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Based on interviews, video recordings review, and record reviews, the hospital failed to ensure four of 34 sampled patients, Patient (Pt) 1, Pt 2, Pt 4, and Pt 33, were free from abuse and harassment while in the Emergency Department (ED) when:


1. LVN 1 was identified as an unauthorized employee to access the electronic health record for Pt 1, followed Pt 1 into the room, asked sexually explicit comments to Pt 1, and without a clinical need or permission the male LVN physycally touched Pt 1's breasts and buttocks.

These failures resulted in actual sexual harassment and abuse, causing emotional harm to Pt 1.

2. Pt 2 and Pt 3 were admitted to the Special Care Unit (SCU- a locked unit within the ED where patients who are in a psychiatric or behavioral emergency and do not require complex medical treatments are placed) for treatment and monitoring and safety. Staff observed Pt 3 get out of bed, took off all of his clothes, verbally assault Pt 2 and then physically attacked and crawled on top of Pt 2 on her gurney before staff intervened. Pt 2 was not physically removed from the scene after the attack.

These failures resulted in actual sexual abuse, causing emotional harm to Pt 2.

3. Staff of the SCU did not effectively address and protect Pt 4 from witnessing the physical and sexual assault of Pt 3 on Pt 2 (cross-reference Finding 2)

This failure resulted in actual emotional harm to Pt 4.

4. Security Officer (SO) 1 and Registered Nurse (RN) 3 left a patient (Pt 33) unattended in the SCU, with another patient (Pt 34) who demonstrated aggressive behavior by hitting the window, reported experiencing visual and auditory hallucinations (seeing, hearing, smelling, feeling things that are not there), and expressed a preference to remain alone in the area. SO 1 and RN 3 did not protect Pt 33 from Pt 34 physically assaulting Pt 33, who was punched in the stomach shortly after being placed in the room with Pt 34.

These failures resulted in Pt 33 experiencing avoidable physical pain, fear, and emotional distress.

Findings:

1. During a review of an Entity Reported Incident (ERI) submitted to the California Department of Public Health (CDPH) on 8/28/25, the report indicated, "18 y/o (year old) female presented to [name of hospital] ED (Emergency Department) on 8/26/25 for fever and concern for continued vaginal discharge. Pt 1 was assessed by ED provider and plan made for pelvic exam. Once the pelvic exam was completed, [a] female ED LVN (Licensed vocational nurse) that chaperoned the procedure went to chart on the computer and saw that a male LVN had previously logged on. The female LVN asked the Pt if a male nurse had come into the room and the Pt stated, "yes" and wanted to make a complaint. ED Manager and Assistant Nurse Manager spoke to the patient, and she reported that the male LVN had been following her everywhere. At one point, he walked her to the bathroom and continuously knocked on the door asking if she needed help. Afterwards, the male nurse told her she left something in the bathroom, and he followed her back in. Pt stated he asked her if she "did full service" "or anal". Pt stated "no" and they left the bathroom. Later, while Pt was in a room for her pelvic exam and undressed from the waist down, the male LVN asked "can I have a peek" and touched her on her breast and buttocks. Pt requested to file a police report but did not wish to stay and was discharged from the ED. [Local PD (Police Department) notified, and APS (Adult Protective Services) report filed. HR (Human Resources - the department that handles employee issues) was notified. Employee was taken off shift and placed on admin leave (paid leave until an investigation is completed.)

During a record review on 9/10/25 at 9:02 a.m. with the Director of the Emergency Department (DED), the DED reviewed Pt 1 ' s Electronic Medical Record (EMR). The document titled, "Face Sheet (FS-a document that provides identifying information about their visit) " dated 8/26/25 indicated Pt 1 arrived at the ED on 8/26/25 at 11:59 a.m. and was discharged from the ED on 8/26/25 at 4:30 p.m. The document titled, "ED Provider Notes" dated 8/26/25 at 12:33 p.m. indicated Pt 1 was an "18 y.o. female presents to the ED with concerns of constant fever for 8 days ...Physical Exam: Exam conducted with a chaperone present ..."

