughing at her because she kept talking about Satan and wanting to be intubated to talk to her son. The physician walked into the room and squirted her with holy water from a syringe and everyone stood at the door and laughed at her. I thought it was horrible. They discharged her and put her in the waiting room. I was in the main registration at that point and the patient was talking about religion and scaring the other patients and we called back into the ER and asked for her to be seen and I was told by the charge nurse she isn't coming back here again. She's discharged call the police. So, I contacted the police and when the police officer came, he demanded the patient to be seen again and was told she was discharged. He demanded to talk to the charge nurse and even said he'd arrest the patient so she could get medical clearance if necessary but, it was clear to him the patient needed medical care. The charge nurse came out talked to the police and then we registered her to be seen. The night shift nurses laughed at her and made fun of her. They stood outside of her door and would yell "Hallelujah and praise god. That is not right, and I tried to report it but, they told me I was blowing it out of proportion."

9. An interview was conducted with Registered Nurse (RN) #3 on 04/02/19 at 12:52 p.m.. When asked to explain her interaction with patient #1, she became tearful and stated in part, She stated in part, "During report we were told about the physician squirting water on the patient and telling her it was holy water and that she was healed and that the staff was laughing at her and yelling Praise to God and Hallelujah into her room. It is terrible what they did to this patient. No patient should be treated the way she was treated.

10. An interview was conducted on 04/02/19 at approximately 2:00 p.m. with the Director of Compliance. Although she was not present for the interviews she concurred that her understanding is the physician did squirt the patient with a syringe and tell her it was holy water and that the staff did laugh at the patient.

Based on medical record review, record review, video monitoring review and staff interview it was determine the Director of the Emergency Department failed to ensure the Charge Nurse correctly supervised patient care. This failure has the potential for all patient who seek care in the Emergency Department to recieve subpar care. (See tag A-0395).

A. An immediate jeopardy to the emerengcy department (ED) staff and physician, heckled and mocked a psychiatric patient and squirted her with a syringe and told the patient it was holy water. An immediate Jeopardy was called on 04/03/19 at 9:50 a.m.

B. Harm or Potential Harm: The patient was discharged from the hospital without any medical care and was removed by security and placed in the Emergency Room waiting room even though she was documented as having altered mental status and no family member was aware she was in the hospital.

C. Immediacy: Although the physician has been placed on a Formal Performance Improvement plan upon entrance for this survey the other emergency personnel had not been removed from patient care until the completion of an investigation. The hospital at the time of entrance had not declared the incident to be abuse and neglect.

An immediate plan of correction was received and sent to the state agency program directors. It was accepted and the facility abated on 04/03/19 at 1:20 p.m.

Based on record review, video review and staff interview it was determined the Director of the Emergency room failed to ensure care was given in a safe setting in one (1) of one (1) patient #1 records reviewed. This failure has the potential for all patients who wish to recieve care in the emergency department to recieve substandard care.

A. An immediate jeopardy to the emerengcy department (ED) staff and physician, heckled and mocked a psychiatric patient and squirted her with a syringe and told the patient it was holy water. An immediate Jeopardy was called on 04/03/19 at 9:50 a.m.

B. Harm or Potential Harm: The patient was discharged from the hospital without any medical care and was removed by security and placed in the Emergency Room waiting room even though she was documented as having altered mental status and no family member was aware she was in the hospital.

C. Immediacy: Although the physician has been placed on a Formal Performance Improvement plan upon entrance for this survey the other emergency personnel had not been removed from patient care until the completion of an investigation. The hospital at the time of entrance had not declared the incident to be abuse and neglect.

An immediate plan of correction was received and sent to the state agency program directors. It was accepted and the facility abated on 04/03/19 at 1:20 p.m.

