HospitalInspections.org

Based on observation, interview, record review and policy review, the hospital failed to:
- Provide house wide staff education regarding abuse and neglect when an abuse allegation was substantiated. (A-0145)
- Ensure the presence of emergency airway equipment for one unit of two units observed. (A-0144)
- Ensure the presence of food expiration dates, removal of expired food items and the separation of staff and patient food on three units of 16 units observed. (A-0144)
- Ensure all Behavioral Health Units (BHU) provide psychiatric safe rooms (a room that has been cleared of any objects a patient might use to harm themselves or others). (A-0144)

These failures had the potential to place all patients seeking care at the hospital at risk for their safety. The cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13, Condition of Participation (CoP): Patient's Rights.

Based on interview, record review and policy review, the hospital failed to follow their own policies and procedures that outlined staff roles for informing, retrieving, assisting with formulation, and documenting Advance Directive (AD, a legal document where the patient can direct their medical care wishes should the patient become unable to make their own decisions) information for 10 (#15, #24, #25, #26, #27, #28, #30, #31, #33 and #34) current patients of 41 current patients reviewed. These failures had the potential to affect all patients who presented to the hospital seeking care.

Findings included:
Review of the hospital's policy titled, "South Administration AD Policy," dated 08/05/22, showed:
- Patients with decision-making capacity who are 18 years of age or older have the right to formulate, review, change, rescind or modify an AD regarding health-care decisions in the event they become unable to make decisions.
- Hospital co-workers will inform patients regarding AD and provide information to his/her family or representattve if the patient is currently unable to receive information.
- Hospital co-workers will inquire periodically and document in the patient's medical record as to whether an individual has executed an AD and if so, seek to obtain a copy for the medical record.
- Hospital co-workers will have a conversation with patients regarding AD at or near the time of admission, or initial encounter.
- Hospital co-workers will ask if the patient already has an AD. If the patient responds yes, the co-worker is to ask for a copy; confirm if the AD is already in the medical record; ask if the patient wants to change the AD; ask the patient to provide a copy of the AD and follow up to obtain the AD.
- If the patient reponds no, the co-worker will offer information and available AD forms; answer questions as appropriate or refer to the AD educator or another co-worker to assist with the patient's questions; contact the Pastoral Care AD resources and notary assistance; assist the patient with the execution of a completed document with witnesses or a notary public when needed and follow up with the patient to obtain a signed copy if forms are provided but not signed.
- The co-worker will place the AD in the appropriate medical record through scanning or other appropriate and available means, document the conversation and existence of ADs in the medical record and document any change or revocations of the AD in the medical record.

Review of Patient #15's medical record showed, she was not assessed for the need to formulate and/or revise an AD.

Review of Patient #24's medical record showed, she was not assessed for the need to formulate and/or revise an AD.

Review of Patient #25's medical record showed, she was not assessed for the need to formulate and/or revise an AD.

Review of Patient #26's medical record showed, she was not assessed for the need to formulate and/or revise an AD.

Review of Patient #27's medical record showed, she was not assessed for the need to formulate and/or revise an AD.

Review of Patient #28's medical record showed, he was not assessed for the need to formulate and/or revise an AD.

Review of Patient #30's medical record showed, he was not assessed for the need to formulate and/or revise an AD.

Review of Patient #31's medical record showed, he was not assessed for the need to formulate and/or revise an AD.

Review of Patient #33's medical record showed, she was not assessed for the need to formulate and/or revise an AD.

Review of Patient #34's medical record showed, she was not assessed for the need to formulate and/or revise an AD.

During an interview on 08/13/24 at 9:35 AM, Patient #28's family member stated he asked several times for help with an AD, and no one came to help. His father was just diagnosed with stage four cancer, and he needed to get this completed. He stated, "when you receive information like this it is very traumatizing, and I was very frustrated because no one would help me."

During an interview on 08/13/24 at 10:30 AM, Staff LL, Nurse Manager, stated they have a social worker that checks on every patient and addressed their needs. She was unaware of the lack of documentation for AD and did not know why patients did not have documentation for follow-up when information was requested. The nurses answered the question but there was no computer message that was sent. The nurse should notify the social worker if someone needed assistance.

During an interview on 08/13/24 at 11:00 AM, Staff QQ, Social Worker, stated that she saw every patient on the floor and followed-up if they wanted additional information for AD. She did not know why these patients did not have any documentation.

