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Based on hospital video footage, medical record review, facility policies, facility documents, and interviews conducted, the facility failed to protect and promote the rights of 1 (Patient #8) of 20 patients sampled. Failure to uphold the rights of Patient #8 resulted in an insufficient assessment causing a deterioration in condition requiring transfer to a higher level of care.

The hospital failed to protect and promote the rights of Patient #8 by not treating the patient with dignity and respect in the ED (Emergency Department) and discharging the patient to the sidewalk in front of the ED entrance for approximately 10 hours.

This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Patient #8, and resulted in the determination of Immediate Jeopardy (IJ) on 05/15/2025. Based on the immediate action of the facility, the findings of Immediate Jeopardy were determined to be removed on 05/15/2025.


Facility immediate actions to remove the Immediate Jeopardy included:

Patient Rights- supervising physician will ensure a complete medical screen is performed by APP (Advanced Practice Practitioner) on every ED patient discharged, all discharged patients waiting for a ride will remain inside the facility until their ride arrives, all staff will complete Compassion Care education, communication: CUS tool (a communication strategy in nursing and healthcare that helps healthcare professionals express their concerns about patient safety. It stands for Concerned, Uncomfortable, Safety issue and is used to escalate safety concerns when a colleague is not taking the situation seriously enough) education, and EMTALA (Emergency Medical Treatment and Labor Act) education. All ED providers and APP's will complete EMTALA education and APP involved will complete additional education assigned by the CMO (Chief Medical Officer).

Verification of the facility's Immediate Jeopardy removal plan was conducted by the survey team on 05/15/2025. Verification of the immediate actions was confirmed through interviews conducted with 7 of 7 currently working ED staff and leadership and through signatures obtained and review of medical records showing that a Physician is reviewing and signing off on the APP medical screen for ED patients.


Refer to A142, A143, A145

Based on review of hospital video footage, medical record review, facility documents, facility policies and interviews conducted, the facility failed to provide nursing care to 1 (Patient #8) of 20 patients sampled. Failure to deliver appropriate nursing care resulted in a decline in the patient's overall condition.

The facility failed to provide a thorough assessment to an Emergency Deprartment (ED) patient (Patient #8) resulting in patient deterioration after discharge while waiting outside the main entrance of the ED.

This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Patient #8 and resulted in the determination of Immediate Jeopardy on 05/15/2025. Based on the immediate action of the facility, the findings of Immediate Jeopardy were determined to be removed on 05/15/2025.

Facility immediate actions to remove the Immediate Jeopardy included: Nursing Services: vital signs will be obtained in arrival and prior to discharge for all ED patients, ensure every ED patient has a medical screen performed by the Advance Practive Provider (APP) prior to patient being discharged, ED staff complete EMTALA (Emergency Medical Treatment and Labor Act) education, and event reports reviewed monthly for trends.

Verification of the facility's removal plan was conducted by the survey team on 05/15/2025. Verification of the immediate actions was confirmed through interviews conducted with 7 of 7 currently working ED staff and leadership and through signatures obtained and review of medical recordss showing that a Physician is reviewing and signing off on the APP medical screen for ED patients.

Refer to tag 395.

Based on review of hospital video footage, medical record review, facility documents, facility policies and interviews conducted, the facility failed to meet the emergency needs of 1 (Patient #8) of 20 patients sampled in accordance with acceptable standards of practice by not performing a medical or nursing assessment, then discharging the patient to wait outside the entrance doors for almost 10 hours prior to another admission. Failure to meet Patient #8's needs resulted in a life-threatening deterioration requiring a transfer to a higher level of care facility.

Refer A1104

This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Patient #8, and resulted in the determination of Immediate Jeopardy on 05/15/2025. Based on the immediate action of the facility, the findings of Immediate Jeopardy were determined to be removed on 05/15/2025.



Facility immediate actions to remove the Immediate Jeopardy included:

Emergency Services: vital signs will be obtained in arrival and prior to discharge for all ED patients, ensure every ED patient has a medical screen performed by the APP prior to patient being discharged, all discharged patients waiting for a ride will remain inside the facility until their ride arrives, all staff will complete Compassion Care education, communication: CUS tool (a communication strategy in nursing and healthcare that helps healthcare professionals express their concerns about patient safety. It stands for Concerned, Uncomfortable, Safety issue and is used to escalate safety concerns when a colleague is not taking the situation seriously enough) education, and EMTALA (Emergency Medical Treatment and Labor Act) education. All ED providers and APP's (Advanced Practice Proveiders) will complete EMTALA education and APP involved will complete additional education assigned by the Chief Medical Officer (CMO).

Verification of the facility's removal plan was conducted by the survey team on 05/15/2025. Verification of the immediate actions was confirmed through interviews conducted with 7 of 7 currently working ED staff and leadership and through signatures obtained and review of medical records showing that a Physician is reviewing and signing off on the APP medical screen for ED patients.

