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Based on record reviews and interviews, the hospital failed meet the requirements for the Condition of Participation for Patient's Rights as evidenced by failure to ensure all patients were free from abuse and neglect. This deficient practice was evidenced by:
1) 1 (Pt. #1) of 5 (Pt. #1 - Pt. #5) patients sampled not being monitored for suicidal ideation by staff as per the hospital's policy;
2) 2 (Pt. #2 and Pt. #3) of 5 (Pt. #1 - Pt. #5) patients sampled physically abused by hospital staff who were not reported to their licensing board;
3) 1 (Pt. #4) of 5 (Pt. #1 - Pt. #5) sampled patients who was referred from a nursing home with chronic dementia eloped from the hospital; and,
4) 1 (Pt. #5) of 5 (Pt. #1 - Pt. #5) patients sampled who was under a Physician's Emergency Certificate (PEC) eloped from the hospital. (See Findings A-0145).

Based on record review and interview, the hospital failed to ensure all patients were free from abuse or neglect. This deficient practice resulted in:
1) 1 (Pt. #1) of 5 (Pt. #1 - Pt. #5) patients sampled not being monitored for suicidal ideation by staff as per the hospital's policy;
2) 2 (Pt. #2 and Pt. #3) of 5 (Pt. #1 - Pt. #5) patients sampled physically abused by hospital staff who were not reported to their licensing board;
3) 1 (Pt. #4) of 5 (Pt. #1 - Pt. #5) sampled patients who was referred from a nursing home with chronic dementia eloped from the hospital; and
4) 1 (Pt. #5) of 5 (Pt. #1 - Pt. #5) patients sampled who was under a Physician's Emergency Certificate (PEC) eloped from the hospital.

Findings:
1) 1 (Pt. #1) of 5 (Pt. #1 - Pt. #5) patients sampled not being monitored for suicidal ideation by staff as per the hospital's policy;
Patient #1
Review of the policy and procedure titled, "Management of High-Risk Patients Levels of Observation" revealed, in part, patients who are identified as high risk due to behaviors, diagnoses, and/or physical conditions, or are being held without consent on an Emergency Certificate of Judicial Commitment shall be placed on levels of observation appropriate to maintain their safety. Emergency Department - When a patient is identified as presenting with risk for self-injurious behavior (e.g. suicidal ideation), injury to others, the registered nurse in the emergency department will remain with the patient until a qualified staff member can be assigned 1:1 while the nurse contacts the physician to notify him/her of the presentation of risk factors.

Review of the policy and procedure titled, "Providing Care for Patients who are under a Physician Emergency Certificate (PEC)/Coroner's Emergency Certificate (CEC)" read, in part, the purpose of this policy is to define the care of patients who are danger to themselves or others or who are gravely disabled while being treated at the hospital. Rooming patients who are a danger to themselves or others or are gravely disabled who present to the ED. 5. Staff member will maintain the level of observation ordered for the patient at all times. Movement of the patient from the designated ED room will require staff escort and close follow-up when not in the room. Documentation of observation will be completed at a minimum of every 15 minutes on the Observation form.

Review of the hospital's event report log revealed on 03/03/2023(no time documented), in the ED triage area, Pt. #1, who presented with a chief complaint of suicidal ideation, was left unattended in chairs outside of the triage rooms 5 & 6 and nurses were not notified that the patient was there.In an interview on 03/07/2023 at 1:04 p.m., S13RN indicated the procedure indicates that all patients who present to the ED with suicidal or homicidal ideation are taken directly back to an ED room for assessment.

In an interview on 03/07/2023 at 1:24 p.m., S1VP indicated Pt. #1, who presented to the front desk of the ED with suicidal ideation on 03/03/2023 was left with her parents in the waiting room and was not immediately escorted to an ED room for assessment.

Review of Pt. #1's electronic medical record navigated by S9RN revealed, in part, Pt. #1 was admitted to the hospital on 03/03/2023 at 8:10 p.m. via a Physician's Emergency Certificate (PEC) for suicidal ideation and was identified as gravely disabled. Further review revealed no documentation of observations every 15 minutes as per the hospital's policy and procedure for patients who are PECd from 8:10 p.m. through 9:00 p.m.

