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Based on review of facility policy, medical record review, review of event reports, and interviews, the facility failed to ensure an environment free from abuse for 1 Emergency Department (ED) psychiatric patient (Patient #2) of 11 ED patients reviewed.

The findings include:

During the investigation it was found Patient #2 was admitted to the Facility's ED on 6/23/2022 with suicidal ideations and homicidal ideations. The patient had a history of post-traumatic stress disorder. The patient was taken to the ED by the police department after he had posted a social media post threatening to potentially shoot up a school or church. Patient #2 had been evaluated by mobile crisis and placed on a 6404 (involuntary psychiatric commitment) prior to being taken to the ED. On 6/23/2022, Patient #2 reported to a nurse a security guard had made an obscene hand gesture (flipped him off) and called the patient a (explicative) moron. The incident was witnessed by 2 staff members and was reported to the ED charge nurse, but no further action was taken. The incident was reported to a supervisor on 6/24/2022 with no action taken. Patient #2 reported the allegations to a staff member on 6/27/2022. The patient reported the incident to the ED Director on 6/27/2022 with no further action. The facility initiated an investigation on 7/7/2022 (2 weeks after the incident). The investigation revealed the security guard on 7/8/2022 (15 days after the incident), admitted to flipping off the patient. The accused security officer worked 8 shifts after the incident.

During a conference with the Chief Executive Officer, the Quality and Patient Safety Manager, the Risk Manager, the Regulatory Compliance Specialist, the Director of Quality and Patient Safety, the Regulatory Compliance Specialist, the Human Resources Partner, the Chief Operating Officer, the Business Operations Manager, the Senior Director of Clinical Operations for Quality, the Director of Regulatory and Quality for Acute Care, the Regional Manager for Accreditation, the Chief Medical Officer, the Chief Finance Officer, and the Director of Nursing for Medical Surgical and Nursing Administration on 7/13/2022 at 3:03 PM, in the conference room, the facility was informed of an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation, has caused, or is likely to cause injury, harm, impairment, or death) at 42 CFR PART 482.13, Conditions of Participation, Patient Rights.

During a conference with the Chief Executive Officer, the Quality and Patient Safety Manager, the Risk Manager, and the Regulatory Compliance Specialist on 7/14/2022 at 1:19 PM, in the conference room, the facility presented a Removal Plan for removal of the Immediate Jeopardy. Review of the Removal Plan revealed the following:

1. The security officer was placed on administrative leave on 7/8/2022.

2. Education was provided for all ED staff and patient attendants providing 1 on 1 observation for psychiatric patients. The education was provided using an SBAR (Situation, Background, Action, Recommendation: A standardized communication tool for educational purposes). The training was implemented on 7/8/2022 and was presented by the ED Director and the Interim Patient Attendant Float Pool Manager. The training will be completed by 7/15/2022 for ED staff and patient attendants. The education included the following:
a. Event Reporting System (ERS).
b. Escalation through chain of command for reporting patient safety concerns.
c. Expectations if there is suspected abuse. Staff ensured there is no retaliation for reporting.
d. The SBAR was posted on the unit for continued awareness.
e. The content within the SBAR was included in a bulleted points document explaining abuse and neglect, how to report suspected abuse, and how to escalate suspected abuse. A bullet points document replaced the SBAR posted on the unit on 7/12/2022.
Monitoring:
A. Department leaders will round daily to ensure the bullet points document is posted. Sample will be 10 per week with compliance goal of 100%. Monitoring will be ongoing until the goal has been met and maintained for 4 consecutive months.
B. Outcomes from department rounding will be reported weekly during hospital leadership huddle.
C. Any noncompliance will be addressed by executive leaders.

