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Based on record review and interview, the hospital failed to ensure the patient's right to receive care in a safe setting. This deficient practice is evidenced by the failure to ensure patient care staff were educated on contraband items that should not be brought to work and are not allowed in the patient care area.
Findings:

A review of hospital policy, "Security Management: Weapons, Illegal Drugs and Alcohol," policy number A-140, with an effective date of 10/2005, last revised 08/2014 and last reviewed 03/2024, revealed in part: "Policy Statement: 2. Contraband is defined as anything not specifically listed within this policy that is not permitted in the BRGMC hospital facilities. 4. Weapons, defined as a physical item that is used for fighting or attacking another person or for defending yourself when someone is attacking you, which, for purposes of this policy, includes, but is not limited to, firearms and/or any ammunition, stun guns/Tasers, batons, knives, explosives, pepper spray, MACE/chemical defense spray, nun chucks, brass knuckles, throwing stars/knives, and swords, are not permitted in BRGMC hospital facilities at any time, unless previously authorized by Hospital Administration under the exceptions listed below. 7. Nothing in this policy shall prohibit any employee, volunteer, vendor or contractor from possessing special knives, cutting instruments, tools or other items that could be classified as weapons under this policy, when such items are required for and possessed or used while in the performance of, their duties. RESPONSIBILITIES FOR ENFORCEMENT: 1. Administrators and department heads are responsible for enforcing this policy as it relates to employees, medical staff, and students, with guidance and involvement of Human Resources. Security personnel are responsible for enforcing the policy as it relates to patients and visitors, and are available to enforce the policy with employees as the situation warrants."

A review of the hospital's safety reporting system log revealed an entry on 08/27/2025, time unavailable, by S5RN (S4PCE confirmed the identity of the writer), "(Staff to Staff/Patient; Disorderly Conduct) [S6BT] and I were performing daily wound care on the patient. Another nurse, [S7RN] came into the room and stood toward the end of the patient's bed. He took a military/hunting style folding knife out of his pocket. He then opened the knife and asked the patient [Patient #1] if he [Patient #1] had ever cut or stabbed anyone. The patient [Patient #1] appeared startled/scared. [S7RN] then proceeded to walk closer to the top of the bed/patient's head and started flickering the knife open and closed. The patient [Patient #1] physically shifted his body as best he could away from that side of the bed. I asked him [S7RN] to put the knife away which he did."

In an interview on 11/19/2025 at 11:00 a.m., S8RN confirmed she has witnessed S7RN having a pocketknife on his person and handling the pocketknife at the nurse's station by continuous opening and closing of the knife.

In an interview on 11/19/2025 at 3:13 p.m., S6BT confirmed he was in Patient #1's room when S7RN entered the room and begin opening and closing a pocketknife. S6BT described the knife as "military grade" and approximately 3 inches in length when closed. S6BT confirmed S7RN used this knife to cut and remove Patient #1's armband.

In an interview on 11/19/2025 at 3:19 p.m., S5RN confirmed she was in Patient #1's room when S7RN entered the room and begin opening and closing a pocketknife. S5RN described the knife as "a knife that would be used to skin a deer" and further described the knife as "a Spyderco style knife" approximately 3-4 inches in length when closed.

In an interview on 11/19/2025 at 2:35 p.m., S1CNO confirmed patient care staff should not be in possession of a pocketknife in the patient care area and this would be considered an item that was not allowed to be used for patient care. S1CNO further confirmed, since the date of the before mention safety event, 08/27/2025, Unit A was the only unit that had received education/in-service review of the hospital's policies related to items that are prohibited by patient care staff to carry and/or possess on the hospital's campus or education/in-service review of potential workplace violence scenarios related to disgruntled staff.