The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on record review, interview, and record review, the facility failed to ensure 1 patient (#10), out of 10 sampled patients, was free from maltreatment by facility staff. This failed practice denied the patient the right to chivalrous treatment and placed him/her at risk for injury and/or psychosocial harm. Findings:

Record review on 8/7-8/19 revealed Patient #10 presented to the emergency department (ED) on the evening of 7/29/19 for complaints of left-sided back pain.

Review of a physician's report, dated 7/29/19 at 11:26 pm revealed Patient #10 had taken Lyrica (seizure medication that can cause drowsiness), Flexeril (muscle relaxer that can cause dizziness and fatigue), and Epson salts. In addition, the Patient was given Ativan (benzodiazepines /antianxiety than can cause sleepiness and weakness) by emergency services prior to arrival. The Patient had a history of bipolar disorder and personality disorder.

Further review revealed the physician's review of systems was "limited secondary to the patient's condition. [Patient] is sleeping, but arouses and denies any complaints ...Medical Decision Making ...The Patient was allowed to sleep here ...I suspect that [his/her] extreme lethargy is due to muscle relaxants combined with 2 mg of Ativan by EMS. The Patient was given Toradol [anti-inflammatory] 30 mg IV [intravenous] push through a hep-well. I have also ordered Zyprexa 2.5 mg [antipsychotic that can cause dizziness and drowsiness] when [he/she] is more arousable, if the patient's exam is unchanged [he/she] will be discharged ..."

Review of a physician's report, dated 7/30/19 at 11:05 am, revealed the Patient had received the Toradol and 60 mg of Geodon [antipsychotic that can cause dizziness and drowsiness] earlier and was "Lethargic easily awakened but falls quickly back to sleep." The toxicology revealed the Patient tested positive for methamphetamine, ecstasy, benzodiazepines, antidepressants, and marijuana.

Review of an ED nursing note, dated 7/30/19 at 5:11 am, revealed "RN [Registered Nurse] ...used ammonia packet to rouse pt. Pt was given juice then became very irritable shouting, ' ...Someone stole my f**king IPhone'. Writer attempted to help pt. find IPhone by looking though linens. Pt [receded to shout through the ER as [he/she] walked to the lobby, 'I hope you enjoy your new IPhone you [expletives]' ...Pt then told security staff at the front desk someone stole her Samsung Galaxy 8."

During an interview on 8/8/19 at 10:00 am, the Quality Officer stated the facility learned of the altercation between Patients #10 and Security Officer [SO] #1 after the Patient returned to the ED and told a nurse. The nurse then filled out an incident report.

During an interview on 8/8/19 at 9:15 am the Security Manager (SM), Risk Analysis, with other staff of the hospital, stated facility staff were unable to confirmed Patient #10 ' s property was missing. Both staff stated there were cameras located throughout the common areas of the hospital. The SM stated some of the feed was digital and some was analog, the cameras are not consistently monitored and they only pull the video when there is a question about an event or incident.

On 8/8/19, review of the video of the incident that occurred on 7/30/19 between SO #1 and Patient #10 revealed the Patient approaching the door from the left. A hand seen on the right side of the screen and pointing to the door, as the Patient moved towards the right, the SO advanced towards the Patient. The Patient was gesturing and waving his/her arms. When Patient #10 still animated, walked forward, the SO pushed the patient 2 times, the second push sending the Patient to the floor where he/she landed on her buttocks. Patient #10 continued to sit on the floor and rummage through a white plastic bag in her lap. The video had no sound.

During the same interview on 8/8/19, when asked what training the SO had received for managing violent patients , the SM stated the facility used NVI (nonviolent intervention), crisis intervention training. When asked if SO#1 was following the NVI training, the SM replied "NO ".

The SM stated they had completed remedial training with SO #1 after the event and the SO had been off the schedule and was to return tonight.

Review of the "Patient Rights and Responsibilities" pamphlet, dated 12/18, revealed, "You have the right to courteous treatment" and "You have the right to privacy, security and personal dignity and to be free from all forms of abuse."