3. ED staff, patient attendant float pool, and security staff reviewed the Abuse and Neglect of Patients policy. The review was implemented on 7/8/2022 and was presented by the ED Director, Security Manager, and Interim Patient Attendant Float Pool Manager. The review will be completed by 7/15/2022. The review included:
a. Abuse definition
b. Types of abuse
c. Methods to report suspected abuse
d. How to use the chain of command
Monitoring:
A. To validate comprehension, executive leaders will conduct rounds weekly to ask staff and managers about abuse and neglect, how to report, and how to escalate. Sample will be 10 per week with compliance goal of 100%. Monitoring will be ongoing until the goal has been met and maintained for 4 consecutive months.
B. Outcomes from department rounding will be reported weekly during hospital leadership huddle.
C. Any noncompliance will be addressed by executive leaders.

4. The security officer was terminated on 7/11/2022.

5. On 7/12/2022, all clinical and ancillary department leaders received the following education:
a. Abuse and Neglect of patients (policy review)
b. Patient Complaints and Grievances, specifically reporting patient complaints and abuse or neglect (policy review)
c. How to report complaints and abuse or neglect using the SBAR
d. How to enter an event report using the Event Reporting System
e. Patient Rights and Responsibilities (policy review)
f. Escalation of Chain of Command (policy review)
Monitoring: To monitor and audit that instances of abuse and neglect are reported and investigations are initiated per policy:
A. ERS reports will be produced weekly for leaders to review for any instances of abuse or neglect.
B. Hospital leaders round daily with staff to determine if there are instances that have not been reported.
C. Any reported abuse or neglect will be investigated according to policy.
D. The staff member(s) in the allegation will be immediately placed on administrative leave pending a full investigation.
E. Components to be audited include:
*Abuse was reported according to policy.
*The staff member(s) were placed on administrative leave.
*An ERS was completed and entered.
F. Outcomes from department rounding will be reported weekly during
hospital leadership huddle.
G. Any noncompliance will be addressed by executive leaders.

6. The Escalation of Patient Care Concerns Using the Chain of Command Policy was revised to include the escalation process for non-medical provider care related concerns. Policy revisions included examples of when to initiate the chain of command, risk reduction strategies, and how to initiate the chain of command. The policy was expedited on 7/12/2022 using emergency processes for approval. The policy was distributed to all staff on 7/12/2022. The changes to the policy were highlighted for staff to easily identify.

7. The Security Manager and System Security Director met with the private security firm that provides security services to the facility to report the incident on 7/12/2022. The facility's expectations were reinforced which included:
a. Following policies and procedures
b. Treating patients with respect
c. Demonstrating professional behavior when working with patients
d. Full compliance with contractual elements and follow all policies
The following policies were reviewed and education was provided for all security staff and the private security firms Operation Manager:
a. Patient Complaint and Grievance policy
b. Abuse and Neglect of Patients policy
c. SBAR-Reporting of Patient Complaints
d. Abuse, Neglect, and Harm
e. Step by step instructions for Event Reporting System
f. SBAR-Chain of Command in Healthcare
g. Escalation of Patient Care Concerns Using the Chain of Command policy
h. Patient Rights and Responsibilities policy
i. Security Personnel Conduct and Authority policy
The education and policy review for security staff will be completed by 7/15/2022.
Monitoring: Compliance with policies and procedures and the contractual metrics will be monitored by a review of ERS reports and the annual contract review.

8. Beginning 7/14/2022, ED and Inpatient Units will identify patients that may create a higher stress work environment. The purpose is to maintain a safe and positive work environment for patients and staff. Also, to mitigate escalation or inappropriate behavior caused by patient behaviors that may contribute to a higher stress work environment.
a. Each bedside Registered Nurse (RN) on shift or prior shift will identify these patients and report to the huddle leader (Charge Nurse).
b. Huddles occur at the beginning of each shift and include all care team members for the shift and department leaders.
c. For patients who arrive mid-shift, the patient's primary nurse will escalate to the charge nurse so caregivers may be rotated to decrease overstimulation.
d. ED leadership (Director, Manager, Supervisors, or Charge Nurses) on duty will round hourly in the behavioral health preferred space of the department.
e. Staff have been reminded and empowered to alert their supervisor if they need a break.
Monitoring:
A. Documentation of those patients creating a higher stress environment will be noted on the Charge Nurse Sheet.
B. The department manager or designee is responsible for reviewing the charge nurse sheet every shift to ensure that staff were rotated as needed.
C. Any instance of non-compliance will be addressed immediately by the department manager by coaching and remediation.
D. Outcomes from department rounding will be reported weekly during hospital leadership huddle.
E. Any noncompliance will be addressed by executive leaders.