During a concurrent interview and video surveillance review on 9/9/25 at 1:25 p.m. with the DED, surveillance footage dated 8/26/25 at 1:39 p.m. was reviewed. The video showed LVN 1 standing outside the patient bathroom in the hallway. LVN 1 was observed knocking on the bathroom door, pacing in the hallway, and moving in circles. LVN 1 then entered the bathroom and closed the door behind him. The DED stated LVN 1 was in the bathroom alone with Pt 1 for "about 4 minutes." The video also showed LVN 2, standing at a distance, appeared to be using a computer. LVN 2 did not interact with Pt 1 or LVN 1 during the observed time frame.

During an interview on 9/10/25 at 8:30 a.m. with LVN 2, LVN 2 stated she has worked in this hospital for over 3 years and recalled the incident involving Pt 1. LVN 2 stated on 8/26/25, she was working in PAT (Provider at Triage) area 3 where pelvic examinations are conducted. LVN 2 stated she prepared the room for Pt 1 ' s pelvic exam, brought Pt 1 to the room, and instructed her to undress from the waist down, providing a drape for privacy. LVN 2 said she left the room to allow Pt 1 to undress privately while waiting for the doctor to do the examination. LVN 2 stated when the doctor was ready, they both went back to the room with Pt 1. LVN 2 stated upon signing into the computer in the exam room, she noticed LVN 1 ' s name had recently signed in. LVN 2 stated, "I should have been the only nurse in the computer at that time. I looked at the chart and couldn ' t see any reason why he would have been in that room, and he wasn ' t even assigned to that area." LVN 2 stated she asked Pt 1 if any other person had entered the room while she was gone, and Pt 1 told her that a male nurse had come in and had been ' following her everywhere. ' Pt 1 described the male nurse by his ethnicity and clothing, which matched LVN 1. LVN 2 stated Pt 1 told her that LVN 1 entered the room while she was undressed and lying on the exam table with only a sheet covering her and asked if he could ' take a peek. ' LVN 2 stated she immediately told her Assistant Nurse Manager (ANM), who involved the ED Manager (EDM). LVN 2 stated, "I don ' t know if she [Pt 1] would have said anything if I hadn ' t asked her directly. She was guarded, but she told me right away." LVN 2 stated she had worked with LVN 1 in the past and observed when selecting the next patients from the lobby for treatment, LVN 1 tended to choose younger female patient and spent longer periods with them than most nurses are with their patients." LVN 2 stated she had noticed LVN 1 had a "tendency to select young patients to work with."

During an interview on 9/12/25 at 2:05 p.m. with Pt 1, Pt 1 stated she was sexually assaulted by a male nurse when she was in the Emergency Department at [name of hospital] on 8/26/25. Pt 1 stated when "the guy" (LVN 1) was starting her IV, he started making small talk. Pt 1 stated, "At first, I didn ' t think anything of it. Then he gave me a urine cup and told me to go to the bathroom and give a urine sample. He asked me if I needed help with it, which I thought was weird. I told him "no", but he followed me into the bathroom anyway." Pt 1 stated, "then he started talking about sexual stuff. He asked me if I liked anal, and I said, no, I don ' t do that." Pt 1 stated LVN 1 asked her not to tell anybody what he said to her, and she promised because she didn ' t feel safe in the bathroom with him alone. Pt 1 stated she was sent to wait in the lobby for a while, then she was taken to an exam room by LVN 2 to have a pelvic exam. Pt 1 stated she undressed and was lying on the table with a drape over her lower body. LVN 2 left the room, and while LVN 2 was gone, LVN 1 came into the exam room while she was on the exam table with only a drape covering her. Pt 1 stated LVN 1 asked her, "can I have a peek?" Pt 1 stated LVN 1 touched her breast and her buttocks. Pt 1 stated she told LVN 1 to get out of the room, and he left. Pt 1 stated when LVN 2 came back into the room, she asked if another nurse came in while she was gone. Pt 1 stated she told LVN 2 what happened. Pt 1 stated she felt humiliated and embarrassed and was shocked that this could happen in a hospital.

