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Based on interview, record review, policy review, and review of digital video recordings the hospital's Governing Body failed to ensure that:
- Medical staff were accountable to the governing body for quality care that met the needs of three discharged patients (#10, #11 and #19), of eleven discharged patients reviewed. (A-0049)
- Medical records reflected an accurate representation of patient visits for two discharged patients (#10 and #11), of two discharged patients reviewed with allegations of abuse. (A-0049)
- The Chief Executive Officer (CEO) effectively managed the hospital in order to meet applicable regulatory requirements. (A-0057)

These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital.

The severity and cumulative effect of these systemic practices resulted in the hospital's non-compliance with 42 CFR 482.12 Condition of Participation: Governing Body. The hospital census was 44.


45073

Based on observation, interview, record review, policy review, and review of digital video records, the hospital failed to ensure that medical staff were accountable to the governing body for quality of care that met the needs of three discharged patients (#10, #11 and #19), of eleven discharged patients reviewed, and failed to ensure that medical record documentation reflected an accurate representation of patient visits for two discharged patients (#10 and #11), of two discharged patients reviewed with allegations of abuse. This had the potential to affect the quality of care provided to patients, and could affect all patients who received care in the hospital. The hospital census was 44.

Findings included:

1. Review of the hospital's document titled, "Medical Staff Bylaws," dated 05/2018 showed that the Board of Directors of the hospital had the ultimate responsibility and authority regarding medical center and medical staff functions. The responsibilities of the medical staff included being accountable to the Board of Directors for the oversight of, and provision of quality patient care, treatment, and services during the patient's entire length of stay.

Review of the hospital's document titled, "Medical Staff Rules and Regulations," dated 09/25/13, showed that there must be coordination of the care, treatment and services among the practitioners involved in a patient's care, treatment and services, and that a member of the medical staff shall be responsible for the medical care and treatment of each patient the physician has admitted to the Medical Center, and for the prompt completeness and accuracy of the medical record.

Review of the hospital's document titled, "Patient Safety Plan," revised 01/2022, showed that the hospital was committed to providing quality healthcare to all patients.

Review of Patient #11's medical record showed that she was a 26 year old female who presented to the Emergency Department (ED) on 05/02/22 at 11:13 AM, with nausea, vomiting and abdominal pain, after she missed a dose of methadone (a medication used to treat narcotic drug addiction). The patient was actively vomiting and intravenous (in the vein) access was attempted once, but was unsuccessful. Patient #11 was administered oral Zofran (a medication used to prevent nausea and vomiting, and when used with methadone, can cause an irregular heart rhythm that may be life threatening), however there was no documentation that the patient's vital signs were monitored after administration. The patient advised ED staff that she previously had an IV placed in her neck, and when the ED Physician informed her they would not do that, she became agitated. Staff LLL, Physician's Assistant (PA), documented at 11:40 AM, that risks associated with leaving against medical advice (AMA), including death or permanent disability, were discussed with the patient, and the patient was able to make an informed decision and understood. Although documentation showed that the patient was escorted out of the ED by security officers, the AMA form indicated that the patient was "voluntarily" leaving the hospital against the advice of a physician, and was signed by Staff MMM, Doctor of Medicine (MD), Staff KKK, Registered Nurse (RN), and Staff K, RN, not Patient #11.

Review of the hospital's document titled, "Behavior," dated 05/02/22, showed that an anonymous healthcare professional filed an incident report which indicated that the Public Safety Officer (PSO, also referred to as security officer) asked the patient if she wanted to be dragged out of the hospital and proceeded to pull the patient out of the ED, into the ambulance entrance.

Review of the hospital's document titled, "Complaint/Compliment/Suggestion, Grievance," dated 05/04/22, showed that Patient #11 called and reported to Staff B, Director of Performance Improvement, that a PSO picked her up and threw her out of a room, then dragged her out of the hospital onto the concrete, where she received cuts and scrapes. She was also given a medication in the ED for nausea and vomiting that should not have been administered because it interacted with one of her current medications.

During an interview on 06/13/22 at 1:35 PM, Patient #11 stated she presented to the hospital because she had missed a daily dose of methadone on 05/01/22, was vomiting and felt she was dehydrated, which she had experienced when she missed a dose of methadone before. Patient #11 stated that her methadone clinic had advised her not to take Zofran because of its interaction with methadone, but staff would not listen when she tried to explain that the Zofran reacted with her methadone and caused her heart to "race." After staff attempted unsuccessfully to start an IV in her foot, the doctor came into her room and told her that she had "lost her privileges to have an IV" and was being discharged. She stated that she begged the nurses to look in her arm for a place to start an IV because she understood that the doctors were not going to start the IV in her neck like another hospital had done. She said she was frustrated, felt ill, and threw the emesis bucket she had brought with her on the bed, and some of the contents splashed on staff. The PSO got very upset and stated they were calling the police, then proceeded to throw her to the ground, and dragged her out of the hospital.

Review of a video recording titled, "0-2022-05-02 11-30-35-036," dated 05/02/22, showed the ED hallway where Patient #11's examination room was located. The review showed that:
- Between 1:29 and 2:37 (timestamped minutes, not actual time), Staff K, RN, Staff X, PSO, and Staff XX, Patient Care Technician (PCT), appeared in or around the ED hallway and Patient #11's room.
- At 2:39, Staff X, PSO, from inside the patient's examination room, flipped Patient #11 over his body, out of the room and into the ED hallway. The patient's body slammed onto the floor, and the patient slid and landed against the wall on the opposite side of the hallway. Staff X then stood over Patient #11 aggressively pointing toward her, and appeared to speak to her as she sat in the hallway.
- At 3:01, while Patient #11 was seated on the floor, Staff X held onto the patient's right upper arm, and pulled her backwards, toward the ambulance bay (ambulance entrance).
- Staff in the area did not attempt to prevent or stop the PSO's abuse of the patient.

During an interview on 07/13/22 at 9:02 AM, Staff MMM, MD, stated that security officers were called to escort Patient #11 out of the ED because she refused to leave. While he sat nearby, he heard a commotion and knew it was Patient #11, but remained at his desk and did not intervene when he observed Patient #11 being dragged by the PSO down the hallway and out of the ED.

During concurrent video review and interview on 07/12/22 at 2:02 PM, Staff LLL, PA, stated that he did not see security remove Patient #11, and was told by Staff MMM, MD, to document in the medical record that Patient #11 was escorted out of the ED by security. After reviewing the video, he no longer felt Patient #11 had left AMA and that what security officers had done to Patient #11 was inappropriate.

During concurrent video review and interview on 07/12/22 at 10:24 AM, Staff KKK, RN, stated that she did not observe the incident with Patient #11, but when a security officer told her that Patient #11 threw herself in the floor and walked out of the ED, that's what she documented in the medical record. After review of the video, Staff KKK stated that the video clearly showed that Patient #11 was dragged from the ED, and that her documentation did not accurately reflect what was shown on the video.

During concurrent video review and interview on 07/13/22 at 1:00 PM, Staff RRR, Governing Board Member, stated that what he saw on the video was "not pretty at all" and seemed "excessive to be thrown out and dragged down the hallway." He was not made aware of the incident with Patient #11 prior to the interview.

