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Based on interview, record review, and policy review, the hospital failed to ensure that:
- Allegations of abuse and neglect against Staff G, Emergency Department (ED) Physician, Alleged Perpetrator (AP), were reported immediately;
- An event/incident report of the alleged abuse was completed;
- All parties involved were interviewed through the internal investigation process;
- The patients were safe when Staff G was allowed to continue providing patient care after the abuse allegations were reported; and
- All hospital staff received education regarding abuse and neglect.
These failures had the potential to place all patients who received care at risk for their health and safety. (C-0962)

These deficient practices resulted in the hospital's non-compliance with specific requirements found under 42 CFR 485.627 Condition of Participation: Organizational Structure. The hospital census was 10.

The severity and cumulative effect of these practices had the likelihood to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 09/09/20, after the survey team informed the hospital of the IJ, the staff put interventions into place to ensure the safety of all patients.

As of 09/09/20, the hospital had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Mandatory training was to be completed by all employees (including physicians and on-site contracted patient care staff) that covered timely completion of event reports and how to identify when it was appropriate to complete an event report based on the existing policy titled, "Patient Safety Evaluation System." This training was initiated with all available staff and was planned to continue with each staff/contracted member prior to the start of their next scheduled shift.
-The ED physician's internal investigation scheduled to be reviewed by the Peer Review Committee on 09/21/20, was rescheduled for 09/09/20 at 5:00 PM.
-The ED physician in question was suspended from the ED physician schedule until such time as a decision was made regarding the investigation.
-Mandatory training was to be completed by all employees (including physicians and on-site contracted patient care staff) over the following policies: Suspected Child, Disabled Person or Elderly Abuse/Neglect/Exploitation, and Abuse/Neglect-Employee Screening and Education.

Based on interview, record review, and policy review, the hospital failed to ensure that:
- Allegations of abuse and neglect against Staff G, Emergency Department (ED) Physician, Alleged Perpetrator (AP) were reported immediately;
- An event/incident report of the alleged abuse was completed;
- All parties involved were interviewed through the internal investigation process;
- The patients were safe when Staff G was allowed to continue to provide patient care after the abuse allegations were reported; and
- All hospital staff received education regarding abuse and neglect.
These failures had the potential to place all patients who received care at risk for their health and safety.

Review of the hospital's policy titled, "Abuse/Neglect-Employee Screening and Education", revised 04/30/19, showed that:
- The policy was to prevent patient abuse, neglect, seclusion, misappropriation of property, and willful mistreatment or exploitation.
- Each employee shall be informed that violation of the abuse/neglect policy will not be tolerated and may be grounds for termination.
- Each employee shall be informed of their responsibility to immediately report any violation of the abuse/neglect policy.
- Employees must report immediately to the Director and/or Charge Nurse, any aggressive or inappropriate behavior (observed, heard about, or suspected).
- An interview of all persons involved shall be conducted by the Director and/or Charge Nurse.
- An event report shall be completed.
- An employee suspected of violation of the neglect/abuse policy may be counseled, disciplined, or suspended pending investigation.

Review of the hospital's policy titled, "Patient Safety Evaluation System", revised 01/01/19, showed that:
- The policy is to provide timely reporting, review, evaluation, and follow-up of reported events.
- A "Patient Safety Event" is an event, incident, or condition that could have resulted or did result in harm to a patient.
- It is the policy of the hospital that all events not consistent with the routine operations of the hospital or the routine care of the patient be reported to Risk Management.
- Event reports are to be completed and reviewed by Risk Management and that information is forwarded to the hospital Leadership.
- The event report is encouraged to be completed within 24-hours of the incident and sent to the Department Director where the event occurred.
- The Department Director will review the Event Report and forward to Risk Management as soon as possible.
- The report will be dated upon arrival to Risk Management.
- The Risk Manager and Department Director will lead a modified root cause analysis (RCA) or care review and provide a report to the Chief Executive Officer (CEO) and any follow-up deemed necessary to the patient/family/physician and any other entity deemed necessary.