In an interview on 03/06/2023 at 2:40 p.m., S9RN verified there was no documentation of 15 minute observation rounds completed on Pt. #1 upon signature of the PEC on 03/03/2023 at 8:10 p.m. through 9:00 p.m.

In an interview on 03/07/2023 at 12:45 p.m., S1VP indicated there were no observation rounds documented on Pt. #1 on 03/03/2023 between 8:10 p.m. and 9:00 p.m.

2) 2 (Pt. #2 and Pt. #3) of 5 (Pt. #1 - Pt. #5) patients sampled physically abused by hospital staff who were not reported to their licensing board;
Patient #2
Review of the hospital's policy and procedure titled, "Code of Conduct" revealed, in part, due to the very nature of the services offered, the hospital mandates the highest standards of work performance, behavior and ethical conduct from its employees since its employees are reflective of the hospital's image in the community. Termination: Termination should be used in cases where the violation of policy is egregious, an employee's performance or behavior is so serious as to be unresolvable or where other corrective measures have failed. C. Violations which may result in immediate discharge include, in part, any act, negligence or conduct detrimental (or potentially harmful) to patients, hospital operations, staff, students, or hospital assets. Inappropriate conduct on hospital property, clinics, offices, or other locations. Inappropriate conduct includes, but is not limited to, making discriminatory remarks or actions, acts of harassment, threats of violence, use of profane or obscene language. Hostile Work Environment: Verbal or physical abuse of an employee, leader, supervisor or designee, patient, physician, contractor, student or visitor; Threatening or coercing an employee leader, supervisor, or designee, patient, physician, contractor, student or visitor; Harassment or intimidation of an employee, leader, supervisor, patient, visitor, student, or physician of a verbal, physical, emotional, or sexual nature. III. Reporting Termination/Disciplinary Actions to Licensing Boards: If an employee is terminated or under disciplinary action for an issue which could impact their license, it is the responsibility of the appropriate VP to notify and gather requested data for the appropriate licensing board.

A review of Pt. #2's electronic medical record navigated by S9RN revealed, in part, Pt. #2 presented to the hospital's ED on 01/15/2023 with diagnoses including in part, Progressive Abdominal Pain and Metastatic Neuroendocrine Adenocarcinoma. Pt. #2 had a history of being incontinent of urine.

Review of the hospital's Abuse/Neglect Initial report submitted to LDH and dated 01/24/2023 revealed Pt. #2 repeatedly called out for assistance to be escorted to the bathroom. Further review revealed S10RN approached Pt. #2 in his room, asked him why he did not use his urinal, and physically pushed Pt. #2 who then landed in a prone position on a stretcher. The hospital substantiated the allegation of patient abuse.

Review of S10RN's Human Resource file with S12HR revealed S10RN was terminated on 01/19/2023 for violation of the Code of Conduct policy and procedure related to Pt. #2.

In an interview on 03/07/2023 at 10:10 a.m., S14RN indicated S10RN had not yet been reported to their licensing board related to the termination based on patient abuse.

Patient #3
Review of a the hospital's Abuse/Neglect report submitted to LDH revealed on 01/24/2023, the hospital filed a final report related to substantiated physical abuse of Pt. #3 which occurred on 01/11/2023 .Further review of the report revealed S11RN initially engaged in a verbal altercation with Pt. #3 and then proceeded to pull Pt. #3 by his jacket toward the exit. S11RN and Pt. #3 ended up on the floor with S11RNs knees almost on top of Pt. #3's head. Following this incident, Pt. #3 was transferred to another area of the ED.

Review of Pt. #3's electronic medical record navigated by S9RN revealed, in part, an admit date of 01/11/2023 with a diagnosis of Alcohol Intoxication. Further review revealed Pt. #3 presented to the ED with a wound to his right hand and a past medial history of Alcohol abuse, Alcohol Dependence, Bipolar 1 Disorder, Borderline Personality Disorder, COPD, Hepatitis C, PTSD, Schizophrenia, Seizures and Suicidal Ideation.

In an interview on 03/07/2023 at 10:18 a.m., S12HR verified that S11RN was terminated on 1/25/2023 related to a violation of the hospital's Code of Conduct policy and procedure related to the actions involving Pt. #3.

