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Based on interview and record review, the facility failed to ensure allegations of patient abuse were escalated and reported to the House Supervisor, the Manager/Director of the unit, and/or the administrator on-call, in accordance with the facility's policy and procedure, for one of 20 sampled patients (Patient 16).

This failure had the potential for Patient 16, and other patients to experience abuse and harm.

Findings:

On September 16, 2025, at 11:30 a.m., an interview was conducted with the Director of the Emergency Department (DED). The DED stated on August 13, 2025, she received an email from the medical director of the fire department (MD 1) highlighting concerns about an incident involving an emergency department technician (EDT 1) when a patient was transferred to the facility's emergency department (ED). The email described that EDT 1 had allegedly slapped Patient 16 in the face and pressed the patient's head down onto the mattress. EDT 1 was asked to leave the room, and this incident was reported to hospital staff. However, the DED stated this allegation of abuse was not escalated to the house supervisor as required by the facility's policy.

On September 16, 2025, at 1:40 p.m., a review of Patient 16's medical record was conducted with the Quality Manager (QM). A facility document titled, "ED [Emergency Department] Physician Record," dated August 12, 2025, authored by Name of Physician (MD 2), was reviewed. The document indicated, Patient 16, was brought to the ED via ambulance following a tonic clonic seizure (a grand mal seizure, a type of seizure that affects the entire brain and body). When the ambulance arrived, Patient 16 was combative, confused and required Versed (a medication used for sedation and anxiety) in route, but it did not have an effect on Patient 16. In the ED, Patient 16 was cursing and uncooperative.

A facility document titled, "Patient Care Report," dated August 12, 2025, authored by the fire department paramedic was reviewed. The document indicated, "...the PT [patient] became combative again with EMS [Emergency Medical Services] and ER [emergency room] staff. Upon attempting to restrain the PT to leather restraints an ER tech at [Name of Facility] was using excessive use of force to restrain the Pt. The tech was twisting the PT upper extremities in unnatural ways and started [sic] that the [sic] was going to break his elbow. The PT grabbed a hold of the ER tech shirt and the tech open hand hit the PT in the face and pushed his face into the mattress. The tech was firmly told to leave due to his behavior and the PT was successfully restrained to the bed...Patient care was transferred to bedside nurse and verbal complaints of the ER tech's behavior was shared..."

A facility document titled. "Patient Care Report," dated August 12, 2025, authored by the EMS paramedic was reviewed. The document indicated, "...Patient moved from gurney to bed. Patient was placed in restraints...During restraint application [Name of EDT 1] became aggressive wih [sic] pt [patient] and was asked to leave the room...reported to charge nurse..."

A facility document titled, "Progress Note," dated August 13, 2025, at 1:28 a.m., authored by Name of Registered Nurse (RN) 1, was reviewed. The document indicated, "...Pt BIBA [brought in by ambulance], screaming fighting, hitting/kicking, cursing, and threatening staff. MD 2 at bedside. Violent restraints applied..."

On September 17, 2025, at 9:10 a.m., an interview was conducted with RN 1. RN 1 stated on August 12, 2025, Patient 16 arrived in the ED via ambulance, exhibiting combative behavior, cursing, yelling, and threatening staff. RN 1 noted that EDT 1 restrained Patient 16's right arm in an "awkward" position and heard the EMS paramedic instructing EDT 1 to leave the room due to his "rough" actions. RN 1 also stated that she did not inform the charge nurse/clinical supervisor about the incident.

On September 17, 2025, at 9:50 a.m., an interview was conducted with the Charge Nurse/Clinical Supervisor (RN) 2. RN 2 stated she was informed by EDT 1 that the EMS paramedic had asked him to leave Patient 16's room due to his aggressive behavior. RN 2 further stated that the paramedic reported EDT 1's behavior as unacceptable and aggressive. RN 2 explained that in such cases, the policy is to immediately send the perpetrator home, notify the house supervisor, director, and law enforcement, but none of these steps were followed.