During an interview on 9/10/25 at 9:00 a.m. with the Human Resources Strategic Business Partner (HR), HR stated he first became aware of the incident on the date it happened when the EDM called him. HR stated LVN 1 had already been put on Administrative Leave and was no longer at the hospital. HR stated he viewed the video of the incident and met with LVN 1 on 9/2/25. HR stated LVN 1 resigned during the meeting.

During an interview on 9/10/25 at 9:15 a.m. with ANM and EDM, ANM stated she recalled on 8/26/25, LVN 2 informed her that she was concerned that LVN 1 was logged onto the computer in Pt 1 ' s exam room when he wasn ' t assigned to care for Pt 1. ANM stated initially, she did not enter the room to speak with Pt 1, instead she obtained Pt 1 ' s name and information and consulted with the EDM. Together they proceeded to speak with Pt 1. The EDM stated when they entered the room, Pt 1 was fully dressed, and she reported her concerns. EDM stated, "She was eloquent. She described what happened. At the end of the discussion I asked if she wanted to talk with a doctor or a Social Worker. We informed her we would report the incident to the Police Department, but she didn ' t want to wait for the PD to come, she wanted to go home." ANM stated she made a referral to the Social Worker, who said she would contact Pt 1 at home.

During an interview on 9/11/25 9:30 a.m. with the Chief Nursing Officer (CNO), HR, and the Director of Risk Management (DRM), HR stated he meets with the EDD regularly to discuss actual and potential employee issues in the ED. HR stated about 8 months ago, some ED staff reported that LVN 1 was not following the patient selection process to be seen and treated by a provider; LVN 1 was selecting the patients he preferred. HR and the EDD reminded all ED staff of the correct process. HR stated LVN 1 was not formally counselled at that time.

During an interview on 9/12/25 at 11 a.m. with the CNO, the CNO stated she expects all staff who enter patient rooms to uphold professional standards. The CNO stated, "We have a chaperone policy. We want to make sure that physical safety is ensured, but privacy is also protected."

During a review of the hospital policy titled, "Patient ' s Rights and Responsibilities" dated 3/14/25, the policy indicated. " ...V. PATIENT RIGHTS A. Patient rights are applicable to all [hospital system] patients ... the hospital shall provide processes to support the following patient rights: 2. To receive considerate and respectful care, be made comfortable and maintain dignity in a safe setting, free from verbal or physical abuse or harassment.

2. During a review of an Entity Reported Incident (ERI) submitted to the California Department of Public Health (CDPH) on 7/25/25, the report indicated, "On 7/23/25 at0850, male patient was brought back into [NAME OF HOSPITAL] ED SCU after his SOC consult [Mental Health evaluation for holding the patient] was completed. At 0856, he removed his burgundy scrubs, getting completely naked. He spoke to female patient in SCU bed 5 for a few seconds and then climbed on her gurney to lay next to her. Security and staff responded and pulled the male patient off the female patient ' s gurney. Rapid Response called. Once additional staff arrived, the male patient was separated from the other patients, redressed and placed in 4-point violent restraints. Female patient immediately assessed after incident. No visible injuries to patient, she reported no injury or pain. Female patient did not make an allegation of sexual assault or that she was touched inappropriately. ... Female patient ' s hold was lifted and she was discharged."

