HospitalInspections.org

Based on interview, record review, policy review and video review, the hospital failed to ensure patients received care in a safe setting and were free from all forms of abuse, neglect or harassment when the hospital failed to:
- Ensure that four-point locking restraints (medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others) had a quick release mechanism or that staff had immediate access to the key. (A-0144)
- Ensure a thorough investigation was performed following an event report with allegations of abuse and neglect. (A-0145)
- Provide education to staff following an incident involving verbal abuse. (A-0145)

This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation (CoP): Patient's Rights.

Based on observation, interviews and policy review the hospital failed to ensure patients received care in a safe setting when the hospital failed to ensure that four-point locking restraints (medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others) had a quick release mechanism or that staff had immediate access to the key.

These failed practices had the potential to adversely affect the quality of care and safety to all patients the in the hospital.

Finings included:

Review of the hospital's undated document titled, "Patient Rights and Responsibility," showed:
- Patients have the right to receive safe, quality care through the services that the ministry provides.
- Patients were to not be denied appropriate care on the basis of mental disability.
- Patients had the right to receive care in a safe setting, to be treated with dignity, respect, and considerate care at all times and under all circumstances.

Review of the hospital's undated policy titled, "Violent Restraint Utilization," showed:
- Patients have the right to be free from restraints of any form that are imposed for coercion, discipline, convenience or retaliation by staff.
- Use of restraints will not result in injury to the patient.
- Patients will be restrained by competent staff following established procedures.
- Patients will be restrained when necessary to ensure safety and when the least restrictive interventions have been determined to be ineffective.

Review of the hospital's document titled, "Restraints 2024," showed violent restraints had been applied to 24 patients in the Emergency Department (ED) from 01/01/24 through 12/09/24.

Observation on 12/09/24 at 3:30 PM, in the ED, showed a set of double locking restraints in a cabinet. There was a locking mechanism for the part of the restraint that went onto the patient's wrist and a separate locking mechanism that attached to the bed. There was no key for the restraints in the cabinet or at the nursing station.

During an interview on 12/09/24 at 3:35 PM, Staff H, Registered Nurse (RN), stated that a key to the restraints should have been in the cabinet where the restraints were kept or at the nursing station. Security Officers had the key to the restraints.

During an interview on 12/09/24 at 3:40 PM, Staff I, Security Officer, stated that he had a key to the restraints. If he had a patient in restraints in the ED and received a call to respond somewhere else on hospital property, he would only leave the patient in restraints if the patient had a one-to-one sitter (1:1, continuous visual contact with close physical proximity) with them. He would take the restraint key with him if he had to respond somewhere else on campus.

During an interview on 12/09/24 at 3:50 PM, Staff J, RN, stated that she did not have a key to the restraints. Security Officers kept the key.

Observation with concurrent interview on 12/10/24 at 10:05 PM, on the Behavioral Health Unit (BHU), showed Staff O, RN, did not have a key for the locking restraints. Staff O stated that the BHU had the same type of double locking restraints that were used in the ED.

During an interview on 12/10/24 at 10:20 AM, Staff G, RN, stated that all staff on the BHU were to have a key to the double locking restraints.

During an interview on 12/10/24 at 9:15 AM, Staff P, Mental Health Technician (MHT), stated that all staff members on the BHU were to have a key to the double locking restraints at all times.

Based on interview, record review, digital video records and policy review, the hospital failed to ensure patients were free from all forms of abuse, neglect or harassment when the hospital failed to ensure a thorough investigation was performed following an event report with allegations of abuse and provide education to staff related to abuse and neglect.

These failed practices had the potential to adversely affect the quality of care and safety of all patients in the hospital.