On September 17, 2025, at 3:30 p.m., an interview was conducted with the Director of Quality (DQ). The DQ stated on August 13, 2025, she became aware of an incident where EDT 1 was accused of using excessive force while restraining Patient 16. The DQ stated RN 1 and RN 2 should have reported this alleged abuse to the house supervisor, administrator on call, or the Director of the Emergency Department (DED) immediately upon learning about it, but this was not done. The DQ stated the facility's policy was not followed.

A review of the facility Policy and Procedure (P&P) titled, "Escalation and Chain of Command," dated July 28, 2022, was conducted. The policy indicated, "... Any employee or medical staff member who identifies a problem and is unable to resolve it should utilize Escalation and the Chain of Command until a satisfactory resolution is achieved. Examples include... Unprofessional conduct involving any health care worker... a patient safety or safety event that does not meet established guidelines placing patient(s) or team members at risk... Escalation/Chain of Command ensures...the appropriate people are aware of the problem or concern... The problem or concern advances through the Chain of Command until resolution is attained...the House Supervisor is the on duty administrative representative; any staff member may contact the House Supervisor for assistance. Additionally, there is an Administrator On-Call....The Administrative Chain of Command is as follows...Clinical Supervisor or designated lead of the unit/department...House Supervisor...Unit/department Manager or Director... Administrator on-Call...Chief Nursing Officer or Chief Operating Officer...Chief Executive Officer...Staff who encounter a patient care concern or other safety issue which, in their judgment could be detrimental to the patient, team member, or the facility must initiate the Chain of Command...Implementation of the chain of command requires voice-to-voice communication...Escalation can occur within one or both Chain of Commands (Administrative, Medical staff) for a given situation..."

A review of the facility P&P titled, "Workplace Violence," dated March 22, 2018, was conducted. The policy indicated, "...Reporting suspected Violent Tendencies or Acts of Violent Behavior... a supervisor or an employee who encounters or witnesses a situation or act such as harassment, intimidation or verbal abuse or threat that does not pose an immediate danger to others must immediately report the incident to a direct supervisor, Administration or the HR department...The individual reporting the incident must provide documentation including specifics such as the name of the individual posing the threat (if known), the date and time of the incident, what was said, to whom it was directed and any other information which will assist in ensuring safety and expediting an investigation of the reported incident..."

A review of the facility P&P titled, "Abuse and Neglect: Recognition and Reporting," dated September 15, 2016, was conducted. The policy indicated, "...Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect and exploitation...[Name of Facility] strives to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff, students, volunteers, other patients, visitors, or family members...Definitions...Abuse - intentional maltreatment of an individual, which may cause injury, either physical or psychological. This includes mental abuse physical abuse and sexual abuse period...Mental abuse - includes humiliation, harassment, and threats of punishment or deprivation...Physical abuse - includes hitting, slapping, pinching, or kicking. Also includes controlling behavior through corporal punishment...Healthcare Practitioner / Mandated Reporter: means a physician, psychiatrist, psychologist, dentist, resident, intern, podiatrist, chiropractor, licensed nurse (RN/LVN [licensed vocational nurse]), dental hygienist, optometrist, marriage and family therapist, clinical social worker, emergency medical technician I [one] or II [two], paramedic or other person; psychological assistant, state or county public employee who treats a minor for venereal disease (sexually transmitted disease) or any other condition; coroner; or a medical examiner or person who performs autopsies...Hospital personnel identifying individuals that have met criteria of suspected abuse neglect or exploitation should initiate the mandated reporting and hospital referral process...Hospital personnel...will immediately notify their manager or a mandated reporter...Reporting procedure...Appropriate law enforcement agency...will be notified via telephone immediately or as soon as practically possible after receiving information regarding the incident..."