9. Education packet was provided to medical staff with bulleted points of need to know information by email distribution of credentialed providers on 7/13/2022. Additional follow-up will be facilitated by the Chief Medical Officer.

10. The Security Officers will ensure:
a. All patient complaints against security will have appropriate documentation in the ERS.
b. Follow-up on all patient complaints against security with an interview of the patient if the patient is still present in the facility.
c. Security will immediately notify the Security Manager or the System Security Director (in the absence of the Security Manager) of any known patient complaints.
d. Obtain a signed written statement from the involved security officer.
e. If the patient has been discharged and has filed a complaint to the facility, a signed written statement of the involved officers will be obtained, based on the complaint.
The Director of Security Operations or designee will immediately notify the private security firm of any instance of alleged abuse or neglect by security. The accused security officer will be placed on administrative leave pending the investigation.

11. Investigations will occur per policy and appropriate actions will be taken depending on the results of the investigation. Monitor and audit that instances of abuse and neglect are reported and investigations are initiated per policy. The ERS reports are produced daily for all leaders to review. Risk Managers are responsible for reviewing the ERS report daily to ensure that any reported cases of abuse and neglect are being investigated per policy. Risk Managers provide weekly updates regarding abuse and neglect report and investigations to the safety event review team.

During an interview on 7/19/2022 at 8:10 AM, in the conference room, the Quality and Patient Safety Manager stated, with the exception of staff on military leave or family medical leave of absence (FMLA), 100% of the ED staff, patient attendants, and security officers had received education regarding abuse and neglect, reporting suspected abuse, and escalating a report of abuse using chain of command.

Review of education rosters showed 100% of the ED staff, patient attendants, and security officers had completed the education regarding abuse by 7/15/2022.

Observation of the ED on 7/19/2022 at 8:40 AM showed the bulleted points document explaining abuse and neglect, how to report suspected abuse, and how to escalate suspected abuse was posted at the nurses stations in the main ED and in the behavioral health area.

Observation of the Security office on 7/19/2022 at 9:13 AM showed the bulleted points document explaining abuse and neglect, how to report suspected abuse, and how to escalate suspected abuse was posted at the nurses stations in the main ED and in the behavioral health area.

Review of the Immediate Jeopardy Removal Plan showed actions were implemented by the facility and the Immediate Jeopardy was removed on 7/15/2022. The facility remains out of compliance at 42 CFR PART 482.13, Conditions of Participation, Patient Rights (Condition).

Refer to A-0145

Based on review of facility policy, medical record review, review of facility video surveillance recordings, review of facility documentation, and interviews, the facility failed to ensure an environment free from abuse and failed to report and investigate an allegation of abuse for 1 Emergency Department (ED) psychiatric patient (Patient #2) of 7 ED psychiatric patients reviewed of 11 ED patients reviewed.

The findings include:

Review of the facility's policy "Abuse and Neglect of Patients" revised 11/16/2015 showed "...It is the policy of [named facility] and its associates to prohibit all forms of abuse and neglect and harassment whether from staff, other patients or visitors in the course of providing patient care...All patients have the right to be free from abuse or neglect as well as the fear of being abused or neglected...Allegations or information indicating that abuse or neglect may have occurred will be thoroughly and promptly investigated with appropriate follow-up action taken...Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish...All forms of abuse, including physical, verbal, emotional, and physiological shall be considered abuse for the purposes of this policy...Abuse, emotional or psychological - An act which results, or is likely to result, in mental impairment of a patient's intellectual or psychological functioning. Examples include, but are not limited to, humiliation, harassment, imitating or mocking behavior, inappropriate threats of punishment or deprivation, use of derogatory nicknames...Employees who witness or have knowledge of patient abuse shall immediately report it to the Nurse Manager, Director or Charge Nurse, Administrator on Call or Risk Management. If for some reason, the employee believes they cannot or should not inform Nursing Supervisor, Administrator on Call or Risk Management, the Employee may contact the Hospital Chief Executive Officer, Director of Nursing, Director of Quality Improvement, Medical Director, or the Compliance Hotline...The Hospital Chief Executive Officer [CEO] or designee is to be informed immediately when information arises to indicate that patient abuse may have occurred. This may be done directly by any employee when they see or otherwise learn of a situation that constitutes abuse or neglect, or it may be done by the supervisor...who received the report from the employee...Documentation in the form of incident reports, progress notes, or written statements are to be completed and provided to a Nursing Supervisor or Director of Nursing, with a copy to Risk Management by employees reporting allegations of abuse or neglect...The investigation process begins when a Nursing Supervisor, the Director of Nursing, the Hospital CEO, the Medical Director, or another member of the Hospital Leadership receives an allegation that abuse or neglect may have taken place. Information may come from a staff member, a patient, visitor, or family member of a patient, a patient advocate, another agency, or other sources. Information may be received orally, in writing, or via [through] electronic communications...If an alleged perpetrator is named, the Hospital CEO, Chief Nursing Officer, or his/her designee should remove the person from the patient care area unless doing so would compromise the safety of the patient or other patients..."

Review of the facility policy "Escalation of Patient Care Concerns Using the Chain of Command" dated 1/15/2019 showed "...Members of the healthcare team are obligated to work toward resolution of identified real and potential problems within the system that may affect patient care. If the team member is unable to resolve such issues independently, the team member is obligated to present the issue in a timely manner to successively higher levels of command until a satisfactory resolution is achieved...Initiation of the Chain of Command (COC) is an administrative method that is in place to resolve clinical patient care issues. Examples include but are not limited to...Disruptive behavior of staff member or medical provider...Abusive verbal and/or body language to patient or staff...Initiating the COC involves...When a team member is aware of a potential or actual issue, the team member is accountable for...Making attempts to prevent or resolve the issue (within their scope of responsibility)...If unresolved, the team member shall contact their immediate supervisor to alert them to the potential or actual issue...If still unresolved, the team member shall notify the next level of command (e.g. [for example] manager/director) during regular business hours or the House Supervisor after business hours...If unable to resolve, the House Supervisor shall contact the Administrator on Call (AOC) for resolution of the issue...In the event the issue is with an immediate supervisor, a level of command may be passed over to the next level on the COC..."

Review of the facility's policy "Event Reporting Policy" revised 10/1/2018 showed "...It is the policy of [named facility] and all its facilities to immediately report all unanticipated events...using the online Event Reporting System (ERS), or when not online by using the ERS Downtime Safety Event Report...Workplace violence events must be reported in ERS...Event - is any event that is not consistent with the routine operations of the hospital and its staff, or the routine care of a patient/visitor. An injury does not necessarily have to occur to report an incident. Examples of occurrences include, but are not limited to...Abuse - Physical, emotional or verbal to a patient, staff or third parties (visitors, students...)..."

Review of the facility's policy "Security Incident & [and] Investigation Reporting" revised 1/2021 showed "...The facility should investigate and document all security related occurrences using Security Incident Reports...A security incident report...shall be filed for all adverse security related occurrences to include, but not be limited to, events occurring on facility property such as: assaults/battery, burglary, thefts, robbery, violent acts, and combative persons and other security near misses and events...Security incidents should be documented by the end of the shift, minimally, in the facility security database..."

Review of the facility's policy "Security Incident Reporting" revised 6/27/2022 showed "...Security Personnel must promptly, and as soon as practicable, notify the Security Director of any Significant Security Incident. This notification may be made through the Security Director's designee (i.e. Security manager), or directly by Security Personnel...The Security Director (or designee) will follow the Ministry's significant event notification process to ensure that all appropriate leaders, including the Ministry Director of Risk Management, are timely informed of the Significant Security Incident..."