During a concurrent interview and record review on 9/10/25 at 10:16 a.m. with the Director of the Emergency Department (DED) and the Manager of the Emergency Department (NM 6), the Electronic Medical Record (EMR) for Pt 2 was reviewed. The document titled, "Face Sheet" dated 9/9/25 indicated Pt 2 arrived at the ED on 7/23/25 at 3:29 a.m. and was discharged from the ED on 7/23/25 at 4:01 p.m. The document titled, "ED Provider Notes" dated 7/23/25 at 5:39 a.m. indicated Pt 2 was an "35 y.o. female with history of substance abuse ... was brought in by ambulance and presents to the ED for suicidal ideation/suicidal intentions that has been ongoing for the past 3 days. Patient endorses using alcohol and methamphetamine prior to arrival. She has a plan to jump in front of a train. ... Denies homicidal ideation or AH/VH (auditory [hearing] hallucinations/visual hallucinations). ..."

During a concurrent interview and record review on 9/10/25, at 10:31 a.m., with the DED and NM 6, Pt 3 ' s Electronic Medical Record (EMR) was reviewed. The document titled, "Face Sheet" dated 9/10/25 indicated Pt 3 arrived at the ED on 7/22/25 at 5:27 p.m. and was discharged from the ED on 7/23/25 at 3:30 p.m. The document titled, "Hospitalist History and Physical" dated 7/23/25 at 5:17 p.m. indicated Pt 3 was an " ....36-year-old male patient with history of chronic psychiatric illness ... It is reported that the patient run out of his ... medication. Patient has been having manic [a distinct period characterized by an abnormality and persistently elevated, expansive or irritable mood and increased goal directed energy or activity, lasting at least one week] like symptoms associated with auditory [hearing] and visual hallucinations. Patient's family is concerned that patient is decompensating. Patient reported that he is unable to calm himself down and he sought medical help. ...". The document titled, "ED notes Addendum", dated 7/22/25, at 5:57 p.m., indicated, "Staff attempted to give pt [Patient] by mouth [brand name] [Medication for anxiety] pt jumps out of chair and grabs staff ' s shirt and says, "How much longer". Staff stays, "I am giving you meds now" pt started talking about random things, took off his bracelet and acted as if he was recording a video. Pt cussing towards staff and family was trying to keep pt clam, attempted to push family away. Per family pt is on meds but pt does end up getting manic episodes." NM stated Pt 2 did not exhibit aggressive behavior and had been resting prior to the incident with Pt 2.

During a concurrent interview and surveillance video review on 9/10/25 at 1:25 p.m. with the DED and NM 6, the surveillance footage dated 7/23/25 at 8:55 a.m. was reviewed. The video showed Pt 2 in the gurney with no movement. Pt 3 was on a separate gurney, perpendicular to Pt 2, located near the corner, with a bathroom situated between the two patients. Pt 4 was observed talking on the phone across the room from Pt 2 and Pt 3. Pt 3 was observed getting off of his gurney, removing all his clothing, and grabbing his genitals. Prompted Pt 4 to scream and pointed at Pt 3. Pt 3 walks over to the foot end of Pt 2 ' s gurney and appears to engage in a conversation with Pt 2. Pt 2 shaking her head "no" in response as Pt 3 crawled on top of Pt 2. Pt 2 was observed pushing and kicking Pt 3 off.. Security staff and other staff members in scrubs entered the room and pulled Pt 3 off of Pt 2 and onto the ground. Pt 2 was observed in gurney moving her legs back in forth. Pt 2 remained in room as Pt 3 was subdued by security officer holding Pt 3 to the ground at the end of Pt 2 ' s gurney. Staff came in and out of camera view to assist with Pt 3. Staff were observed consoling and hugging Pt 4. Pt 2 was observed to have no staff attended to her nor move her out from the scene.

During an interview, on 9/11/25, at 9:05 a.m., with the DED, DED stated, she saw that no one went to console or attend to Pt 2 after the assault from Pt 3. DED stated, she expected staff to attend to Pt 2 and move her away from Pt 3.