A review of the facility P&P titled, "Patient's Rights and Responsibilities," dated August 25, 2022, was conducted. The policy indicated, "... To establish guidelines to ensure that patients are informed of their rights and responsibilities regarding their care, treatment, and services and to assist patients in exercising their rights. To provide an environment that respects patients' values, beliefs, and preferences...Patient Rights...You have the right to...Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment. You have the right to access protective and advocacy services including notifying governmental agencies of neglect or abuse..."

Based on observation, interview, and record review, the facility failed to ensure the facility's policies and procedures (P&P) were implemented, for two of 20 sampled patients (Patients 15, and 16), when:

1. For Patient 15, the facility failed to ensure a leaving against medical advice (AMA) form was completed; and

2. For Patient 16, the facility failed to ensure allegations of patient abuse were escalated and reported to the House Supervisor, the Manager/Director of the unit, and/or the administrator on-call.

These failures had the potential to compromise patient safety, leaving patients unaware of the risks and possible consequences of leaving AMA, and increased risk of patient abuse and harm.

Findings:

1. On September 16, 2025, at 3:10 p.m., a review of Patient 15's medical record was conducted with the Quality Manager (QM). A facility document titled, "ED [Emergency Department] Physician Record," dated August 11, 2025, was reviewed. The document indicated, Patient 15, was brought to the ED via ambulance for complaints of left hip pain, and headache. The document further indicated, Patient 15 had a urinary tract infection (UTI, when bacteria enter the urinary system) with a risk for urinary sepsis (when a UTI spreads into the bloodstream and makes the whole-body sick), and needed to be admitted to the facility for further observation, cardiac monitoring, and antibiotics.

A facility document titled, "Discharge Request Task Order," dated August 11, 2025, was reviewed. The document indicated, "...Order...Requested Start Date/Time...8/11/2025 [August 11, 2025] 22:04 [10:04 p.m.]...Discharge To...Against Medical Advice..."

There was no documented evidence an AMA form was completed for Patient 15.

On September 17, 2025, at 11 a.m., an interview was conducted with the Quality Director (QD). The QD stated Patient 15's medical record should have included an AMA form and confirmed that the policy was not followed.

A review of the facility Policy and Procedure (P&P) titled, "Leaving Prior to Discharge," dated January 26, 2023, was conducted. The policy indicated, "...When a patient states they are leaving prior to discharge...the patient will be asked to sign the AMA form...Whenever possible, the AMA form should include the risks or possible consequences as stated by the physician/provider...If the patient refuses to sign the AMA form, the nurse documents on the form that the patient refused to sign...The AMA form is incorporated into the patient's medical record..."

2. On September 16, 2025, at 11:30 a.m., an interview was conducted with the Director of the Emergency Department (DED). The DED stated on August 13, 2025, she received an email from the medical director of the fire department (MD 1) highlighting concerns about an incident involving an emergency department technician (EDT 1) when a patient was transferred to the facility's emergency department (ED). The email described that EDT 1 had allegedly slapped Patient 16 in the face and pressed the patient's head down onto the mattress. EDT 1 was asked to leave the room, and this incident was reported to hospital staff. However, the DED stated this allegation of abuse was not escalated to the house supervisor as required by the facility's policy.

On September 16, 2025, at 1:40 p.m., a review of Patient 16's medical record was conducted with the Quality Manager (QM). A facility document titled, "ED [Emergency Department] Physician Record," dated August 12, 2025, authored by Medical Doctor (MD) 2, was reviewed. The document indicated, Patient 16, was brought to the ED via ambulance following a tonic clonic seizure (a grand mal seizure, a type of seizure that affects the entire brain and body). When the ambulance arrived, Patient 16 was combative, confused and required Versed (a medication used for sedation and anxiety) in route, but it did not have an effect on Patient 16. In the ED, Patient 16 was cursing and uncooperative.

