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Based on interview, record review, policy review and video review the hospital failed to:
- Recognize the abuse of one discharged patient (#27) of five discharged patients reviewed. (A-0145)
- Immediately remove one staff member after allegations of abuse were reported for two discharged patients (#16 and #26) of five discharged patients reviewed. (A-0145)
- Recognize a pattern of abuse for four discharged patients (#16, #26, #28 and #29) of five discharged patients reviewed. (A-0145)
- Follow their policy and complete a face-to-face (a qualified staff member's evaluation of a patient in violent restraints [medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others]) assessment within one hour after violent restraints were placed on one discharged Emergency Department (ED) pediatric (pertaining to children) patient (#17) of two discharged records reviewed. (A-0178)
- Seek the written consent for treatment for five current patients (#2, #9, #12, #14 and #31) of 18 records reviewed. (A-0131)
- Ensure the metal cover over the thermostat was secured in one adult behavioral unit of two units observed. (A-0144)

The failures resulted in a systematic failure and noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights.






48359

Based on interview, record review and policy review, the hospital failed to seek the written consent for treatment for five current patients (#2, #9, #12, #14 and #31) of 18 records reviewed. This failure had the potential to affect all patients admitted to the hospital.

Findings included:

Review of the hospital policy titled, "Physician and Hospital Services Agreement (PHSA) Completion Policy," dated 03/19/24, showed:
- A PHSA form must be on file for all services provided in the hospital setting.
- All patients presenting for a Mercy service must have an active PHSA on file with an electronic/written signature scanned into the electronic medical record (EMR).
- The Mercy coworker will review the PHSA form within the documents table in the EMR. The co-worker will confirm the scanned date and/or the date that the patient signed the form.
- All pages of the PHSA document must be scanned into the EMR.
- A PHSA form is effective for one calendar year from the date of execution.
- All fields, on all pages of the PHSA must be completed to include the patient or representative signature, date and time.
- When a verbal agreement is received, the agreement expires in 24 hours.

Review of the hospital's policy titled, "Informed Consent Policy," dated 04/09/24 showed:
- To be consistent with quality patient care, informed consent must be obtained
pursuant to this policy and documented in the medical record before proceeding with surgical, diagnostic, or medical procedures, treatments, and anesthesia.
- The credentialed provider who directs the patient's care/treatment is responsible for obtaining informed consent from the patient/representative and documenting this process in the patient's medical record.
- A Mercy, or aligned, clinical coworker may act as a witness to the patient/representative signing the consent form.

Although requested the hospital failed to provide a report of patients with verbal and expired consent for the PHSA.
Review of Patient #2's medical record showed:
- On 04/09/24 at 4:24 PM, the PHSA was scanned into the EMR.
- The PHSA was completed via verbal consent.
- The PHSA was incomplete without a written time.
- On 06/09/24 Patient #2 was treated at the hospital with an expired and incomplete PHSA.

Review of Patient #9's medical record showed:
- On 11/28/23 at 9:10 AM the PHSA was scanned into the medical record.
- The PHSA was incomplete without a written date or time.
- On 06/10/24, Patient #9 was treated at the hospital without a completed PHSA.
- The Consent to Procedure was incomplete without an identified credentialed provider, written patient/representative signature, date, time or witness.

Review of Patient #12's medical record showed:
- On 06/07/24, Patient #12 was treated at the hospital.
- The PHSA was not scanned into the EMR.
- The PHSA was incomplete without a written date or time.

Review of Patient #14's medical record showed:
- On 06/06/24, Patient #14 was treated at the hospital.
- The PHSA was not scanned into the EMR.
- The PHSA was incomplete without a written time.

Review of Patient #31's medical record showed:
- On 01/29/24 at 8:12 PM, the PHSA was scanned into the EMR.
- The PHSA was incomplete without a written date or time.
- On 06/10/24, Patient #31 was treated at the hospital without a completed PHSA.

During an interview on 06/12/24 at 2:10 PM, Staff HH, Registration Supervisor, stated that verbal permission for the PHSA expired in 24 hours. If the consent was initially obtained verbally, patients may be hospitalized for "days" without a current PHSA. There was no consistent process to inform the registration staff that the PHSA was expired.