During a telephone interview, on 9/11/25, at 1:30 p.m., with RN 7, RN 7 stated she had been assigned to care for Pt 2 and Pt 3. RN 7 stated she had been talking to Pt 3 prior to him attacking Pt 2, and Pt 2 had had breakfast and seemed ok. RN 7 stated, he was answering questions appropriately and no history of taking off his clothes. RN 7 stated, she was charting and heard another patient screaming. RN 7 stated she went into the room and saw Pt 3 on top of Pt 2 and called for assistance. RN 7 stated when Pt 3 had been taken to the ground, she was shaken herself and was looking to move patients around so they could move Pt 3 to a private room. RN 7 stated she went in later and assessed Pt 2. RN 7 stated, Pt 2 had been "mad" at the moment and shaken up. RN 7 stated they were trying to get placement (trying to find a psychiatric facility to transfer her to for continued care) and she was anxious. RN stated, "we should have moved Pt 2 away from Pt 3 after he had assaulted her."

On 9/11/2025, at 2:10 p.m. attempted to call and interview Pt 2. The phone was out of service.

During an interview on 9/12/25 at 11:00 with the Chief Nursing Officer (CNO), the CNO stated she expects nurses to care for the victims of an assault and to attend to the patient. The CNO stated, nurses should have communicated with Pt 2 and assisted with getting her out of the space The CNO stated, the staff should not have left Pt 2 alone immediately after the assault.

During a review of the hospital ' s policy and procedure (P&P) titled, "Standard of Practice for Emergency Department", dated 9/23/24, indicated, " ... Intervene appropriately to correct unsafe situations ...".

During a review of the hospital ' s policy and procedure titled, "Patient ' s Rights and Responsibilities (PR)"", dated 3/14/25, the "PR" indicated, " ... Purpose ... To define rights and responsibilities of patients who receive services ... Patient Rights ... To be free from neglect; exploitation or harassment; and verbal, mental, physical, physical, sexual abuse and corporal punishment [the use of physical force to discipline or punish someone] ...".

3. During a review of an Entity Reported Incident (ERI) submitted to the California Department of Public Health (CDPH) on 7/25/25, the report indicated, "On 7/23/25 @0850, male patient was brought back into [NAME OF HOSPITAL ED SCU (Special Care (Psych) Unit)] after his SOC consult [Mental Health evaluation for holding the patient] was completed. At 0856, he removed his burgundy scrubs, getting completely naked. He spoke to female patient in SCU bed 5 for a few seconds and then climbed on her gurney to lay next to her. Security and staff responded and pulled the male patient off the female patient ' s gurney. Rapid Response called. Once additional staff arrived, the male patient was separated from the other patients, redressed and placed in 4-point violent restraints. Female patient immediately assessed after incident. There were no visible injuries to patient and she reported no injury or pain. Female patient did not make an allegation of sexual assault or that she was touched inappropriately. ... Female patient ' s hold was lifted, and she was discharged."

During a concurrent interview and record review, on 9/10/25, at 10:31 a.m., with the Director of the Emergency Department (DED) and the Manager of the Emergency Department (NM 6), the Electronic Medical Record (EMR) for Pt 3 was reviewed. The document titled, "Face Sheet" dated 9/10/25 indicated Pt 3 arrived at the ED on 7/22/25 at 5:27 p.m. and was discharged from the ED on 7/23/25 at 3:30 p.m. The document titled, "Hospitalist History and Physical" dated 7/23/25 at 5:17 p.m. indicated Pt 3 was an " ... 36-year-old male patient with history of chronic psychiatric illness ... It is reported that the patient run out of his ... medication. Patient has been having manic [a distinct period characterized by an abnormality and persistently elevated, expansive or irritable mood and increased goal directed energy or activity, lasting at least one week] like symptoms associated with auditory [hearing] and visual hallucinations. Patient's family is concerned that patient is decompensating. Patient reported that he is unable to calm himself down and he sought medical help. ...". The document titled, "ED notes Addendum", dated 7/22/25, at 5:57 p.m., indicated, "Staff attempted to give pt [Patient] by mouth [lorazepam, a medication for anxiety] pt jumps out of chair and grabs staff ' s shirt and says, "How much longer". Staff stays, "I am giving you meds now" pt started talking about random things, took off his bracelet and acted as if he was recording a video. Pt cussing towards staff and family was trying to keep pt clam, attempted to push family away. Per family pt is on meds but pt does end up getting manic episodes." NM stated, no other aggressive issues and had been resting prior to interaction with Pt 2.

