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Based on document review, policy review and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to seperate an employee after an incident of abuse. Staff witnessed an incident of abuse between Paramedic D and Patient #3 and failed ensure Patient #3 and all other patients were free from abuse. The CAH administrative continued to allow the alleged abuser to remain in work status and provide care to patients. The cumulative effect of this failure and deficient practice resulted in the hospital staff failing to ensure they protected all patients and failed to ensure patients were free from abuse. The hospital's administrative staff identified a census of 3 patients at the start of the investigation.

Please see C-2525

Based on medical record review, policy review, hospital incident report review and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to separate an alleged abuser from all patients after a witnessed incident of abuse for 1 of 1 patients (Patient #3).

Failure to remove an alleged abuser from all patients resulted in the alleged abuser continuing to have access to Patient #3 and all other patients. This placed vunerable patients at risk for further incidences of abuse.

Findings include:

1. During an interview on 11/7/23, at 2:10 PM, Chief Executive Officer (CEO) A acknowledged he was absent from the facility the week the alleged abuse incident occurred between Paramedic D and Patient #3 and confirmed Paramedic D had not been removed from patient care until his return on 10/2/23. CEO A attributed this due to the staffs lack of experience with abuse allegations and reported upon his return, the CAH started following their abuse policy and reported the abuse allegation to the state agency and suspended Paramedic D. CEO A confirmed he thought Paramedic D finished his shift on 9/25/23 and worked 1 other shift before his suspension and ultimate termination on 10/4/23.

2. Review of policy, "Patient Abuse in a Clinical Setting", last reviewed 12/2022, revealed in part: "... The [CAH] CEO/designee will thoroughly investigate all alleged incidents of abuse, neglect, mistreatment, or misappropriation of patient property ... [CAH] will take all appropriate steps to prevent any further potential abuse while the investigation is in process ...".

3. Review of the CAH's investigation revealed the following:
a. Chief Nursing Officer (CNO) F interviewed Paramedic D on 9/25/23, at 10:00 AM, and Paramedic D reported Patient #3 was behind him and grabbing at his belt on his right side. Paramedic D explained when he started turning around to his left, he knocked Patient #3 off balance causing the fall.
b. CNO F interviewed Emergency Medical Technician (EMT) I, Paramedic H, Registered Nurse (RN) E and Director of Physical Therapy J on 9/25/23. EMT I reported he was turning toward the door and he saw Patient #3 on the ground. Paramedic H reported he witnessed Paramedic D push Patient #3 and the patient fell. Director of Physical Therapy J described Paramedic D's actions as an aggressive shove causing Patient #3 to fall and RN E described Paramedic D's actions as aggressively knocking the patient over.
c. The CAH suspended Paramedic D and reported the abuse allegation to the state agency and the Bureau of Emergency Medical Services and Trauma on 10/2/23.

4. Review of the Emergency Medical Services Schedule for September revealed Paramedic D remained on the schedule for 9/25/23 for a 24-hour shift and 9/29/23 for another 24-hour shift.

5. Review of Paramedic D's timesheet showed his hours worked on 9/25/23 as 7:54 AM to 8:09 PM and on 9/29/23 as 7:53 AM to 8:10 PM.

6. Review of Paramedic D's personnel file showed documentation of his notification of suspension on 10/2/23 at 12:47 PM and notification of termination on 10/4/23 at 11:45 AM.

7. On 9/25/25, at 9:15 AM, RN E documented in Patient #3's medical record that an altercation occurred between Patient #3 and Paramedic D due to patient's aggression and patient fell to the floor. RN E documented staff immediately responded and the patient had no obvious injuries and the provider had been notified.

8. Review of an Occurrence Report Summary, completed on 9/25/23, at 10:29 AM, revealed RN E documented Charge Nurse G, Paramedic H, EMT I Paramedic D and herself entered Patient #3's room at 9:10 AM to change his brief and everyone had exited the room after the brief change, except Paramedic D, to allow the patient to decompress. RN E further documented Paramedic H, EMT I and herself remained in the hallway. RN E documented she saw Patient #3 grabbing and attempting to strike Paramedic D, then Paramedic D punched Patient #3 in the chest with both fists causing him to fall onto the floor beside his bed. RN E identified Paramedic H, EMT I and herself witnessed the altercation from the hallway and the altercation had been reported to Patient #3's provider, CNO F, Charge Nurse G and the Medical Director.

6. During an interview on 11/7/23, at 4:15 PM, CNO F reported Charge Nurse G informed him of an incident between Paramedic D and Patient #3, around 9:30 AM on 9/25/23. CNO F reported he went to the area of Patient #3's room and found Paramedic D sitting in the hallway and took him to an empty room and asked Paramedic D to explain what happened. CNO F reported Paramedic D explained Patient #3 had been grabbing at this belt and thought he must have nudged Patient #3 with his arm as he turned and reported he did not put his hands on Patient #3. CNO F reported he viewed the video footage of the hallway, around the time of the incident, to identify who might have witnessed the incident and interviewed Director of Therapy J, RN E, EMT I and Paramedic H and all but EMT I admitted to witnessing Paramedic D placing his hands on or about Patient #3's chest and pushing him, resulting in a fall. CNO F acknowledged Paramedic D remained at work for the remainder of the 24 hour shift and could not confirm he had not interacted with Patient 3#, or any patients again during the shift.