Findings included:

Review of the hospital's undated document titled, "Patient Rights and Responsibility," showed:
- Patients had the right to receive safe, quality care through the services that the ministry provides.
- Patients had the right to receive appropriate and compassionate care at all times and under all circumstances.
- Patients were to not be denied appropriate care on the basis of mental disability.
- Patients had the right to receive care in a safe setting, to be treated with dignity, respect and considerate care at all times and under all circumstances.
- Patients had the right to be free from all forms of abuse or harassment.
- The hospital expects all patients and visitors to follow the code of conduct while at the hospital. Examples of violent, threatening, or aggressive action include but are not limited to intimidating, harassing, unwanted physical touching, or making verbal or written threats to hospital team members or other patients.

Review of the hospital's policy titled, "Caregiver Misconduct," revised 11/17/23, showed:
- Caregiver misconduct means abuse, neglect, misappropriation of a patient's property or harassment of a patient.
- Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, mental anguish or death. This includes staff neglect or indifference to the infliction of injury or intimidation of one patient by another.
- An eligible adult is an adult with a disability, between the ages of 18 and 59 who is unable to protect their own interests or adequately perform or obtain services which are necessary to meet their essential human needs.
- Harassment is repeated, knowing and purposeful conduct that alarms or causes distress to another and serves no legitimate purpose.
- Immediately upon observing or becoming aware of incidents of possible abuse, neglect and harassment in the health care setting, any staff must report such incidents to their immediate supervisor.
- The staff who observes or becomes aware of an incident must complete an event report in the event reporting system.
- When a determination of the individual involved cannot be made based on available information, risk management and human resources (HR) should be contacted to discuss how to best protect patients while the investigation occurs.
- For the protection of patients and involved personnel, patient care providers involved in patient abuse, neglect or harassment must be relieved of patient care responsibilities and removed from patient care areas of the hospital during the pendency of a prompt investigation.
- Matters requiring relief of patient care responsibilities due to patient abuse, neglect and harassment of patients will be addressed by the hospital's Chief Medical Officer (CMO) in a manner consistent with this policy and as otherwise required by the hospital Medical Staff Bylaws.
- All incidents of possible caregiver abuse should be initiated within one business day of identification and be given high priority by those individuals needed to participate in the investigation.
- Risk management and HR will oversee the investigation, the investigation should include collecting and preserving any physical and documentary evidence; interview alleged victims, witnesses and if deemed appropriate, those alleged to have committed acts of abuse; collect other corroborating or disproving evidence; include other regulatory authorities; document each step taken during the internal investigation.
- Upon the conclusion of an investigation into patient abuse, neglect or harassment a written summary of the investigation will be completed and distributed, as indicated, by risk management; and results of investigations and remedial actions will be communicated to appropriate hospital leadership, HR, regulatory, appropriate medical staff, leadership, and affiliated organizations.
- Following an investigation, incidents shall be reported to the appropriate regulatory agency when the ministry has reasonable cause to believe there is sufficient evidence or another regulatory authority could obtain the evidence, to show the alleged incident occurred, and reasonable cause to believe the incident meets, or could meet the definition of abuse, neglect or misappropriation.

Review of the hospital's undated document titled, "Abuse Allegations for 2024," showed there were two allegations of abuse investigated for 2024. On 05/21/24 at 11:15 PM, in the Emergency Department (ED), there was an allegation of abuse by a security officer on Patient #21. The Investigation was completed and unsubstantiated. The other abuse allegation was unrelated to the event on 05/21/24.

Review of the hospital's document titled, "Event by Patient 5212024," dated 05/21/24, showed on 05/21/24 Patient #21 had a fall in the ED. An event description showed the patient attempted to elope (when a patient makes an intentional, unauthorized departure from a medical facility) and ran through the ED. The patient was first contacted by security and the patient fell backwards to the ground, landing on his left elbow. The patient was then helped to his feet and he began to run through the ED once again. Attempting to stop the patient, security grabbed for the patient and in doing so, fell to the ground landing on his chest and right arm. The patient was then successfully stopped by security and placed back in his room. There was no identification of who completed the event report.