During an interview on 06/13/24 Staff FF, Chief Nursing Officer (CNO), stated that she was unfamiliar with the PHSA process. She expected a complete and unexpired PHSA and procedure consent with a signature, date and time.

During an interview on 06/13/24 at 1:50 PM, Staff WW, Emergency Department and Intensive Care Unit (ICU, a unit where critically ill patients are cared for) Director, stated that he expected a signed and complete PHSA and procedure consent. The hospital had an opportunity for improvement with the consent process.




48359

Based on observation, interview and policy review, the hospital failed to ensure the metal cover over the thermostat was secured in one adult behavioral unit of two units observed. This failure placed all patients admitted to the adult behavioral health unit at risk for their safety.

Findings included:

Review of the hospital's policy titled, "Behavioral Health Services Environmental Checks," dated 05/24/24, showed environmental checks are performed twice daily in all behavior health units to maintain a safe environment.

Observation on 06/11/24 at 1:40 PM, in the Adult Behavioral Unit, showed the metal thermostat cover was unsecured.

During an interview on 06/11/24 at 1:45 PM, Staff CC, Manager, stated that the thermostat cover was to always be locked. Environmental rounds were performed twice daily on the behavioral health unit.

During an interview on 06/13/24 at 3:00 PM, Staff FF, Chief Nursing Officer (CNO), stated that she expected the thermostat covers to always be locked in the Behavioral Health Units.

Based on interview, record review, policy review and video review, the hospital failed to:
- Recognize the abuse of one discharged patient (#27) of five discharged patients reviewed.
- Immediately remove one staff member after allegations of abuse were reported for two discharged patients (#16 and #26) of five discharged patients reviewed.
- Recognize a pattern of abuse by the same staff member (Staff II) for four discharged patients (#16, #26, #28 and #29) of five discharged patients reviewed.

Findings included:

Review of the hospital's policy titled, "Reporting Response to Patient Abuse Neglect by a Coworker," dated 08/03/21, showed:
- Abuse is the willful infliction of unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. This includes staff disregard or indifference to the infliction of injury. Abuse also includes verbal intimidation, inappropriately raising one's voice, cursing and threats of punishment toward a patient.
- The consequences for abuse will be termination of employment, reporting offenders to their respective State Licensing Board, and possible criminal charges.
- Mercy creates and maintains a proactive approach to identify and escalate events and occurrences that may constitute or contribute to abuse and neglect.
- Mercy protects our patients from abuse during the investigation of any allegations of abuse or neglect or harassment, by immediately removing coworkers alleged of committing abuse from the workplace until the investigation is concluded.
- Mercy assures that any incidents of abuse, neglect or harassment are reported and analyzed; and appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State or Federal law.
- The person in charge and/or their manager immediately removes the coworker who allegedly abused a patient from direct patient care.
- When potential abuse or neglect has been identified the leader handling the immediate investigation will escort the coworker from the hospital premises.
- The coworker will be placed on suspension pending further investigation.
- Members of the Senior Leadership Team/Administrator on Call (AOC) will meet (President, Vice Presidents, Chief Medical Officer, Director of Quality, and Manager of Human Resources) to review all the facts of the investigation.

Review of the hospital's document titled, "Mercy Safety Event Review #363496," dated 01/05/24 showed:
- On 01/03/24, Patient #27 was escorted out of the building by security and was then brought to the ground by security, resulting in a one-centimeter (cm) head laceration (a deep cut or tear in skin), an alleged shoulder injury and a chipped tooth.
- Patient #27's statement showed, he was exiting the building with a security escort. "They pointed toward a door, but it didn't feel right. I moved quickly and as soon as I moved, they jumped me." They put him on the ground, injured his right shoulder, caused a one cm laceration to the right side of his head and chipped his tooth.
- On 01/03/24, Staff LL's, Public Safety Officer (PSO), statement showed he escorted Patient #27 out of the Emergency Department (ED), the patient stopped several times and needed verbal redirection to exit the building. The patient complained he did not receive the pills that he came for and was upset. Patient #27 attempted to turn back around and enter the ED. Staff LL, placed his right hand on the door to prevent him from entering the ED. Staff JJ, PSO, placed Patient #27 on the ground, the patient was secured, and medical attention was provided.
- Staff JJ's, PSO, statement showed he received a call that stated Patient #27 was discharged and "wandering around the ED." Staff LL, PSO, and Staff JJ found Patient #27 wandering the hallway. Patient #27 was directed to the ED waiting room. The patient seemed confused and "slightly agitated." Patient #27 walked through the ED waiting room door and stated in an angry voice, "I'm supposed to have a bottle of fucking pills in my hand." Patient #27 turned around and attempted to reenter the ED hallway. Staff LL placed his right arm out to guide Patient #27 back to the waiting room. Patient #27 spun away and contacted Staff JJ. Staff JJ contained Patient #27 to prevent reentry and Patient #27 placed his hands on the wall and pushed off into Staff JJ. Staff JJ placed Patient #27 on the ground. The Crystal City Police Department (CCPD) was called. Patient #27 was searched for weapons and was medically evaluated.
- On 01/04/24, the leadership team determined no "intent to harm" and the abuse allegation was unsubstantiated.

