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Based on review of facility policy, medical record review, review of security documentation, review of video footage, and interviews, the facility failed to ensure a patient was free from abuse by a security guard and failed to follow facility policy related to abuse for 1 patient (#1) during an altercation with a security officer, of 5 patients reviewed.

The findings included:

Patient #1 was admitted to the Emergency Department (ED) on 1/17/2023 at 6:00 AM related to an elevated blood pressure. He was evaluated by the Provider in Triage where diagnostic testing was ordered and completed, he was diagnosed with Influenza B, and was awaiting further treatment. On 1/18/2023, the patient walked out into the ED lobby and was observed by the registration clerk staff yelling and being disruptive. Security was called to check on the patient. The registration staff were unable to determine if the patient was an active ED patient or if he was discharged. The registration staff did not check with the ED staff to confirm the patient's status. When the security officer approached the patient, there was verbal arguing between the patient and the officer, which escalated to a physical hands-on altercation. The security officer escorted the patient out of the ED and into the ED parking lot garage and there was a physical altercation between the patient and the security officer there. Patient #1 struck the security officer and the security officer then struck the patient. The patient was handcuffed by the officer. During this time, other officers were in the vicinity where the altercation took place and none of those officers reported the observation of the security officer hitting the patient to administration. Patient #1 had not been discharged from the ED and he was still under the care of the ED staff for evaluation at the time of the incident. There was no notification by the registration staff or the security officer to the ED staff related to the altercation. The patient was not evaluated by a medical provider after the physical alteration occurred. While in the parking lot, security asked the ED Tech to remove the patient's INT (Intravenous catheter), however the patient was not assessed or evaluated for injury. The local police department was called and responded to the ED parking garage where the patient was issued a no trespassing citation, and he was taken to jail by local police. The contracted security company was notified of the incident and reviewed the incident as an officer involved injury during the altercation, but were not informed the security officer struck the patient at the time of the incident. Security supervisors reviewed the video footage of the incident on 1/18/2023 and an investigation of the security officer's actions was started by the contracted security company. The contracted security company failed to notify facility administration of the alleged abuse of the patient by the officer until 1/19/2023 at 2:35 PM (1 day after the incident occurred). The facility then failed to escalate the incident of the officer hitting the patient to Risk Management until 1/20/2023 at 11:12 AM (2 days after the incident occurred). Interviews showed the officer failed to use appropriate "use of force" techniques and he was terminated on 1/20/2023 for conduct unbecoming of an officer. The facility failed to follow the abuse policy for escalating an allegation of abuse to administration after the incident occurred and failed to perform a medical evaluation for the patient after the incident, as the patient was still a patient in the ED.

Refer to A-0145

Based on review of facility policy, medical record review, review of security documentation, review of facility timeline, review of video footage, and interviews, the facility failed to follow proper de-escalation techniques which led to a physical altercation between a security officer and the patient, and failed to follow facility policy related to an allegation of abuse for 1 patient (#1) who had an altercation with a security officer, of 5 patients reviewed.

The findings included:

Review of facility policy, "Duty to Intervene" dated 9/2021, showed "...all members must recognize and act upon the duty to intervene to prevent or stop any member from conducting any act that is unethical, or that violates law or policy [i.e. excessive force...inappropriate language...inappropriate behavior]. Intervention may be verbal and/or physical...if aid is required by an individual by any individual, ensure medical attention has been rendered...take a preventative approach, whenever possible...examine the circumstances surrounding the incident to determine the appropriate form of intervention...take an active approach to intervene to stop any unethical behavior or misconduct, when such conduct is being committed by another member...if verbal intervention are not sufficient to stop the act, come between the offending member and the other individual involved...immediately notify a supervisor after conducting any type of intervention...when a physical intervention was performed, document the incident..."

