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Based on staff and family interview and record review, the hospital failed to a protect the rights and emotional safety of a vulnerable elderly patient (Patient #1) who was experiencing disorientation, agitation, fear, and a sudden change in their mental function. Findings include:

Patient #1, in his/her late 70's, was admitted to the hospital on 5/15/25 with diagnoses that include Hyponatremia (low blood sodium) and hypertension. Patient #1 was admitted to the hospital for observation, intravenous fluids and monitoring of sodium blood levels. On 5/16/25 a case management note states "Mood/Mental status: Alert & oriented x 2, pleasant....". On 5/17/25 Patient #1 started receiving intravenous 3% sodium in an attempt to correct the sodium levels which continued to remain abnormal. The evening of 5/17/25 Patient #1 told hospital staff s/he was "hearing things" overnight, possibly related to hospital machinery or air exchanges.

Review of a nursing progress note from 5/18/25, reveals that shortly after 1:00 AM the bed alarm sounded in Patient #1's room. Upon arrival, the assigned nurse observed Patient #1 standing beside the hospital bed, actively pulling out his/her IV's and pulling off his/her cardiac monitor wires. As the nurse approached, Patient #1 began swinging his/her arms/fists hitting the nurse in the face and charging toward the nurse. During the event, Patient #1 was described as "...not redirectable". The nurse called for help and additional staff arrived to assist with the management of Patient #1's unexpected behavior. The Code Green procedure was activated which brings a rapid response of additional staff to assist during a security incident. Per the Code Green Response Checklist, the call was initiated at 1:03 AM and cleared at 1:12 AM, as staff assisted getting Patient #1 resettled back in his/her hospital room and bed.

At the time of the incident on 5/18/25, the nurse who experienced the assault by Patient #1, decided to press criminal charges against Patient #1. A call was made to the police department by a member of the hospital nursing administration. Shortly after the event, and per the police report the "Initial Call Information" dated 5/18/25 at 01:15 officers were dispatched and were on-site at the hospital at 01:21:21 on 5/18/25. A statement was obtained by police from the nurse, regarding the event involving Patient #1. Staff then proceeded to allow the police to investigate and interview Patient #1, only minutes after the event. Patient #1 was in an altered mental state and identified later to be experiencing symptoms of Hospital Delirium. [Per the New England Journal of Medicine published 10/12/2017/VOL. 337 NO 15- "Delirium is also known as acute confusional state, altered mental status....that is extremely common among hospitalized elders......" In addition, "... the presence of delirium requires: acute change in mental status.....inattention, disorganized thinking and altered level of consciousness"]. Despite the symptoms of Hospital Delirium, Patient #1 was experiencing, hospital staff allowed Patient #1 to be questioned by police. In addition, although Patient #1's family requested to be notified of any changes or issues associated with Patient #1, hospital staff failed to contact them, thus eliminating an additional opportunity to provide emotional support, reorientation and comfort during this acute incident. Per interview on 8/12/25 at 4:08 PM, a family member of Patient #1 confirmed staff failed to notify him/her regarding the incident.

The police report states, Patient #1 was asked "......to explain what happened during the incident." Patient #1 told the police officer s/he did not remember. " S/he stated s/he did not even know where s/he was when s/he work up". Patient #1 acknowledged "I did punch a lady". The patient then further stated an incident happened when s/he was waking up but did not recall...."doing it". The patient, still with symptoms of delirium, was then given a citation to appear in court.

Further interview with Patient #1's family, noted that their family member had only limited recall and when informed of the charges of assault against Patient #1, s/he experienced significant emotional response and disbelief. Patient #1 was discharged on 5/19/25.