Review of ED video surveillance for 05/21/24, from multiple views without time stamps, showed Staff CC, Security Officer, and Staff Z, Security Officer, were outside of Patient #21's room when the patient walked into the hallway. Patient #21 ran in the opposite direction and the officers ran after him. After chasing him down the hallways and around the nurses station, Staff CC lowered his shoulder and the patient ran into him. Patient #21 fell backwards hitting his elbow on the floor. Three staff members in scrubs, and one physician, were present. Staff Z was behind Staff CC. They assisted Patient #21 up, off the floor, and he began to run again in the opposite direction. Staff Z ran after him, followed by Staff CC. After running around the nurses' station, Staff Z tried to reach for the patient and fell on his chest and shoulders. Staff CC continued to run after the patient. Staff Z got up from the floor and began walking in the direction they were running. Both officers caught up with the patient from different directions, grabbed the patient by the arms and escorted him back to his room. Staff BB, Security Officer, arrived and walked ahead of them to the patient's room. Staff BB entered first, followed by Staff CC and Staff Z with Patient #21, and then nursing staff. The entire event lasted approximately one minute and 50 seconds. Six staff in scrubs and three security officers were seen in the video recordings of the event.

Review of body camera video footage from Staff CC, Security Officer, for 05/21/24 at 11:05:08 PM, showed the events that took place after Patient #21 and Staff Z, Security Officer, fell. Footage began just before apprehension of Patient #21 and included escorting him back to his room, where a verbal exchange occurred.
- At 23:05:33, Staff Z grabbed the patient's left arm and stated, "I'm gonna whoop your ass". Staff CC grabbed the patient's right arm and they began walking the patient back to his room. Patient #21 said, "I'm sorry. I'm sorry, I'll go back to my room" while they walked.
- At 23:05:49, an unidentified voice stated, "you're going to jail". Staff BB, ahead of them, entered the patient's room followed by the escorted patient.
- At 23:05:57, the patient's bed jingled as Staff Z sat him on the bed. Nursing asked the patient why he ran and he replied, "I'm sorry, they're in my head; the government." Staff CC told nursing staff that he knocked Patient #21 down. Nursing staff said the patient may have hit his head.
- At 23:06:21, Staff BB walked over to Staff Z and asked him a question. Staff Z, glanced down at his chest, then told him that he fell and pointed to the place in the hallway. Staff BB stepped outside the room. Nursing staff asked Staff Z if he was okay.
- At 23:06:27, Staff Z, still in the room, pointed his finger at the patient and stated, "I'm gonna tell you something," (body cam was turned so audio became jumbled for a moment), "running again tonight, I'm gonna lose my job. I'm gonna beat your ass."
- At 23:06:35, Staff BB went back to the doorway and directed Staff Z out of the room. Staff Z continued to say on his way out, "I'll tell you what, hurt my damn arm." Staff CC said that Staff Z needed to be checked out and nursing encouraged him.
- At 23:18:23, Staff CC told another officer that he had to stay and write a report. The other officer then told Staff CC that he should check with Staff BB first as he might write the report.