Review of facility policy, "Use of Force" last revised on 12/2021, showed "...security officers will use only the degree of force that appears reasonably necessary to manage the situation. Security officers will use de-escalation tactics including but not limited to verbal communication before resorting to any means of physical force...officers shall, whenever possible, meet with staff assigned to the patient/subject and determine any relevant information before engaging with the individual. This should include medical condition and recent medical history which would affect any level of force deployed...location of patient...listen to the subject's issues. Give them the opportunity to explain the problem. In many cases this will de-escalate the situation allowing staff to provide the service desired...use verbal de-escalation techniques prior to the use of physical force...the director of security or the designated security manager will report all such incidents involving use of force to the proper administrative representative..."

Review of facility policy, Alleged Assault or Abuse of Patients Receiving Services at a (named) Health Facility, last revised 6/2022, showed "...all patients have the right to be free from verbal...physical...abuse...this includes patients receiving services at [named facilities] at the time of the alleged abuse/assault occurred. Procedure: all staff have a duty to immediately report any witnessed, suspected, or alleged physical, sexual, verbal abuse to the manager/supervisor...for patients receiving treatment in a hospital or an Emergency Department [ED] setting [1] the patient's physician or physician on call will be notified of the allegations and any resulting treatment needs [2] the supervisor will inform the patient of the next steps...[E] after the interview with the patient and any other individuals, notify the Risk Manager immediately to review the facts of the allegation...Risk Manager will assume responsibility for leading the internal investigation in conjunction with hospital security and other hospital personnel...Risk Manager will notify the Administrator on Call..."

Medical record review showed Patient #1 presented to the ED on 1/17/2023 at 10:16 PM related to an elevated blood pressure. He was triaged at 10:55 PM with complaints of light headedness and dizziness. He had previous history of Bipolar Disease (mood disorder that can cause intense mood swings) and Depression. His vital signs were as follows: BP 117/74, Pulse 116, Respirations 18, Oxygen Saturations 97% on room air. He was triaged with an Emergency Severity Index (ESI) of a 3 indicating urgent needs.

Medical record review of a Provider in Triage Record dated 1/17/2023 at 11:01 PM showed the patient presented with a suspected adverse reaction to a new medication. He had stated he was feeling diaphoretic (sweating) and lightheaded 2-3 hours after taking Seroquel (antipsychotic medication). An electrocardiogram (EKG) was performed which showed no acute findings.

Medical record review of the Laboratory Diagnostic Testing showed the patient's Urine Drug Screen (UDS) was positive for Amphetamines and he was positive for Influenza B (flu).

Medical record review of an ED Physicians Record dated 1/18/2023 at 5:25 AM showed the ED Physician reviewed the record and had ordered intravenous fluids, Toradol (nonsteroid anti-inflammatory modification) and Zofran (medication used for nausea). His diagnoses included Influenza B, Methamphetamine use, Post Traumatic Stress Syndrome (PTSD), and Schizoaffective (mental health) disorder. The patient left his ED room prior to the ED physician seeing the patient.

Medical record review of a Nurses Note dated 1/18/2023 at 6:23 AM showed "...I went to room to administer ordered medication, patient was not in the room. I was informed by security that patient was found in the lobby and started an altercation with security officers. Patient escorted out of the lobby and IV [Intravenous catheter] removed by clinical staff..."