Review of the hospital ED video footage on 01/03/24 showed:
- At 4:34:43 PM, Patient #27 walked in the ED hallway followed by Staff JJ, PSO and Staff LL, PSO.
- At 4:34:47 PM, Patient #27 turned to speak to Staff LL.
- At 4:34:48 PM, Staff EEE, Registration Clerk, entered the hallway.
- At 4:34:57 PM, Staff JJ, reached towards a door.
- At 4:34:58 PM, Patient #27 turned to his right.
- At 4:35:02 PM, Patient #27 turned around, away from the door.
- At 4:35:03 PM, Staff JJ placed his right arm around Patient #27 and turned him back towards the door.
- At 4:35:04 PM, Staff JJ placed both arms around Patient #27 chest from behind.
- At 4:35:05 PM, Patient #27 took a step forward and Staff JJ pulled Patient #27 towards his right side towards the ground.
- At 4:35:06 PM, Patient #27 was on the ground with Staff JJ on top of him. Staff EEE, turned around to walk away from the event.
- At 4:35:07 PM, Patient #27 slid across the floor, his feet hit the wall.
- At 4:35:10 PM, Staff EEE, turned around and walked toward the patient and the PSOs. Staff JJ remained on top of Patient #27.
- At 4:35:14 PM, Staff EEE, entered the door. Staff JJ remained on top of Patient #27.
- At 4:35:17, Staff JJ reached towards his right back side.
- At 4:35:21 PM, Staff JJ held Patient #27's right hand towards the patient's head.
- At 4:35:26 PM, the video ended. Staff JJ remained on top of Patient #27.

Review of Patient #27's medical record showed:
- On 01/03/24 at 4:15 PM, he arrived at the ED with a complaint of hallucinations (seeing or hearing things which are not there) via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.).
- His past medical history was anxiety, back pain, headache and opiate addiction (extreme desire and misuse of addictive pain medication).
- At 4:20 PM, Patient #27's chief complaint was updated to recently left jail - no chief complaint. The patient requested a case worker.
- The History of Present Illness showed Patient #27 had no significant complaints. He stated, "in no uncertain terms that he did not want any medical assistance or help."
- At 4:30 PM, he was discharged.
- At 4:58 PM, he arrived at the ED via police with a complaint of a head laceration.
- At 5:06 PM, a nurse note showed, Staff GGG, Registered Nurse (RN), was called due to a security use of force. Patient #27 sat holding his head and blood was on the floor. A laceration was observed to the right side of his head, bleeding was controlled. The patient was assisted to a standing position, was cooperative, and agreed to a reassessment due to a new head laceration and complained of dizziness.
- At 5:24 PM, Patient #27 complained of a right-side chipped tooth.
- At 5:37 PM, Patient #27 declined repair of his half-cm head laceration.
- At 6:08 PM, he was discharged.

During an interview on 06/13/24 at 11:00 AM, Staff OO, Public Safety Director, stated that the PSOs received a call that "someone was wandering in the ED." The officers contacted Patient #27 and guided him toward the exit door. The patient was uncooperative. The patient did not go out the door, he spun towards the PSOs. Staff LL, PSO, used his left arm to redirect the patient towards the waiting room. Patient #27 placed his hands on the door and pushed back. Staff JJ, PSO, and the patient ended up spinning toward the floor. If Staff JJ was not so close to Patient #27, he would not have pushed off him. Staff OO would not have stood that close to a patient, he would have ensured there was space between the patient and himself. During a debrief with Staff JJ, he discussed the need to maintain five feet of distance between himself and the patient and never would have put himself in the "zone." The only time hands were placed on a patient was to prevent injury. Staff JJ was on a performance improvement plan in response to a cumulation of events. Staff JJ "read the room well and had a great ability to identify threats quickly." His quick reacting did not always "play to his favor." He needed redirection. Staff OO agreed this event was a failure to recognize, protect and educate staff.