Based on observation, interview, record review and policy review, the hospital failed to:
- Ensure the presence of emergency airway equipment for one unit of two units observed.
- Ensure the presence of food expiration dates, removal of expired food items and the separation of staff and patient food on three units of 16 units observed.
- Ensure that all Behavioral Health Units (BHU) provide psychiatric safe rooms (a room that has been cleared of any objects a patient might use to harm themselves or others).

Observation on 08/13/24 at 3:05 PM, of the BHU showed:
- In patient room 229, an unsecure toothbrush in the bathroom.
- In the common area of unit 2B, five patient chairs with torn seat and backing covering; one unsecured plastic clock; one table with a broken metal leg and unsecured white board.
- In the common area of unit 2C, two patient chairs with torn seat coverings.

During an interview, on 08/13/14 at 3:35 PM, Staff HHH, BHU Director, stated that the toothbrush should not be left in the patient's room, the chairs should not have tears in them, the table should not have a broken leg and the clock and white board should be fastened securely to the wall.

Review of the hospital's document titled, "Resources for Optimal Care of the Injured Patient," dated 03/2022 showed all trauma centers must have equipment immediately available to establish an emergency airway.

Observation on 08/13/24 at 8:50 AM, in the Labor and Delivery Operating Room Area, showed no emergency tracheostomy equipment.

During an interview on 08/13/24 at 8:50 AM, Staff R, Labor and Delivery/Post Partum (LDRP) Manager stated there was no emergency tracheostomy equipment in the operating room area.

During an interview on 08/15/24 at 9:07 AM, Staff GGGG, CNO, stated she expected emergency tracheostomy equipment to be available in the Labor and Delivery operating room area.

Observation on 08/12/24 at 4:15 PM, in the 4700-unit patient nutrition room, showed:
- One box of tea bags without an expiration date.
- One box of tea bags with an expiration date of 12/09/21.
- Coffee ground bags without expiration dates.
- One package of horseradish without an expiration date.
- Single pack tea bags without expiration dates.

Observation on 08/13/24 at 8:45 AM, in the Labor and Delivery and Post Partum Unit patient nutrition room, showed:
- One box of tea bags with an expiration date of 12/09/21.
- Single pack tea bags without expiration dates.
- Broth packages without expiration dates.
- Coffee pods without expiration dates.
- Hot chocolate packages without expiration dates.
- Creamer packages without expiration dates.
- Sugar packages without expiration dates.
- Sweetener packages without expiration dates.

Observation on 08/13/24 at 9:40 AM, in the 4600-unit patient nutrition room, showed:
- One open single-use ranch dressing packet in the refrigerator.
- Salt packets without expiration dates.
- Pepper packets without expiration dates.
- One staff multi-use flavored coffee creamer in the patient's refrigerator.

During an interview on 08/15/24 at 9:07 AM, Staff GGGG, CNO, stated that expired food in the patient care areas did not meet her expectations. She expected all food items to be dated for expiration and bagged. Staff food items did not belong in patient refrigerators.



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48359

Based on observation, interview, record review, and policy review, the hospital failed to provide hospital-wide staff education for abuse, de-escalation and Mandt (a behavioral crisis interaction training program that focuses on communication skills and conflict management) to all employees after a substantiated incident of abuse from an employee to one discharged patient (#14) to prevent re-occurence.

Findings included:

Review of the hospital's policy titled, "Alleged Patient Abuse, Neglect or Harassment by a Co-Worker Policy," dated 05/16/22, showed:
- The hospital sets an expectation of zero tolerance for all forms of abuse, neglect and harassment whether reportedly inflicted by co-workers, patients, visitors or other persons.
- Abuse is the willful inflection of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.
- Willful, as used in this definition of abuse, means the individual must have intended to inflict injury or harm.
- Co-workers must report witnessed or alleged abuse, neglect or harassment and clinical indicators of suspected abuse. Clinical indicators include the following: bruises, fractures, burns, decayed teeth, matted or tangled hair, nails needing clipping, malnutrition/dehydration, bed sores, injuries to sexual organs, acute (sudden onset) untreated medical conditions, indicators of chemical restraints (medication administered with the primary intent of restraining a patient who presents a likelihood of serious physical injury to himself or others, and not prescribed to treat a person's medical condition) and patient abandonment.
- Alleged abuse, neglect, or harassment is defined as any report from family members, patients, or co-workers of abuse, neglect or harassment.
- There must be a report made even if the co-worker does not believe the allegation is true.
- Co-workers are responsible for reporting any abuse, neglect, or complaint allegation. Co- workers will document the observation/allegation in the medical record and who was notified.