Review of a Security Report dated 1/18/2023 at 6:00 AM, written by Security Officer Security Officer #1, showed "...ED had requested assistance with a discharged patient in the lobby area causing a disturbance. Officer began escorting subject from the hospital when subject became combative. Subject was placed in handcuffs and [local police department] notified. Subject taken into custody by [local police department] without incident..." On "...January 18, 2023 at approximately 6:00 AM, [Security Officer #1] was talking to the registration desk when they informed that there was a person in the lobby that was discharged and that they would like him to leave. I [Security Officer #1] made first contact with patient [Patient #1] who was sitting in the Emergency Department [ED] lobby. At approximately 6:02 AM (19 seconds) I asked him to calm down, that it was a simple question and that the ladies at the front desk said that you were. I am here just to check. [Patient #1] became more aggravated and stated 'them bit----are wrong, I am not discharged'. At this time, I told [Patient #1] to stop talking like that and there was no reason for these actions. [Patient #1] said 'what the he--you going to do about it?' I told the patient to stop with the behavior while I figured out what was going on. At approximately 6:02 AM (44 seconds) I returned back to the registration desk and asked the registration staff to check his status. [Registration Staff #1] said 'he has a room and she didn't know why he's just chilling in the ED lobby'. At approximately 6:03 AM (01 seconds), I asked [Patient #1] what room he was assigned to. He started to become hostile and started to throw gestors [gestures] with his hands as he was talking. As [Patient #1] was passing me at the desk, he continued talking and getting more angry. Saying 'you can't do sh--, your just security. I can do what I want'. I told the patient that his actions and behavior will not be tolerated and I told him that he needs to stop or he can leave. The patient said 'Fu-You', and walked off toward the triage door. At approximately 6:03 AM (35 seconds), I told the patient he had to leave due to his actions and behavior. [Patient #1] turned and looking like he was going to throw a strike at me. At that time, I placed the patient in an escort position and began escorting him to the ED off garage. He began to resist and pushed the sliding glass doors off track. Once the patient was in the drop off garage. I directed him to depart the property. The patient stated 'I'm not fu------ leaving'. At this time, I placed [Patient #1] in an escort position again, and began escorting him off property. At approximately 6:03 AM (49 seconds), while I was escorting the [Patient #1] off property, he attempted to strike me with a closed fist. [Security Officer #2] witnessed the strike and assisted me with taking the patient to the ground. At approximately 6:03 AM (51 seconds), [Security Officer #2] was pushed to the ground resulting in the officer hitting his head on the ground. At that time, I took [Patient #1] to the ground and began attempting to place him in handcuffs. At approximately 6:04 AM (19 seconds), a by-stander that was sitting in his car came to assist [Security Officer #2] and myself to the patient into handcuffs. At approximately 6:04 AM (44 seconds), once the patient stopped resisting, I was able to place him in handcuffs at approximately 6:05 AM. Shortly after the cuffs were applied, [Sergeant (Sgt.) #1, shift supervisor] arrives in the ED drop off garage. [Sergeant #1 and Security Officer #1] sat the patient up in a recovery position. Once he was in recovery position, [Sergeant #1] grabbed a wheelchair for the patient to sit in. [Sergeant #1] went to review footage of the incident. At approximately 6:32 AM (08 seconds), [named local police department] arrives on scene and begins investigation of the incident. After receiving all information, [Patient #1] was taken into custody by [named local police officer]. While [Patient #1] was siting in the police cruiser, I issued the patient a criminal trespass warning and explained that he is no longer allowed on a [named facility] property unless he is seeking emergency medical attention. [Local Police department] also advised us that the patient had made several calls to 911 about someone breaking into his home and have had them running everywhere. At approximately 7:07 AM, local police departed property. [Security Officer #2] was checked by house supervisor. No other injuries were reported. Report will be updated once charges are found and local police department report is completed..."

Review of a facility Timeline related to the incident showed the following events on 1/18/2023 immediately after the incident:
6:30 AM: Sgt. #1 contacted the contracted security company's Captain and informed him about Security Officer #2 being injured during an incident where security attempted to escort a discharged patient off property.
6:40 AM: Captain notified the Major of the contracted security agency of Security Officer #2 injuries and details of the incident.
7:30 AM: Lieutenant (Lt.) with the security company reviewed video camera footage of the incident and initiated investigation of Security Officer #2's injuries.
7:36 AM: Captain reviewed video camera footage to investigate Security Officer #2's injury.
7:39 AM: Captain noticed that Security Officer #1's report of the incident did not align with the video footage.
10:30 AM: Lieutenant and Sergeant reviewed Security Officer #1's written report in the officer's presence.
1:30 PM: Captain advised Lieutenant to create a schedule without Security Officer #1 because he would likely be placed on suspension pending the results of the investigation.
10:43 PM: Captain met with third shift registrar of the ED and asked her to write a statement explaining what she witnessed during the incident with Security Officer #1. Captain also asked her to get Registrar #1 to also write a statement.

