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Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Patient Rights as evidenced by: 



1. The facility failed to ensure one of 30 sampled patients (Patients 1), was free from abuse (the improper treatment of a person), when Patient 1 was physically assaulted (when someone physically attacks another person causing bodily harm) by facility staff.

This deficient practice resulted in Security Guard 1 (SG 1) inappropriately responding by physically assaulting Patient 1 after getting provoked by the patient. (Refer to A-0145).



The cumulative effect of these deficient practices resulted in the facility ' s inability to provide quality health care in a safe environment.

Based on interview, and record review, the facility failed to meet the Condition of Participation for Nursing Services as evidenced by:



1.The facility failed to develop the nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) based on patients ' admitting diagnosis for four of 30 sampled patients (Patient 26, Patient 27, Patient 28 and Patient 29).



This deficient practice had the potential result in Patient 26, Patient 27, Patient 28 and Patient 29 not receiving the right level of care and not meeting the needs for the identified patient's concerns. (Refer to A-0396)



The cumulative effect of these deficient practices resulted in the facility ' s inability to provide quality health care in a safe environment.

Based on observation, interview, and record review the facility failed to prevent one of 30 sampled patients (Patient 1) from being physically abused, by not following the hospital ' s policy regarding the use of force against aggressive patients. Patient 1 was pushed or struck and possibly injured by one of the facility ' s security staff.

This deficient practice resulted in Security Guard 1 (SG 1) inappropriately responding by physically assaulting Patient 1 after getting provoked by the patient.



Findings:



During an observation of the emergency department ' s video recording on 3/4/2025, accompanied by the Risk and Regulatory Director (RRD), this recording from 4/27/2024 at 2:06 am showed Patient 1 sitting in a chair against the far wall from the check in station in the emergency department. At this time SG1 and SG 2 (security guards) were standing one chair width from Patient 1 ' s right side. At the 2:08 am marker of this video Patient 1 appeared to be agitated as demonstrated by Patient 1 ' s hand gestures directed at SG1 and SG2. At this same Patient 1 took a step closer to both SG1 and SG2. At the same time one of the security guards either pushed or struck Patient 1 in the upper body and Patient 1 fell to the floor; It was unclear as to if Patient 1 was pushed or struck since one of the security guards blocked the view of the camera. At the 2:09 am marker of this video emergency department staff was on the scene attending to Patient 1. At the 2:15 pm marker of this video Patient 1 was still on the ground but talking to the emergency department staff.

During an interview on 3/4/2025 at 10:35 am , with the SS (Security Supervisor) stated the morning after the event on 4/28/2024 SS was notified of the two security guards involved and SS stated these two security guards were told not to return to work; SS stated these two security guards were still employed with the security company but not in a hospital setting. SS said that is the security company ' s procedure to avoid a physical confrontation with an aggressive client is to take two steps back from an approaching client; SS also stated if a security guard is pressed to defend himself or herself then that person can use any force necessary to do so. However, SS stated the main responsibility of a security guard encountering an aggressive client is to deescalate (decrease) the situation. SS subsequently stated he interview SG1 after the incident and SG1 admitted hitting Patient 1; SS also stated he understood the security company ' s policy standard regarding the use of force must match that of this facility.



During an interview on 3/4/2025 at 1:45 am, SS stated SG1 and SG2 had violated the (security company) policy regarding ' Workplace Violence ' and this was the reason their employment was terminated.



During an interview 3/4/2025 at 10:40 am, the RRD stated this hospital does not have a policy stating staff are allowed to hit a patient even during a show of aggression by staff or patients; The contracted security company must follow the hospital ' s abuse policy.



During a review of an email sent by the Clinical Manager on 5/2/2024, this document indicated after Patient 1 was struck by SG1 on 4/27/2024, Patient 1 was found on the ground wearing a ski mask and bleeding from his nose. Patient 1 subsequently decided to be seen by emergency department staff for pain.



During a review of the ' Security Incident Report ' dated 4/27/2024, the ' Security Incident Report ' indicated SG1 was called by the emergency department and informed there was a male in the waiting room causing issues by being loud after being released from the emergency department. This statement noted SG1 approached Patient 1 whereupon Patient 1 started yelling and grabbed his pockets; SG1 then told Patient 1 to please lower his voice. At this point, Patient 1 tried to grab SG1; SG 1 then pushed and put Patient 1 to the ground. This document indicated SG2 was present during this entire event.



