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Based on video surveillance review, document review and interview, it was determined that the Hospital failed to comply with the Condition of Participation 42 CFR 482.13 Patient Rights.

Findings include:

1. The Hospital failed to ensure patients were free from abuse which resulted in a patient being punched in the face/head. See deficiency at A-145 (A).

2. The Hospital failed to have an abuse policy/training program that addressed the required components of abuse prohibition. See deficiency at A-145 (B).

3. The Hospital failed to protect a patient/patients from the alleged perpetrator/abuser during an investigation of an allegation of abuse. See deficiency at A-145 (C).

The Immediate Jeopardy (IJ) began on 8/4/2023 due to the Hospital's failure to: protect Pt #1 from abuse; conduct a thorough investigation and follow-up of abuse and have an abuse program/training with all the required components for abuse prohibition. The IJ was identified on 10/4/2023, at 42 CFR 482.13, Patient Rights. The IJ was announced on 10/4/2023 at 1:30 PM during a meeting with the Chief Executive Officer, Chief Financial Officer, Director of Service and Experience, Vice President (VP) of Administrative Services, Director of Nursing, Director of the ED, Director of Patient Care Services, VP of Mission Integration, Educator, Director of Risk Management, Director of Human Resources, Director of Public Safety, VP Marketing & Public Relations, Lead Quality Coordinator, Quality Manager, System Director of Accreditation, and Manager of the ED and was not removed by the survey exit date of 10/4/2023.

A. Based on video surveillance review, document review and interview, it was determined that for 1 of 2 clinical records (Pt #1) reviewed for abuse, the Hospital failed to ensure that Pt #1 was free from abuse and failed to conduct a thorough investigation and follow-up for the abuse incident. This resulted in Pt #1 being punched in the face/head by a Security Officer during an ED (emergency department) visit.

Findings include:

1. On 10/2/2023 at 11:50 AM, the Hospital's video footage (dated 8/4/2023 from 11:47 AM to 11:52 AM) of the ED hallway was reviewed with the Director of ED (E #4) and the Director of Risk Management (E #5). The video footage noted the following:
-8/4/2023 at 11:47 AM - Pt #1 sitting on EMS (emergency medical services) cart holding laptop and pen
-8/4/2023 at 11:49 AM - Pt #1 threw laptop and pen
-8/4/2023 at 11:50 AM - Pt #1's sitter (E #10) throws scrubs (pants and shirt) at Pt #1
-8/4/2023 at 11:50:45 AM - Security officers (E #9 & E #6) are applying 4-point restraints to Pt #1.
-8/4/2023 at 11:50:47 AM - Security officer (E #6) punched Pt #1 in the face with a closed fist 3 times. There was no staff intervention to stop the punches. Staff present during the incident included sitter (E #10), ED nurse (E #8), Behavioral Health Counselor (E #11), and Security Officer (E #9)
-8/4/2023 at 11:52 AM - Security Officer (E #6) forcefully places a hood over Pt #1's face while having E#6's upper body on top of Pt. #1's upper body. E #9 places and continues to hold E#9's hand over Pt #1's face after the spit hood is put on Pt. #1's head

2. On 10/2/2023, Pt #1's clinical record (dated 8/3/2023 to 8/5/2023) was reviewed and indicated:
-Pt #1's ED care timeline included:
-8/3/2023 at 8:45 PM - Pt #1 arrived in ED, arrival complaint -psychiatric evaluation (alcohol intoxication)
-8:55 PM - Restraint order - clinical justification -imminent risk of harm to self and others, restraint type (violent) locked restraint right wrist, left wrist, right ankle, and left ankle
-9:55 PM - restraints discontinued
-10:40 PM - Pt #1 sedated at this time.
-8/4/2023 at 2:10 AM - Verified with MD #1 (ED Physician) - Pt #1 needed to have inpatient psych and would be transferred as soon as referring accepting hospital calls with a bed available
-8/5/2023 at 12:04 AM - MD #1's notes - "When Pt #1 was on EMS stretcher (for transfer to another hospital for inpatient behavioral health unit), Pt #1 became agitated. I (MD #1) placed medications to help with agitation. When I (MD #1) went to assess Pt #1 on the ER stretcher (Pt #1) was being combative yelling about someone taking his bag. Multiple staff members were trying to restrain Pt #1 when Pt #1 leaned forward and spit in a security guard's (E #6) face. I (MD #1) then witnessed E #6 hit Pt #1 with closed fist and face at least 3 times. Pt #1 had no LOC (loss of consciousness). I (MD #1) examined Pt #1 immediately after event and noted him (Pt #1) to have no facial trauma, Pt. #1 denied any facial pain however Pt #1 is an unreliable historian due to Pt. #1's overall mental status and the amount of medications Pt. #1 has been given while being here. Pt #1 will require imaging of the face, head and neck before Pt. #1 can leave. I (MD #1) have informed charge nurse of the situation asked [charge nurse] to contact nursing supervisor and other administration to immediately come to ER and help navigate the situation."
-8/5/2023 at 2:13 AM - CT (computerized tomography scan) spine cervical - normal cervical spine, CT facial bones - no acute facial fracture identified, CT head/brain -normal head CT
-8/5/2023 at 3:03 AM - Pt #1 accepted at Hospital B for inpatient behavioral health unit
-8/55/2023 at 11:33 AM - Pt #1 transferred to Hospital B