On 1/19/2023 at 2:35 PM (1 day after incident occurred), the Lieutenant with the contracted security company spoke with the facility's Vice President of Operations and debriefed him about the details of the Workplace Violence incident involving Patient #1 and Security. On 1/20/2023 (2 days after the incident), Officer #1 was terminated and at 1:04 PM, the Risk Manager of the facility was provided information from the contracted security company and the facility's security department related to the investigation and the possible abuse of Patient #1. On 1/23/2023, the Assistant Chief and Major with the contracted security company met with the Risk Manager to present the security company's findings and to determine if the incident met the criteria for patient abuse.

Review of video footage of the incident showed the following:
1/18/2023 (Camera #1 at the registration desk)
6:00 AM: Patient #1 in the ED lobby. Security Officer #1 was located at the registration desk speaking with the registration staff.
6:02 AM (08 seconds): Security Officer #1 walked over to the area where the patient was located. He was observed pointing at the patient and having a discussion with the patient.
6:02 AM (44 seconds): Security Officer #1 walked back to the registration desk.
6:03 AM (37 seconds): Patient #1 walked to the registration desk and there was a verbal exchange between the patient and Security Officer #1.
6:03 AM (37 seconds): Security Officer #1 and the patient moved to the ED lobby exit doors. Security Officer #1 had his hands on Patient #1. They go through the exit doors and the patient knocked the sliding ED doors off of the tracking.

Camera #4 (ED main entrance parking lot)
6:03 AM (40 seconds): Security Officer #1 and the patient were observed walking into the ED entrance parking area. Both the patient and the officer were aggressive with hands on each other and pushing each other.
6:03 AM (44 seconds): Security Officer #1 punched the patient and had his hands on the patient's neck and chest area.
6:03 AM (48 seconds): Security Officer #1 had his hands around the patient's neck and chest and they were fighting with each other. Security Officer #2 is at the side and attempting to assist. Security Officer #2 fell to the ground onto his back.
6:03 AM (55 seconds): Security Officer #1 had the patient's upper extremities restrained attempting to place handcuffs on the patient. Security Officer #2 was holding the patient's lower extremities.
6:03 AM (57 seconds): Security Officer #1 had his hands on the patient's neck and chest. The patient was on the ground.
6:05 AM (55 seconds): the patient was in handcuffs and Security Officer #1 and Security Officer #2 picked the patient up from the ground.

Camera #5 (ED Parking lot)
6:07 AM (55 seconds): ED staff member removed INT out of the patient's arm.
6:08 AM (54 seconds): ED staff brought patient's belongings out to the parking lot.
6:22 AM (57 seconds): Officer brings wheelchair and Patient #1 was placed in the wheelchair with handcuffs still in place.
6:33 AM (11 seconds): Local police department arrived in the ED parking area.
6:42 AM: Handcuffs were changed to local police department handcuffs.
6:51 AM: Local police department had patient in police cruiser and leave with the patient.

During an interview on 1/30/2023 at 10:15 AM, the Chief Nursing Officer (CNO) stated the patient was in the ED in a room and had walked to the ED lobby to make a phone call. The patient had sat in the lobby for an extended amount of time and the registration staff was not sure if the patient had been discharged or was still an ED patient. The registration staff called security to talk to the patient and find out why he was still in the ED. The officer went and talked to the patient and there was a verbal exchange between the officer and the patient. Security had asked the patient to leave the ED. She stated the registration staff was not sure if the patient had been discharged or if he was still an ED patient. The ED nursing staff was not aware of the incident with the patient or that the officer had asked the patient to leave. Security staff were investigating the incident as an occurrence of workplace violence and did not investigate as abuse. The VP [Vice President] of Operations was notified on 1/19/2023 of the incident and of the video findings.