Review of the hospital's undated document titled "Investigation," showed:
- On 05/21/24, Patient #21 was on a 96-hour hold (court-ordered evaluation by behavioral specialist to determine if a person is safe to themselves and others). He left his room and ran in the ED stating he needed to get out of there. Security stopped the patient, he fell backwards to the floor and fractured his right elbow.
- The hospital's abuse policy defined abuse as, "The willful infliction of injury, unreasonable confinement, intimidation, coercion, financial exploitation, or punishment, with resulting physical harm, pain, fear, or mental anguish. This includes staff neglect or indifference to the infliction of injury or intimidation of one patient by another."
- The section titled, "Situation," showed a 38-year-old male who presented via law enforcement for a 96-hour evaluation. The patient was disorganized, paranoid (excessive suspiciousness without adequate cause) and noncompliant with his behavioral health care. Affidavit (a written statement confirmed by oath, for use as evidence in court) reports showed that on 05/18/24, the patient called police paranoid that the government was out to get him, additionally he locked his wife out of the home. The patient had a history of schizophrenia (serious mental disorder that affects a person's ability to think, feel, and behave clearly) and questionable compliance with his medications. He was evaluated and it was determined that he needed inpatient psychiatric treatment. 11 hours after his ED admission, the patient left his room and stated he needed to get out of there and ran through the ED, which was full of patients.
- Staff listed as witnesses of Patient #21's fall included Staff JJ, ED Technician; Staff KK, Registered Nurse (RN); and Staff Y, RN.
- In the section titled, "Statements obtained from the alleged," showed unable to obtain because of paranoia. Post fall the patient stated, "I am sorry, it's the government's fault."
- The investigation included a medical record review, video review and staff interviews.
- During an interview on 05/23/24 at 7:00 AM, Staff JJ, ED Technician, stated that she heard someone yell there was a runner, she moved out of the way because she didn't know what to do. She saw security officers and the patient running around the circle. Staff CC, Security officer, ran into the patient and the patient fell backwards and was stopped.
- During an interview on 05/23/24 at 7:15 AM, Staff Y, RN, stated that she was with another patient when she heard someone shout there was a runner. She stepped out of the other room and heard Patient #21 hit the floor. Staff CC had physically stopped the patient. She heard security officers yell at the patient to get up, that was when he ran again. There was a lot of verbal escalation between security officers, especially Staff Z, and Patient #21. She tried to de-escalate the situation. Staff Z was very verbal, she and Staff BB, Security Officer, tried to calm down Staff Z. Staff BB grabbed Staff Z and told him to get out of the room. Staff Y felt she could have re-directed the patient verbally.
- During an interview on 05/23/24 at 8:00 AM, Staff KK, RN, stated she had been walking in the hallway when she heard someone say there was a runner. She saw a patient in paper scrubs, she knew that meant it was a behavioral health patient, so she immediately went into a room eight or nine. She did not know how the patient ended up falling to the ground. She stayed in the other room during the event because she was concerned about safety. She ended up going into Patient #21's room to make sure other people were there.
- During an interview on 05/23/24 at 12:35 PM, Staff CC, Security Officer, stated that staff had trouble keeping Patient #21 in his room. The patient had been re-directed five or six times. The patient left his room several times and stated he needed to leave. At one point Staff CC had the nurse intervene. Staff CC stated that he got a small briefing on patients, but it was usually rushed. He had his back to Patient #21's room and was giving report to Staff Z, Security Officer, when the patient left his room. That was when Staff CC and Staff Z took off after the patient. Patient #21 made two laps around the nurses' station. Staff CC and Patient #21 both turned a corner, he went into the patient with his left shoulder and his other arm was back and to his side. The patient was bigger than him. He used what he was taught in Awareness-Vigilance-Avoidance-Defense-Escape (AVADE, a program that teaches people how to prevent, avoid, de-escalate, and reduce risk of violence in the workplace) training. After the patient fell, he tried to help him up. The patient then ran again, a technician tried to stop the patient, but when they realized he wasn't stopping they moved out of the way. After the patient fell, he went around the circle again, then Staff Z fell and Staff CC continued to pursue the patient.
- The findings of the investigation showed the "Determination of Abuse (physical allegation only)", reviewed by the Campus Executive Team, Risk, HR, and the Manager of Security, that abuse or neglect did not occur or that the findings were inconclusive, the manager and the HR Director would determine whether other actions were needed. No letter was sent to the alleged person because it was non-applicable. It was determined that physical force was necessary to stop the patient from running. The patient was on 96-hour-hold and he was a risk to himself and others. The techniques used to stop him were appropriate. The activity did not rise to the level of abuse because it did result in physical injury but did not meet all of the criteria of abuse as defined in the abuse policy.
- Recommendations included coaching security staff to immediately turn on the body camera. Security officers used the correct AVADE stance except for the officers closed fist so they recommended a review of AVADE stance for Staff CC. The three nursing staff interviewed indicated they did not feel comfortable attempting to stop the patient, were uncertain of how to stop the patient and felt comfortable leaving it up the security officers. It was recommended that those three employees attend AVADE training. A care team review of the patient's record was recommended to determine if he could have benefited from medications due to his anxiety and his pacing in his room and into the hallway.

