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Based on document review and interview, it was determined that the Hospital failed to ensure patients received care in a safe setting by failing to escort the patients safely and with respect and dignity, per Hospital policy; and failing to ensure incident reports were completed accurately and timely. As a result, the Condition of Participation 42 CFR 482.13, Patient Rights is not in compliance.

1. The Hospital failed to ensure the patient was escorted safely and with respect and dignity. See deficiency at A-144 (A).

2. The Hospital failed to ensure incident reports were completed accurately and reviewed timely. See deficiency at A-144 (B).



An Immediate Jeopardy (IJ) began on 2/22/2023 due to the Hospital's failure to ensure a patient was escorted out of the Hospital safely and with respect and dignity, and was identified on 4/5/2023, at 42 CFR 482.13, Patient Rights. The IJ was announced on 4/5/2023 at 12:30 PM during a meeting with the CEO, Chief Nursing Officer, Director of Patient Safety, Vice President of Patient Safety and Quality, Manage of Security, Chief Medical Officer, Regional Regulatory Director, Director of Security and Assistant Vice President of Security. The IJ was not removed by the survey exit date of 4/5/2023.

A. Based on document review and interview, it was determined that for 1 of 2 (Pt. #1) patients who refused to leave the Hospital after discharge, the Hospital failed to ensure the patient was escorted safely and with respect and dignity, per Hospital policy.

Findings include:

1. The Hospital's policy titled, "Patient Rights and Responsibilities" (revised 10/1/2020) was reviewed on 4/4/2023 and required, "As a patient, you have a right to: Considerate and respectful care at all times. ... Expect privacy ... and dignity concerning ... medical care."

2. The clinical record of Pt. #1 was reviewed on 4/4/2023. Pt. #1's clinical record included that Pt #1 presented to the Hospital's ED (emergency department), via the fire department, on 2/22/2023 at 3:04 PM with the diagnosis of alcohol intoxication. Pt #1 was an amputee, with partial left foot and right below the knee amputations.

- A physician's note (MD#1), dated 2/22/2023 at 9:57 PM, included, "Patient now clinically sober. Speaking coherent sentences. Patient stable for discharge home at this time."
- A nurse's note (E#7), dated 2/22/2023 at 11:42 PM, included, "Patient [Pt. #1] continues to be verbally abusive towards staff. Refusing to get dressed, refusing to move from bed. Security notified and assisting patient to leave. Police notified."

3. The internal security report, related to Pt. #1, dated 3/2/2023 at 6:00 AM, included that Security Officer (E#1) responded to the ED on 2/23/2023 at 12:02 AM regarding a patient [Pt. #1] who didn't want to leave. Pt. #1 was informed that if he did not leave, he would be arrested for trespassing. Pt. #1 did not respond and would not get out of the bed. The nursing staff informed Pt. #1 that the police were notified and were enroute to the hospital. The police arrived at approximately 12:12 AM and informed Pt. #1 that he needed to leave the hospital. Pt. #1 told the police that they would have to lock him up because he was not leaving. The police arrested Pt. #1 and took Pt. #1 from the hospital." The report did not include the exact time that the patient was taken outside or how long the patient was outside.

4. Per internet search on 4/5/2023 (www.timeanddate.com/weather), the temperature on Thursday, February 23, 2023, from 12:00 am - 6:00 am, was 36 degrees Farenheit.

5. The Security Shift Supervisor (E#1), who was called to assist with Pt. #1, was interviewed on 4/4/2023 at 2:35 PM. E#1 stated that he was called to the ED because Pt. #1 refused to leave. E#1 stated, "[Pt. #1] was being verbally aggressive, using racial slurs and wouldn't let anyone near [Pt. #1]. I told [Pt. #1] that he had to leave, I offered to get him dressed, [Pt. #1] still refused. So ... I helped him leave. It is not safe to remove a patient on a bed in the cold weather. I took [Pt. #1] out of the hospital on the stretcher onto the ambulance bay to wait for the police." E#1 did not recall how cold it was but stated that Pt. #1 had a gown and a sheet on. E#1 stated, "I did nothing wrong, the patient was using the 'N' word and was aggressive, so [Pt. #1] needed to go."

6. The Security officer (E#5), who assisted with Pt. #1, was interviewed on 4/5/2023 at 7:50 AM. E#5 stated that he was called at the beginning of the shift to assist with getting a patient to leave the hospital. E#5 stated, "[Pt. #1] was cussing and threatening the staff if they made [Pt. #1] leave. The staff did not feel safe around [Pt. #1]." E#5 stated that E#1 took Pt. #1 outside to the ambulance bay ramp in the hospital bed. [Pt. #1] was wearing a gown and a sheet. E#5 stated it was cold outside. They waited for about 5 -10 minutes for the police to arrive. The police put a blanket on Pt. #1. E#5 stated, "I would never have taken the patient outside in cold weather. I think [E#1] wanted to make [Pt. #1] get dressed because it was cold, but [Pt. #1] still refused. Taking someone outside not dressed is not something that we are trained to do. [Pt. #1] was arrested by the police and taken to the police department."