During an interview on 1/30/2023 at 10:45 AM, the Vice President of Operations stated the contracted security Lieutenant had notified him on 1/19/2023 at 2:35 PM (1 day after the incident occurred) of the incident. The incident was reported as an altercation between Security Officer #1 and the patient. The altercation became hands-on after the patient struck the officer and the officer struck the patient. The contracted security company conducted the investigation as a workplace violence incident related to Security Officer #2 being injured and the officer had refused to be examined by a physician. There were questions related to whether Patient #1 was still a patient in the ED or if he had been discharged. The registration clerks were not sure of the patient's status and did not know how to check the patient's status. The VP of Operations stated the facility was not notified on 1/18/2023 after the incident. The incident was not investigated initially as abuse but after video review and interviews, "it became apparent there was more to the story. There was a verbal altercation initially which turned into a hands-on event. The officer had told the patient he needed to leave but there was no information as to if the patient was still an ED patient. Nursing was not notified of the incident and the officer was informed the patient was a discharged patient, but the patient had not been discharged..."

During an interview on 1/30/2023 at 11:00 AM, Lieutenant Officer (with the contracted security company) stated they were made aware of the incident on 1/18/2023. Security Officer #1 reported the patient struck Security Officer #2 and a "hands-on" was implemented by the officers. The registration staff had contacted security because the patient was in the ED lobby and they were not sure if the patient was an ED patient or if he had been discharged from the ED. Security Officer #1 had gone to talk to the patient and a verbal altercation followed between Security Officer #1 and the patient. The patient was verbally disruptive and after attempts by the officer to calm the patient down, the patient continued with behaviors. Security Officer #1 did not know if the patient was an ED patient and told the patient he needed to leave related to his behaviors. Security Officer #1 and the patient went out the ED main lobby doors and the patient knocked the sliding glass doors off the track. When Officer #1 and Patient #1 got to the ED parking lot, the patient remained disruptive and attempted to push the officer and the officer pushed the patient 3 times. Patient #1 was held down until he was placed in handcuffs. The Security Shift Supervisor notified the Captain that Security Officer #2 was injured during a "use of force" incident between Security Officer #1 and Patient #1. The incident was escalated to the Captain and Major and after reviewing the video and report, there appeared to be discrepancies with the report and the video footage. The Lieutenant Officer stated security administrative staff reviewed and considered the incident as an incident of workplace violence and did not identify the officer's actions as abuse at the time of the initial review. The Lieutenant confirmed the nursing staff were not contacted by the officer or the security supervisor and the registration staff had not contacted the nursing staff of the patient leaving the ED.

During an interview on 1/30/2023 at 1:35 PM, the Risk Manager stated Risk Management was made aware on 1/20/2023 (2 days after the incident) of an investigation by the contracted security company of a workplace violence incident which occurred on 1/18/2023. She stated " ...it was initially reported as an officer related injury, but after video review and review of the security report, the findings were reported as an alleged abuse... "

During a telephone interview on 1/30/2023 at 2:00 PM, Registration Clerk #1 stated Patient #1 was in the ED lobby and security had come to check on the patient and the staff. Registration staff were not sure if the patient was an ED patient or if he had been discharged. Security Officer #1 went to the patient and asked the patient if he was discharged and a verbal altercation between the officer and the patient ensued. The verbal altercation continued between the officer and the patient. She stated "...at some point, I heard [Security Officer #1] yell at the patient 'get the [fu--] out' very loudly at the patient. The officer and the patient went out the ER [ED] lobby sliding doors into the parking lot. We did not see what happened after that, but security did ask someone to take the INT out of the patient's arm. We did not notify nursing of the incident... "

During an interview on 1/30/2023 at 2:30 PM, the Assistant Chief of Security of the facility stated on 1/18/2023 the video footage was reviewed by the contracted security administrative staff. Video review revealed Security Officer #1 did have hands-on with Patient #1 during the altercation. The video review was escalated to the Captain of the contracted security agency by the Lieutenant and Major of the contracted security company. The Captain (of the contracted security company) reviewed the video and determined Security Officer #1 used excessive force. He confirmed "...the hands-on was without justification. If the officer had known the patient was still an admitted patient, he should have taken the patient back into the ED for a medical evaluation..." Security Officer #1 was terminated on Friday 1/20/2023 for conduct unbecoming of an officer and excessive use of force. The officer's actions and the video review were reported to the Vice President of Operations on 1/19/2023 (1 day after the alleged abuse occurred).