Review of the hospital's policy titled, "Agitated and Combative Person Response
Security Assistance and Code Strong (a response from all available staff to respond to an escalating patient in attempt to de-escalate the situation without using force and using the least restrictive intervention)," dated 01/01/2019, showed:
- This emergency response plan is intended to guide the response and the management of escalating behavior by clients, patients and/or visitors, before or during a violent eruption of aggressive or violent behavior, with use of verbal de-escalation techniques and the minimum control necessary by our employees to ensure the safety of all hospital staff and clients, patients and/or visitors.
- The facility prohibits physical assaults such as strikes, grabs, threatening comments, intimidation, harassment, intentional destruction of any hospital property or merchandise, or any behavior that causes intimidation or reasonable fear responses in others.
- The Code Strong Response Team objectives include the utilization of verbal control techniques prior to the initiation of escort techniques or positive control techniques unless a safety issue demands an immediate physical control response.
- The response process was designed to deal with and control unarmed persons who display behaviors consistent with that of a person who has lost control of their actions and may pose an imminent threat (direct or indirect) to the wellbeing of themselves or others. This may also include persons who appear to be unmanageable and/or assaultive.
- The response of any employee who is witnessing or working with a difficult, agitated patient or
person should begin with de-escalation and include the following: a team intervention should be utilized when at all possible, starting with verbal de-escalation techniques, before any hands-on techniques, one person at a time should speak/communicate with the acting out person, employ verbal de-escalation techniques, monitor non-verbal cues by staff and the person acting out, maintain a protective distance between staff and the acting out person and if the person continues to escalate, and verbal de-escalation techniques are not working, or staff feel/sense that the situation is escalating and would benefit from early intervention the local police should be contacted by dialing 911.

Review of the hospital's policy titled, "Performing Event Reviews Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) Policy," dated 08/16/22, showed:
- A RCA is a structured facilitated team process to identify root causes of an event that resulted in an undesired outcome and develop corrective actions.
- This event review process provides a way to identify breakdowns in processes and systems that contributed to the event and how to prevent future events. Event reviews do not focus on individual performance. Instead, event reviews focus on process or performance improvement through a review of hospital systems.
- The Mercy Event Review Process will be followed for all serious reportable events.

Review of the hospital's document titled, "Missouri Department of Health and Senior Services (DHSS) Self-Report Investigation," dated 09/25/23, showed:
- On 9/23/23 at 12:37 AM, a 44-year-old male arrived at Mercy Hospital South Emergency Department (ED) following a multi-vehicle crash.
- Lab results were positive for alcohol (ETOH, level of alcohol in your body, normal is less than 10) level of 159.
- The patient's medical history included polysubstance (multiple drugs) abuse, depression and anxiety.
- Affidavits were obtained from the police and it was planned to admit the patient involuntarily.
- While awaiting placement to a BHU, he remained in the ED BH area.
- On 9/24/23 at 3:00 PM, he escalated, harmed himself and was verbally and physically aggressive toward coworkers.
- Security was called and during this interaction, Staff PPPP, Paramedic, worked on the unit and assisted with the patient. He used inappropriate language with the patient as well as excessive force when managing the incident. Staff PPPP, did not use Mandt approved techniques.
- He was removed from the room.
- The patient complained of jaw pain following the altercation, x-rays (test that creates pictures of the structures inside the body-particularly bones) of his jaw were obtained and resulted negative.
- The patient was transferred to a BH bed on 9/25/2023 at 1:50 PM.
- Staff PPPP was suspended indefinitely while termination was in process with Human Resources.

Review of education that was submitted with the self-report, showed ED personnel were educated on the Abuse Policy, education was not provided house-wide.

Review of the education provided with the self-report, showed de-escalation training and Mandt simulation was not provided following this event. The hospital submitted prior yearly education of the training.