3. On 10/2/2023, the Hospital's Safety/Security Event (dated 8/5/2023) noted, "At approximately 11:50 AM, officer (E #6) noticed Pt #1 grabbing and throwing objects (transporter [rubber case used to carry laptop] laptop, etc..), officer (E #6) arrived on scene at Behavioral Unit (of ED) noticed suspect had gotten hold of weapon (pen) in attempt to retrieve pen, suspect spit in officer (E #6) face (mouth and eye), officer (E #6) in fear of bodily harm to E#6 and others threw punches 2-3, then took weapon from suspect's hand and staff began trying to place transporter's trap (spit hood) and restraints on Pt #1. Doctor (MD #1) for room informed security MD#1 needs to examine Pt #1 and to place Pt #1 in room on bed, 4-point restraints were applied. Police notified report #23 Of 04597.
-Immediate Actions - Police Notified - Supervisor Notified"

4. On 10/2/2023, the Hospital's policy titled, "Report of Patient Abuse Policy" (dated 7/2023) required, "Purpose - to protect patients from being abused in a hospital setting ...No administrator, agent, or employee of a hospital or a member of its medical staff my abuse a patient in the hospital ..." The Hospital did not have an abuse policy that addressed the types of abuse, prevention of abuse, interventions and detection of abuse.

5. On 10/2/2023, the Hospital's policy titled, "(Sentinel) Adverse Event Investigation Procedure" (dated 12/2022) was reviewed and indicated, "This policy will ensure a thorough and comprehensive analysis and evaluation of patient-related adverse events ...A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof ...The phrase "the risk there of" includes any process variation of a reoccurrence that would carry a significance chance of a serious adverse outcome... Sentinel Event Review whose purpose is to investigate the event for cause (Root Cause Analysis)... Root Cause Analysis is the process for identifying the basic or causal factor(s) that underlie variations in performance, including the occurrences or possible occurrences of a sentinel event..."

6. Security Officers were required to have MOAB (management of aggressive behavior) training per the course curriculum. The personnel file of E#6 indicated that E#6 did not receive MOAB training. In addition, the MOAB Training Transcript for Security Guards was reviewed and indicated that 25 out of the 39 current Security Officers (including E #9) lacked this training on de-escalation techniques and how to manage individuals with aggressive behaviors, despite being available/called to assist with behavioral health patients in the ED.

7. On 10/2/2023, at approximately 12;25 PM, an interview was conducted with the Director of Public Safety (E#3). E#3 stated that holding a patient's face or chest is not proper procedure under MOAB. E#3 stated that in a situation where a patient is agitated and is escalating, it is not appropriate to throw scrubs at the patient, "that does nothing but exacerbate the situation." E #3 stated that the new Security Officers have not received the training yet and presented a list of current Security Officers in the Hospital. E #3 acknowledged that not all Security Officers have received the mandatory training yet.

8. On 10/2/2023 at 12:15 PM, an interview was conducted with the ED Physician (MD #1). MD #1 stated that MD#1 witnessed a Security Officer punch Pt #1 with a closed fist three times after Pt #1 spit at the Security Officer. MD #1 stated that MD#1 immediately informed the charge nurse about the incident. MD #1 stated that MD#1 examined Pt #1 and ordered a CT head and facial x-rays which were all negative. MD #1 stated that it is inappropriate to hit a patient.