A facility document titled, "Patient Care Report," dated August 12, 2025, authored by the fire department paramedic was reviewed. The document indicated, "...the PT [patient] became combative again with EMS [Emergency Medical Services] and ER [emergency room] staff. Upon attempting to restrain the PT to leather restraints an ER tech at [Name of Facility] was using excessive use of force to restrain the Pt. The tech was twisting the PT upper extremities in unnatural ways and started [sic] that the [sic] was going to break his elbow. The PT grabbed a hold of the ER tech shirt and the tech open hand hit the PT in the face and pushed his face into the mattress. The tech was firmly told to leave due to his behavior and the PT was successfully restrained to the bed...Patient care was transferred to bedside nurse and verbal complaints of the ER tech's behavior was shared..."

A facility document titled. "Patient Care Report," dated August 12, 2025, authored by the EMS paramedic was reviewed. The document indicated, "...Patient moved from gurney to bed. Patient was placed in restraints...During restraint application [Name of EDT 1] became aggressive wih [sic] pt [patient] and was asked to leave the room...reported to charge nurse..."

A facility document titled, "Progress Note," dated August 13, 2025, at 1:28 a.m., authored by Name of Registered Nurse (RN) 1, was reviewed. The document indicated, "...Pt BIBA [brought in by ambulance], screaming fighting, hitting/kicking, cursing, and threatening staff. MD 2 at bedside. Violent restraints applied..."

On September 17, 2025, at 9:10 a.m., an interview was conducted with RN 1. RN 1 stated on August 12, 2025, Patient 16 arrived in the ED via ambulance, exhibiting combative behavior, cursing, yelling, and threatening staff. RN 1 noted that EDT 1 restrained Patient 16's right arm in an "awkward" position and heard the EMS paramedic instructing EDT 1 to leave the room due to his "rough" actions. RN 1 also stated that she did not inform the charge nurse/clinical supervisor about the incident.

On September 17, 2025, at 9:50 a.m., an interview was conducted with the Charge Nurse/Clinical Supervisor (RN) 2. RN 2 stated she was informed by EDT 1 that the EMS paramedic had asked him to leave Patient 16's room due to his aggressive behavior. RN 2 further stated that the paramedic reported EDT 1's behavior as unacceptable and aggressive. RN 2 explained that in such cases, the policy is to immediately send the perpetrator home, notify the house supervisor, director, and law enforcement, but none of these steps were followed.

On September 17, 2025, at 3:30 p.m., an interview was conducted with the Director of Quality (DQ). The DQ stated that on August 13, 2025, she became aware of an incident where EDT 1 was accused of using excessive force while restraining Patient 16. The DQ stated that RN 1 and RN 2 should have reported this alleged abuse to the house supervisor, administrator on call, or the Director of the Emergency Department (DED) immediately upon learning about it, but this was not done. The DQ stated that the policy was not followed.

A review of the facility P&P titled, "Escalation and Chain of Command," dated July 28, 2022, was conducted. The policy indicated, "... Any employee or medical staff member who identifies a problem and is unable to resolve it should utilize Escalation and the Chain of Command until a satisfactory resolution is achieved. Examples include... Unprofessional conduct involving any health care worker... a patient safety or safety event that does not meet established guidelines placing patient(s) or team members at risk... Escalation/Chain of Command ensures...the appropriate people are aware of the problem or concern... The problem or concern advances through the Chain of Command until resolution is attained...the House Supervisor is the on duty administrative representative; any staff member may contact the House Supervisor for assistance. Additionally, there is an Administrator On-Call....The Administrative Chain of Command is as follows...Clinical Supervisor or designated lead of the unit/department...House Supervisor...Unit/department Manager or Director... Administrator on-Call...Chief Nursing Officer or Chief Operating Officer...Chief Executive Officer...Staff who encounter a patient care concern or other safety issue which, in their judgment could be detrimental to the patient, team member, or the facility must initiate the Chain of Command...Implementation of the chain of command requires voice-to-voice communication...Escalation can occur within one or both Chain of Commands (Administrative, Medical staff) for a given situation..."