During an interview on 06/13/24 at 1:50 PM, Staff WW, ED and Intensive Care Unit (ICU, a unit where critically ill patients are cared for) Director, stated that he was involved in the investigation of the alleged abuse of Patient #27. The PSOs were called to the ED to escort the patient out after he was discharged. Staff JJ, PSO, believed the patient's actions were aggressive. "The takedown could have been a little more controlled." Staff WW felt the takedown was excessive.

During an interview on 06/13/24 at 2:50 PM, Staff XX, ED Manager, stated that she believed Staff JJ, PSO, felt the patient was going to strike. She stated that "the video did not appear that way." Staff JJ skewed the perception of his duties. He maybe had a "sterner presence."

During an interview on 06/13/24 at 3:00 PM, Staff E, Chief Nursing Officer (CNO), stated the video did not clearly show what lead to the event. There was not a deliberate attempt to cause harm. There was a deliberate attempt to take Patient #27 down to the ground.

During a telephone interview on 06/13/24 at 9:35 AM, Staff LL, PSO, stated that he did not remember why he was asked to escort Patient #27 out of the ED. Patient #27 was "mad at the doctors, wanted medications and refused to leave." He did not know why Staff JJ, PSO, took Patient #27 to the ground. "It happened so fast." He was "shocked it happened." He put his arm up to redirect the patient, stated "sir to this way" and the next thing he knew, the patient was on the floor. Staff JJ wrapped his arms around the patient and went down to the ground with the patient. He believed the situation could have been "handled in a different way."

During a telephone interview on 06/13/24 at 10:15 AM, Staff JJ, PSO, stated that he was called to the ED to escort Patient #27 out. The patient talked about medications. The patient was "really agitated, kept turning and looking and required redirection." The patient "raged" when they got to the door. He placed his left arm around the patients "stomach area," his right arm was higher to block the patient from striking. Patient #27's back contacted his chest, and they spun to the ground. The situation escalated very fast. The patient was not reasonable at the time.

During a telephone interview on 06/17/24 at 5:12 PM, Staff GGG, RN, stated that she was called to care for Patient #27 after the event. Patient #27 was paranoid and possibly under the influence of "something." When she arrived at the scene there was "blood everywhere from his head laceration." Staff LL, PSO, later asked to speak with her because she was the Charge Nurse that day. He stated that "it should not have happened the way it happened." The CCPD were called and reviewed the video to evaluate if the patient assaulted the staff. After they viewed the video, they responded to Staff GGG with "it looked bad." Staff JJ, PSO, was "more excessive, he reacted before he really knew." She voiced her concerns to leadership, but there was no response.

During an interview on 06/13/24 at 2:45 PM, Staff EEE, Registration Clerk, stated that she felt the takedown "could have been a lot less. The patient was talking very loudly, not necessarily yelling." She was "surprised" by the takedown, that was why she turned around to walk the other direction.

Review of the hospital's document titled, "Mercy Safety Event Review #340947," dated 08/11/23, showed:
- Staff II, RN, was unfriendly and unnecessarily rough when looking for Patient #29's intravenous (IV, in the vein) access on 08/08/23 and 08/09/23.
- On 08/11/23, Staff C, President, stated Patient #29 stated that his elbow was pushed away which caused him severe pain and the patient denied physical abuse. The patient seemed to contradict. The statements from other caregivers confirmed there were no other issues during the stay and that Staff II attended to the patient; not necessarily that the patient did or did not feel pain. There were no concerns for other patients, though only one could verbalize their care. The patient likely felt some pain during his care, but he could not determine that there was any intention to do harm or negligence that resulted in harm. He thought this was an unfortunate occurrence for the patient but did not see abuse or neglect by the definition.
- No written statements were available in the document.
- On 08/16/23 the investigation was completed; Staff II was cleared to return to work. Follow up was provided with Staff II regarding the way he handled patients.