Review of Patient #7's medical record dated 08/17/20 at 3:53 PM, showed:
- He was a 39-year-old male.
- He had an appointment with his primary care physician (PCP) at the time he arrived in the ED.
- His chief complaint was left-sided chest pain and shortness of breath (SOB).
- He informed the nurse of heroin use the day prior.
- His past medical history included anxiety and hypertension (HTN, high blood pressure).
- A thorough medical exam was performed as well as an electrocardiogram (EKG, test that checks for problems with the electrical activity within the heart) with normal results.
- He was previously seen in early August and had a complete cardiac work-up, which was negative.
- He was instructed to follow-up with his PCP immediately after discharge from the ED.

Review of Patient #7's medical record dated 08/17/20 at 6:54 PM, showed:
- He returned to the ED after his previous discharge with similar complaints of chest pain, inability to breathe, diarrhea, dizziness, muscle weakness, and twitching.
- A thorough medical exam was performed as well as an x-ray (type of radiation called electromagnetic waves, that creates pictures of the inside of the body) of the chest and abdomen, urinalysis (a test of urine to determine if an infection is present) and blood work.
- He was able to talk in complete sentences with no distress noted.
- He reported that he took a substance the evening prior, which could have been methamphetamine (a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant).
- He reported that he had not taken his Valium (medication to treat anxiety, muscle spasms, and seizures) since 08/12/20, and that he became anxious without it.
- His drug screen was positive for Benzodiazepines (a depressant that produce sedation, induce sleep, relieve anxiety and prevent seizures).
- His abdominal x-ray showed signs of constipation.
- He was provided Golytely (laxative solution that stimulates bowel movements) and Simethicone (medication to treat symptoms of gas such as painful pressure, fullness, and bloating) prior to discharge from the ED.
- He was given a prescription for Ketorolac (medication used to relieve moderately severe pain) at discharge.

Review of Patient #7's medical record dated 08/18/20 at 3:57 AM, showed:
- He returned to the ED after his previous discharge with a complaint of chest pain.
- He reported that he wanted a medication so he could return home and sleep.
- A thorough medical exam was performed.
- Ketorolac (a nonsteroidal anti-inflammatory drug used to treat pain) was ordered,; however, the patient refused and requested a muscle relaxer.
- The physician noted the patient exhibited drug-seeking behavior.
- He was discharged at 4:27 AM.
- He returned to the lobby and waited for a ride home.

Review of Patient #7's medical record dated 08/18/20 at 6:08 AM, showed:
- A nurse was called to the hospital's cafeteria to assist with a patient found on the floor.
- In the cafeteria, the patient was found lying on the floor and shaking.
- He was able to respond to questions and the nurse assisted him into a wheelchair.
- He reported that "he did a line of meth".
- The physician met the patient in a triage room for assessment.
- The physician noted, "patient was feigning (pretending to be affected by) semi-consciousness until I broke two ampoules of ammonia inhalant under his nose. He finally had to grab my hands to push away and righted himself in the wheelchair."
- A thorough medical exam was completed.
- He was educated to follow-up with his PCP as needed and discharged from the ED.

Review of document titled, "Event Investigation/Timeline," showed that:
- On 08/20/20 at 9:00 AM, Staff A, ED Director, was contacted by Staff O, ED Registered Nurse (RN), who reported a potential physician-patient abuse event between Staff G, ED Physician, AP, and Patient #7, that occurred on 08/18/20 at 6:00 AM.
- On 08/20/20 at 9:23 AM, Staff A reported the event to Administration as well as Staff M, Risk Manager.
- The allegation was not reported until 08/20/20, two days after the alleged event.
- The investigation did not begin until 08/21/20.
- The patient was not interviewed.
- Staff G, ED Physician, AP, was not interviewed.
- Staff G was not removed from direct patient care pending an investigation.
- On 08/21/20 at 9:00 AM, via telephone conference call, Staff A, ED Director; Staff M, Risk Manager; Staff B, Chief Nursing Officer (CNO); Staff C, Chief Executive Officer (CEO); and the hospital's risk management company interviewed Staff O, ED RN, regarding the events of 08/18/20.
- Staff G, ED Physician, AP, was scheduled to work 08/22/20, and ED nursing staff were informed by Staff A, ED Director, that there was an ongoing confidential investigation, and should Patient #7 return to the ED to be seen, there should be another staff member present in the room at the time Staff G was with the patient.
- On 08/24/20 at 10:30 AM, Staff N, ED RN, was interviewed regarding the events of 08/18/20.
- No further investigation was completed.
- Results of the investigation showed an opportunity for staff education on timeliness of event reporting and staff expectations when abuse/neglect by another staff member may be suspected.
- Results of the investigation showed an opportunity for current policies to be reviewed and updated as needed, and for staff to be educated when significant changes were made to a policy.
- The event would be sent to the Peer Review Committee.