Review of the hospital's document titled, "HR Investigation Summary," dated 05/21/24, showed:
- The "Complaint" section indicated there was verbal escalation towards a patient in the emergency room.
- The "Investigation" section included various investigation teams had interviewed multiple staff to discuss the event that occurred in the ED.
- The interview on 05/23/24 at 07:15 AM, with Staff Y, RN, was included in the HR investigation.
- On 05/23/24, Staff BB, Security Officer, was interviewed and stated that he was in a different area when the event began. A nurse asked him to respond. He saw the patient being escorted by Staff CC and Staff Z to his room. He did not see Patient #21 or Staff Z fall. He found Staff Z's body camera in the bathroom, it appeared to have come off during his fall. When he arrived at the patient's room, he saw Staff CC and Staff Z at the door. Staff Z looked at the patient and stated, "If you do that shit again, I'm going to whoop your ass, I may lose my job." Staff BB had to remove Staff Z from the patient's room. After that, the patient stayed in his room and Staff BB stayed with the patient for around 10 minutes.
- On 05/24/24 at 12:35 PM, Staff CC, Security Officer, was interviewed and stated that he and Officer Z took the patient back to his room and returned him to bed. Staff Z had fallen during the event and he was very upset. At one point, Staff Z pointed at the patient and said, "I'm going to mess you up." Staff BB then removed him from the room and he went to be checked out.
- On 05/24/24 at 8:30 AM, Staff Z, Security Officer, was interviewed and stated that he was getting report from Staff CC when the patient asked if he could use the restroom. After exiting the restroom, the patient began to run down the hallway. Staff Z yelled that they had a runner, he and Staff CC ran after him. They cut through a nursing area when the patient collided with Staff CC and fell. They helped him up and he ran again. Staff Z was in the lead and thought he could grab the patient, but fell hitting his right shoulder hard on the floor. He got up and continued the pursuit with Staff CC. Finally, the officers caught up with the patient and escorted him to his room. Nursing staff then took over and Staff Z went to get checked out. He stated that Staff BB was also in the room and told Staff Z to leave because he was mad and needed to calm down. Staff Z stated that he told Staff BB that he was going to beat the patient but did not say anything to the patient. Staff Z said he told the patient that he wasn't going to have any more running. Staff Z went on to say that he did not know that Staff CC's body camera was on and did not remember stating that he may lose his job, or telling the patient he would whoop his ass. Staff Z said that he should have walked away.
- On 05/24/24 at 11:45 AM, Staff II, ED Technician, was interview and stated that she could tell the Security Officers were aggravated with the patient but wasn't sure what was said. She said Staff Z and Staff CC were there and Staff BB came later. She could not recall if any officers were asked to be removed from the room. She said Staff Z was very upset, said some words that could have been threatening, could have been cuss words, but she wasn't sure what they were exactly. She stated they could use more training on how to redirect a patient in that situation.
- The "Findings" section showed the investigating teams used interviews with staff present during the event and unnamed video camera footage to substantiate the claim of verbal escalation. Staff Z would receive a Final Corrective action and attend de-escalation training. The Security Manager was able to discuss the need for a de-escalation training requirement for Staff Z with their training curriculum provider. They currently did not have one but could develop one. The training would likely last two or three hours.
- The document was prepared by the HR Partner and HR Manager.

Review of the hospital's undated document titled, "Competencies 2024," showed that Staff Z, Security Officer, received level two AVADE training on 02/19/24, and AVADE de-escalation training on 07/19/24 and 11/18/24. He completed abuse and neglect training on 11/17/24; harassment in the workplace on 11/18/24; and non-violent and inclusive language on 11/17/24.