A review of the facility P&P titled, "Workplace Violence," dated March 22, 2018, was conducted. The policy indicated, "...Reporting suspected Violent Tendencies or Acts of Violent Behavior... a supervisor or an employee who encounters or witnesses a situation or act such as harassment, intimidation or verbal abuse or threat that does not pose an immediate danger to others must immediately report the incident to a direct supervisor, Administration or the HR department...The individual reporting the incident must provide documentation including specifics such as the name of the individual posing the threat (if known), the date and time of the incident, what was said, to whom it was directed and any other information which will assist in ensuring safety and expediting an investigation of the reported incident..."

A review of the facility P&P titled, "Abuse and Neglect: Recognition and Reporting," dated September 15, 2016, was conducted. The policy indicated, "...Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect and exploitation...[Name of Facility] strives to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff, students, volunteers, other patients, visitors, or family members...Definitions...Abuse - intentional maltreatment of an individual, which may cause injury, either physical or psychological. This includes mental abuse physical abuse and sexual abuse period...Mental abuse - includes humiliation, harassment, and threats of punishment or deprivation...Physical abuse - includes hitting, slapping, pinching, or kicking. Also includes controlling behavior through corporal punishment...Healthcare Practitioner / Mandated Reporter: means a physician, psychiatrist, psychologist, dentist, resident, intern, podiatrist, chiropractor, licensed nurse (RN/LVN [licensed vocational nurse]), dental hygienist, optometrist, marriage and family therapist, clinical social worker, emergency medical technician I [one] or II [two], paramedic or other person; psychological assistant, state or county public employee who treats a minor for venereal disease (sexually transmitted disease) or any other condition; coroner; or a medical examiner or person who performs autopsies...Hospital personnel identifying individuals that have met criteria of suspected abuse neglect or exploitation should initiate the mandated reporting and hospital referral process...Hospital personnel...will immediately notify their manager or a mandated reporter...Reporting procedure...Appropriate law enforcement agency...will be notified via telephone immediately or as soon as practically possible after receiving information regarding the incident..."

A review of the facility P&P titled, "Patient's Rights and Responsibilities," dated August 25, 2022, was conducted. The policy indicated, "...To establish guidelines to ensure that patients are informed of their rights and responsibilities regarding their care, treatment, and services and to assist patients in exercising their rights. To provide an environment that respects patients' values, beliefs, and preferences...Patient Rights...You have the right to...Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment. You have the right to access protective and advocacy services including notifying governmental agencies of neglect or abuse..."

Based on interview and record review, the facility failed to ensure the Conditions of Admission (COA, a consent form to receive treatment while in the facility) was signed by the Patient Access Services Rep (PASR) for one (Patient 10) of 20 sample patients.

This failure had the potential to cause a delay in patent care.

Findings:

A review of Patient 10's medical record was conducted on September 18, 2025, at 9:35 a.m., with the Clinical Effectiveness Coordinator (CEC).

A review of the facility document titled, "History & Physical," dated July 21, 2025, indicated, Patient 10 was admitted to the facility with diagnoses of hyperglycemia (high amount of sugar in the blood) and Altered Level of Consciousness (confusion) with a history of Dementia (progressive state of decline in mental abilities).

A review of the facility document titled "Conditions of Admission/Registration" dated July 21, 2025, was reviewed. The document indicated, the family member gave verbal consent by phone because Patient 10 was medically unable to sign. The area on the form designated for staff to verify consent was left blank.

On September 18, 2025, at 12:40 p.m., an interview was conducted with the Director of Patient Access Services (DPAS). The DPAS stated, the COA consent form is signed by the patient or a family member when the patient is in the emergency department. The DPAS stated the family member gave a verbal consent over the phone with the PASR but the form was not signed. The DPAS further stated, it is the facility's policy that the COA consent form to be signed by the PASR.

A review of the facility Policy & Procedure titled, "Condition of Admission," dated February 27, 2025, indicated, "...During the telephone delivery, the Registration staff will deliver and explain the COA to the patient's legal guardian or representative. The Registration staff will annotate on the COA consent form and following: the staff person initiating the contact, the name of the representative contacted by phone ..."