Review of the hospital's interview with Staff O, RN, on 08/21/20, showed that:
- She waited until a scheduled ED meeting on 08/20/20, to report the allegation.
- Patient #7 had been into the ED four times that day and once to his PCP's office.
- On 08/18/20, between 06:00 AM and 06:30 AM, a staff member came to the ED and reported there was a man unconscious in the cafeteria.
- Upon her arrival in the cafeteria, Patient #7 was lying on the floor, moaning.
- She quickly assessed him, assisted him into a wheelchair, and brought him to the ED triage room.
- Staff G, ED Physician, AP, came to triage to examine him.
- She stated she could not recall Staff G's exact words to Patient #7, but that he said something along the lines, "you go ahead and do your thing and I'll do mine."
- Staff G held ammonia salt over the patient's nose and mouth and used his other hand to hold the back of the patient's head.
- Staff G told the patient he would "hold it over his mouth until he suffocated."
- Patient #7 was "dramatic and still acting lethargic, but did come around," and he was able to walk out of the ED at discharge.
- She was the only witness to the event.

During a telephone interview on 09/09/20 at 8:55 AM, Staff O, ED RN, stated that:
- Patient #7 had been in several times that day, he was discharged and returned a few hours later.
- Towards the end of the shift, a staff member came to the ED and stated that a patient had passed out in the cafeteria.
- Upon arrival in the cafeteria, she realized it was Patient #7. She assessed him to ensure there were no cardiac issues or seizure activity, she also asked if he had ingested any drugs since his previous discharge, and the patient responded, "No."
- She used a wheelchair to push him back to the ED triage area.
- Staff G, ED Physician, AP, entered the triage room and stated to the patient that he had been in and out of the ED all day and he was tired of dealing with it.
- Staff G left the room, returned with ammonia salts, placed the salts under the patient's nose, held the back of his head and said, "I will suffocate you if I have to."
- The patient began to cough and spit after the ammonia.
- She was unsure what she would consider abuse, but she assumed it would be anything she would not want done to her.
- She did not report the incident earlier because she worked nights and knew there was a staff meeting that Thursday, 08/20/20.
- She did not fill out an Event Report after the incident.
- She was unable to speak to what the hospital's abuse policy stated regarding defining or reporting abuse.
- After reporting the incident, education was provided from Staff A, ED Director, on the abuse policy and "they hit hard" on what types of behaviors were not tolerated and that abuse/neglect incidents should be reported immediately.
- She was unsure if staff were to be suspended pending an investigation after abuse/neglect was reported.
- She had worked with Staff G twice since this incident.

During a telephone interview on 09/09/20 at 9:15 AM, Staff G, ED Physician, AP, stated that:
- He saw Patient #7 four times in less than 16 hours, beginning 08/17/20, and into the morning of 08/18/20.
- During the patient's first visit, he did not believe the patient was drug-seeking; however, by the patient's third visit, when he prescribed Toradol, and the patient refused, he began to question the patient's intentions.
- During the fourth visit, he entered the triage room and the patient immediately leaned his head back over the wheelchair and closed his eyes.
- He felt that the patient was faking unresponsiveness.
- He attempted to verbally redirect the patient with no success, so he left the triage room to retrieve some ammonia salts.
- He held the ammonia salts under the patient's nose and the patient attempted to continue feigning unresponsiveness for as long as possible.
- Eventually the patient shoved his hand away and sat up in the wheelchair and began answering questions.
- He told the patient, "If you do that again, I will do what I did again."
- He denied that he placed his hand on the back of the patient's head.
- He denied that he told the patient he would suffocate him because "that would be verbal abuse."
- He stated that he was upset with the patient and told him that he had more ammonia salts that he would use again if the feigning of symptoms occurred, but denied that he threatened the patient.
- He was not interviewed by any staff in regard to the incident.
- He was unaware that an abuse allegation had been reported until 09/08/20, when Staff C, CEO, called him to inform him of the surveyors' presence and that he would be contacted for an interview.
- During the phone call with Staff C, he was informed there would be a peer review scheduled regarding the incident.