Patient #11 presented for care needs related to nausea and vomiting. She requested an IV because she felt she was dehydrated, and when nursing staff were unsuccessful in their IV attempt, and because she reported that IV placement was historically difficult, she requested the IV in her neck at previously done at another hospital. She did not want to take Zofran because her methadone clinic had advised not to, and because its interaction with methadone made her heart race. When she attempted to explain this to staff, staff administered the Zofran anyway, and then failed to monitor the patient for potential interactions. When the hospital informed the patient they would not attempt an IV in her neck and that she would be discharged, she became agitated. PSOs were called to respond, who threatened the patient that police would be called, and then proceeded to physically throw the patient out of her examination room and drag her out of the ED. The medical record did not reflect this, but indicated that the patient "voluntarily" wanted to leave against the advice of a medical provider, and was "escorted" out by security. On 05/02/22, the hospital was made aware of the allegations by an anonymous staff member, followed by the patient's grievance on 05/04/22, both of which included allegations of abuse as well as inconsistencies with documentation in the medical record. Over two months had elapsed, and as of 07/13/22, the governing body members had not been informed of the event.

2. Review of the hospital's policy titled, "Public Safety Handcuff Procedure," revised 08/28/18, showed that Public Safety Department personnel were not authorized to use handcuffs unless involved in an arrest sequence or to temporarily gain control of a combative patient who unless restrained in this manner, was an immediate danger to themselves or others. They were not to be considered normal hospital restraints.

Although requested, the hospital failed to provide a policy related to the care of psychiatric patients in the ED.

Review of the medical record and video recording for Patient #10 showed that he was a 29 year old male brought to the Emergency Department (ED) by law enforcement on 03/12/22 at 10:45 PM for concerns of violent behavior, threats of physical harm to family members, nonsensical statements, and paranoid (excessive suspiciousness without adequate cause) thoughts. His past medical history included paranoid thinking, hallucinations (seeing or hearing things which were not there), sleep disturbances, and asthma. He was placed in an ED exam room and his girlfriend was allowed to stay in the room with him. His belongings were not searched and he was allowed to remain in his street clothes. Patient #10 was evaluated by Staff GGG, ED Physician, and a behavioral health assessment was completed with a recommendation for inpatient psychiatric care. Documentation by Staff GGG, ED Physician, on 03/12/22 at 11:58 PM, showed that Patient #10 would not be agreeable to inpatient psychiatric care and a request was made for an affidavit (a written statement confirmed by oath, for use as evidence in court) to hold the patient. Affidavits were completed by Staff GGG and the patient's girlfriend. Per medical record documentation Patient #10 remained calm and cooperative until 03/13/22 at 12:25 PM, when he refused to cooperate with the hospital process to change into a hospital gown and relinquish personal belongings. Patient #10 exited his room and was seen on video approaching the nurses' station. Three PSOs wrestled him to the ground and applied handcuffs. Staff E, RN, administered an injection of medication in an attempt to calm him down. Patient #10 was escorted back to his room by the PSOs. On 03/13/22 at approximately 8:00 PM Patient #10 exited his ED room and approached the nurse's station, three PSO's again wrestled him to the ground and applied handcuffs, while Staff GGG, ED Physician overseeing the patient's care, remained seated at the nurses station. On 03/14/22 at approximately 11:00 PM, while awaiting transportation to an inpatient behavioral health center, Patient #10 eloped (when a patient makes an intentional, unauthorized departure from a medical facility) from the ED, and only one PSO followed after him. Nursing staff who were seated at the nurse's station did not get up to assist the PSO, and again, Staff GGG remained seated at the nurse's station. Staff GGG documented that Patient #10 had been anxious and had been in and out of his room all evening, however, no medication was ordered by Staff GGG to be administered to help relieve Patient #10's anxiety. Documentation in the medical record did not reflect the use of handcuffs by the PSOs on 03/13/22 at approximately 12:25 PM or 8:00 PM, and nursing did not document the events of his elopement.

During an interview on 07/14/22 at 08:30 AM, Staff GGG, ED Physician, confirmed that she did not request Patient #10 remove his clothing or relinquish his personal belongings upon admission to the ED. She did not know what occurred between the Patient #10 and the PSOs while he was under her care in the ED, and had "absolutely not" reviewed the videos related to the take downs, handcuffing and elopement of the patient. Staff GGG refused to answer who was ultimately responsible for the care of the patient in the ED, and refused to speak to which policies she followed when functioning as a provider in the St. Mary's Blue Springs ED.

During concurrent video review and interview 07/13/22 at 11:00 AM, Staff PPP, Doctor of Osteopathic Medicine (DO), Director of Emergency Department, stated that:
- Patient #10's clothes and personal belongings should have been removed on admission to the ED, instead of 12 hours later.
- Missing the first step of removing clothing and belongings on admission, added to the patient's frustration and anxiety.
- He would expect that the ED physician on duty would be involved with the care of a patient whose anxiety was escalating either by verbal de-escalation (reduction of the intensity of a conflict or potentially violent situation) techniques or by giving medication.
- He would expect that the ED physician on duty would be involved with the care of a patient who tried to elope or who had eloped.

During concurrent video review and interview on 07/13/22 at 12:30 PM, Staff QQQ, MD, Chief Medical Officer (CMO), stated that:
- Leaving a psychiatric patient in their street clothes and not removing their belongings on admission was not the policy of the hospital, and placed the patient and the ED staff's safety at risk.
- It was never ok to handcuff a patient unless they had broken the law.
- After learning about the incident involving Patient #10, he felt as if security was in charge of Patient #10.

During concurrent video review and interview 07/13/22 at 1:15 PM, Staff RRR, Hospital Governing Board Member, stated that he was not informed of the physical take-downs, handcuffing incidents, and elopement of Patient #10, which occurred in March 2022.

3. Review of Patient #19's medical record showed that the patient was a 54-year-old male who presented to the ED by ambulance on 04/08/22 at 1:42 AM. The patient had reported to local law enforcement that he had a microchip in his head which was overheating, he was Jesus Christ, and that his schizophrenia (serious mental disorder that affects a person's ability to think, feel, and behave clearly) allowed him to communicate with dead people. The medical record showed that Staff WWW, RN, documented that the patient verbalized to her that there were individuals that he wanted to "kill with a gun," and an affidavit was completed. Staff GGG, ED physician documented on 04/08/22 at 3:40 AM that Patient #19 had psychiatric symptoms of agitation and hallucinations (seeing or hearing things which are not there) and that the patient reported feeling he could rip somebody's head off. He was diagnosed with acute psychosis (mental disorder characterized by a disconnection from reality where a person experiences delusions, hallucinations, talking incoherently, and agitation) and methamphetamine abuse, and a mental health evaluator was contacted for an mental health evaluation (MHE). Staff GGG documented that at 4:40 AM the patient attempted to elope from the ED and that she was able to convince the patient to return to his room. The patient continued to show signs of increased agitation and unstable behavior and again attempted to leave the ED. Staff GGG, documented that for the "safety of staff and other patients, he has eloped the ED" and local law enforcement were notified of the elopement. Staff GGG documented that the hospital was notified by local law enforcement that they had located the patient and that the notifying officer stated that the patient was not suicidal or homicidal and that the officer had decided to take the patient home.

During a telephone interview on 06/09/22 at 4:05 PM, Law Enforcement Officer VVV, stated that he accompanied Law Enforcement Officer XXX back to the hospital on 04/08/22, after Patient #19 was recovered at a nearby gas station. Law Enforcement Officer VVV stated he went inside the hospital ED to find out if the patient needed to be returned to the ED for further care or evaluation, but was told there were no affidavits for the patient and that the patient could not be held in the ED.

Multiple attempts made to interview Staff GGG, specific to Patient #19 who was in the ED and under her care, were unsuccessful.

Patient #19 presented with agitation and hallucinations, reported he wanted to kill people with a gun, and an affidavit was completed. Staff GGG, ED Physician, documented that the patient was unsafe to others, and after he eloped, allowed law enforcement to decide whether the patient was safe to return home. Law enforcement reported that they located the patient after he eloped, returned him to the hospital, and were informed that there were no affidavits or reason for him to be returned to the ED, and the patient was returned home.