Review of Patient #14's medical record dated 09/23/23, showed:
- Patient #14 presented to the ED via Emergency Medical Services (EMS, emergency response personnel, such as paramedics (a healthcare professional that provides advanced emergency medical care), first responders, etc.) following a multi-vehicle collision on 09/23/23 at 12:37 AM.
- Past medical history included polysubstance abuse, depression (extreme sadness that doesn't go away) and anxiety (a feeling of fear or worry experienced intermittently).
- Laboratory results showed an ETOH level of 159
- He was seen by central intake for a mental health evaluation due to suicidal ideation (SI, thoughts of causing one's own death) and alcohol intoxication (the condition of having physical or mental control markedly diminished by the effects of alcohol or drugs).
- He was verbally aggressive, agitated and refused to answer assessment questions.
- It was determined Patient #14 would be admitted to an in-patient BHU as he was an imminent danger to self and others.
- On 09/23/23 at 1:25 PM, he became agitated, banged his head on the wall that resulted in a hole in the wall. Additional staff were requested, and Patient #14 was given Haldol (a medication used to treat mental disorders by decreasing excitement of the brain) and Ativan (a medication used to treat anxiety or sleep difficulty).
- At 11:20 PM, the patient was agitated, slammed the door and walked out of his room to the restroom shouting profanities. He returned to his room, knocked items off table and slammed the table into wall. Security was notified, who then called for additional security. He attempted to block the door with a table and attempted to cover the security camera with a napkin. The panic button was activated, additional security, physician and other staff members arrived.
- Orders given for Haldol and Ativan were given by the physician. When the nurse arrived with the medication, Patient #14 charged at the nurse. He was stopped by security and then was restrained.
- On 09/24/23 at 3:00 PM, Patient #14 awaited transfer when he became aggressive toward staff. Security was called and multiple staff members present in the room. The patient punched himself in the throat and hit his head against a television. He became physically aggressive with staff and spit at staff. The physician was paged, and the patient was placed in restraints.
- On 09/24/23 at 4:25 PM, Patient #14 complained of jaw pain following the altercation. He alleged he was "pushed hard with an open hand into the bed" by a medic in the ED.
- The patient stated that, "I was being an ass, I know, but he pushed me really hard with an open hand multiple times into the bed and now the left side of my jaw feels like it's broke." He was examined by the physician; an x-ray of his jaw was obtained and was negative for an injury.
- He was transferred to a BHU on 09/25/23 at 10:50 AM.

During an interview with Staff L, CNO, on 08/14/24 at 2:30 PM, stated that she was the Quality Risk Manager at the time of the incident. She stated that she did not provide house wide education for abuse and did not provide additional de-escalation and Mandt simulation following this incident. She did complete the investigation but failed to recognize the importance of educating all staff in the hospital. Staff PPPP, Paramedic, was terminated following the investigation.

During an interview with Staff DDD, ED Director, on 08/14/24 at 3:00 PM, stated that if an employee was accused of abuse, that employee was immediately removed from patient care. He then conducted interviews of everyone involved and escalated up the chain of command. He stated that the abuse education for Patient #14 was provided to the ED staff only and was not escalated to hospital-wide education.

Based on interview, record review and policy review the hospital failed to arrange a safe discharge for two patients (#43 and #46) of three medical records reviewed.

This failure had the potential to lead to unsafe discharges, inappropriate transitions of care and result in poor discharge outcomes for all patients in the hospital.

The severity and cumulative effects of the systemic failures resulted in the hospital being out of compliance with 42 CFR Condition of Participation (CoP): Discharge Planning.

Based on interview, record review and policy review the hospital failed to provide a safe discharge for two patients (#43 and #46) of three medical records reviewed.

Review of the hospital's policy titled, "Case Management (CM) Discharge Planning Policy," dated 08/04/23 showed:
- CM recognizes discharge planning as a process and service.
- Discharge planning is provided to patients for assessing, evaluation and assisting with safe transition to the discharge designation.
- The discharge planning process may include, but is not limited to, identification of needs, evaluation of patient and any planning for needs the patient will need for a safe and smooth transition.
- Discharge planning is a multi-disciplinary, hospital wide process available to assist patients and families in establishing a safe and efficient hospital plan to the patient discharging.
- CM will develop or supervise the development of and reassess the discharge plan, identify available resources and involve the patient and/or patient representative in the discharge planning process.
- Reassessment and documentation are required with a change in the discharge plan or each time the CM has relevant information regarding the patient's situation or condition.
- If a patient previously identified as not needing discharge planning has a change in condition, an assessment should be authorized, and an evaluation completed.
- Screening, assessment and additional information is documented in the electronic medical record (EMR).