During an interview on 09/08/20 at 2:15 PM, Staff A, ED Director, stated that:
- Once the incident was brought to his attention, he reported it to Staff M, Risk Manager.
- The nurse did not complete an Event Report after the incident.
- Although he was present for the investigation interviews, Risk Management conducted the interviews.
- He performed post-incident education to ED nursing staff only.
- He was unaware if the patient was interviewed.
- He was unaware if the physician was interviewed.

During a telephone interview on 09/09/20 at 9:42 AM, Staff M, Risk Manager, stated:
- The physician had not been interviewed during the investigative process because it was set to happen during the peer review.
- Since the physician was a credentialed employee, the interview, and any disciplinary action would fall back to the physician's peers and the peer review process.
- The portion of the investigation timeline that stated Staff G would have another staff member present during exams, only applied to Patient #7's possible return to the ED, and only applied for the weekend of 08/22/20.
- The patient was not interviewed because she, along with the hospital's liability company, determined that the patient was not credible.
- Education after an incident was the responsibility of the unit manager where the abuse occurred.

During an interview on 09/09/20 at 9:55 AM, Staff C, CEO, stated that:
- The Peer Review Committee was held by members of the medical staff every two months.
- He felt the investigation interview with Staff G, ED Physician, AP, should be looked at from a medical staff point of view.
- Staff G was not made aware that there was an abuse allegation, he was only made aware that there had been a complaint, along with the patient's name, so he would be able to review the medical record.
- Staff G was made aware of the complaint "last week" and informed that a peer review would be scheduled.

During an interview on 09/09/20 at 1:10 PM, Staff C, CEO, stated that:
- Members of the Peer Review Committee were Staff Z, Chief Medical Officer (CMO), Vice Chief of Medical Staff, and Staff G, ED Physician, AP.
- Staff G's peer review was scheduled for 09/21/20.

During an interview on 09/09/20 at 4:00 PM, Staff Z, CMO, stated that:
- He was unsure what staff were part of the Peer Review Committee.
- He was unsure of how often the Peer Review Committee met.
- Any issues with care provided by physicians were brought to the Medical Staff Meetings.
- Medical Staff Meetings were attended by "whomever has voting staff privileges."

During a telephone interview on 09/09/20 at 4:05 PM, Staff Y, Board of Directors Member, stated that:
- Board members were made aware of all pertinent hospital events.
- In cases of abuse or neglect allegations the hospital would perform an investigation and present their findings to the Board.
- Board members were involved in the disciplinary actions of nurses and emergency medical services (EMS) staff after an abuse or neglect incident so he "assumed they would be for physicians as well if the need arose.".
- He was not made aware of any physician-to-patient abuse allegations.

Multiple attempts to contact Patient #7 for an interview were unsuccessful.

Review of the ED physician schedule for Staff G, ED Physician, AP, showed:
- He worked six additional shifts between 08/18/20 and 09/07/20.
- On 08/19/20, he worked a shift prior to the incident being reported.
- On 08/22/20, after the incident had been reported, he worked and staff were directed to accompany him to examine Patient #7, should he return to the ED.

The hospital failed to provide quality care in a safe environment when they did not recognize the seriousness of the abuse allegations and did not follow their policy by thoroughly investigating allegations of staff-to-patient verbal and physical abuse. Furthermore, delayed reporting and failure to implement immediate measures to remove Staff G from patient care placed all patients who arrived to the ED for treatment at risk for possible abuse.