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45073

Based on interview, record review, policy review, and digital video recordings, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital including accountability for the effective oversight of staff to comply with the requirements under 42 CFR 482.12 Condition of Participation (CoP): Governing Body, 42 CFR 482.13 CoP: Patient's Rights and 42 CFR 482.23 CoP: Nursing Services. These failures had the potential to affect the quality of care and safety of all patients. The hospital census was 44.

Findings included:

Review of the hospital's document titled, "Medical Staff Bylaws," dated 05/2018, showed that the CEO was the highest ranking corporate officer in the medical center's administration of the hospital. The Board of Directors of the hospital had the ultimate responsibility and authority regarding medical center and medical staff functions. The medical staff acts by delegation of authority, or removal thereof, from the Governing Body.

1. The CEO failed to ensure compliance with the CoP of Governing Body as evidenced by the ineffective management of the hospital that resulted in the failure to meet applicable regulatory requirements.

2. The CEO failed to ensure compliance with the CoPs of Governing Body, Patient's Rights, and Nursing Services, as evidenced by the failure to ensure that patients were provided quality care to meet the patient care needs, accurately documented in the medical record, and provided in a safe setting with the lest restrictive means of restraint, and with adequate nursing supervision when:
- One discharged patient (#10) was brought into the Emergency Department (ED) for homicidal ideation (HI, thoughts or attempts to cause another's death), and was allowed to remain in his street clothes and with his cell phone for approximately 12 hours. He became upset when he was asked to change into a hospital gown, and was then taken down to the floor by three security officers, given an intramuscular injection, and handcuffed. Approximately 12 hours later, he attempted to elope from the ED, and once again was taken to the floor by security officers, handcuffed and then placed in four point locking restraints, while nursing staff and a physician remained in the nurses station and did not intervene. Nursing documentation indicated that the patient remained in four point locking restraints, even while the patient slept. Approximately 12 hours later, Patient #10 became upset when he was not allowed to use the telephone to call his father, and security was contacted to respond. Patient #10 then eloped from the ED, while nursing staff and a physician remained in the nurses' station. Staff GGG, the ED physician who oversaw the patient's care when he eloped, documented that the patient had been anxious and had been in and out of his room all evening, however, no medication was ordered by Staff GGG to help relieve Patient #10's anxiety. Documentation in the medical record did not reflect the use of handcuffs on the patient, and nursing did not document the events of his elopement. (A-0049, A-0144, A-0145, A-0154, A-0164 and A-0395)
- One discharged patient (#11) presented to the ED on 05/02/22, for nausea and vomiting. She became upset with hospital staff when they refused to start a central line (long, thin, flexible tube placed in a large vein that allows multiple fluids to be given and blood to be drawn). She was given an oral medication for nausea and vomiting, which had the potential for a major drug interaction (heart rhythm irregularity) with her daily medication. No vital signs or repeat assessment were documented in the medical record following the administration of the medication. When the patient refused to leave the hospital after she was told she would be discharged, security was contacted. An against medical advice (AMA) form was completed by the physician and two nursing staff, which indicated that the patient was voluntarily leaving against the advice of a provider. However, video review showed that the patient was forced to leave the hospital when security staff physically threw her from her room into the hallway, then dragged her down the hallway and out of the ED. Nursing staff and a physician witnessed the physical abuse of Patient #11, did not intervene, and the security officer was allowed to continue working until 05/26/22. (A-0049, A-0144, A-0145 and A-0395)
- One discharged patient (#19) presented to the ED by ambulance on 04/08/22 at 1:52 AM, with report from law enforcement that the patient had stated that he had a microchip in his head that was overheating, that he was Jesus Christ and that his schizophrenia (serious mental disorder that affects a person's ability to think, feel, and behave clearly) allowed him to communicate with dead people. ED Staff S, Registered Nurse (RN) completed an affidavit (a written statement confirmed by oath, for use as evidence in court) due to verbalized HI by the patient, however, the patient eloped at 4:50 AM. Law enforcement was called, and the patient was brought back to the hospital, but ED staff reported there was no affidavit and no reason for the hospital to hold the patient, so the patient was returned to his home by law enforcement. (A-0049)

During an interview on 07/13/22 at 1:39 PM, Staff A, CEO, stated that he had the ultimate responsibility for the oversight of Governing Body, Nursing Services and Patient's rights. Staff A added that he had not informed the Governing Body of the event details related to Patients #10, #11, and #19.


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45073

Based on interview, record review, policy review and review of digital video recording, the hospital failed to provide a safe environment, free from abuse, when they failed to:
- Remove one staff member (X, Patient Safety Officer [PSO]) who had not received abuse training, after he was determined by members of hospital leadership to have abused Patient #11. (A-0144)
- Remove PSO staff who had not received abuse training, pending a 17 day delayed investigation of Patient #10's alleged abuse. (A-0144)
- Ensure staff were competent to prevent, identify, and respond to all forms of abuse, when hospital staff were witnessed to have abused two patients (#10 and #11) of two patients reviewed for abuse. (A-0145)
- Ensure one staff member (XX, Patient Care Technician [PCT]) reported the witnessed abuse of Patient #11 by Staff X, PSO. (A-0145)
- Ensure a thorough investigation was completed to accurately determine whether abuse had occurred for two patients (#10 and #11) of two patients who alleged abuse. (A-0145)
- Prevent one patient (#10) of one patient record reviewed, from being handcuffed by PSOs prior to placing him in locking restraints. (A-0154)
- Ensure that nursing staff were accountable and responsible for the restraint process for one patient (#10) of one patient record reviewed. (A-0154)
- Ensure that four-point locking restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) had the key at the bedside, or with nursing staff, to quickly unlock restraints if needed. (A-0154)
- Ensure the least restrictive method was used to control behavioral symptoms for one patient (#10) of one patient reviewed who was placed in restraints. (A-0164)

These failures created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety. The hospital census was 44.

The severity and cumulative effect of these systemic practices resulted in the overall noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights, which resulted in a condition of Immediate Jeopardy (IJ).

As of 05/27/22, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented the following actions:
- The AP had been placed on administrative leave as of 05/26/22 and remained on administrative leave until he was terminated on 05/26/22. A police report was filed with the local Police Department.
- House wide education began to all staff, on 05/27/22 and continued until all employees were educated and prior to their next scheduled shift.
- Education related to the use of restraints, abuse and neglect, suspected and reporting with emphasis on reporting potential abuse to the supervisor was given to all staff.
- All staff who witnessed the abuse incident regarding Patient #11 received a written corrective action in their personnel file.

Based on interview, record review, policy review, and review of digital video recordings, the hospital failed to provide care in a safe setting when they failed to remove one staff member (Staff X, Patient Safety Officer [PSO]) who had not received abuse training, after he was determined by members of hospital leadership to have abused Patient #11, and failed to remove PSO staff who had not received abuse training, pending a 17 day delayed investigation of Patient #10's alleged abuse. These failed practices by the hospital placed all patients admitted to the hospital at increased risk for their safety. The hospital census was 44.

Findings included:

1. Review of the hospital's document titled, "Patient Rights and Responsibility," revised 03/2020, showed the following:
- The patient has the right to receive care in a safe setting.
- The patient has the right to be free from all forms of abuse or harassment.
- All patients have the right to be free from physical or mental abuse, and corporal punishment.