1. . Review of the medical record for patient #1, revealed the patient arrived at the Emergency Department via ambulance on 03/23/19 at 4:52 a.m. was triaged by charge nurse #1, with documentation patient skin cold to touch heated blankets applied. Temperature upon triage is documented at 97.5 degrees Fahrenheit. Documentation by physician #1, is as follows: Complaint of altered mental status that a few minutes later she stated, "Fell off a porch". EMS states the patient was running from the police...No loss of consciousness from her fall per EMS. The patient repeatedly states that she is dehydrated and "wants put on life support". Full history of present illness is unobtainable from patient secondary to altered mental status and unwillingness to talk. Full review of systems is unobtainable from patient secondary to altered mental status. History: Bipolar disorder, Post-traumatic stress disorder and Schizoaffective disorder, bipolar type. A normal head to toe assessment is completed as normal. Electrocardiogram (EKG) is documented as bradycardia. Review of old records available with a note from psychiatry...doing well. 5:24 a.m. patient is agreeable to treatment plan at this time. 5:43 a.m. Patient is refusing all evaluation and care that I was trying to offer. Does not appear to be any sign of emergent medical condition. I will let patient leave. Patient is to return here to the Emergency department if she changes her mind or if new or worsening symptoms appear. The patient is in stable condition at the time of discharge. 5:25 p.m. Registered Nurse #1 documented, patient awake and talking none sense. States she wants "placed on life support... Demanding critical care because she is a critical patient. Physician is at bedside attempting to assess patient. States, she "wants on life support so she can talk to her son."...States, "She fell off porch and broken multiple bones"...Patient has stopped talking to us. Heart rate between 40-50. Walked into room to draw blood and patient keeps talking to her lord. Saying we are the devil and she will not allow us to do anything to her. Doctor in room. Patient continuous to refuse treatment. Patient is ready for discharge. 6:03 a.m. patient refuses to leave room...Security called to escort patient to waiting room. Called her father who is on her contact list unable to get in contact with him. Left a message. Patient in waiting room. No written documentation in the medical record of refusal of treatment from patient or patient representative.

2. Review of the job title for the charge nurse states in part, "Supports the delivery of quality patient care by holding peers accountable to established patient care and regulatory standards.

3. When the patient arrived at 04:42 a.m. EMS gave verbal report to the Charge nurse, which included the patient had been out in the cold since 12:30 a.m., was running from the police and fell.
A review of a telephone recording on 03/23/19 of emergency medical personnel calling a report to the ED, 20 minutes after the patient's arrival, revealed she had hypothermia and suffered a two (2) story fall and was not upgraded to a P2 trauma at that time.

4. A review of video of 03/23/19 from 4:42 a.m. through 5:15 a.m. in the presence of security who is also explaining the hospital personnel when asked revealed in part. The patient can be seen being taken to an Emergency Department (ED) room at 4:42 a.m. Charge nurse #1, can be seen going into the room with the emergency medical personnel. At 4:46 p.m. Physician #1 can be seen going into the room and then exiting and going down the hallway. He returns from the hallway and appears to have a syringe in his hand that he is showing to the staff at the nursing station. He re-enters the patient's room and nine (9) staff members surround the patients room looking into the room and appear to be laughing while observing the inside of the patients room the physician comes out of the room and appears to be laughing, he then sits down and continues to appear to laugh. Employees can be seen going to the patients room doorway and their mouths moving and what appears to be laughing as other personnel are at the nurses station laughing. The patient is discharged at 6:05 a.m. and escorted by wheelchair to the ED waiting room by security.

5. A telephone interview was conducted on 04/02/19 at 7:43 a.m. with Charge nurse #1. When asked if she remembered patient #1 and her interaction with the patient and if so please describe she stated in part, "We got her in and I am the nurse who triaged her. she didn't say anything and wouldn't answer my questions. She did eventually tell us her medications with dosages. When asked if she was present for the physician squirting holy water on the patient she stated in part, "A few people were standing around when he squirted her and they were laughing and he was laughing I just walked away." When asked if she knew the patient had a second story fall she stated in part, "No, I would have made her a trauma if I knew she fell from a 2nd story deck."