Review of Patient #43's medical record dated 08/01/24, showed:
- At 7:17 AM, she was a 54-year-old female who arrived at the gastroenterology (GI, branch of medicine concerned with the structure and diseases of the stomach and intestines) laboratory for an elective scheduled outpatient procedure.
- Her past medical history was Aagenaes syndrome (impaired bile [a digestive fluid] flow from the liver), anxiety (a feeling of fear or worry experienced intermittently), autoimmune autonomic ganglionopathy (when your immune system attacks healthy nerve cells), bone cancer, celiac disease (disorder that damages the small intestine and is triggered by eating foods containing gluten), liver failure, diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing), gastroparesis (a paralysis of your stomach muscle), high blood pressure, irritable bowel syndrome (IBS, ongoing disorder of the colon which includes diarrhea, cramping and abdominal pain), sclerosing cholangitis (liver disease), MALToma gastric (a type of lymphoma [a cancer that begins in infection-fighting cells of the immune system and the cells change and grow out of control]), nutritional anemia (when the body does not get enough nutrients from the diet), pancreatitis (inflammation of the pancreas) and stomach cancer.
- Her past surgical history was eight esophagogastroduodenoscopy (EGD, procedure in which a thin scope with a light and camera at its tip is used to look inside the organs of the upper digestive tract) with gastrostomy tube (G-tube, soft, flexible tube inserted through the skin of the abdomen and into the stomach) placements, hysterectomy (hollow, pear-shaped organ that is located in a woman's lower abdomen between the bladder and the rectum), appendectomy (a surgical procedure that removes the appendix [a small tube-shaped part that is joined to the intestines on the right side of the intestines]), liver biopsy (take a sample of tissue or cells for testing), a jejunostomy tube (J-tube, soft, flexible tube placed through the skin of the abdomen into the midsection of the small intestine) placement, cholecystectomy (surgical removal of the gallbladder; a small organ that stores liquid called bile and helps your body break down food) and bone tumor removal.
- At 7:30 AM, she signed a consent for procedure form for an "esophagogastroduodenoscopy to replace "PEG" tube.
- At 8:30 AM, the procedure started.
- At 8:55 AM, her preprocedural history and physical (H&P, a document in a patient's medical record that contains the physician's initial assessment and treatment plan) showed she was alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation). The procedure planned was an EGD for replacement of the percutaneous endoscopic gastrostomy (PEG, a tube inserted through a person's abdomen directly into the stomach to provide a means of feeding when oral intake is not possible) J-tube due to feeding tube dysfunction. Staff OOO, Physician, discussed the plan, risks, benefits and alternatives with the patient.
- At 10:10 AM, she was upset the new tube was placed in the old site due to skin irritation. Staff OOO and QQQ, NP, were at her bedside to explain the reasoning to keep the tube in the old site. The patient insisted she wanted the tube removed. The tube was removed, and pressure was applied to the site by Staff OOO and Staff QQQ. Staff RRR applied a dressing to the site. The patient called her son and he requested to speak with Staff OOO. Staff MMMM, Endoscopy Manager, was at the patient's bedside to talk with the patient and provide comfort. Staff OOO returned to bedside to discuss placing another tube, the patient was referred back to Staff PPP, Physician, for management of her reoccurring symptoms. Staff PPP's contact information was provided to the patient.
- At 12:00 PM, she sat on the bed dressed and waited for her son's arrival for transport home. Discharge instructions were provided, the patient was advised to access her "My Mercy" account for new instructions for after PEG tube removal care. She verbalized an understanding.
- At 12:28 PM, a progress note showed she was scheduled for a replacement of the feeding tube for leakage of tube feeding causing skin irritation. The tube was found coiled in the stomach which was the most likely cause for the leaking of feeding material around the tube. A new site was not created because the reason for the leakage was the coiled tube, not the location of the tube. Post procedure the patient was upset because the site was not changed. It was explained to the patient that placing a new tube through a new site would not eliminate the problem of leakage. The patient requested tube removal, she was concerned for recurrent leakage and aggravation of the skin irritation and soreness. Staff OOO believed the tube removal and an oral gastroparesis diet was an alternative option for management of her illness in the presence of significant skin irritation. The patient was given instructions for a gastroparesis diet, to start with clear liquids and advance to full liquids the following day and then advance as tolerated. She was encouraged to eat small portions frequently of a low residual diet with increased physical activity. The patient's son was educated on the patient's condition and the recommendations. The patient was referred back to Staff PPP, Physician, for further management of her recurrent symptoms of nausea, vomiting and gastroparesis.
- At 12:19, she was assisted to the car, was pleasant and thankful.
- Her discharge instructions showed she was discharged to home. She was instructed to resume her previous diet and return to her primary physician. She had no upcoming appointments scheduled. The discharge instructions showed if a complication or emergency arose and she was unable to reach her physician, she was to go to the nearest Emergency Department (ED) with the discharge form.