Review of the hospital's document titled, "Abuse Neglect Allegations Reporting," dated 05/12/20, showed the following:
- Physical abuse was defined as an employee's non-accidental and inappropriate contact with an individual that causes bodily harm. Bodily harm was defined as any injury, damage, or impairment to an individual's physical condition, or making physical contact of an insulting or provoking nature with an individual.
- Staff shall ensure that all employees are trained upon hire, and at least biennially thereafter, and are held responsible for carrying out the designated duties set forth in the policy. The hospital educates staff about how to recognize signs of possible abuse and neglect and about their roles in follow-up.
- If an employee witnesses, is told of, or suspects an incident of physical abuse, sexual abuse, mental abuse, financial exploitation, neglect or a death has occurred, the employee or agency shall report the allegation to the Administrative Representative.

Although requested, the hospital failed to provide a policy related to abuse investigations.

2. Review of the hospital's document titled, "Complaint/Compliment/Suggestion, Grievance," dated 05/04/22, showed that Patient #11 called and reported to Staff B, Director of Performance Improvement, that a security officer handled her rough, and was unprofessional. Patient #11 had gone to the Emergency Department (ED) because she had been vomiting for over 24-48 hours. Staff tried to start intravenous (IV, in the vein) access in her foot but were unsuccessful. The physician told her that she would not have an IV, but could have medications by mouth. Patient #11 reported that she overreacted and threw a cup of vomit on the bed, and the security officer picked her up and threw her out of the room, then dragged her out of the hospital onto the concrete, where she received cuts and scrapes from it. When the security officer was dragging her, she asked if she could get up and walk, but the security officer told her no. Staff forced her to walk off of the property.

Review of a video recording titled, "0-2022-05-02 11-30-35-036," dated 05/02/22, showed the ED hallway where Patient #11's examination room was located. The review showed that:
- Between 1:29 and 2:37 (timestamped minutes, not actual time), Staff K, RN, Staff X, PSO, and Staff XX, Patient Care Technician (PCT), appeared in or around the ED hallway and Patient #11's room.
- At 2:39, Staff X, PSO, from inside the patient's examination room, flipped Patient #11 over his body, out of the room and into the ED hallway. The patient's body slammed onto the floor, and the patient slid and landed against the wall on the opposite side of the hallway. Staff X then stood over Patient #11 aggressively pointing toward her, and appeared to speak to her, as she sat in the hallway.
- At 03:01, while Patient #11 was seated on the floor, Staff X held onto the patient's right upper arm, and pulled her backwards, toward the ambulance bay (ambulance entrance).

Review of the hospital's document titled, "Behavior," dated 05/02/22, showed that an anonymous healthcare professional, filed an incident report related to Staff X, PSO, and his interaction with Patient #11. In the document, the reporter indicated that the PSO asked the patient if she wanted to be dragged out of the hospital and proceeded to pull the patient out of the ED, into the ambulance entrance.

During an interview on 05/26/22 at 1:30 PM, Staff D, ED Director, stated that Staff K, RN, reported the incident to him immediately, because she was uncomfortable with the situation, and felt Staff X, PSO was aggressive.

During an interview on 05/31/22 at 3:10 PM, Staff XX, PCT, stated the following:
- Staff X used a loud tone of voice while speaking to Patient #11.
- Staff X grabbed Patient #11 by the arm and flung her out of the bay area onto the hallway floor.
- Staff X was scary, he was very aggressive and angry, and Patient #11 seemed afraid of him.

During a concurrent video review and interview on 05/25/22 at 9:30 AM, Staff A, Chief Executive Officer, stated that it appeared that Patient #11 was thrown from the room by Staff X, and that Staff X had abused the patient when he dragged the patient from the ED by her arm.

During an interview on 06/01/22 at 1:31 PM, Staff UU, Chief Nursing Officer (CNO), stated that she watched the video, began an investigation, and believed that Staff X abused Patient #11, but when Human Resources finished their investigation, Staff X was provided with only a verbal warning.

Review of the hospital's document titled, "Corrective Action/Performance Improvement Form," dated 05/09/22, showed that Staff X, PSO, was given a verbal warning (seven days after the incident), for not using the least amount of force necessary to remove an uncooperative patient.

During an interview on 05/24/22 at 12:55 PM, Staff FF, PSO Director, stated that PSO staff did not have direct training on abuse and neglect, that he did not feel Staff X had abused Patient #11, and added that Staff X continued to work as a PSO in the hospital.

During an interview on 05/24/22 at 2:40 PM, Staff X, PSO, stated the following:
- He was actively employed by the hospital as a PSO (three weeks after the abuse).
- He did not receive training for abuse or neglect.
- Patient #11 was not threatening anyone or trying to hurt anyone, and that he should not have dragged her out of the ED by her arm.

The hospital continued to employ a staff member who was observed to slam a patient's body into the floor and then drag the patient out of the hospital. This had the potential to lead to abuse of other patients.

3. Review of the hospital's document titled, "Complaint/Compliment/Suggestion, Grievance," dated 03/19/22 at 12:00 AM, showed that the patient contacted the House Supervisor and complained that while he was a recent patient in the ED, a PSO pressed his knee onto the patient's skull and held it there.

Review of the medical record for Patient #10, showed that he was brought to the ED by police on 03/12/22 at 10:45 PM, for concerns of violent behavior, threats of physical harm to family members, nonsensical statements, and paranoid (excessive suspiciousness without adequate cause) thoughts. His past medical history included a history of paranoid thinking, hallucinations, (seeing or hearing things which were not there) sleep disturbances, and asthma. The patient was evaluated by a behavioral health team member and inpatient behavioral health care was recommended. He eloped (when a patient makes an intentional, unauthorized departure from a medical facility) on 03/14/22 11:30 PM while awaiting transportation to an inpatient behavioral health center.

Review of video recording's titled, "0-2022-03-13 12-00-31-050," dated 03/13/22, showed the camera view of the ED nurses' station with three nurses sitting at the desk. The review showed:
- At 5:22 (timestamped minutes, not actual time), Patient #10 entered the area in the front of the nurses' station, followed by Staff U, PSO, Staff X, PSO, and Staff FFF, PSO, who forcibly took the patient down to the ground and laid on top of him.
- At 7:11 Staff, V, Patient Care Assistant (PCA), stood on the back of Patient #10's lower leg while Patient #10 was face down on the floor, while three PSOs continued to lay on top him.
- At 8:41 Staff U, Staff X, and Staff FFF assisted Patient #10 to his feet, with his hands handcuffed behind his back, and exited the area.

Review of video recording's titled, "0-2022-03-13 19-45-30-016," dated 03/13/22, showed the camera view of the ED nurses' station with two nurses and one doctor sitting at the nurse's station. The review showed:
- At 9:32 Patient #10 entered the area, followed by Staff FFF, PSO, and Staff HHH, PSO. Staff W Emergency Medical Technician (EMT) came from behind the nurse's station and assisted the PSOs in forcibly taking Patient #10 to the floor, where they remained and appeared to struggle until 11:05.
- At 11:05 PSOs handcuffed Patient #10.
- At 14:55 PSOs assisted Patient #10 to his feet, with his hands handcuffed behind his back, and exited the area.
- No movement was made by the two nurses or the doctor at the nurses' station to intervene on the patient's behalf, during the physical altercation or handcuffing.

During an interview on 05/25/22 at 10:00 AM, Staff Y, ED RN, stated that he did not intervene when Patient #10 was handcuffed because PSOs were in charge of the patient.

Review of incident reports dated 03/13/22, showed that reason Patient #10 was placed in handcuffs was because he became argumentative and verbalized that he wanted, and then attempted to leave.

During an interview on 05/24/22 at 03:30 PM, Staff U, PSO, stated that:
- Patient #10 was on a 96 hour hold for making threats to his girlfriend's family.
- If a patient was on a 96 hour hold they were not allowed to leave the ED.
- Patient #10 tried to leave the ED so he was taken to the floor and handcuffed.