Review of the hospital's document titled, "Work Schedule," dated 05/2024 through 08/2024, showed that Staff Z, Security Officer, returned to work on 05/31/24 on light duty.

Review of Patient #21's medical record dated 05/21/24 through 06/17/24, showed:
- He was a 38-year-old male who presented to the ED at 12:27 PM, with law enforcement for a 96-hour-hold evaluation due to concern about worsening psychosis (mental illness characterized by defective or lost contact with reality) and his ability to care for himself.
- Affidavit reports dated 05/18/24 showed he called the police paranoid that the government was out to get him and he locked his wife out of the home.
- His past medical history included bipolar disorder with depression (characterized by clear changes in mood, energy, and activity levels with periods of extremely sad or hopeless behavior), back pain, high blood pressure, schizophrenia, medication non-compliance and obesity.
- A psychiatric assessment indicated he was inattentive, withdrawn, paranoid, delusional (false ideas about what is taking place or who one is), with suicidal ideation (SI, thoughts of causing one's own death). He was impulsive (to act with little or no forethought or consideration of the consequences) and inappropriate.
- On 05/21/24 at 2:32 PM, the patient tried to elope from the ED.
- On 05/21/24 at 4:30 PM, the plan was to follow through on the 96-hour evaluation with an accepting psychiatric facility.
- On 05/21/24 at 11:15 PM, nursing documentation showed that Patient #21 attempted to run out of the ED, security chased the patient and attempted to stop him by the door. Security made contact with him and he fell to the floor, landing on his left elbow. The patient was helped to his feet and he attempted to run again. The patient was then stopped by security staff and directed back to his room. The patient stated, "I'm sorry, it's the government's fault." He repeatedly talked about the government and the Federal Bureau of Investigation (FBI) with paranoid statements.
- Physician documentation showed Patient #21 walked to the bathroom and at that point he started running around the ED to try and leave. He appeared to be paranoid and was talking about the FBI and Central Intelligence Agency (CIA) trying to control him and he needed to leave. While trying to be brought back to his room by security staff the patient fell. Staff were unsure how he landed; he did not lose consciousness. He had no bruising and denied tenderness to his scalp. He had tenderness to his right elbow joint with some mild swelling, the skin was intact. An x-ray (test that creates pictures of the structures inside the body-particularly bones) of the right elbow was ordered. He was given an intramuscular (IM) injection.
- On 06/17/24, the discharge summary showed Patient #21 was admitted to the behavioral health unit (BHU) for a 96-hour-hold initially, but then placed on a 21-day hold. His medications were adjusted. He was initially noncompliant with medications but became compliant at least a week prior to his discharge. He showed overall improvement, was able to develop a safety plan and his sleeping improved. He denied any paranoia regarding his wife and reported he felt good.

During an interview of 12/16/24 at 9:45 AM, Staff Y, RN, stated that Patient #21 had been assigned to her on 05/21/24. She was in another patient's room when he tried to elope. She heard the patient hit the ground when he fell. He got up and ran again. Security Officers chased him and one of the security officers fell onto the floor. Things got heated with Staff Z, Security Officer, after he fell. Staff Z was standing in the doorway of Patient #21's room and told Patient #21, he was going to "beat his ass." That was when she said they needed to get Staff Z out of the room. She felt that what the officer said was verbal abuse because it was a threat. She did not think Staff Z was really going to hurt the patient, he was just injured and embarrassed from falling. She told Security Officers that Patient #21 was psychotic, scared and not in his right mind. Patient #21 was never a threat and didn't want to hurt anyone. She reported the verbal abuse to HR during her interview. She felt that the patient could have been verbally de-escalated. She did not remember if she completed an event report related to the incident.