During a concurrent interview and surveillance video review on 9/10/25 at 1:25 p.m. with the DED and NM 6, Video shows 7/23/25 at 8:55 a.m. at the top of the screen as date and time of incident. The video shows Pt 2 on a gurney with no movement. Pt 3 was on a gurney that was perpendicular to Pt 2 and between a bathroom in the corner of the room. Pt 4 observed talking on the phone across the room from Pt 2 and Pt 3. Pt 3 observed getting off of the gurney, taking off all his clothes and grabbing his genitals. Then Pt 4 observed screaming and pointing at Pt 3. Pt 3 walks over to the foot end of Pt 2 ' s gurney and observed speaking to Pt 2. Pt 2 responds and is shaking her head "no" as Pt 3 crawls on top of Pt 2. Pt 2 observed pushing at Pt 3 and kicking at him. Security staff and staff in scrubs observed coming into the room and pulling Pt 3 off of Pt 2 and onto the ground. Pt 2 was observed on the gurney moving her legs back in forth. Pt 2 remained in room as Pt 3 was subdued by security officer holding Pt 3 to the ground at the end of Pt 2 ' s gurney. Staff came in and out of camera view to assist with Pt 3. Staff were observed consoling and hugging Pt 4. Pt 2 was observed to have no staff attending her, nor did they remove her from the scene.

During a concurrent interview and record review on 9/11/25 at 9:05 a.m., with DED and NM, the EMR for Pt 4 was reviewed. The document titled, "Face Sheet" dated 9/9/25 indicated Pt 4 arrived at the ED on 7/22/25 at 6:54 p.m. and was discharged from the ED on 7/23/25 at 1:42 p.m. The document titled, "ED Provider Notes" dated 7/22/25 at 9:39 p.m. indicated Pt 4 was an "The patient is a 26 y.o.[year old] female, who presents to the ED brought in by ambulance from clinic on a 5150 hold [a section of law code that allows for involuntary psychiatric hospitalization of individuals who meet certain criteria] for suicideal [sic] ideation/ suicidal intentions. ... Today patient allegedly had plan to overdose on medication. ... Denies current suicidal [sic] ideation/suicidal intentions, homicidal ideation, auditory/ visual hallucinations on arrival. ..." DED stated the nurse in the video who took care of Pt 4 was now on leave. DED stated, there was nothing in Pt 4 ' s EMR about the event and what was observed in the video. DED stated, the nurses should have documented what happened to Pt 4 and the interventions she took to console her after witnessing what Pt 3 had done to Pt 2.

On 9/11/2025, at 2:05 p.m. attempted to call and interview Pt 4. The phone was out of service.

During an interview on 9/12/25 at 11:00 with the Chief Nursing Officer (CNO), the CNO stated she expects nurses to care for the victims of an assault and to attend to the patient. The CNO stated, she expects nurses to assess the patients and document their findings and interventions.

During a review of the hospital ' s policy and procedure (P&P) titled, "Standard of Practice for Emergency Department", dated 9/23/24, indicated, " ... Intervene appropriately to correct unsafe situations ...".

During a review of the hospital ' s policy and procedure titled, "Patient ' s Rights and Responsibilities (PR)"", dated 3/14/25, the "PR" indicated, " ... Purpose ... To define rights and responsibilities of patients who receive services ... Patient Rights ... To be free from neglect; exploitation or harassment; and verbal, mental, physical, physical, sexual abuse and corporal punishment [the use of physical force to discipline or punish someone] ...".