Review of Patient #29's medical record showed:
- On 08/11/23, he was a 49-year-old male admitted to the hospital with a positive blood culture (a laboratory test to check for bacteria or other germs in a blood sample).
- Staff II, RN, cared for Patient #29 overnight on 08/08/23 and 08/09/23.
- On 08/08/23, Staff II, administered seven IV medications.
- On 08/09/23, Staff II, administered 11 IV medications.
- On 08/10/24, Staff II, administered seven IV medications.

Review of the hospital document titled, "Mercy Safety Event Review #344830," dated 09/07/23, showed:
- On 09/06/23 at 11:00 PM, Patient #16's reported that Staff II, RN, made her feel uncomfortable and she requested another nurse. Staff II requested to look at the bruising on her ribs. He attempted to view her rib cage under her breast from the top of her gown. She told him "that's not where the bruises were and pushed his hands off her." She was concerned about her morphine (an opioid pain medication) administration. She demonstrated him holding her hand in a way that prevented her from seeing him administer the medication. Staff II "put something into the sharp's (a term used for devices with sharp points or edges that can puncture or cut the skin) container." When she questioned Staff II about what he placed in the sharp's container, he responded "the morphine vial". Patient #16 believed this was suspicious, he had already put something else in the sharp's container after he gave her the medication.
- Staff II's statement showed he attempted to complete an assessment by looking at her rib fracture site. He attempted to lift the left side of her gown and when he approached her, she became upset, pulled away and told him the site was all on her side.
- Staff II did not meet the criteria for drug testing per the "Reasonable Suspicion Checklist" for a drug diversion assessment.
- The AOC was made aware of the situation. Staff II did not display behaviors indicating the need for a drug screen. The AOC agreed that since the checklist criteria wasn't met, Staff II did not need to be drug tested nor did he need to be removed from patient care.
- On 08/01/23 through 09/08/23 a drug diversion audit was completed without diversion identified.
- There was no meeting of the Senior Leadership team.

Review of the hospital's document titled, "Timecard," dated 06/04/23 through 02/23/24 showed Staff II, RN, completed his shift on 09/06/23.

Review of Patient #16's medical record showed on 09/06/24, she was a 61-year-old female admitted to the hospital for multiple left sided broken ribs. At 8:25 PM, Staff II, RN, administered morphine four milligrams (mg) IV.

Review of the hospital's document titled, "Mercy Safety Event Review #362651," dated 01/01/24, showed:
- On 01/01/24 at 4:30 AM, Patient #26 notified the Charge Nurse that Staff II, RN, touched her breast and nipples. The patient stated that when Staff II entered the room with coworkers, he acted fine. When he entered her room alone, he touched her breast and nipples. She stated that she was constantly woken up by him, she did not like him, and he bothered her all night.
- Staff II's statement showed Patient #26 had been uncooperative all night. She pulled off her telemetry leads (wires affixed to the skin for heart monitoring). At approximately 4:50 AM the patient claimed he had touched her breast and nipples. He informed the patient when he performed the electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) he needed to raise her left breast, she told him to go ahead but hurry up about it. In summary, the patient was verbally abusive and non-compliant with her diet and in keeping her nasal cannula (NC, a lightweight tube with two prongs for insertion into the nostrils and delivery of oxygen) in her nose all night. Staff II and other staff were frequently required to replace the cannula. The patient appeared more confused than at baseline. The patient appeared to need a psychiatric (relating to mental illness) consultation.
- Staff KKK, RN's statement showed the patient did not like Staff II. He "touched her nipples." Staff KKK witnessed Staff II replace her heart monitor in a professional manor. She did not see any signs of abuse to the patient.
- Staff LLL's, Patient Care Technician (PCT), statement showed she never saw any inappropriate things go on. Staff II placed EKG leads on the patient but never touched her inappropriately.
- Staff II was not immediately removed from all patient care.
- The event was reviewed with Staff II and he was cleared by the AOC.
- There was no meeting of the Senior Leadership team.

Review of the hospital's document titled, "Timecard," dated 06/04/23 through 02/23/24 showed Staff II completed his shift on 01/01/24.