Review of the hospital's internal investigation, showed that it began on 04/05/22 (17 days after the patient reported the abuse allegation).

During an interview on 05/24/22 at 10:00 AM, Staff D, ED Manager stated that he met with Staff FF, PSO Director, on an unknown date, and it was decided that they would not suspend any of the staff members involved during the investigation, because in review of the video, Staff FF did not believe it was abuse.











45073

Based on interview, record review, policy review, and review of digital video recordings, the hospital failed to ensure:
- Staff were competent to prevent, identify, and respond to all forms of abuse, when hospital staff were witnessed to have abused two patients (#10 and #11) of two patients reviewed for abuse.
- One staff member (XX, Patient Care Technician [PCT]) reported the witnessed abuse of Patient #11 by Staff X, Patient Safety Officer [PSO]).
- Ensure a thorough investigation was completed to accurately determine whether abuse had occurred for two patients (#10 and #11) of two patients who alleged abuse.
These failed practices by the hospital placed all patients admitted to the hospital at increased risk for their safety. The hospital census was 44.

Findings included:

1. Review of the hospital's document titled, "Patient Rights and Responsibility," revised 03/2020, showed that the patient has the right to be free from all forms of abuse or harassment, including physical or mental abuse, and corporal punishment.

Review of the hospital's policy titled, "Abuse, Neglect Allegations Reporting," dated 05/12/20 showed the following:
- Physical abuse was defined as an employee's non-accidental and inappropriate contact with an individual that causes bodily harm. Bodily harm was defined as any injury, damage, or impairment to an individual's physical condition, or making physical contact of an insulting or provoking nature with an individual.
- All employees are trained upon hire, and at least biennially thereafter, and are held responsible for carrying out the designated duties set forth in the policy. The hospital educates staff about how to recognize signs of possible abuse and neglect and about their roles in follow-up.
- If an employee witnesses, is told of, or suspects an incident of physical abuse or mental abuse, the employee or agency shall ensure immediate care and protection of the victim, and report the allegation to the Administrative Representative.
- Any employee who suspects, witnesses, or is informed of an allegation of abuse is a required reporter.

Review of the hospital's policy titled, "Security Use of Force/Continuum," dated 09/28/18, showed that when it is necessary for a Patient Safety Officer (PSO) to use physical force on a patient, use only the force that is reasonably necessary to control the patient.

Although requested, the hospital failed to provide a policy related to abuse investigations.

2. Review of the hospital's document titled, "Complaint/Compliment/Suggestion, Grievance," dated 05/04/22, showed that Patient #11 called and reported to Staff B, Director of Performance Improvement, that a PSO handled her rough, when he picked her up and threw her out of her ED examination room, then dragged her out of the hospital onto the concrete, where she received cuts and scrapes from it. When the security officer was dragging her, she asked if she could get up and walk, but the security officer told her no.

Review of Patient #11's medical record showed that she was a 26 year old female who presented to the Emergency Department (ED) on 05/02/22 at 11:13 AM, with nausea, vomiting and abdominal pain, after she missed a dose of methadone (a medication used to treat moderate to severe pain or to treat narcotic drug addiction). The patient was actively vomiting and intravenous (in the vein) access was attempted but unsuccessful. The patient advised ED staff that she previously had an IV placed in her neck, and when the ED Physician informed her they would not do that, she became agitated, and was removed by PSOs.

Review of a video recording titled, "0-2022-05-02 11-30-35-036," dated 05/02/22, showed the ED hallway where Patient #11's examination room was located. The review showed that:
- Between 1:29 and 2:37 (timestamped minutes, not actual time), Staff K, Registered Nurse (RN), Staff X, PSO, and Staff XX, Patient Care Technician (PCT), appeared in or around the ED hallway and Patient #11's room.
- At 2:39, Staff X, PSO, from inside the patient's examination room, flipped Patient #11 over his body, out of the room and into the ED hallway. The patient's body slammed onto the floor, and the patient slid and landed against the wall on the opposite side of the hallway. Staff X then stood over Patient #11 aggressively pointing toward her, and appeared to speak to her as she sat in the hallway.
- At 03:01, while Patient #11 was seated on the floor, Staff X held onto the patient's right upper arm, and pulled her backwards, toward the ambulance bay (ambulance entrance).
- Staff in the area did not attempt to prevent or stop the PSO's abuse of the patient.

During an interview on 05/31/22 at 3:10 PM, Staff XX, Patient Care Technician (PCT), stated that Staff X was angry and aggressive with Patient #11, used a loud tone of voice when he spoke to her, and the patient seemed afraid of him. Staff XX confirmed that Staff X grabbed the patient by the arm and flung her onto the hallway floor. She stated that she did not report the abuse because she was "too scared."

Review of the hospital's document titled, "Behavior," dated 05/02/22, showed that an anonymous healthcare professional filed an incident report which indicated that the PSO asked the patient if she wanted to be dragged out of the hospital and proceeded to pull the patient out of the ED, into the ambulance entrance. There was no indication in the incident report that the anonymous writer attempted to prevent or stop the patient from being dragged out of the hospital.

During an interview on 05/26/22 at 1:30 PM, Staff D, ED Director, stated that when Staff K, RN, reported the incident, she felt Staff X, PSO, was aggressive with the patient.

During a concurrent video review and interview on 05/25/22 at 9:30 AM, Staff A, Chief Executive Officer, stated that he believed Staff X abused the patient when he dragged her from the ED by her arm.

During an interview on 06/01/22 at 1:31 PM, Staff UU, Chief Nursing Officer (CNO), stated that she watched the video, and believed Staff X had abused Patient #11.

Review of the hospital's document titled, "Corrective Action/Performance Improvement Form," dated 05/09/22 (seven days after the alleged abuse occurred), showed that Staff X, PSO, was given a verbal warning for not using the least amount of force necessary to remove Patient #11.

During an interview on 05/24/22 at 12:55 PM, Staff FF, PSO Director, stated that he did not feel Staff X abused Patient #11, that dragging her down the hall was not considered abuse, and that Staff X continued to be employed by the hospital as a PSO. Staff FF confirmed that PSO staff did not received training on abuse or neglect.

During an interview on 05/24/22 at 2:40 PM, Staff X, PSO, stated that he should not have dragged Patient #11 out of the ED, as it was not appropriate. Staff X confirmed that he had not received abuse or neglect training, and continued to be actively employed by the hospital as a PSO.

The hospital failed to prevent the abuse of the patient when PSO staff were not educated on abuse, failed to intervene and stop the abuse of the patient when it was witnessed by staff, failed to ensure that staff reported the witnessed abuse of the patient, failed to ensure that their investigation into the allegations was thorough enough to accurately determine if abuse had occurred, and failed to appropriately educate all staff after the abuse occurred, to mitigate the risk of it occurring again.

3. Review of the hospital's document titled, "Complaint/Compliment/Suggestion, Grievance," dated 03/19/22 at 12:00 AM, showed that the patient contacted the House Supervisor and complained that while he was a recent patient in the ED, a PSO pressed his knee onto the patient's skull and held it there.

Review of the medical record for Patient #10 showed that he was brought to the ED by police on 03/12/22 at 10:45 PM, for concerns of violent behavior, threats of physical harm to family members, nonsensical statements, and paranoid (excessive suspiciousness without adequate cause) thoughts. His past medical history included a history of paranoid thinking, hallucinations, (seeing or hearing things which were not there) sleep disturbances, and asthma. The patient was evaluated by a behavioral health team member and inpatient behavioral health care was recommended.