9. On 10/2/2023, at approximately 4:07 PM, an interview was conducted with Security Officer (E#14). E#14 stated that if a patient starts to spit, they can apply a spit hood over the patients head. E#14 stated that the spit hoods are available in a drawer at the Synergy (Behavioral Health area of the ED) nurses station. E#14 stated that once the spit hood is on, there is no reason to continue holding the patients head/face to stop them from spitting.

10. On 10/3/2023 at 1:45 PM, an interview was conducted with the Security Officer (E #9). E #9 stated that Pt #1 spit at another Security Officer (E #6), and E #6 hit Pt #1. E #9 stated that then "we strangled Pt #1 down" and "tied Pt #1 down." E #9 stated that E#9 has not had training for aggressive patients, but E #9 heard the Hospital is working on the training.

11. On 10/3/2023 at 1:50 PM, an interview was conducted with the Director of Quality Management (E #1). E #1 stated that there was no RCA (root cause analysis) for this incident. Only a "Quality Review" was conducted. E#1 had provided a copy of the Quality Review and Action Plan for this incident. The Quality Review and Action Plan lacked any areas identified for process improvement and lacked any corrective actions implemented following this incident to prevent further occurrences of patient abuse, other than terminating E#6.


B. Based on document review and interview, it was determined that the Hospital failed to ensure abuse policies, procedures and training program included the types of abuse, detection of abuse, prevention of abuse, and interventions.

Findings include:

1. On 10/3/2023, the Hospital's policy titled, "Report of Patient Abuse Policy" (dated 7/2023) indicated, "Purpose - to protect patients from being abused in a hospital setting ...No administrator, agent, or employee of a hospital or a member of its medical staff my abuse a patient in the hospital ..." The policy did not include the different types of abuse, abuse prevention, or detection of abuse.

2. On 10/3/2023, the Hospital's annual abuse training content was reviewed. The annual abuse training did not define the types of abuse, abuse prevention, immediate abuse reporting, intervention, or detection of abuse.

3. On 10/3/2023, an interview was conducted with the Director of Quality Management (E #1). E #1 stated that the "Report of Patient Abuse Policy" is the general abuse policy for all patients.



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C. Based on document review and interview, it was determined that for 1 of 2 (Pt. #10) abuse allegations reviewed, the Hospital failed to escalate an allegation of abuse to the appropriate department in order to promptly initiate an investigation, and failed to protect the patient/patients from the alleged perpetrator/abuser pending results of an investigation.

Findings include:

1. The Hospital's policy titled, "Report of Patient Abuse Policy" (revised 07/2023), was reviewed and required, "...Any hospital administrator, agent, employee, or medical staff member who has reasonable cause to believe that any patient with whom he or she has direct contact has been subjected to abuse in the hospital shall promptly report or cause a report to be made to the Administrator on call... Upon receiving a report, the Risk Management and Human Resources departments will be notified and will immediately conduct an internal review to ensure the alleged victim's safety. Measures to protect the alleged victim shall be taken as deemed necessary by the hospital's administrator and shall include, but are not limited to, removing suspected violators from further patient contact during the hospital's internal review..."

2. The Hospital's "Serious Safety Event & Alleged Patient Abuse Response Plan" (attachment to above policy, dated 7/20/2023), was reviewed and included, "Event occurs that results in 1) Allegation of Patient Abuse... Patient Stabilized/Made Safe: Notification of event by coworker to supervisor or appropriate next level Chain of Command/ if on off-shift or weekend, Nursing Supervisor is called. **Supervisor goes to site of incident to assure patient and coworkers are safe and supported, initiates call tree... Call Tree: Nursing Supervisor is responsible to inform Administrator on Call (AOC), and Risk Management... Risk Management immediately goes to location of event and will begin to support coworkers, patient, and family... Will initiate an immediate investigation of the event..."

3. An incident report filed for Pt. #10 on 8/10/2023 was reviewed and included, "[On] 8/9/2023 at 9:45 PM... Patient reported claims of being punched by this RN (registered nurse identified as E#20) while cleaning the patient... Patient stated, "Stop punching me, you're punching me... I (E#20) excused myself from the room and notified my charge nurse. The Investigation Report for Pt. #10's allegation of abuse indicated that Risk Management was notified on 8/10/2023 at 7:50 AM and that's when the investigation began (nearly 10 hours after the allegation of abuse was made to staff).