Medical record review showed Patient #2 was evaluated by a Qualified Mental Health Provider and a Certificate of Need for involuntary psychiatric commitment was completed prior to the patient's arrival to the ED on 6/23/2022 at 6:41 PM.

Medical record review of an ED nurse triage note (initial assessment) showed Patient #2 presented to the facility's ED on 6/23/2022 at 7:28 PM. The patient was taken to the ED by the police department after he had posted homicidal statements on social media. The patient reported suicidal ideation with previous suicide attempts by hanging and suffocation. A 6404 (involuntary psychiatric commitment) had been placed on Patient #2 by the police department.

Medical record review of an ED physician note dated 6/23/2022 at 8:46 PM showed Patient #2 had a suicidal history and Post-Traumatic Stress Disorder and presented to the ED for a psychiatric evaluation. The patient was taken to the ED by the police department after he had made a post on social media threatening to potentially "...shoot up a school or church. He arrives to emergency department after mobile crisis evaluation and 6404 form signed by them recommending inpatient psychiatric hospitalization as he was deemed an imminent threat to himself and others..." Patient #2 reported a long history of psychiatric medication use but stated he had not taken the medication for months. The patient was hostile and threatening to the physician and staff, was speaking "...tangentially [random, irrelevant ideas and topics] with multiple references to the president of the United States and political issues with a country..." Patient #2's diagnoses included Suicidal Ideation and Homicidal Ideation. The patient was medically cleared and was awaiting placement at a psychiatric facility while under a 6404 hold.

Review of the facility's video surveillance recording for 6/23/2022 from 9:32 PM-10:00 PM showed Patient #2 was in a hall bed in the ED. At 9:32 PM, the patient was sitting on the side of the bed reading some papers (reported to be the 6404 form). The security officer identified as the alleged perpetrator was standing at the head of the patient's bed with his hands clasped in front of his waist and was swaying from side to side. There were 2 additional security officers, 2 nurses and a patient care partner in the hall near the patient. At 9:36 PM, Patient #2 picked up paper scrubs and followed a nurse down the hallway and out of view of the camera. The patient returned to the hall bed wearing the paper scrubs at 9:39 PM. The patient remained on the hall bed, occasionally talking to a patient attendant from 9:40 PM-9:46 PM. Patient #2 was observed looking back toward the nurses station which was located behind and to the right side of the patient. The alleged perpetrator approached Patient #2's bedside for approximately 10-15 seconds and spoke to the patient at 9:51 PM. Patient #2 did not respond, only looked at the security officer. The officer returned to the nurses station and out of view. At approximately 9:53 PM, Patient #2 sat up on the edge of the bed, pointed toward the nurses station and appeared to be yelling and appeared to be agitated. The patient did this twice within a 30-40 second period. Patient #2 continued to occasionally look over his right shoulder toward the nurses station between 9:53 PM-9:55 PM. At approximately 9:56 PM, the alleged perpetrator came from the nurses station and turned the corner to the left out of view. The alleged perpetrator had not returned to the area at 10:00 PM.

Medical record review of an ED Narrative Charting (nurses note) dated 6/23/2022 at 10:00 PM showed Patient #2 refused to change into paper scrubs and became agitated and stated he was going to call his attorney. "...Pt [patient] was educated on what a 6404 is and why he was placed on a hold. Pt requested a copy of 6404. After reading the 6404 pt [patient] changed into paper scrubs but remained agitated..."

Medical record review of an ED Narrative Charting dated 6/23/2022 at 11:14 PM showed Patient #2 was in a hall bed "...asked if he would like to be moved to a room. PT declined stating, 'If I go into that room I'm going to go crazy and want to kill all of y'all' PT then requested bible, given one..."

Medical record review of an ED Narrative Charting dated 6/27/2022 at 7:23 PM showed Patient #2 was sitting in his room by the sink "...WITH PILLOW CASE OVERHEAD WITH PILLOW IN FACE. PILLOW WAS REMOVED FROM ROOM PT CUSSING AT STAFF..."

Medical record review of a Hospital to Hospital Transfer Form showed Patient #2 was transferred to a psychiatric facility on 6/29/2022 at 12:10 AM.