Review of Patient #43's medical record from Facility B dated 08/08/24, showed:
- She received a feeding tube in 01/2022 which was replaced multiple times.
- One week ago, her feeding tube was removed and not replaced.
- She reported she did not tolerate oral intake due to nausea and vomiting.
- She stated that everything she ate came "right through the tube feeding site." The site appeared to be healing without leakage.
- Her weight at Hospital A was 151 pounds, at Facility B she weighed 145 pounds.
- Her blood sugar logs showed low blood sugar readings.
- The plan was to trial oral feeds and adjust her medication regimen, if she failed the trial in one month, consider a feeding tube insertion or referral to surgery.

During an interview on 08/14/24 at 11:15 AM, Staff OOO, Physician, stated he cared for Patient #43 for two and a half years. Her previous tube coiled back into her stomach, the tube feeding pooled in her stomach and leaked out of the tube insertion site. He confirmed the tube was coiled via an x-ray and discussed the findings with her prior to scheduling her procedure. He was called to her room because she was upset the tube was not relocated. She "demanded" he take the tube out. He offered for her to keep the tube in place for a few days because it was replaced into her intestine and was no longer coiled in her stomach. If she was dissatisfied after a few days she could come to his office, and he would remove the tube. She did not agree to that option and wanted the tube out. He asked her if she was able to eat before he agreed to remove the tube. He believed she could tolerate food and liquid in small amounts. He believed she was able to supplement her nutrition orally when her tube leaked or clogged in the past. He felt "strongly" she was able to eat. He removed the tube according to the "standard of care, it came out easily and only took two seconds." He instructed her to keep the site clean and dry with gauze until the site healed. The hole would close in a few days.

During an interview on 08/14/24 at 11:30 AM, Staff PPP, Physician, stated he called to check on Patient #43 after her procedure. She did not tolerate an oral diet well. She was a very complicated case and he cared for her for two to three years. When she initially arrived at his office she weighed 80 pounds, with the tube she weighed 140 to 150 pounds. He instructed her to follow up at Facility B for a different type of tube placement. She was an established patient at Facility B. He believed she would be scheduled quickly. He informed her if she had a delay in scheduling an appointment at Facility B she could come to his office. He instructed her to return to the ED if she "felt dehydrated." She could not be admitted to the hospital on the day of her procedure because she did not have a "diagnosis." Patient #43 made the decision to have the tube removed and go home.

During an interview on 08/14/24 at 11:35 AM, Staff QQQ, NP, stated Patient #43 was well known to her, she had undergone multiple procedures. Patient #43 reached out to her when the feeding tube began to leak. Her feeding tube was a tube within a tube, and it shimmied up and coiled into the stomach. The tube feeding then went into the stomach and leaked. An x-ray confirmed the tube was coiled into the stomach prior to this procedure. She spoke with Patient #43 about the coiling and scheduled her for the outpatient procedure. She walked into Patient #43's room when she saw her speaking with Staff OOO, Physician, and the nurse. The patient was upset because a new tube was placed into the same site. Staff OOO requested the patient try the tube for a few days. If she was not satisfied, she could come to the office and the tube would be removed. The patient wanted the tube out. She was reminded she would not have access to food. Patient #43 responded that "she would change her ways and wanted the tube out." Staff QQQ gathered gauze and tape and returned to the room. She and Staff OOO donned gloves and pulled the tube. The patient was instructed the hole would close. Staff OOO spoke with Staff PPP, physician, to explain the patient no longer wanted the tube. Staff QQQ was unsure of what resources were available for Patient #43 prior to her discharge. She did not provide outside resources for Patient #43. The patient stated she would "do what she needed to do." Staff OOO instructed her how to eat small sips of clear liquids and advance her diet over the weekend. She agreed a social service consult could have been beneficial.