Review of video recording's titled, "0-2022-03-13 12-00-31-050," dated 03/13/22, showed the camera view of the ED nurses' station with three nurses sitting at the desk. The review showed:
- At 5:22 (timestamped minutes and seconds - not actual time), Patient #10 entered the area in the front of the nurses' station, when Staff U, PSO, Staff X, PSO, and Staff FFF, PSO forcibly took Patient #10 down to the ground and laid on top of him.
- At 7:11, Staff, V, PCT stood on the back of Patient #10's lower leg while Patient #10 was face down on the floor, while three PSOs continued to lay on top him.
- At 7:47, Staff V removed himself from standing on Patient #10's leg.
- At 8:41, Staff U, Staff X, and Staff FFF assisted Patient #10 to his feet, with his hands handcuffed behind his back, and exited the area.
- Staff remained at the desk and did not prevent or stop the abuse of the patient.

During an interview on 05/25/22 at 10:00, Staff Y, RN, stated that PSOs were in charge of Patient #10 when he was taken down to the floor and placed in handcuffs.

Review of an incident report dated 03/13/22 for Patient #10, showed staff U, PSO, Staff X, PSO, and Staff FFF, PSO placed handcuffs on Patient #10 on 03/13/22 at 12:00 PM. Patient #10 had become argumentative when he was asked to remove his clothes and put on a hospital gown, he then exited ED Exam Room #17 and tried to leave the ED.

Review of video recording's titled, "0-2022-03-13 19-45-30-016," dated 03/13/22, showed the camera view of the ED nurses' station with two nurses and one doctor sitting at the nurses' station. The review showed:
- At 7:53, Staff W, Emergency Medical Technician (EMT), entered the nurses' station.
- At 9:32, Patient #10 entered the area, followed by Staff FFF, PSO, and Staff HHH, PSO. Staff W came from behind the nurses' station and assisted the PSOs in forcibly taking Patient #10 to the floor, where they remained and appeared to struggle, until 11:05.
- At 11:05, the PSOs handcuffed Patient #10.
- At 14:55, the PSOs assisted Patient #10 to his feet, with his hands handcuffed behind his back, and exited the area.
- Staff in the area did not attempt to prevent or stop the abuse of the patient.

During an interview on 05/25/22 at 10:00 AM, Staff Y, ED RN, stated that he did not intervene when Patient #10 was handcuffed because PSOs were in charge of the patient.

Review of incident reports dated 03/13/22, showed that reason Patient #10 was placed in handcuffs was because he became argumentative and verbalized that he wanted, and then attempted to leave.

During an interview on 05/24/22 at 03:30 PM, Staff U, PSO, stated that:
- Patient #10 was on a 96 hour hold for making threats to his girlfriend's family.
- If a patient was on a 96 hour hold they were not allowed to leave the ED.
- Patient #10 tried to leave the ED so he was taken to the floor and handcuffed.

During an interview on 05/24/22 at 2:40 PM, Staff X, PSO, stated that he did not recall having abuse or neglect training.

During an interview on 05/24/22 at 3:30 PM, Staff U, PSO, confirmed that he had laid on top of Patient #10, while the patient was laying on the floor. Staff U was unsure if he had received abuse training.

Review of of the hospital's internal investigation, which began on 04/05/22, showed that interviews were limited to only those staff who physically engaged with the patient during the alleged events, and consisted of two questions: If anyone had placed their knee on the patient's skull, and if their actions were racially motivated toward the patient. There were no additional questions asked, and there were no additional staff interviewed who were witnesses to the events.

During an interview on 05/24/22 at 10:00 AM, Staff D, ED Manager stated that he met with Staff FF, PSO Director, on an unknown date, and Staff FF reviewed the video and did not believe it was abuse.

During an interview on 05/24/22 at 12:55 PM, Staff FF, PSO Director, stated that PSO staff attended Behavior Violence Training (clinical recognition and intervention used to calm psychiatric patients) annually, but did not receive training on abuse. After he spoke with the PSOs involved in both of the incidents related to Patient #10, and he did not feel they had abused the patient. .

The hospital failed to prevent the abuse of the patient when PSO staff were not educated on abuse, staff failed to intervene and stop the abuse of the patient when it was witnessed by staff, failed to ensure that their investigation into the allegations was thorough enough to accurately determine if abuse had occurred, and failed to appropriately educate all staff after the abuse occurred to mitigate the risk of it occurring again.


45073

Based on interview, record review, policy review, and review of digital video recording, the hospital failed to:
- Prevent one patient (#10) of one patient record reviewed, from being handcuffed by Patient Safety Officers (PSOs) prior to placing him in locking restraints.
- Ensure that nursing staff were accountable and responsible for the restraint process for one patient (#10) of one patient record reviewed.
- Ensure that four-point locking restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) had the key at the bedside, or with nursing staff to quickly unlock restraints if needed.
These failures had the potential to place all patients at risk for their safety. The facility census was 44.

Findings included:

1. Review of hospital's policy titled, "Patient Rights & Responsibility," dated 11/23/21 showed that:
- The patient had the right to receive care in a safe setting.
- All patients have the right to be free from physical or mental abuse, and corporal punishment.
- All patients have the right to free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff.
- Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others, and must be discontinued at the earliest possible time.

Review of the hospital's policy titled, "Restraints (Non-Violent)," dated 10/23/20, showed that restraints may only be used when less restrictive interventions have been determined to be ineffective to protect the patient from harm.

Review of the hospital's policy titled, "Public Safety Handcuff Procedure," revised 08/28/18, showed that Public Safety Department personnel were not authorized to use handcuffs unless involved in an arrest sequence or to temporarily gain control of a combative patient who unless restrained in this manner were an immediate danger to themselves or others. They were not to be considered normal hospital restraints.

Review of the medical record for Patient #10 showed that he was brought to the ED by police on 03/12/22 at 10:45 PM, for concerns of violent behavior, threats of physical harm to family members, nonsensical statements, and paranoid (excessive suspiciousness without adequate cause) thoughts. His past medical history included a history of paranoid thinking, hallucinations, (seeing or hearing things which were not there) sleep disturbances, and asthma. The patient was evaluated by a behavioral health team member and inpatient behavioral health care was recommended.

Review of the hospitals video recordings in the ED dated 03/13/22 at 12:00 PM and 03/13/22 at 8:00 PM showed Patient #10 being forcibly taken to the floor by three PSOs, who then laid on top of him, and handcuffed him.

Review of incident reports dated 03/13/22, showed that reason Patient #10 was placed in handcuffs was because he verbalized that he wanted and attempted to leave.

During an interview on 05/24/22 at 2:40 PM, Staff X, PSO, stated that Patient #10's handcuffs were removed after a
few minutes and were replaced with locking restraints. Staff X stated that PSOs carried the keys for the locking restraints, but he did not stay with Patient #10 after the patient was placed in them.

During an interview on 05/25/22 at 4:25 Staff E, Registered Nurse (RN), stated that:
- She felt that Patient #10 should not have been handcuffed.
- PSOs were in control of Patient #10, not nursing staff.
- Nursing staff did not carry keys to four-point locking restraints, PSOs had them.
- After the PSO placed a patient in locking restraints, the PSO did not stay with patient.
- If the night nurse would have tried deescalation techniques with the patient, he may have not needed to be restrained.

During an interview on 05/25/22 at 10:00 AM, Staff Y, RN, stated that:
- PSOs carried the keys to the four-point locking restraints.
- PSOs were in charge of Patient #10 during the locking restraint application
- The PSOs did not confer with him about the decision to handcuff his patient.

During an interview on 06/01/22 at 01:30 PM, Staff UU, Chief Nursing Officer (CNO), stated that:
- She was unaware that PSO's carried handcuffs.
- She did not believe Patient #10 should have been handcuffed.
- It was not OK that PSO's were managing patients.