During a telephone interview on 1/30/2023 at 3:55 PM, Nursing Supervisor #1 stated the Security Supervisor called her and only reported the possible injury to Security Officer #2 and confirmed she was not notified of an allegation of abuse of Patient #1.

During a telephone interview on 1/30/2023 at 4:50 PM, Paramedic #1 stated Patient #1 met her in the hallway and stated he was going to the ED lobby to make a phone call. She went into the patient's room later to administer medications and the patient was not in the room. Paramedic #1 was informed by the registration staff the patient and security had gotten into an altercation. The Paramedic stated the triage nurse or charge nurse were not aware of the incident and she informed them.

During a telephone interview on 1/30/2023 at 3:10 PM, Security Officer #2 with the contracted security company stated when he came into the parking lot, he saw Security Officer #1 and Patient #1 coming out the ED lobby doors in a scuffle. Security Officer #1 and the patient were arguing, and the situation had become "hands-on". Both of them were fighting aggressively with each other and he responded to assist. Security Officer #2 stated the patient was taken to the ground and handcuffed.

During a telephone interview on 1/30/2023 at 8:30 PM, Security Officer #1 stated he was called by the registration staff for a patient in the ED lobby. He was informed by registration staff they were not sure if he had been discharged. He made contact with the patient in the ED lobby and asked the patient if he was still an ED patient or if he had been discharged. The patient had told Security Officer #1 it was "none of his business" and he was "just a security officer" and the officer could not do anything. Security Officer #1 stated "...at that time the patient was very disruptive and bullying and I told him that behavior would not be tolerated. There was a verbal altercation and I walked back to the registration desk to see if they had found out if the patient was still an ED patient or if he was discharged. The patient came to the desk with his fist drawn and started yelling and cursing at me. I told him he needed to calm down or he needed to leave. He told me that I could not do 'sh--' to him and I told him to get the 'Fu--' out of the ED. He said he was going to kick my 'a--'...at that point he walked toward the triage area and then back toward the registration desk. I grabbed his arm and then we went toward the exit doors. He was aggressive and knocked the sliding doors off track as we were exiting the ED. When we went outside, he was trying to hit me with his fist and the situation became hands-on at that point. He was swinging at me and the other officer which caused [Security Officer #2] to fall to the ground. At that time, I took him to the ground, and we were wrestling. [Security Officer #2] had his lower extremities and I had his upper extremities trying to get the handcuffs on. I did use a chin lock on him and rolled him to the ground, and got him on his stomach, to get the handcuffs on the patient. After that, we set the patient up into a sitting position. He continued to curse and to be disruptive. My supervisor came out and asked what had happened. I still was not sure if the patient was an ED patient or if he was discharged, but found out later he was still an ED patient. We asked someone to remove the IV line and the ED staff brought his clothes out to him. By this time, we had already called [local police department]. They came and took the patient to jail as we had issued a no trespassing citation for the patient..."

During a telephone interview on 2/1/2023 at 5:10 PM, Sgt #1 stated she had heard the radio call for assistance in the ED but was not aware of what was going on. She arrived on scene at the ED Parking Lot after the altercation had occurred and she attempted to get information about what happened. The officers already had Patient #1 on the ground and the patient was handcuffed when she arrived. She was told the patient had pushed the officers and Security Officer #2 had fallen and was reportedly injured. Security Officer #1 stated the patient had swung at him and they had taken the patient to the ground. She stated "...I went and looked at the video and saw it was aggressive and I would have not handled the situation that way...I called [named Lt.] and my Chief and told them of the situation.." Sgt #1 stated security's main goal was to verbally deescalate any situation and not use hands-on unless absolutely necessary. She confirmed the officer was verbally and physically aggressive with the patient.

During an interview on 2/7/2023 at 12:22 PM, the contracted security company educational Training Officer stated a chin lock was not an accepted physical hold for any patient and was not taught in the Crisis Intervention Training. He stated "...the position the officer was using was not an escort hold and it looks like the officer escalated the event with his actions. We do not teach any chin holds in our training and the officer should not have his hands around a patient's neck or chest. We teach verbal de-escalation as the first priority and hands-on should be only used as a last resort..."