7. Video recording of the ED ambulance bay for 2/22/2023 - 2/23/2023 was requested on 4/4/2023, and the Manager of Security (E#4) stated that the video was unavailable due to only a 30-day loop, and 2/23/2023 was beyond 30 days.

8. The Manager of Security (E#4) was interviewed on 4/5/2023 at 8:10 AM. E#4 stated, "We do not train our officers to remove patients from the hospital in that fashion. It is not safe to remove a patient on a bed in the cold weather."

B. Based on document review and interview, it was determined that the Hospital failed to ensure incident reports were completed accurately within the required timeframe and reviewed timely to ensure safe care was provided to all patients.

Findings include:

1. The Hospital's policy titled, "Security Incident Reporting" (revised 2/3/2023) was reviewed on 4/5/2023 and included, "Information included in the Event Reporting System report must be objective in nature and should include the basic facts known at the time the report is entered. ... Security Personnel involved in a Security Incident ... Must complete a Security Incident Report prior to the end of the shift. ... The security manager must review all Security Incident Reports for Security Incidents."

2. The internal security report, related to Pt. #1, dated 3/2/2023 at 6:00 AM (8 days after event), was reviewed on 4/4/2023 and included that Security Officer (E#1) responded to the ED on 2/23/2023 at 12:02 AM regarding a patient [Pt. #1] who didn't want to leave. Pt. #1 was informed that if he did not leave, he would be arrested for trespassing. Pt. #1 did not respond and would not get out of the bed. The nursing staff informed Pt. #1 that the police were notified and were enroute to the hospital. The police arrived at approximately 12:12 AM and informed Pt. #1 that he needed to leave the hospital. Pt. #1 told the police that they would have to lock him up because he was not leaving. The police arrested Pt. #1 and took Pt. #1 from the hospital."

- The security report did not include taking the patient outside, on a hospital stretcher, undressed, and out in the cold.

- As of 4/4/2023, E #1 and E #5 were both working as Security Officers at the Hospital following this incident.

3. The Security Shift Supervisor (E#1), who was called to assist with Pt. #1, was interviewed on 4/4/2023 at 2:35 PM. E#1 stated that he was called to the ED because Pt. #1 refused to leave. E#1 stated, "[Pt. #1] was being verbally aggressive, using racial slurs and wouldn't let anyone near [Pt. #1]. I told [Pt. #1] that he had to leave, I offered to get him dressed, [Pt. #1] still refused. So ... I helped him leave. I took [Pt. #1] out of the hospital on the stretcher onto the ambulance bay to wait for the police." E#1 did not recall how cold it was or if it was raining but stated that Pt. #1 had a gown and a sheet on. E#1 stated that E#1 and E#5 (security officer) waited outside with Pt. #1 until the police arrived. E#1 stated, "I did nothing wrong, the patient was using the 'N' word and was aggressive, so [Pt. #1] needed to go." E #1 stated that the incident report was not completed prior to the end of the shift because "[E #1] had other priorities".

4. Video recording of the ED ambulance bay for 2/22/2023 - 2/23/2023 was requested on 4/4/2023, and the Manager of Security (E#4) stated that the video was unavailable due to only a 30-day loop, and 2/23/2023 was beyond 30 days.

5. The Manager of Security (E#4) was interviewed on 4/5/2023 at 8:10 AM. E#4 stated that if the incident report had been filled out on time and with all the details that were revealed in the interview [conducted by surveyor with E #1 on 4/4/2023], a complete investigation would have been done, including a video review."

Based on document review and interview, it was determined that for 1 of 1 clinical record (Pt #10) reviewed for nonviolent restraints, the Hospital failed to ensure that restraints were discontinued at the earliest possible time, as required.

Findings include:

1. On 4/4/2023, the Hospital's policy titled, "Restraint and Seclusion Management Policy" (dated 2/10/2023) was reviewed and indicated, "...Restraints or seclusion may be imposed to ensure the immediate physical safety of the patient, a staff member, or others...must be discontinued at the earliest possible time once the unsafe situation endless regardless of the scheduled expiration of the order..."

2. On 4/4/2023, Pt #10's clinical record was reviewed and noted:
-Pt #10's history & physical dated 3/5/2023 note that Pt #10 was seen in the ED on 3/5/2023 following a fall and loss of consciousness and admitted to 3 north medical floor.
-Pt #10's physician orders dated 3/5/2023 noted "Restraints non-violent or non-self destructive - Soft restraint: right wrist and left wrist - reason for restraints - interference with medical treatment - continuous for 24 hours - start date/time -3/5/2023 at 7:05 PM."
-Pt #10's restraint flowsheet dated 3/5/2023 noted Pt #10 was in bilateral soft wrist restraints from 7:05 PM on 3/5/2023 until 7:00 AM on 3/6/2023. Pt #10's restraint flowsheet documented that Pt #10 was sleeping at 10:00 PM, 12:00AM, 2:00 AM, 4:00 AM and 6:00 AM.

3. On 4/4/2023 at 12:00 PM, an interview was conducted with the ED Manager (E #3). E #3 stated that Pt #10's restraints should have been discontinued when Pt #10 was asleep.