Based on interview, record review, and policy review, the hospital failed to use the least restrictive method to control behavioral symptoms for one patient (#10) of one patient reviewed who was placed in restraints. This failure had the potential to place all patients admitted to the facility at risk for their right to be free from restraints used to impose for coercion, discipline or convenience. The facility census was 44.

Findings included:

1. Review of hospital's policy titled, "Patient Rights & Responsibility," dated 11/23/21 showed that:
- The patient had the right to receive care in a safe setting.
- All patients have the right to be free from physical or mental abuse, and corporal punishment.
- All patients have the right to free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff.
- Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.

Review of the hospital's policy titled, "Restraints: Violent Behavior or Seclusion," dated 06/2020, showed that:
- Restraint may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.
- Restraint may only be used when less restrictive interventions have been determined to be effective to protect the patient from harm.
-The hospital was committed to actively monitor and decrease the use of restraints in all clinical areas. When restraints were necessary and unavoidable, it was performed in a manner that protects the patient's health, safety, dignity, rights, and well-being.

Review of the medical record for Patient #10 showed that he was brought to the Emergency Department (ED) by police on 03/12/22 at 10:45 PM, for concerns of violent behavior, threats of physical harm to family members, nonsensical statements, and paranoid (excessive suspiciousness without adequate cause) thoughts. His past medical history included a history of paranoid thinking, hallucinations, (seeing or hearing things which were not there) sleep disturbances, and asthma. The patient was evaluated by a behavioral health team member and inpatient behavioral health care was recommended.

Review of an incident report dated 03/13/22, showed the patient was restrained because he had become argumentative when he was asked to remove his clothes and put on a hospital gown, he then exited ED exam room and tried to leave the ED.

Review of the medical record for Patient #10 showed no medication was administered and no least restrictive measures were documented from admission on 03/12/22 at 10:30 PM, until his first application of restraints on 03/13/22 at 12:30 PM. Patient #10 was documented to be sleeping for four hours when wearing locking four-point restraints.

During an interview on 05/25/22 at 10:00 AM, Staff Y, Registered Nurse (RN), stated that he did not try any interventions, such as medications, before Patient #10 was restrained.

During an interview on 05/25/22 at 4:25 PM, Staff E, RN, stated that she felt if the night nurse had tried other interventions, such as medication administration, Patient #10's behavior would not have escalated.

During an interview on 06/01/22 at 1:30 PM, Staff UU, Chief Nursing Officer (CNO), stated that staff could have done a better job of de-escalation for Patient #10, so that restraints could have been avoided, and added that nurses should be responsible for managing patients in restraints, not the PSOs.

Based on interview, record review, policy review and digital video review, the hospital failed to adequately supervise the nursing care for patients and provide a safe and therapeutic environment when nursing staff failed to:
- Perform and document de-escalation techniques for two discharged patients (#10 and #11) of two discharged patient reviewed, which led to the involvement of Patient Safety Officers (PSO, also referred to as security) and resulted in physical takedowns, and the use of excessive force and/or excessive restraints. (A-0395)
- Prevent the elopement (when a patient makes an intentional, unauthorized departure from a medical facility) of one patient (#10) of one patient reviewed who eloped from the hospital. (A-0395)
- Remove potentially dangerous personal items from one discharged homicidal (HI, thoughts or attempts to cause another's death) patient (#10) of one homicidal patient reviewed. (A-0395)
-Perform physical assessments on two discharged patients (#10 and #11) of two discharged patient records reviewed, following physical altercations with PSOs that could have resulted in injuries. (A-0395)
These failures created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety. The hospital census was 44.

The severity and cumulative effect of these systemic practices resulted in the overall noncompliance with 42 CFR 482.23 Condition of Participation: Nursing Services, that resulted in a condition of Immediate Jeopardy (IJ).

As of 05/27/22, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented the following actions:
- The Chief Nursing Officer (CNO) or other member of the senior leadership team were to be physically present in the ED for a minimum of one hour daily, with multiple visits throughout the day, for a total of no less than eight hours weekly including presence on nights and weekends.
- Education related to the use of restraints, abuse, neglect, suspected and reporting abuse and neglect, suicidal risk assessments, sitter (person assigned to continuously observe a patient within close proximity, to ensure their safety) policy, elopement (when a patient makes an intentional, unauthorized departure form a medical facility) and de-escalation (reduction of the intensity of a conflict or potentially violent situation), including the review of the policy was given to all staff prior to, or at the start of their next shift. .
- Leadership staff completed training in patient rights, behavioral health patient rights and responsibilities and identifying victims of abuse and neglect.
- Education related to assessments and reassessments of the patient after the utilization of restraints, with related documentation including but not limited to, a psychosocial and physical assessment and nursing's role in directing and interacting in restraint application where security staff were involved was given to all ED staff.


45073

Based on interview, record review, policy review and digital video review, the hospital failed to adequately supervise the nursing care for patients and provide a safe and therapeutic environment when nursing staff failed to:
- Perform and document de-escalation techniques for two discharged patients (#10 and #11) of two discharged patient reviewed, which led to the involvement of Patient Safety Officers (PSO, also referred to as security) and resulted in physical takedowns, and the use of excessive force and/or excessive restraints.
- Prevent the elopement (when a patient makes an intentional, unauthorized departure from a medical facility) of one patient (#10) of one patient reviewed who eloped from the hospital.
- Remove potentially dangerous personal items from one discharged homicidal (HI, thoughts or attempts to cause another's death) patient (#10) of one homicidal patient reviewed.
-Perform physical assessments on two discharged patients (#10 and #11) of two discharged patient records reviewed, following physical altercations with PSOs that could have resulted in injuries.
These failures put all patients in the hospital at risk for their health and safety. The hospital census was 44.

Findings included:

1. Review of the hospital's document titled, "Patient Rights and Responsibility," revised 03/2020, showed that the patient has the right to receive care in a safe setting, free from all forms of abuse, including physical and mental, and have the right to respectful treatment, which recognizes and maintains your dignity.

Review of the hospital's document titled, "Abuse Neglect Allegations Reporting," dated 05/12/20, showed that if there is an allegation or indication of a physical injury, or any situation where a victim's health is in question, seek appropriate medical attention.

Review of the hospital's policy titled, "Assessment of the Emergency Department Patient," dated 04/10/19, showed that nurses will assess and document a musculoskeletal (bones, muscles, joints, tendons and ligaments which all work together to provide the body with support, protection, and movement) assessment with any change in the patient's condition.

The hospital's undated document titled, "Behavioral Violence Prevention," showed the following:
- A behavioral crisis can happen anywhere. A healthcare setting by itself can be a trigger for people. Loss of control, fear and anxiety can cause a person to escalate and display dangerous behaviors.
- Life-disrupting behavior can result from severe anxiety, loss of control, loss of contact with reality and mood disorders.
- Life-impairing behavior may result from intoxication or withdrawal from alcohol/drugs, toxic or unwanted reactions to medication, or any other type of alteration to brain function.
- Dangerous behaviors included loud, high-pitched speech, cursing, shouting, destroying property or direct verbal warnings and could be caused by alcohol/drug withdrawal.
- Staff need to help a patient express themselves in a safe manner using verbal de-escalation when they were displaying dangerous behaviors.

2. Review of the hospital's document titled, "Complaint/Compliment/Suggestion, Grievance," dated 05/04/22, showed that Patient #11 called and reported to Staff B, Director of Performance Improvement, that a PSO picked her up and threw her out of a room, then dragged her out of the hospital onto the concrete, where she received cuts and scrapes.