Medical record review of an Inpatient Psychiatric Facility Discharge Summary showed Patient #2 was admitted to the psychiatric facility on 6/29/2022. Patient #2 was arrested on 6/29/2022 for aggravated assault charges. The patient had a history of domestic violence and an assault of an officer in the past. The patient's admission diagnoses included "...Bipolar disorder, current episode depressed, severe, with psychotic features...incarceration..." Patient #2 was discharged to the custody of the county jail on 7/4/2022.

Review of facility documentation dated 7/7/2022 (2 weeks after the event) at 12:40 PM showed the alleged incident of abuse of Patient #2 occurred on 6/23/2022. The event type was documented as "...Behavioral>Bullying or Intimidation..." The documentation showed Patient #2 had made complaints regarding a "...security office [officer] 'flipping him off' [obscene hand gesture] and commenting that he [Patient #2] was a 'f..king moron'..." A police officer who was working off-duty on the behavioral health hallway was contacted by risk management. The off-duty officer reported he had observed the security officer flip off Patient #2. The off-duty officer also stated the security officer had made comments to Patient #2 "...that had a derogatory tone, but could not make out the context of what was said..."

Review of the Security Officer's schedule showed Security Officer #1 worked the following shifts (2:00 PM - 10:00 PM) after the event with Patient #2 on 6/23/2022, 6/24/2022, 6/25/2022 (shift supervisor), 6/26/2022 (shift supervisor), 6/27/2022, 6/30/2022, 7/1/2022, 7/2/2022, and 7/3/2022. Security Officer #1 worked 4 shifts while Patient #2 remained in the ED. It is not known if the Security Officer worked around Patient #2 again.

During an interview on 7/6/2022 at 11:35 AM, in the conference room, the ED Director stated on 6/27/2022, Patient #2 told the ED Director a Security Officer "...gave him the finger [obscene hand gesture]..." and called him a (explicative) moron. The patient reported the incident occurred on 6/23/2022 at approximately 9:30 PM. As of 7/6/2022 (13 days after the event), the patient's complaint had not been entered in the Event Reporting System. The patient's allegations had not been reported to Risk Management and had not been investigated.

During a telephone interview on 7/7/2022 at 2:27 PM, Registered Nurse (RN) #1 stated he went to retrieve some supplies after Patient #2 had changed into paper scrubs on 6/23/2022. When RN #1 returned to the patient's bedside, the patient and the security officer were "...yelling back and forth..." at each other. Patient #2 asked RN #1 if he had been disrespectful to him or the staff or called them names. RN #1 responded no, Patient #2 then asked "...Why did he [security officer] call me a [explicative] moron..." In a second interview on 7/12/2022 at 2:56 PM, RN #1 stated he did not report Patient #2's allegations to anyone in security but had reported the allegations to the charge nurse the evening the event occurred (6/23/2022).

During a telephone interview on 7/7/2022 at 3:03 PM, Security Officer #5 stated he was not involved with the event which occurred with Patient #2 on 6/23/2022. Security Officer #5 reported, later in the patient's ED stay, the patient had broken a phone and punched the wall in his room. He waited outside of the patient's room while a nurse went in and tried to de-escalate the patient. The security officer stated Patient #2 started toward the patient attendant in his room with his "...fist balled..." Security Officer #5 redirected the patient's attention toward himself and Patient #2 "...punched..." Security Officer #5 in the face.

During a telephone interview on 7/7/2022 at 3:50 PM, Security Officer #1 (alleged perpetrator) stated he attempted to talk to Patient #2 after the patient had changed into paper scrubs on 6/23/2022, but the patient started yelling and cursing him. Security officer #1 stated, on Sunday night (3 nights after the event) one of the charge nurses told him his "...presence was aggravating him [Patient #2]..." and asked him to leave the ED. Security Officer #1 denied flipping the patient off (obscene hand gesture) and denied calling the patient a (explicative) moron on 6/23/2022.