7. During an interview on 11/8/23, at 7:30 AM, EMT I acknowledged he witnessed the incident between Paramedic D and Patient #3 on 9/25/23. EMT I reported he couldn't recall what time it occurred, but had left Patient #3's room and while standing in the hallway, heard something that caused him to turn around. EMT I reported at the time he turned around, he saw Patient #3 appeared to be off balance and falling and Paramedic D had a hand on Patient #3's arm, up by the shoulder, which Paramedic D described as a push. EMT I confirmed Patient #3 fell to the floor after being pushed by Paramedic D.

8. During an interview on 11/8/23, at 8:08 AM, Paramedic H acknowledged he witnessed the incident between Paramedic D and Patient #3 on 9/25/23 and reported he had been in Patient #3's room that morning, with Paramedic D and EMT I to assist the nursing staff in the completion of a brief change. Paramedic H explained all of the staff left the room except Paramedic D, who remained in the doorway of Patient #3's room. Paramedic D reported he was in the hallway outside of the patient's room when the incident occurred. Paramedic H reported Patient #3 appeared off balance as Paramedic D turned toward the patient and Paramedic D pushed Patient #3 back and he fell to the floor. Paramedic H recalled hearing Paramedic D tell Patient #3 to stop touching him twice and described the push as "aggressive". Paramedic H confirmed Paramedic D pushed Patient #3 with both hands up near the shoulders.

9. During an interview on 11/8/23, at 9:00 AM, Director of Therapy J reported being at the nurse's station, across the hall from Patient #3's room, and estimated the incident occurred between 9:00 and 10:00 in morning. Director of Therapy J recalled Paramedic D had been just inside the doorway of Patient #3's room, and reported she saw him put both hands on Patient 3#'s upper chest and pushed, resulting in the patient falling to the floor. Director of Therapy J described the push as "fairly aggressive" and reported hearing Paramedic D say to Patient #3 something about not touching him as he pushed the patient.

10. During an interview on 11/8/23, at 9:41 AM, RN E reported Paramedic D assisted in managing Patient #3 during a brief change, along with Charge Nurse G, RN P, Paramedic H and EMT I, because Patient #3 could display aggressive and combative behaviors with staff when attempting to provide personal care. RN E reported after completion of the brief change, everyone left Patient #3's room to allow Patient #3 some time to calm down, except Paramedic D, who remained just inside the doorway of the room. RN E reported as she turned toward Patient #3's doorway, she heard Paramedic D yell an expletive to Patient #3 to keep hands off him and described Paramedic D used a "double fist punch" to Patient #3's chest, and Patient #3 fell to the floor. RN E described Paramedic D's behavior as "aggressive". RN E confirmed Paramedic D continued to work after the incident, seated outside of Patient #3's room for awhile after the incident, and came to the unit a few times during the rest of her shift to see if the nursing staff needed any help.

11. During an interview on 11/8/23, at 10:30 AM, Charge Nurse G reported she had been in Patient #3's room to assist with the brief change and had exited the room and went across the hall into the nurse's station. Charge Nurse G acknowledged her back was turned to the room so did not witness the incident, but heard the noise from Patient #3's fall and when she turned around, saw Patient #3 on the floor. Charge Nurse G explained she asked RN E what had happened and RN E reported to her Paramedic D pushed the patient. Charge Nurse G acknowledged she notified CNO F, Medical/Surgical Unit Manager O and Emergency Room Manager Q of the incident. Charge Nurse G reported CNO F informed her he would talk to Paramedic D and handle the incident. Charge Nurse G confirmed Paramedic D remained on the unit and sat outside of Patient #3's room for awhile after the incident and checked with her periodically to see if the nursing staff needed any help.

12. Review of the saved video clip on 9/25/23, from approximately 09:29:40 to 09:30:51, revealed a view of the hallway outside of Patient #3's room, located across from the medical/surgical unit nurse's station. The Director of Therapy Services walked into the nurses's station at the beginning of the clip and her legs and feet could be seen standing near the doorway of the nurse's station, at the time of the incident. The video confirmed RN E, Paramedic H and EMT I stood in the hallway outside of Patient #3's room and faced toward the patient's door at the time of the incident, allowing a clear view into the room.


16. During an interview on 11/9/23 at 1:15 PM, CEO A reported CNO F knew the appropriate steps to take for an abuse allegation but confirmed the CAH failed to identify the incident as an abuse allegation and ensure separation of Paramedic D from all patients, pending the CAH's investigation.