During a telephone interview on 12/16/24 at 9:30 AM, Staff A, Regulatory Director, stated that Staff CC, Security Officer, did not activate his body camera footage until after Patient #21 fell so she did not watch the body camera footage for her investigation. Staff D, Regional President, had seen the body camera footage. Staff A was only involved in the investigation related to the patient's fall since the patient fractured his elbow. Inappropriate conduct went to HR to be investigated and she was not a part of that. Security Officers were appropriate with the physical contact that resulted in an injury to the patient. The only aspect identified in her investigation was related to the AVADE stance, everything else was done according to AVADE. She did not interview Staff Z, Security Officer, because he was not able to be interviewed since he was out on workman's compensation due to the injuries he sustained in the incident.

During an interview on 12/11/24 at 11:40 AM, Staff X, Security Manager, stated that Staff Z, Security Officer, said something like, "If you try to run again, I'm going to fuck you up," to Patient #21 but it was after the incident was over. He expected better of his security officers. Staff Z was off work after the incident and did not return to work until 05/31/24, on light duty. When he returned to work, he was on modified duty and not in patient care areas, he sat at the visitor entrance desk, in plain clothes and counted people when they entered the hospital. The visitor entrance was for the public and had nothing to do with patients. Patients would only use the visitors entrance if they were lost. Staff Z completed de-escalation training on 07/19/24.

During a telephone interview on 12/16/24 at 12:45 PM, Staff Z, Security Officer, stated that he did not remember when he went back to work or when he did de-escalation training. When he returned to work he sat at the visitors desk and counted patients and visitors that entered the hospital. He had not done anything wrong to Patient #21. He did not remember when, but he did his de-escalation training with Staff X and it was a verbal discussion.

During a telephone interview on 12/16/24 at 7:45 AM, Staff BB, Security Officer, stated that he was one of the officers that escorted Patient #21 back to his room. He heard Staff Z tell Patient #21 something along the lines of, "If you do that again, I am going to fuck you up." He never felt that Staff Z would actually hurt the patient, he was just hurt and embarrassed and took it out on the patient and said something he didn't mean. Staff immediately pulled Staff Z from the patient care area. He reported what was said through the chain of command. HR did call him about the incident. He did not know if Risk Management was involved in the investigation. He did not remember if he completed an event report, but thought that he and Staff CC, Security Officer completed one.

During a telephone interview on 12/18/24 at 8:00 AM, Staff CC, Security Officer, stated that during shift change, when Staff Z was giving him report, Patient #21 tried to run from the ED. He and Staff Z attempted to stop the patient from leaving and the patient fell. When the patient got up he attempted to run again, that was when Staff Z fell to the ground. He received education related to his stance according to AVADE a few days after the incident. What Staff Z told the patient was not what he would tell a patient, but Staff Z would not have hurt the patient, he just didn't want the patient to run again. Patient #21 knew what he was doing, he was able to answer questions and listen. The patient was responsive to the nursing staff and could follow their instructions, so the patient was aware of what he was doing. Staff CC stated that he completed an event report following the incident. When he spoke with Staff A, Regulatory Director, he reported to her that what Staff Z said to Patient #21 was profane and inappropriate.

During an interview on 12/12/24 at 9:38 AM, Staff AA, Patient Safety Specialist and HR Partner, stated that she received a report of an employee injury after a fall in the ED and that the event escalated. Staff Z's, Security Officer, behavior got out of control and staff were upset about his behavior. She spoke to all staff members involved in the incident to determine if it was substantiated or not. She made sure the staff member wasn't working until she was able to determine what kind of behavior they were dealing with. Based off of interviews and body camera footage they were able to substantiate the allegation for inappropriate behavior. Staff Z, Security Officer, was given a level three corrective action, which meant that if he did one more thing wrong, he would be terminated. Staff Z was off work due to injuries sustained in the incident. If an employee was out on leave of absence, they had seven days to complete corrective action after their first day back to work. If Staff Z had been on medical restrictions or did not have access to a computer, he may not have been able to do his recommended education and that was fine.

During an interview on 12/11/24 at 3:45 PM, Staff A, Regulatory Director, Staff D, Regional President, and Staff C, CNO, stated they did not feel that the incident met the definition of abuse or verbal abuse.