6. A telephone interview was conducted with physician #1 on 04/02/19 at 9:44 a.m. the Chairman of the ED was present for the interview. When asked to explain his interaction with patient #1 he stated in part, "She came in after running from the police and bizarre behavior. She was reluctant to talk to me. She felt her primary issues were dehydration, life support and she hurt everywhere. She couldn't say where she hurt though. Her vital signs were normal and she did allow us to do labs and they were normal. An EKG did show a low heart rate but, she refused care and she didn't want to be there. She was hyper-religious and was calling the techs the devil. She kept esculating and I was afraid I was keeping her against her will. She was determined to leave. I felt she had capacity because when she would talk she answered my questions. I feel like I did an adequate medical screening before she was discharged." When asked if he squirted the patient with a syringe and told her it was holy water he stated in part, "I did take a syringe in her room and squirted some water on her chest and told her it was holy water and she calmed down. I didn't do it for any mean reason but, in hindsight it was a poor decision. I've already been called in and this discussed with me." When asked if he has been placed on an action plan for the care of patient #1 he stated in part, "Yes, I am on a focal performance improvement plan.

7. An interview was conducted with the Chairman of the ED on 04/02/19 immediately following the interview with physician #1. When asked if physician #1 was on a performance improvement plan, he stated in part, "He is on a focal performance improvement plan that has three parts to it and it includes compliance and a course on sensitivety for psychiatric patients.

8. An interview was conducted on 04/02/19 at 12:13 p.m. with registration clerk #1. When asked to describe her interaction with patient #1 she stated in part, "Well. I was in the ER when they brought the patient in and the nurses were laughing at her because she kept talking about Satan and wanting to be intubated to talk to her son. The physician walked into the room and squirted her with holy water from a syringe and everyone stood at the door and laughed at her. I thought it was horrible. They discharged her and put her in the waiting room. I was in the main registration at that point and the patient was talking about religion and scaring the other patients and we called back into the ER and asked for her to be seen and I was told by the charge nurse she isn't coming back here again. She's discharged call the police. So, I contacted the police and when the police officer came, he demanded the patient to be seen again and was told she was discharged. He demanded to talk to the charge nurse and even said he'd arrest the patient so she could get medical clearance if necessary but, it was clear to him the patient needed medical care. The charge nurse came out talked to the police and then we registered her to be seen. The night shift nurses laughed at her and made fun of her. They stood outside of her door and would yell "Halleluiah and praise god. That is not right, and I tried to report it but, they told me I was blowing it out of proportion."

9. An interview was conducted on 04/02/19 with Registered Nurse (RN) #3. When asked to explain her interaction with patient #1, she became tearful and stated in part, She stated in part, "During report we were told about the physician squirting water on the patient and telling her it was holy water and that she was healed and that the staff was laughing at her and yelling Praise to God and Halleluiah into her room. It is terrible what they did to this patient. No patient should be treated the way she was treated.

10. An interview was conducted on 04/02/19 at approximately 2:00 p.m. with the Director of Compliance. Although she was not present for the interviews she concurred that her understanding is the physician did squirt the patient with a syringe and tell her it was holy water and that the staff did laugh at the patient.

Based on observation, document review and interview it was determined that the Director of the Emergency Department (ED) failed to ensure the ED staff did not have food and drinks in patient care areas. This failure has the potential for all patients seen in the ED to have cross-contamination of blood borne pathogens.

1. A tour of the ED was conducted on 04/01/19 at 1:42 p.m. with the Director of the Emergency Department and the Director of Compliance. Upon entrance into triage room one (1) three (3) fluid filled cups were noted. Upon entering the ED core a nurse was seen eating a cookie and had two (2) fluid filled cups at her nursing pod. Further tour of the ED showed that nine (9) other fluid filled containers marked water were noted.

2. An interview with the Director of the ED during the tour revealed the expectation is the ED staff would use the provided hydration station and not have food or drinks at the nursing station.

3. A review of the Occupational Standards and Health Administration (OSHA) states in part, "OSHA's bloodborne pathogens standard prohibits the consumption of food and drink in areas in which work involving exposure or potential exposure to blood or other potentially infectious material takes place, or where the potential for contamination of work surfaces exists [29 CFR 1910.1030(d)(2)(ix)]. Also, under 29 CFR 1910.141(g)(2), employees shall not be allowed to consume food or beverages in any area exposed to a toxic material.

4. An interview was conducted immediately following the tour and she concurred the expectations would be for the staff to use the hydration station for storing of drinks.