4. Staffing Assignments from 8/9/2023-8/10/2023 were reviewed and indicated that Pt. #10 was reassigned to another nurse on the unit; however, E#20 continued to work on the same unit where Pt. #10 was located and was assigned to work with 4 other patients. E#20's timesheets from 8/9/2023-8/10/2023 were reviewed and indicated that E#20 worked from 8/9/2023 at 6:55 PM to 8/10/2023 at 10:38 AM.

5. An interview was conducted with Risk Management Specialist (E#21) on 10/4/2023, at approximately 9:40 AM. E#21 stated that when staff are made aware of an allegation of abuse, they should follow the chain of command to report to the Charge Nurse, the House Supervisor, and the Manager/Director and/or Administrator on call (if after hours). E#21 stated that any one of those staff should report the allegation to Risk Management immediately even if after hours. E#21 stated, "We (Risk Management) will come in even in the middle of the night." E#21 was not notified of the allegation of abuse until the following morning and that's when they started the investigation. E#21 stated that Risk Management in conjunction with Human Resources are the responsible parties that investigate allegations of abuse and make a determination. E#21 stated that it ended up being unfounded as the patient retracted their statement when E#21 spoke with Pt. #1 the morning of 8/10/2023, at approximately 8:15 AM; however, E#21 stated that the staff member should have been suspended immediately (sent home) pending investigation in order to protect that patient and the other patients on the unit.

Based on document review and interview, it was determined that for 2 of 4 (Pt #2, Pt #6) clinical records reviewed for nursing assessments, the Hospital failed to ensure that patient's IV (intravenous) assessments were completed in accordance with policy.

Findings include:

1. The Hospital's policy titled, "Intravenous: Adult Peripheral Venipuncture; Care and Maintenance Guideline", (dated 1/2023) was reviewed and required, " In inpatient departments, assess PIVC's [peripherally inserted venous catheter/IV] at least every 4 hours...[for] assess PIVC's in patients who are critically ill/sedated or have cognitive deficits every one to two hours ..."

2. The clinical record for Pt #2 was reviewed on 10/2/2023. Pt #2 presented to the Emergency Department (ED) on 7/10/2023, with an admitting diagnosis of rhabdomyolysis (breakdown of muscle releasing damaging protein in the blood). Pt #2 was transferred to the Intensive Care Unit (ICU) on 7/10/2023. Pt #2 was critically ill and required sedation. On 8/4/2023 at 2:15 AM, Pt #2 was transferred to [another acute care Hospital], for a higher level of care.

-Pt #2's nursing flowsheets from 7/10/2023-8/4/2023, were reviewed. The flowsheets included nursing assessments of the patient's IV (intravenous) sites (left forearm, right forearm, and midline centrally inserted IV). The IV access assessments were documented every 4 hours. However, per the IV policy for a critically ill patient who is sedated, documentation is required every 1-2 hours. The clinical record lacked the required 1-2 hour assessments.

3. The clinical record of Pt. #6 was reviewed on 10/3/2023. Pt. #6 was admitted on 9/3/2023, with a diagnosis of Asthma Exacerbation. Pt #6 was not critically ill or sedated. Nursing flowsheets indicated that Pt. #6 had and intravenous (IV) access in the left upper arm since 9/17/2023. IV site assessments from 9/27/2023-10/3/2023 were reviewed and lacked documentation that the patient's IV site was assessed at least every 4 hours as required between the following times:
- From 9/27/2023 at 4:12 PM to 9/28/2023 at 8:00 AM (nearly 16 hours).
- On 10/1/2023 between 8:00 AM to 3:00 PM (7 hours).
- On 10/2/2023 between 8:00 AM to 3:00 PM (7 hours).

4. On 10/3/2023 at 10:15 AM, an interview was conducted with an ICU RN (E #16). E #16 stated that ICU nurses have been charting on IV sites every 4 hours, even for critically ill patients.

5. On 10/4/2023 at 9:50 AM, an interview was conducted with the Nursing Director (E #19). E #19 stated that nurses have been charting IV assessments every 4 hours, but E #19 does acknowledge how there can be confusion with the charting expectation since the general adult IV policy states that critically ill/sedated patients should be charted on every 1-2 hours. E #19 stated, that whereas, the critical care policy states that the nurses should chart every 4 hours on the IV site.