4. During a review of Pt 33 ' s "ED Provider Note (EDPN-medical history, exam, and interactions with ED physician)", dated 9/9/25, "Emergency Department Care Timeline (EDCT- list of all care provided to patient in the ED)" dated 9/9/25 and 9/10/25 and "Nurse ' s Note (NN)", dated 9/10/25, the documents indicated, on 9/9/25, at 11:32 p.m., Pt 33 arrived at the Emergency Department (ED) via ambulance, reportedly experiencing shortness of breath due to anxiety. During transport, Pt 33 made statements to Emergency Medical Services Staff (EMS) indicating thoughts of self-harm, prompting a 5150 psychiatric hold (5150-a state law that allows law enforcement and mental health professionals to detain someone for 72 hours for a mental health evaluation and treatment) for danger to self. At 11:37 p.m., the ED physician admitted Pt 33 to the Special Care Unit (SCU- a locked unit within the ED) under the 5150 hold, as documented in the "EDPN". Shortly after admission, on 9/10/25, at 12:05 a.m., the "NN" indicated, Pt 33 denied expressing suicidal ideation (SI-thoughts of self-harm) to EMS or police, stating, "I want to live, that is why I'm here." At this time, Pt 33 was moved to SCU-03. At 12:19 a.m., the "EDPN" noted a code assessment was called overhead and the physician examined Pt 33 following an incident in which another patient (Pt 34) punched Pt 33 in the stomach while he was seated on his gurney in the SCU. The physician did not document any injuries. By 12:20 a.m., Pt 33 was relocated to Green Hall-02 (an area outside the SCU) for safety. The "NN" at 1:48 a.m. further detailed the assault, confirming that staff escorted Pt 33 out of the SCU and into a hallway bed. The physician was contacted, pain medication was ordered and administered, and Pt 33 spoke with the Police Department (PD). Pt 33 was monitored with a sitter at bedside, and no acute distress was observed.

During a telephone interview on 9/12/25 at 1:52 p.m. with Pt 33. Pt 33 stated he was agreeable to an interview about the incident in the Special Care Unit (SCU) from 9/9/25. Pt 33 stated he was punched in the stomach by another patient in the unit. Pt 33 stated he was lying on his hospital gurney in the SCU, and the other patient (Pt 34) was "way across the room". Pt 33 stated he called out to Pt 34 and said, "hey how are you doing?" Pt 33 stated Pt 34 hopped up out of his bed and ran across the room and punched him, on the left side of his stomach, "in my liver". Pt yelled out and tried to kick Pt 34, and Pt 34 just ran back to his bed. Pt 33 stated Pt 34 did not speak to him at all throughout the incident. Pt 33 stated the Registered Nurse (RN), and the Security Officer (SO 1) came in right away and asked him if he was alright. Pt 33 stated the staff moved him from the SCU into a bed in the main Emergency Department (ED). Pt 33 stated that after Pt 34 punched him, his stomach hurt, and the nurse examined him and gave him pain medication. Pt 33 stated the pain medications helped a little bit. Pt 33 stated the physician did not order any x-rays. Pt 33 stated he was discharged the day after the incident.