During a telephone interview on 7/8/2022 at 12:32 PM, Patient Attendant #1 stated Patient #2 did not want to change into paper scrubs and asked to see the 6404 document. The patient eventually changed clothes, came back and sat down on the bed. Patient Attendant #1 stated one of the security officers (#1) asked the patient if he could talk to him. She reported the patient "...said no, he didn't want to talk to anyone..." Patient Attendant #1 stated as the security officer was walking to the nurses station the officer said "...I bet your sergeant in the army would not deal with your bull [explicative]..." The patient attendant stated she was standing next to the nurses station and saw the security officer flip the patient off and heard him call Patient #2 a [explicative] moron. Patient Attendant #1 stated this incident occurred on the day Patient #2 was admitted (6/23/2022) between 9:45 PM and 10:00 PM. The patient attendant reported she notified the charge nurse the evening it occurred and notified her supervisor the next day.

During an interview on 7/11/2022 at 11:15 AM, in the conference room, the ED Director stated he spoke with Patient #2 on 6/27/2022 and told the patient he would look into his allegations. The ED Director told the patient the facility would investigate his complaint and the facility would notify him of the outcome of the investigation. He asked Patient #2 if it was okay to wait until the Security Manager returned since his complaint was a security issue. The ED Director stated he did not file an ERS report at that time because he wanted to hand it off to the Security Manager. The ED Director stated he was under the impression the security officer filling in for the Security Manager was investigating the patient's allegations. The ED Director reported the event was entered in ERS on 7/5/2022 (facility documentation showed it was entered on 7/7/2022).

During an interview on 7/11/2022 at 12:35 PM, in the conference room, the ED Nurse Manager stated she found Patient #2's face sheet with his allegations written on it the morning of 6/27/2022. The face sheet had been slid under her door. The ED Nurse Manager stated she spoke with Patient #2's nurse regarding the patient's allegations the morning of 6/27/2022. The patient's nurse (RN #2) told her she did not think she (nurse manager) needed to speak with the patient because she had spoken with the security supervisor (Security Officer #3) earlier in the shift and he was going to speak with the patient.

During an interview on 7/11/2022 at 12:40 PM, in the conference room, Security Officer #3 stated Patient #2's nurse notified him of the patient's allegations on 6/27/2022. The security officer stated Patient #2 was in the shower when he went to talk to the patient. Security #3 notified the oncoming security officer the patient wanted to speak with someone from security. The following day (6/28/2022) Security Officer #3 was told to begin investigating the patient's allegations. Security Officer #3 confirmed he did not report the patient's allegations up the chain of command.

During an interview on 7/11/2022 at 2:20 PM, in the conference room, the Security Manager stated Security Officer #1 was placed on administrative leave on 7/8/2022 (15 days after the event) after he admitted he had flipped off Patient #2 and admitted to calling the patient a moron on 6/23/2022.

During a telephone interview on 7/11/2022 at 2:45 PM, Patient Attendant #2 stated he did not see Security Officer #1 make an obscene hand gesture to Patient #2 off, but heard the security officer call the patient a moron.

During a telephone interview on 7/11/2022 at 5:04 PM, RN #4 (charge nurse on 6/23/2022) stated Patient #2's nurse told her the patient reported a security officer had flipped him off. RN #4 stated she did not report Patient #2's allegations to the ED Nurse Manager or the ED Director.

During a telephone interview on 7/12/2022 at 11:00 AM, Security Officer #4 confirmed he witnessed Security Officer #1 flip-off Patient #2 and heard him call him a "...not so nice name..." but could not recall exactly what Security Officer #1 had called the patient "...struck me as unprofessional..."

During an interview on 7/12/2022 at 3:35 PM, in the conference room, the Security Manager stated he was out of town until 7/5/2022. In the absence of the Security Manager, the security officer who was notified of the incident was to call the Director of Security when the event occurred. The security officer was expected to interview the patient and enter the incident in the event reporting system. The security officer "...didn't escalate the event...if he had put in the system, it would have gone straight to risk...He dropped the ball..."

