HospitalInspections.org

Based on the review of the facility policy, review of facility documentation, medical record review, and interview, the facility failed to report an occurrence resulting in injury and failed to report an allegation of abuse to the proper authorities for 1 patient (Patient #1) of 3 patients reviewed.

The findings include:

Review of the facility policy, "Abuse, Neglect, and Rape Reporting," dated 11/2023, showed "...if a hospital patient demonstrates any of the criteria for abuse, Care Management or the House Supervisor should be notified for the proper referral notification..."

Review of the facility policy, "Occurrence Reporting" dated 11/2022, showed "...All events should be reported into the electronic safety software...as soon as possible after detection by the employee or by the healthcare provider most closely involved in the situation...Event should be reported timely and ideally no later than the end of the scheduled shift of duty..."

Review of facility documention showed an occurrence report was entered by Risk Management on 1/16/2025, 4 days after an incident with injury occurred on 1/12/2025. The report was entered into the facility's electronic reporting system after a social media outlet posted information related to the incident.

Medical record review showed Patient #1 was seen in the facility's ED on 1/12/25 and left Against Medical Advice (AMA) at 9:22 PM. The patient was returned to the ED by ambulance on 1/12/25 at 11:24 PM, due to being injured when hospital security officers drug him to a bus stop.

Medical record review of Patient #1's triage record revealed the second visit, dated 1/12/25 at 11:24 PM, showed Registered Nurse (RN) #1, recorded Patient #1 a 56-year-old male, arrived by Emergency Medical Services (EMS) with a complaint of foot injury, related to dragging his feet while being escorted to the bus stop by security officers. The chief complaint noted was Foot Injury, Abrasion of Right Foot, and Abrasion of Knee Bilateral.

During a telephone interview with RN #1 on 1/24/25 at 10:30 AM, she stated she was working as the triage nurse for the ambulance patients on 1/12/25. Interview confirmed she triaged Patient #1 on 1/12/25 at 11:24 PM, and documented his complaint was a foot injury. RN #1 stated she was told in report Patient #1 received his injuries as he was being dragged off hospital property by security officers. RN#1 stated she did not report the injuries on the foot, knees, and hands to anyone, including the House Supervisor. Interview confirmed RN #1 did not not complete an occurrence report and had not followed the abuse policy.

During a telephone interview with the RN Clinical Director of Emergency Services on 2/22/25 at 2:37 PM, she confirmed RN#1 did not complete an Occurrence Report and she was not notified of the suspected abuse, and neither was the House Supervisor or Care Management.

During a telephone interview with Paramedic #1 and Paramedic #2 on 2/28/25 at 9:06 AM, Paramedic #1 stated when they arrived on scene for the "traumatic injury 911 call" Patient #1 was sitting on the bench with one shoe. His feet were swollen and he had scratches all over his feet. Paramedic #1 said Patient #1 stated "the police did it." Paramedic #1 stated she gave report to the facility ED staff.

A telephone interview on 2/28/25 at 11:50 AM, with the physician treating Patient #1, confirmed he remembered seeing the patient and he stated he had seen Patient #1 "earlier in the day." Interview revealed as the physician examined the patient, Patient #1 stated his wounds were from being dragged and confirmed he didn't know if anyone in nursing reported the allegation of abuse.

Based on review of facility policy, observation, and interview, the facility failed to ensure medications were stored appropriately, for 1 of 2 nursing computer carts.

The findings include:

Review of the facility policy, "Medication Storage and Security Including Controlled Substances," revised 7/2024, showed "...drug storage throughout the hospital are under the supervision of the Senior Director of the Pharmacy or his/her pharmacy designee...medications stored in locked storage areas will be stored under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security..."

Observation on 2/19/2025 at 3:55 PM, in the Emergency Department (ED) triage area, showed 1 prepackaged injectable syringe of 40 milligrams (mg) of Lovenox (medication used to prevent blood clots) and 1 bottle of Nitroglycerin (medication used to treat chest pain) 0.4 mg, which were lying unsecured on the nursing computer cart. The cart was located in the hallway of the triage area. There were 3 patients observed on stretchers located in the area and no ED staff members were present.

During an interview on 2/19/2025 at 4:00 PM, the ED Director confirmed the medications were stored on the nursing computer cart and were not secured.