Based on review of facility policy, medical record review, review of security documentation, review of facility timeline, and interviews, the facility failed to ensure an Emergency Department (ED) patient was assessed after a physical altercation with a security officer for 1 patient (#1) of 5 ED patients reviewed.

The findings included:

Patient #1 was admitted to the ED on 1/17/2023 at 6:00 AM related to an elevated blood pressure. He was evaluated by the Provider in Triage where diagnostic testing was ordered and completed. He was diagnosed with Influenza B and was awaiting further treatment. On 1/18/2023, the patient walked out into the ED lobby and was observed by the registration clerk staff yelling and being disruptive. Security was called to check on the patient. The registration staff was unable to determine if the patient was an ED patient or if he was discharged and they did not confirm the patient's status with the ED staff. When the security officer approached the patient, there was a verbal altercation between the patient and the security officer, which escalated to a physical hands-on altercation. The security officer escorted the patient to the ED parking lot garage and there was a physical altercation leading to the patient striking the officer and the officer struck the patient. The patient was handcuffed by the officer. There was no notification by the registration staff or the security officer to the ED staff after the altercation. While in the parking lot, security asked the ED Tech to remove the patient's INT (Intravenous catheter) which she completed, however the ED Tech did not notify the nursing staff of the incident between the security officer and the patient and the patient was not evaluated by nursing staff. The local police department was called and responded to the ED parking garage where the patient was issued a no trespassing citation, and he was taken to jail by local police. The patient had not been discharged from the ED and he was still under the care of the ED staff, but was not evaluated after the altercation.

Refer to A-0395

Based on review of facility policy, medical record review, review of security documentation, review of facility timeline, and interviews, the facility failed to ensure appropriate supervision of care for an Emergency Department (ED) patient and failed to ensure a medical evaluation was performed for a patient after a physical abuse incident for 1 patient (#1) of 5 patients reviewed.

The findings included:

Review of facility policy, Alleged Assault or Abuse of Patients Receiving Services, last revised 6/2022, showed "...all patients have the right to be free from verbal...physical...abuse...this includes patients receiving services at [named facility] at the time of the alleged abuse/assault occurred. Procedure: all staff have a duty to immediately report any witnessed, suspected, or alleged physical, sexual, verbal abuse to the manager/supervisor...for patients receiving treatment in a hospital or an Emergency ED setting [1] the patient's physician or physician on call will be notified of the allegations and any resulting treatment needs..."

Medical record review showed the patient presented to the ED on 1/17/2023 at 10:16 PM related to an elevated blood pressure. He was triaged at 10:55 PM with complaints of light headedness and dizziness. He had previous history of Bipolar Disease (mood disorder that can cause intense mood swings) and Depression. His vital signs were as follows: BP 117/74, Pulse 116, Respirations 18, Oxygen Saturations 97% on room air. He was triaged with an Emergency Severity Index of a 3 indicating urgent needs.

Medical record review of a Provider in Triage Record dated 1/17/2023 at 11:01 PM showed the patient presented with a suspected adverse reaction to a new medication. He had stated he was feeling diaphoretic and lightheaded 2-3 hours after taking Seroquel (antipsychotic medication). An electrocardiogram (EKG) was performed which showed no acute findings.

Medical record review of the Laboratory Diagnostic Testing showed the patient's Urine Drug Screen (UDS) was positive for Amphetamines and he was positive for Influenza B (flu).

Medical record review of an ED Physicians Record dated 1/18/2023 at 5:25 AM showed the ED Physician reviewed the record and had ordered intravenous fluids, Toradol (nonsteroid anti-inflammatory modification) and Zofran (medication used for nausea). His diagnoses included Influenza B, Methamphetamine use, Post Traumatic Stress Syndrome (PTSD), and Schizoaffective (mental health) disorder. The patient left his ED room prior the ED physician seeing the patient.

Medical record review of a Nurses Note dated 1/18/2023 at 6:23 AM showed "...I went to room to administer ordered medication, patient was not in the room. I was informed by security that patient was found in the lobby and started an altercation with security officers. Patient escorted out of the lobby and IV removed by clinical staff..."