Review of an electronic mail correspondence from S15HR and dated 01/17/2023 revealed, in part, the video footage shows S11RN dragging Pt. #3, falling on the patient and then sitting on the patient's face and neck area. When the patient was able to stand to his feet again, S11RN pushes the patient down the hallway. It was concluded that S11RN's behavior was a clear violation of the Code of Conduct HR Policy #404 regarding physical abuse of a patient with the recommendation for termination.

In an interview on 03/07/2023 at 10:10 a.m., S14RN indicated S11RN had not yet been reported to their licensing board.

3) 1 (Pt. #4) of 5 (Pt. #1 - Pt. #5) sampled patients who was referred from a nursing home with chronic dementia eloped from the hospital; and,
Patient #4
Review of Pt. #4's electronic medical record navigated by S9RN revealed, in part, an ED encounter on 01/04/2023 when Pt. #4, who was diagnosed as having Chronic Dementia with behavioral disturbance, was transferred from a local nursing home via emergency medical services following an altercation with another resident. Further review revealed Pt. #4 was in the ED, not on observation precautions and awaiting removal of a PEG tube.

Review of the hospital's Abuse/Neglect report submitted to LDH and dated 01/11/2023 revealed, in part, on 01/04/2023 at 1:31 p.m. Pt. #4 eloped from the ED. Further review revealed at 5:15 p.m., Pt. #4 was brought back to the hospital by a family member. Subsequently, on 01/04/2023 at 6:02 p.m., Pt. #4 was placed on a Physician's Emergency Certificate and transferred to a local behavioral health hospital. The hospital did not substantiate this occurrence as neglect and was unable to provide evidence of the implementation of effective interventions to
prevent elopements from the ED.

4) 1 (Pt. #5) of 5 (Pt. #1 - Pt. #5) patients sampled who was under a Physician's Emergency Certificate (PEC) eloped from the hospital.
Patient #5
Review of the policy and procedure titled, "Providing Care for Patients who are under a Physician Emergency Certificate (PEC)/Coroner's Emergency Certificate (CEC)" read, in part, the purpose of this policy is to define the care of patients who are danger to themselves or others or who are gravely disabled while being treated at the hospital. Rooming patients who are a danger to themselves or others or are gravely disabled who present to the ED. 5. Staff member will maintain the level of observation ordered for the patient at all times. Movement of the patient from the designated ED room will require staff escort and close follow-up when not in the room. When toileting, the bathroom door should be kept ajar to allow for safety and privacy. Documentation of observation will be completed at a minimum of every 15 minutes on the Observation form.

Review of the hospital's Abuse/Neglect report submitted to LDH and dated 01/19/2023 revealed, in part, on 01/11/2023 Pt. #5 presented to the ED via law enforcement for evaluation of drug ingestion at 2:00 p.m. Pt. #5 allegedly ingested heroin and cocaine while in the police car and Narcan was administered.

Review of Pt. #5's electronic medical record navigated by S9RN revealed, in part, Pt. #5 was PECd on 01/11/2023 at 3:50 p.m. and S16PCT was assigned to perform and document the 15 minute observation rounds.

Review of the hospital's Abuse/Neglect report submitted to LDH revealed on 01/11/2023 at 10:14 p.m., Pt. #5 eloped from the facility. Further review revealed S16PCT escorted the Pt. #5 to the bathroom but did not keep the door ajar to allow for safety and privacy as per the hospital's policy. Further review revealed S16PCT received disciplinary action. The final report substantiated neglect of Pt. #5.

Review of S16PCT's HR file with S12HR revealed no documentation of disciplinary action related to this occurrence.

In interview on 3/6/23 at 1:15 p.m., S1VP indicated the team was in the process of putting a behavioral health kit together to mitigate the most recent report to LDH, and it has not yet been presented to the hospital staff.

In an interview on 03/07/2023 at 3:03 pm., S1VP indicated S13RN verbally counseled S16PCT and this action had not been forwarded to HR.

In interview on 03/07/2023 at 3:05 p.m., S1VP verified S16PCT did not follow policy related to toileting patients who were PECd and the allegation of neglect was substantiated.

The hospital was unable to provide documented evidence that S16PCT was counseled regarding the elopement of Pt. #5.

The hospital was unable to provide evidence of the implementation of effective interventions to prevent elopements from the ED.