During an interview on 08/15/24 at 9:07 AM, Staff GGGG, CNO, stated she expected to see follow up appointments with the doctor on Patient #43's discharge paperwork. She expected collaboration between the physician, social work and a nutritionist to ensure Patient #43 was successful at home. It was not acceptable to wait for the patient to develop symptoms and return to the hospital. Patient education goes a long way.

During an interview on 08/15/24 at 10:12 AM, Staff MMMM, Endoscopy Manager, stated she met Patient #43 after the tube was removed. She was "very upset" and wanted the tube moved. She gave a detailed description of how the tube's location affected her life, and she requested the tube was removed. Patient #43 planned to follow up with "friends" at an "urgent care facility" she frequented if she had needs. Staff MMMM believed Patient #43 clearly understood the consequences of her decision and the physician wanted her to try small sips of clear liquids through Friday and advance to full liquids by Saturday. She asked Patient #43 if she was "okay" to go home. Social work was never consulted. Staff MMMM called Staff PPP, Physician, to tell him the tube was removed. Staff PPP followed up with the patient.

During an interview on 08/15/24 at 9:56 AM, Staff KKK, CM Manager, stated if CM was aware of Patient #43's situation, they would have consulted with her to determine what was the best course of action for her. A follow up phone call could have taken place to "close the loop." Resources could have been provided if CM was notified. It was not acceptable to discharge a patient with a plan to return to the ED if he/she developed dehydration.

During an interview on 08/15/24 at 10:18 AM, Staff A, Quality Vice President, stated on 08/02/24 the Patient Relations department received a call from Patient #43. She verbalized her blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person's health) was low and she was worried. She was told she could return to the ED. She was concerned that Patient #43 was unsafe for the weekend. Staff PPP reached out to Patient #43 for a follow up in his office on Monday or a referral to another hospital. She was scheduled at Facility B. She agreed a "cool off" period could have been offered to Patient #43 before the tube was removed while she waited in the recovery room. A Social Service consult was always available. There was a difference of opinion between the physicians regarding Patient #43's ability to eat. It would be beneficial to provide resources to future patients in similar situations. She agreed the endoscopy staff needed increased awareness of how to reach out to Social Services.

During an interview on 08/14/24 at 11:55 AM, Staff RRR, Registered Nurse (RN), stated she was Patient #43's recovery nurse. The patient told Staff OOO, Physician, and Staff QQQ, NP, she was unhappy with the feeding tube in the same site. The patient was tearful. The patient was told to follow up with Staff PPP, Physician. She believed a consult to a nutritionist and/or Social Services would have been best.

During an interview on 08/14/24 at 1:17 PM, Staff UUU, RN, stated she discharged Patient #43. The patient stated she was unhappy with the feeding tube location and asked for it to be removed. She asked the patient if she could eat. The patient responded, "little bits." Staff UUU was not aware Patient #43 could not eat. If a patient was not able to get nutrition, they could not be sent home. She believed Patient #43 could "sustain herself." She did not look malnourished, she looked well. Staff UUU was unaware of Patient #43's complex condition. Staff UUU was aware she could call for assistance with outside resource prior to discharging a patient.

During an interview on 08/14/24 at 1:30 PM, Staff VVV, RN, stated she was the room nurse for Patient #43's procedure. Patient #43 was a "frequent flyer." She was aware Patient #43 could not tolerate oral intake and was "surprised" she chose to have the tube removed. If she was concerned about discharging a patient, she would refer to her manager for help with available resources. She expected resources were offered to patients in need. She would "absolutely" have given Patient #43 resources for expectations and follow up appointments.

During an interview on 08/15/24 at 8:45 AM, Staff IIII, RN, stated she was the procedure nurse for Patient #43. She stated Patient #43 needed to be educated by the physician, nurse and/or NP to ensure she understood the consequences of the decision she made.