During a review of Pt 34 ' s "EDPN" dated 9/10/25, and "EDCT" dated 9/9/25 to 9/10/25, the "EDPN" indicated Pt 34 arrived in the ED by ambulance on 9/9/25. ED physician admitted Pt 34 to the ED SCU on 9/9/25 at 7:45 p.m. under a 5150 hold for danger to self and others. The "EDPN" indicated that law enforcement initiated the 5150 after Pt 34 was found experiencing hallucinations (person perceives something that is not actually present, may see, hear, smell, or taste) involving snakes and was yelling in a store. The patient repeatedly told EMS personnel, "this isn ' t real." The "EDPN" also documented methamphetamine (a powerful, highly addictive, and illegal synthetic stimulant) use, aggressive behavior, and responses to internal stimuli. Pt 34 had a known history of schizophrenia (a chronic mental health condition that affects a person's thoughts, perceptions, and behaviors). The "EDCT" indicated, Pt 34 was initially placed in SCU-04 at 7:45 p.m. and then moved to SCU-07 at 8:01 p.m. At 8:05 p.m., RN 3 documented that Pt 34 endorsed auditory and visual hallucinations, including seeing griffins (mythical creature with head, wings and talons of an eagle combined with the body, tail and legs of a lion), dragons, space aliens, and satanic imagery, and reported that voices were yelling at him. At 12:15 a.m. on 9/10/25, a continuous observation notes described Pt 34 as agitated and awake, having struck another patient in SCU-3 while experiencing hallucinations. At 12:30 a.m., RN 3 documented a significant event addendum (note added to an original document to modify or clarify) noting Pt 34 ' s paranoid behavior and hitting the SCU door. RN 3 redirected Pt 34 to bed, and he expressed frustration about sharing space with another patient (Pt 33). After requesting food and drink, Pt 34 initially calmed but later ran toward and made physical contact with Pt 33, punching him in the stomach. Security intervened, a code assessment was called, and the physician ordered violent restraints and medication. Law enforcement was notified.

During an interview and surveillance video review on 9/12/25 at 2:10 p.m. with the Director of Emergency Services (DES), and Nurse Manager (NM) 6, the surveillance video of the SCU was reviewed. The footage did not include audio. The first video, time-stamped 12:18 a.m. on 9/9/25, showed Pt 33 lying on a hospital gurney on his left side with his right hand covering his face. The gurney was positioned against the east wall under SCU 3. No other patients were visible in the frame, and the nearby SCU bays (a unit design that features several beds in an open area) were empty. Patient 34 continued to lie in approximately the same position until 12:18:56 a.m., when he (Pt 33) sat up, turned his head to the left, appeared to be speaking, and moved to the end of the gurney. Pt 33 was sitting upright with his knees bent at a 90-degree angle and his feet on the bed. At 12:18:59 a.m., Pt 34 ran up to Pt 33 ' s gurney and hit him in the stomach. Pt 33 responded by kicking Pt 34, causing Pt 34 to move backwards out of the surveillance video view. At 12:19 a.m., SO 1 and RN 3 entered the room. RN 3 checked on Pt 33, and SO 1 moved out of the video frame toward Pt 34. Pt 33 was removed from the SCU unit by staff. The second video, time-stamped 12:13 a.m., showed Patient 35 lying on a hospital gurney on his back with his eyes open while RN 3 and hospital staff were talking to him. The gurney was positioned in an alcove (a small space created by building part of a wall further back from the rest) on the south wall, SCU 7, with the glass observation window visible at the bottom left of the screen. Hospital staff left the SCU at 12:14 a.m. At 12:18:57 a.m., Patient 35 was observed moving his feet side to side. At 12:18:59 a.m., Pt 34 jumped out of bed and ran towards Pt 33 ' s bed, moving out of camera frame, Pt 34 returned to his bed immediately. At 12:19 a.m., Pt 34 was lying on his back, SO 1, and RN 3 were standing in front of the gurney. Patient 35 appeared calm while speaking with staff. Patient 34 was observed through the observation window being moved to a bed in the green zone (area in the ED). The DES stated Pt 34 showed no indication of violence until the point where he jumped out of bed and hit patient 34.

During an interview on 9/12/25 at 2:32 p.m. with Registered Nurse (RN) 3, RN 3 stated she was caring for Pt 33 and Pt 34 in the SCU. RN 3 stated Pt 34 had admitted to using methamphetamine but was calm and cooperative at first. RN 3 stated Pt 34 began to bang on the door of the unit, was paranoid and didn ' t want other people in the room with him because they were "bad" people. RN 3 stated she went into the SCU to calm Pt 34 with Security Office (SO) 1 and a paramedic inte