Review of Patient #26's medical record showed:
- On 12/31/24, she was a 59-year-old female admitted to the hospital with pneumonia (infection in the lungs), chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing) and anxiety.
- At 8:58 PM, she was alert and oriented and appeared confused.
- On 01/01/24 at 12:03 AM, an EKG was completed.
- At 12:58 AM, she was eating "sugary treats" and non-compliant with her diabetic controlled diet.
- At 3:54 AM, she removed her nasal cannula and her oxygen saturation (measure of how much oxygen is in blood. A normal is between 95% and 100%. Lung disease normal oxygen saturation level may be lower) decreased to 80%. She was non-compliant with staff attempts at providing care, became angry and verbally abusive.
- At 4:20 AM, she became agitated with Staff II, RN, and required a different nurse. She was demanding, continued to remove her oxygen and ate sugary foods.

Review of the hospital document titled, "Mercy Safety Event Review #365971," dated 01/22/24, showed Staff II, RN, was rude, refused to let Patient #28 urinate or make decisions. He was forced to wear an oxygen mask. He requested something for sleep and was given what felt like an extremely high dose of something. Staff tried to force him to sign out against medical advice (AMA, a patient chooses to leave the hospital before the treating physician recommends discharge). He was given a Lovenox (a medication used to help prevent the formation of blood clots) shot aggressively which was extremely painful and made him kick the nurse. Patient #28 requested a new nurse but was told that was not possible.
- A statement from Patient #28's mother showed she remained on the phone the entire night because she was concerned about Staff II's care of her son. Staff II would not allow the patient out of bed or to take a shower. She described care surrounding a shot.
- Patient #28's statement showed Staff II was "very combative" with him the whole time. He was given a "blood clot shot." Staff II "shoved the shot in him," he pushed Staff II back, the needle broke off and Staff II placed his hand and "jammed" the needle in him. He was given a sleeping pill to "put him out." He did not believe the correct medication was given.
- Staff II's statement showed he felt it was "risky" for the patient to walk because both of his feet were deep purple and his pedal pulses (pulse that is felt on the top of the foot in front of the ankle) were barely detectible. The patient had rapid and pressured speech (rapid, compulsive talking, a classic symptom of bipolar disorder) and Staff II assessed the speech was related to anxiety or psychiatric issues. The patient spoke to his mother on the phone and made statements about inadequate care. At approximately 12:30 AM, the patient requested sleep medication. Trazadone (a medication used to treat depression) was given. The patient slept, awoke at about 4:00 AM and called his mother. He claimed Staff II was trying to poison him or knock him out and that he was overdosed. The patient refused to listen and told his mother on the phone that he was given too much medication. Staff II asked Patient #28 if he could give him a heparin shot (a medication used as a blood thinner or to prevent blood clots from forming). The patient told Staff II to "do what he needed to do." Staff II cleansed the area with alcohol, inserted the needle, the patient jumped and punched Staff II's left arm, which dislodged the needle. A small amount of blood appeared at the needle insertion site. Staff II cleaned the site and applied brief pressure. The patient started swinging towards Staff II. The patient yelled "no procedures, no procedures". The Charge Nurse entered the room and Staff II informed her he could no longer care for the patient. Staff II believed Patient #28 had psychiatric issues. He requested a psychiatric consultation, which was not done.
- A statement collected from Staff MMM, RN, showed the patient was very confused, argumentative, compulsive and hard to understand. Patient #28 pulled out his IV and said he was attacked and stabbed overnight.
- A statement collected from Staff NNN, RN, showed she saw Patient #28 attempt to strike Staff II. When she entered the patient's room, he yelled Staff II "assaulted" him, he did not want the medication or any procedures. Staff NNN took over the care of Patient #28.
- On 01/23/24 the leadership team meeting identified no intent to harm, the patient was not harmed, the complaint was unsubstantiated.
- Staff II's contract was terminated.