Review of Patient #46's medical record dated 08/07/24 showed:
- He was an 80-year-old male with no past medical history on file.
- At 8:58 PM, he arrived to the ED via Emergency Medical Service (EMS, emergency response personnel, such as paramedics, first responders, etc.) due to having an altercation with his son at home and he did not feel safe at home.
- At 10:46 PM, Staff AAA, ED Physician, made initial contact with patient. He documented there was a concern for elder abuse. The patient's son threatened to beat him up and wanted to kill him. The patient stated that his son struck him three to four times on the right wrist. Patient #46 declined to press charges.
- Documentation showed he was alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation) and had the capacity to make his own decisions. Patient #46 wanted to go back home. Social Services was notified, and they were going to report the case. Patient #46 denied any other medical concerns.
- At 3:00 AM on 08/08/24, Staff NNNN, RN, documented she received report from the triage (process of determining the priority of a patient's treatment based on the severity of their condition) nurse and Patient #46 needed an EMS transfer home. He was at the ED because he did not feel safe at home. Staff NNNN told Patient #46 social services could help find a better placement for him in the morning if he decided to stay with them. He told her he did not want to stay, and it was safe to go home.
- At 4:33 AM, he was discharged home.

Review of Patient #46's medical record dated 08/11/24 showed:
- At 2:37 PM, he arrived at the ED via EMS.
- He presented with left hip pain and requested placement into a nursing home.
- Staff BBB, ED Physician, documented there was a concern for elder abuse versus poor social setting at home.
- The patient had chronic (long-term, ongoing) left hip pain due to the setting of a non-surgically treated left hip fracture (break in a bone). The patient was wheelchair-bound, reported he had an argument with son and was unable to live at home. The patient had no active thoughts of wanting to hurt himself or other mental health issues. The left hip appeared to be chronic pain in nature with a low suspicion for an acute (sudden onset) injury or infectious etiology at this time.
- At 9:44 PM, documentation showed a social worker from the Veterans Affairs (VA) called and stated that the patient was not safe to go back to his son's house due to the son's threatening behavior towards the patient. They stated that they should have beds for placement that night.
- At 10:06 PM, Staff BBB documented based on the initial story, concern for elder abuse by the son and with no living situation at that time Patient #46 needed to be admitted. The patient was wheelchair bound due to a chronic left hip injury and fracture. At that time, it was an unsafe to discharge him and he was admitted to in-patient care for placement and a concern of malnutrition.
- He remained in the hospital awaiting placement.

During a telephone interview on 08/21/24 at 10:00 PM, Staff NNNN, RN, stated Patient #46 hung out in triage while she received report from the triage nurse. She was told to contact EMS to take Patient #46 home. She was aware of the alleged abuse but followed instructions to discharge the patient. She stated, "I did not necessarily agree to discharge the patient to an unsafe environment, but he answered all the orientation questions correctly." She did not fill out an against medical advice (AMA) form and he was discharged. He did state that he was ready to go home. She was not aware that social services were available 24 hours per day. She made him comfortable until EMS arrived. She was unsure if the physicians saw the patient in triage. The physicians did not routinely see the patients in triage, so she was usure when the physician saw the patient.

During an interview on 08/15/24 at 10:10 AM, Patient #46 stated:
- When he called 911 on 08/07/24, he wanted to be transported to the VA. EMS told him that they called the VA, and they could not see him, so he was transported to Mercy Hospital South.
- When he was at the hospital, the ED physician told him he needed to see the case manager from the VA, there was nothing they could do for him at that time.
- He received verbal abuse when he got home and then was roughed up by his son. His son wanted him out of his home. His son charged him his entire social security check to live there, and he had no money left over. He had nowhere else to go. He was very tearful and did not make eye contact during this interview.

During a telephone interview on 08/14/24 at 3:00 PM, and 08/15/24 at 10:00 AM, Staff GGG, ED Medical Director, stated he would notify the police in these situations when the patient did not want to file charges. The police would come to the ED and usually the patient agreed to press charges or obtain a restraining order, depending on the circumstances. It was hard to hold a patient if they wanted to go home. An AMA was not completed with the patient. The hospital had been pushing the physicians to decrease the total numbers of AMA's but that he did not mean they could not use the AMA form. An ED provider meeting was scheduled for the following week and planned to use Patient #46's situation as a teaching tool. He reviewed the entire chart, and a hotline call was made to report the alleged abuse. He felt that based on all the documentation, the hospital did everything they could for this man.

During a telephone interview on 08/16/24 at 10:00 AM, Staff AAA, ED Physician, stated Patient #46 was alert and oriented and able to make his own decisions. He wanted to go home, and he discharged him. He felt like the patient changed his stories and was not sure if the alleged abuse had actually occurred.

During a telephone interview on 08/16/24 at 11:00 AM, Staff BBBB, ED Physician, stated he felt that Patient #46 was unsafe to be discharged due to the alleged abuse. He looked unkept and malnourished.




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