Review of Patient #11's medical record showed that she was a 26 year old female who presented to the ED on 05/02/22 at 11:13 AM, with nausea, vomiting and abdominal pain, after she missed a dose of methadone (a medication used to treat moderate to severe pain or to treat narcotic drug addiction). The patient was actively vomiting and intravenous (in the vein) access was attempted but unsuccessful. The patient advised ED staff that she previously had an IV placed in her neck, and when the ED Physician informed her they would not do that, she became agitated. Nursing documentation showed that the patient's behavior was in an escalated or aggressive state at 11:30 AM, 11:37 AM, and 11:40 AM, prior to the patient being removed by PSOs. There was no documentation in the medical record that indicated nursing staff attempted to de-escalate the patient while in the ED.

Review of the hospital's document titled, "Miscellaneous/Other," dated 05/02/22, showed that Staff X, PSO, filed an incident report dated 05/02/22 at 11:25 AM, which documented that he and another PSO were called to the ED because Patient #11 refused to leave. While the patient was belligerent (indicating that her behavior was already escalated), Staff K informed the patient that police would be called if she would not leave, and when she further escalated, Staff X removed her from the ED.

During an interview on 05/31/22 at 3:10 PM, Staff XX, Patient Care Technician (PCT), stated that Staff X was angry and aggressive with Patient #11, used a loud tone of voice when he spoke to the patient, and that the patient seemed afraid of him. Staff XX confirmed that Staff X grabbed the patient by the arm and flung her onto the hallway floor.

Review of the hospital's document titled, "Behavior," dated 05/02/22, showed that an anonymous healthcare professional filed an incident report related to Patient #11's interaction with Staff X, PSO. The incident report showed that when the patient refused to leave the ED, the PSO asked her if she wanted to be dragged out of the hospital, and proceeded to pull the patient out of the ED and into the ambulance entrance.

Review of a video recording titled, "0-2022-05-02 11-30-35-036," dated 05/02/22, showed the ED hallway where Patient #11's examination room was located. The review showed that:
- Between 1:29 and 2:37 (timestamped minutes - not actual time), Staff K, Registered Nurse (RN), Staff X, PSO, and Staff XX, PCT, appeared in or around the ED hallway and Patient #11's room.
- At 2:37, Staff K, RN, backed out of Patient #11's room (moved away from the patient) into the hallway.
- At 2:39, Staff X, PSO, from inside the patient's examination room, flipped Patient #11 over his body, out of the room, and into the ED hallway. The patient's body slammed onto the floor, and the patient slid and landed against the wall on the opposite side of the hallway. Staff X then stood over Patient #11, aggressively pointing toward her, and appeared to speak to her as she sat in the hallway.
- At 02:51, Staff X grabbed Patient #11's upper right arm, stepped behind her and grabbed under her left arm, and attempted to lift her.
- At 03:01, while Patient #11 was seated on the floor, Staff X held onto the patient's right upper arm, and dragged her backwards toward the ambulance bay (ambulance entrance).
- Nursing staff moved away from the patient and did not intervene on the patient's behalf to prevent the physical interaction with the PSO, nor move toward the patient in attempt to assess the patient for possible injuries that may have occurred as the result of her body being flipped and slammed on the floor, or from attempts of being lifted, or dragged by her arm.

During an interview on 05/26/22 at 1:10 PM, Staff K, RN, stated when she went to discharge the patient, Patient #11 said, "I am not fucking leaving," so she called security to assist the patient out the door. Staff K confirmed that she did not attempt to de-escalate Patient #11, and did not assess the patient after the incident with security.

3. Review of the hospital's policy titled, "Elopement Risk Patient," revised 05/2022, showed that the hospital shall provide a safe, secure, legal containment for patients who are a high risk for leaving the hospital.

Review of the medical record for Patient #10, showed that he was brought to the Emergency Department (ED) by police on 03/12/22 at 10:45 PM, for concerns of violent behavior, threats of physical harm to family members, nonsensical statements, and paranoid (excessive suspiciousness without adequate cause) thoughts. His past medical history included a history of paranoid thinking, hallucinations, (seeing or hearing things which were not there) sleep disturbances, and asthma. The patient was evaluated by a behavioral health team member and inpatient behavioral health care was recommended. The patient eloped from the ED on 03/14/22 at 11:30 PM, after it was documented by the ED Physician that the patient was at high risk for elopement. Prior to the first application of violent restraints on 03/13/22 at 12:30 PM, there was no documentation of medication administration or de-escalation techniques attempted, and there was no musculoskeletal reassessment documented after two physical takedowns by PSOs.

Review of video recording's titled, "0-2022-03-13 12-00-31-050," dated 03/13/22, showed the camera view of the ED nurses' station with three nurses sitting at the desk. The review showed:
- At 5:22 (timestamped minutes and seconds - not actual time), Patient #10 entered the area in the front of the nurses' station, when Staff U, PSO, Staff X, PSO, and Staff FFF, PSO forcibly took Patient #10 down to the ground and laid on top of him.
- At 7:11, Staff, V, PCT stood on the back of Patient #10's lower leg while Patient #10 was face down on the floor with three PSOs laying on top him.
- At 7:47, Staff V removed himself from standing on Patient #10's leg. The patient was wearing his personal clothing at that time.
- At 8:41, Staff U, Staff X, and Staff FFF assisted Patient #10 to his feet, with his hands handcuffed behind his back, and exited the area.
- Two nurses remained at the nurses' station and did not attempt to intervene on the patient's behalf.

Review of video recording's titled, "0-2022-03-13 19-45-30-016," dated 03/13/22, showed the camera view of the ED nurses' station with two nurses and one doctor sitting at the nurse's station. The review showed:
- At 7:53, Staff W, Emergency Medical Technician (EMT), entered the nurses' station.
- At 9:32, Patient #10 entered the area, followed by Staff FFF, PSO, and Staff HHH, PSO. Staff W came from behind the nurses' station and assisted the PSOs in forcibly taking Patient #10 to the floor, where they remained and appeared to struggle, until 11:05.
- At 11:05, the PSOs handcuffed Patient #10.
- At 14:55, the PSOs assisted Patient #10 to his feet, with his hands handcuffed behind his back, and exited the area.
- No movement was made by the two nurses or the doctor at the nurses' station, to intervene on the patient's behalf, during the physical altercation or handcuffing.

Review of video recording's titled, "3-2022-03-1422 -18-29-033," dated 03/14/22, showed the camera view of the ED nurses' station with three nurses sitting at the desk. The review showed:
- At 2:34, Patient #10 entered the nurses' station area and ran out the door.
- At 2:47, no nurses who were seen at the nurses' station followed the patient, or attempted to prevent the patient from leaving.
- At 3:44, eight staff members were at the nurses' station and appeared to be laughing. No one was observed attempting to follow the patient, or attempted to prevent the patient from leaving.

Even though requested the hospital failed to provide a policy on removing potentially dangerous personal items from a homicidal patient.

During an interview on 05/25/22 at 10:00 AM, Staff Y, RN stated that:
- He did not try to de-escalate the patient before the patient was placed in locking restraints.
- He did not remove Patient #10's clothing or search his personal items on admission to the ED, and confirmed that it was dangerous to leave a homicidal patient in their personal clothing.
- He did not have a means to unlock the locking restraint PSOs placed on the patient, as he did not have a key.

During an interview on 05/24/22 at 2:40 PM, Staff X, PSO, stated that he did not stay with Patient #10 after locking restraints were applied, and added that PSOs carried the keys for the locking restraints.

During an interview on 05/25/22 at 4:25 PM, Staff E, RN, stated that:
- Patient #10 was fully clothed in street clothes when she assumed care of him on 03/13/22 at 7:00 AM.
- Leaving a suicidal or homicidal patient in street clothes and not checking their personal items was against hospital protocol.
- If the night RN had tried de-escalation techniques, Patient #10's behavior may not have escalated to the point of needing restraints.




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