During a review of the (security company) ' Ch 1 Personnel Policies ' dated February 2024, this document indicated ' Actual or threatened violence or any other conduct that threatens, intimidates, or coerces another employee, client, vendor, contractor, or other third party on our property or with whom we do business – whether verbal, non-Verbal, electronic, or physical – will not be tolerated. All threats of (or actual) violence or other threatening conduct, both direct and indirect, should be reported immediately to a manager and DCSC Human Resources, or to emergency personnel (911) if appropriate under the circumstances. Do not engage in either physical or verbal confrontation with a potentially violent individual. '



During a review of the policy titled ' Code Grey (Security Response Needed) ' , reviewed 5/20/2024, this document indicated security response will be provided by the "Code Grey Team" (emergency code indicating a combative or dangerous person is in the hospital) consisting of engineers, security, administration, supervisors, and employees who have completed specialized training in Crisis Prevention Intervention (CPI, training to deal with diffusing hostile situations) assaultive behavior. The ' Code Gray ' policy indicated employees having difficulty resolving a problem should consult a supervisor if available. During this event staff will make all effort to deescalate the situation; If not able to deescalate by calm intervention, the team will notify the local police department.

Based on interview and record review, the facility failed to develop the nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) based on patients ' admitting diagnosis for four of 30 sampled patients (Patient 26, Patient 27, Patient 28 and Patient 29).



This deficient practice had the potential result in Patient 26, Patient 27, Patient 28 and Patient 29 not receiving the right level of care and not meeting the needs for the identified patient's concerns.



Findings:



1. During a review of Patient 26's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/1/2025, with Registered Nurse (RN 5), the H&P indicated Patient 26 ' s was admitted on 3/1/2025 due to cellulitis (an infection of the deeper layers of skin and the underlying tissue), Chronic Obstructive Pulmonary Disease (COPD, a lung disease characterized by long-term poor airflow), and pulmonary hypertension (a condition that occurs when the blood pressure in the lungs is too high).



During a concurrent interview and record review on 3/5/2025 at 3:55 p.m., with RN5, Patient 26's care plan was reviewed. The care plan indicated no plan of care was developed for Patient 26 ' s diagnoses of cellulitis for this admission. The RN 5 stated, nurse should develop a plan of care for Patient 26 regarding skin integrity. Nurse must develop a care for all actual or potential patient's needs to plan patient care and interventions toward meeting those needs, but the primary nurse did not.





2. During a review of Patient 27's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/3/2025, with Registered Nurse (RN 5), the H&P indicated Patient 27 ' s was admitted on 3/3/2025 due to acute abdominal pain (sudden and severe pain in the abdomen), cholecystitis (an inflammation of the gallbladder), and pancreatitis (an inflammation of the pancreas).



During a concurrent interview and record review on 3/5/2025 at 3:55 p.m., with RN5, Patient 27's care plan was reviewed. The care plan indicated no plan of care was developed for Patient 27 ' s diagnoses of acute abdominal pain for this admission. RN5 stated, nurse should develop a plan of care for patient 27 regarding patient ' s 27 pain problem. Nurse must develop a care for all actual or potential patient's needs to plan patient care and interventions toward meeting those needs, but the primary nurse did not.





3. During a review of Patient 28's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/28/2025, with Registered Nurse (RN 5), the H&P indicated Patient 28 ' s was admitted on 2/28/2025 due to Acute Kidney Injury ( AKI-a condition where the kidneys suddenly lose their ability to function properly, leading to a decline in urine output and an accumulation of waste products in the blood), failure to thrive (a state of decline and may be caused by chronic diseases and functional impairments; manifestations include weight loss, decreased appetite, poor nutrition, and inactivity), and dehydration (a harmful reduction in the amount of water in the body).



During a concurrent interview and record review on 3/6/2025 at 9:30 a.m., with RN5, Patient 28's care plan was reviewed. The care plan indicated no plan of care was developed for Patient 28 ' s diagnoses of AKI due to dehydration for this admission. RN5 stated, nurse should develop a plan of care for patient 28 regarding fluid and risk for electrolyte imbalance. Nurse must develop a care for all actual or potential patient's needs to plan patient care and interventions toward meeting those needs, but the primary nurse did not.





4. During a review of Patient 29's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/27/2025, with Registered Nurse (RN 5), the H&P indicated Patient 29 ' s was admitted on 2/27/2025 due to acute right femur fracture (a break in the thigh bone on the right side of the body), left forearm fracture (a break in one or both of the bones of the left forearm, the radius and/or ulna, that can occur near the elbow, wrist, or in the middle of the bone), and post motor vehicle accident (MVA - collision between two or more vehicles).



During a concurrent interview and record review on 3/6/2025 at 10:00 a.m., with RN5, Patient 29's care plan was reviewed. The care plan indicated no plan of care was developed for Patient 29 ' s diagnoses of post MVA fracture with femur and forearm for this admission. RN5 stated, nurse should develop a plan of care for patient 29 regarding patient ' s 29 pain problem. Nurse must develop a care for all actual or potential patient's needs to plan patient care and interventions toward meeting those needs, but the primary nurse did not.



During a review of the facility's policy and procedure (P&P) titled, Patient Care Planning, dated 8/19, indicated the Plan of Care/Problem list is individualized and based upon the patient needs, patient goals, timeframes, settings and services required to meet the patient's needs and/or goals and the data collected during the interdisciplinary assessment process. Expected patient outcomes and/or goals will be realistic and measurable. The Care Plan/Problem List will be reviewed and updated every shift and as patient condition, and progress indicates.