Review of a Security Report dated 1/18/2023 at 6:00 AM showed the ED registration staff had requested assistance with a discharged patient in the lobby area causing a disturbance. At 6:02 AM, the officer was told the patient had a room in the ED but they were unsure of why the patient was in the lobby. There was no notification to the triage nurse, charge nurse, or ED staff to obtain the patient's status. The incident escalated between Security Officer #1 and the patient, resulting in a verbal and physical altercation. At 6:03 AM the altercation escalated and the patient was taken to the ground and placed in handcuffs. The patient had an intravenous catheter (INT) in his arm and at 6:07 AM, the ED Technician removed the intravenous catheter per the officer's request. The incident was not reported to the nursing staff or the ED Provider by the security officer or the registration staff. The patient was taken to jail by the local police department.

Review of a facility timeline dated 1/18/2023 showed no documentation the nursing staff or the ED provider were notified and the patient was not evaluated by the ED staff or a medical provider prior to being taken to jail by local police. The contracted security company had reviewed the video footage on 1/18/2023 at 7:30 AM and confirmed inappropriate de-escalation techniques were used.

During an interview on 1/30/2023 at 10:15 AM, the Chief Nursing Officer (CNO) stated the patient was on the tracking board as an ED patient. He had walked to the ED lobby to make a phone call and sat in the lobby for an extended amount of time. The registration staff was not sure if the patient had been discharged or was still an ED patient. The registration staff called security to talk to the patient and find out why he was still in the ED. The officer went and talked to the patient and there was a verbal exchange between the officer and the patient. Security had asked the patient to leave the ED. The ED nursing staff was not aware of an incident with the patient or of the officer asking the patient to leave. She confirmed the patient was not evaluated by the nursing staff or an ED Provider prior to being taken to jail by local police. The ED tech, who removed the IV catheter, did not notify nursing staff security had asked the tech to remove the IV catheter and that the patient was in the ED parking lot with security officers.

During an interview on 1/30/2023 at 10:45 AM, the Vice President of Operations stated "...There was a verbal altercation initially which turned into a hands-on event. Nursing was not notified of the incident and the officer was informed the patient was a discharged patient, but the patient had not been discharged..."

During an interview on 1/30/2023 at 11:00 AM, the Lieutenant Officer for the contracted security company stated they were made aware of the incident on 1/18/2023 when the officers reported the patient struck Security Officer #2 and a hands-on was implemented by the officers. A verbal and physical altercation followed between Security Officer #1 and the patient. A hands-on ensued and the patient was held down until he could be placed in handcuffs. He confirmed the nursing staff was not informed of the patient leaving the ED by the officer or the security supervisor.

During a telephone interview on 1/30/2023 at 2:00 PM, Registration Clerk #1 stated they were not sure if the patient was an ED patient or if he had been discharged. The officer went to the patient and asked the patient if he was discharged and a verbal altercation between the officer and the patient ensued. Security had asked for the intravenous catheter to be removed. She confirmed she did not notify nursing of the incident.

During an interview on 1/30/2023 at 2:30 PM, the Assistant Chief of Security stated on 1/18/2023 the video was reviewed by the contracted security administrative staff. It was found Officer #1 did have hands-on with the patient during the altercation. He confirmed "...if the officer had known the patient was still an admitted patient, he should have notified nursing or taken the patient back into the ED for a medical evaluation..."

During a telephone interview on 1/30/2023 at 4:50 PM, Paramedic #1 stated the patient had met her in the hallway and stated he was going to the ED lobby to make a phone call. She went into the patient's room to administer medications and he was not in the room. She was informed by the registration staff the patient and security had gotten into an altercation in the lobby and in the parking lot. Paramedic #1 did not notify the triage nurse or charge nurse of the incident with Patient #1.

During a telephone interview on 1/30/2023 at 8:30 PM, Security Officer #1 (the officer involved with the alleged incident) confirmed a verbal and physical hands-on altercation occurred between the officer and the patient on 1/18/2023. He confirmed he had not notified the nursing staff of the incident prior to the patient leaving the ED parking lot with the local police department.