- Review of Patient #28's medical record showed on 01/22/24, he was a 56-year-old male admitted to the hospital with congestive heart failure (CHF, a weakness of the heart that causes it to not pump blood like it should leading to a buildup of fluid in the lungs and surrounding body tissues) and respiratory failure (condition in which not enough oxygen passes from the lungs into the blood).
- On 01/18/24 at 9:06 PM, he was a moderate to high fall risk.
- At 9:58 PM, he refused to get off the telephone with his mother and refused to wear an oxygen mask.
- At 10:11 PM, he continued to speak on the telephone with his mother.
- At 11:51 PM, he rescinded his request to leave AMA. He remained on the telephone with his mother. The patient wanted to sleep flat on the bed. This was not in his best interest and Staff II, RN, would allow Patient #28 to sleep flat. Patient #28 was not allowed to walk due to his high risk for falls. Patient #28 agreed to bedrest and this agreement was witnessed by other nurses.
- At 4:17 AM, Patient #28 requested medication for sleep and Trazadone was administered. The patient called his mother and informed her that Staff II tried to knock him out, gave him "too powerful" of a medication and he requested to speak with the Charge Nurse.
- At 4:44 AM, the patient punched Staff II when he gave him a Heparin shot. The patient's behavior resulted in an open unsheathed needle being ejected from his abdomen to his bed.

During an interview on 06/13/24 at 3:00 PM, Staff EEE, CNO, stated that she believed Patient #16 did verbalize that she did not want to be touched in the manner she was. She believed this was an invasion of privacy, a violation of patients' rights and caused emotional harm. She understood even though there was no intent to harm, the patient suffered emotional harm. She stated that the hospital was "consistent about their investigation process but that there was room to improve. It was the hospital's responsibility to protect the patients." She agreed the hospital had an opportunity with the definition of "intent to harm." The focus on "intent" had been driving the abuse investigations. She saw the opportunity to work through the process and educate staff to the understanding and definition of abuse. The hospital needed to be mindful of patterns of behavior. Staff II, RN, should have been removed from all patient care after the allegations.

During an interview on 06/13/24 at 1:50 PM, Staff WW, ED and ICU Director, stated that Staff II, RN, was not the most verbal nurse. He believed Staff II's approach to the assessment of Patient #16 was reasonable and maybe Staff II was misperceived by Patient #16, until three additional abuse allegations were brought to his attention. Staff II continued to work and was not removed from patient care. He expected staff would be removed from patient care and would not return to work until the investigation was completed and the allegation was found to be unsubstantiated. He stated that no additional staff education was provided in response to the four allegations of abuse against Staff II. Staff participated in yearly abuse and neglect education.

During an interview on 06/13/24 at 3:45 PM, Staff A, Accreditation and Regulatory Compliance Executive Officer, stated that Staff II, RN, and Staff JJ, PSO, were not reported to the Department of Health and Senior Services or the Missouri Board of Nursing.








48359

Based on interview, record review and policy review, the hospital failed to follow their policy and complete a face-to-face (a qualified staff members evaluation of a patient in violent restraints [medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others]) assessment within one hour after violent restraints were placed on one discharged Emergency Department (ED) pediatric (pertaining to children) patient (#17) of two discharged patients reviewed. This failure had the potential to affect all patients when restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) or seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) were used.

Findings included:

Review of the hospital's policy titled, "Use of Restraint and Seclusion for Management of Violent of Self-Destructive Behavior Policy," dated 11/09/21, showed a face-to-face evaluation, is completed within one hour of the initiation of violent or self-destructive restraint. The face-to-face documentation includes clinical justification, specific medical conditions and behaviors requiring restraints.

Review of Patient #17's medical record showed:
- On 05/11/23 at 7:12 PM, he arrived at the ED with homicidal ideation (HI, thoughts or attempts to cause another's death) and a plan to kill his father with a knife.
- On 05/12/23 at 12:05 PM, Patient #17 was placed in five-point restraints (medical cuffs applied to both arms, both legs and waist to prevent someone from causing harm to themselves or others) for the patient's and staff's safety.
- The required face-to-face assessment to include clinical justification, medical conditions and behaviors was not completed.

During an interview on 06/13/24 at 3:00 PM, Staff E, Chief Nursing Officer (CNO), stated that she expected a face-to-face assessment was completed with every violent restraint episode.

During an interview on 06/13/24 at 1:50 PM, Staff WW, ED and Intensive Care Unit (ICU, a unit where critically ill patients are cared for) Director, stated that a face-to-face assessment was expected with each violent restraint placement.

During an interview on 06/13/24 at 2:50 PM, Staff XX, ED Manager, stated that she expected a face-to-face assessment with every violent restraint placement.