During a telephone interview on 7/12/2022 at 3:57 PM, the Interim Float Pool Manager confirmed Patient Attendant #1 had notified her of the incident on 6/24/2022. The Interim Float Pool Manager confirmed she did not escalate the allegation of abuse up the chain of command.

During an interview on 7/12/2022 at 4:01 PM, in the conference room, Security Officer #2 stated he was the security supervisor on the evening of 6/23/2022 and confirmed no one had reported the security officer's behaviors to him.

During an interview on 7/12/2022 at 4:30 PM, in the conference room, the Quality and Patient Safety Manager and the Risk Manager confirmed the abuse incident occurred on 6/23/2022 and risk was not made aware of the allegations until 7/6/2022. They also confirmed several staff members failed to escalate Patient #2's allegation of abuse. The Quality and Patient Safety manager and the Risk Manager confirmed the charge nurse on 6/23/2022 did not escalate the patient's allegations; the patient attendant's supervisor did not escalate the allegations on 6/24/2022; Security Officer #3 did not escalate the allegations on 6/27/2022; and the Administrator on Call who was the ED Director did not escalate the patient's allegations on 6/27/2022. The Quality and Patient Safety Manager confirmed abuse had occurred "...with a vulnerable patient..." The Risk Manager stated from 6/23/2022-7/6/2022 "...nothing was done except talking with the patient and telling him that security would follow-up..."

During a telephone interview on 7/12/2022 at 4:50 PM, RN #3 (day shift charge nurse on 6/26/2022) stated Patient #2's nurse notified her the patient wanted to file a complaint about a security officer and wanted to talk to someone in security. On 6/26/2022, Patient #2 told RN #3 a security officer was mouthing off at him and called him a "...flipping moron..." and had flipped him off. RN #3 stated the patient provided a time frame the event had occurred. The patient also reported he thought the security officer had looked in his medical record. RN #3 stated Patient #2 "...pointed out..." Security Officer #1 in the ED and told her "...he was the one..." RN #3 stated she reported the patient's allegations to the oncoming night shift charge nurse but did not report the allegations to the house supervisor. RN #3 stated she was unable to enter the patient's allegations in ERS on 6/26/2022 because the system was not working. RN #3 printed Patient #2's face sheet, wrote the patient's allegations on the face sheet, and slid it under the ED Nurse Manager's door at the end of the shift (6/26/2022 and 3 days after the event).

During a telephone interview on 7/12/2022 at 5:35 PM, RN #4 (night shift charge nurse on 6/23/2022 when the event occurred) confirmed she did not report Patient #2's allegations to the Security Supervisor on 6/23/2022.

During a telephone interview on 7/12/2022 at 6:35 PM, Security Officer #1 admitted to flipping-off Patient #2. Security Officer #1 denied calling the patient a (explicative) moron but admitted saying "...If you're going to act like a moron that's how you're going to be treated..."

During a telephone interview on 7/13/2022 at 11:22 AM, RN #2 stated Patient #2 was complaining on Sunday (6/26/2022) and wanted to talk about what had happened with a security officer on Thursday night (6/23/2022). Patient #2 told RN #2 about the security officer flipping him off and calling him a (explicative moron). RN #2 stated she told the patient she was sorry it had happened and she reported the patient's allegations to the charge nurse. RN #2 stated the security supervisor that night (6/26/2022) was the accused security officer so she did not ask him to speak with the patient. She reported the charge nurse spoke with the patient. RN #2 reported that Patient #2 said he did not want the security officer around him. The RN stated the patient was agitated because he was angry about the incident and no one had talked to him. RN #2 stated the accused security officer was in the ED on 6/26/2022, but she was unsure if the patient had seen the officer. RN #2 told an off-duty police officer working in security to try to keep the security officer away so it would not agitate the patient while she tried to work on getting the situation resolved. RN #2 stated she took over Patient #2's care the morning of 6/27/2022 and the patient was still agitated and stated "...that charge nurse told me I would talk to a [security] director today..." She reported Patient #2 got mad at her later in the shift and punched the wall. RN #2 stated the ED Director and someone from security spoke with the patient on 6/27/2022.