Based on video footage, medical record review, facility policies, and interviews conducted, the facility failed to ensure privacy for 1 (Patient #8) of 20 sampled. Failure to ensure privacy resulted in an incomplete assessment.


Findings included:

Review of video footage revealed:
7:49 PM Patient#8 brought in by EMS (Emergency Medical Service) via stretcher.
7:50 PM brought to nurses' station then immediately to fast track (a designated area or system designed to provide rapid care for patients with less severe conditions, allowing them to be seen and treated efficiently without taking up resources needed for more critical cases.)
7:51 PM brought to lobby moved from stretcher to wheelchair.
7:53 PM EMS talking with Staff B, Medic to register him.
7:55 PM Patient #8 registered.
7:57 PM Staff B, Medic took patients temp.
7:58 PM EMS hands patient an emesis bag and a tissue.
8:00 PM EMS in ED waiting room. APRN (Advanced Practice Registered Nurse) in waiting room, walks outside the building.
8:01 PM APRN back inside the waiting room.
804 PM APRN in waiting room behind room divider screen talking to patient. Hands in pockets.
8:05 PM APRN to triage room.
8:08 PM Staff A, RN (Registered Nurse) comes to patient in lobby. Gets patient and brings him to Fast track Room 1.
8:14 PM Radiology picks up patient.
8:28 PM back from radiology to Room 1, staff in full PPE.
8:34 PM Registration inside Room 1 with patient.
8:36 PM registration leaves room and talks with APRN.
8:43 PM APRN walks through Emergency Department (ED) lobby.
8:44 PM Staff A, RN goes into room1 with Patient #8 with paperwork in his hand.
8:45 PM Staff A, RN walked out of room 1.
8:49 PM Staff A, RN back in room.
8:50.28 PM Staff A, RN brings Patient #8 out ED lobby doors to the outdoors via wheelchair, wearing mask Patient #8 has black shirt, hat and blanket over his lap.
8:50.52 PM Locks wheelchair and returns to the lobby and to the back of the ED (out of sight)
8:51.33 PM Patient #8 seen outside lobby doors on the right side, leaning forward in wheelchair.
8:51.49. PM Patient #8 slumped over, head leaning down with head down, Staff A, RN goes outside with paper in his hand to talk to patient, Paper given to patient.
8:52.07 PM Lobby doors open again due to Staff A, RN in proximity of doors, patient seen slumped over in chair. Patient seen slouched and reading papers,
8:53 PM patient seen on video moving blanket, slouched over.
9:02 PM A person from outside in black scrubs noted to get behind patient and moved Patient #8 via wheelchair to lobby and met by Staff B, Medic in lobby. Staff B, Medic pushes patient back outside.
0906 PM Staff D, CN (Charge Nurse) and 2 male RNs seen in lobby heading to lobby doors. Staff D, CN and 1 male nurse (possibly Staff B, Medic) go outside to see patient.
9:06.19 PM Staff D, CN noted standing to right of patient with hands on hips.
9:11 PM Female nurse seen walking out talking to patient.
912 PM Nurse leaves patient and comes into ED, talks with Staff B, Medic and then returns to back of ED.
9:15 PM Staff B, Medic went out the lobby doors and moved the patient to the left side outside the lobby doors, outside of camera view.
9:33 PM - Staff B, Medic seen going outside lobby doors and returning to desk to grab gloves and going back outside, returning to desk art 9:34 PM
9:43 PM Staff D, CN brings bottle of water outside to patient. Comes back into ED lobby and speaks with Staff Medic.
9:55 PM Security noted to be talking with patient outside and then comes into lobby.
10:03 PM Staff B, Medic leaves, and the new nurse takes over new Medic.
10:48 PM Medic seen going outside to get empty wheelchair and bring it into the ED for an incoming patient, no contact noted with Patient #8.
10:55 PM Staff D, CN seen double masked going outside. She walks to the left where Patient #8 is, looks like she walks past the patient. Appears to stand with hands on her hips. Then came back in at 10:57 and talked to Medic.
11:00 PM closing fast track, multiple staff members seen come to lobby leave the unit.
11:31 PM Medic went outside the lobby doors to get a wheelchair.
11:34 PM Staff D, CN seen coming out to lobby picking up a different patient and taking her to the back.
11:50 PM Medic leaves and dark long hair staff takes over,
11:52 PM Can see patient #8 movement - can see through window patient moves blanket into view and then unable to see further.

04/25/2025
6:51 AM Medic went outside,
6:57 AM Staff F, CN, went outside.
6:58 AM Patient wheeled in by Staff F, CN. Pointing at bottom of wheelchair.
6:59 AM Staff F, CN and PCT (Patient Care technician) take Patient #8 to the bathroom via wheelchair.
7:01 PM Staff C, CN came to the outside and looked at where patient had been sitting.
7:16 AM Patient #8 brought out of bathroom via wheelchair by nurse and tech, into room 6.
7:18 AM Patient placed in bed and wheelchair removed from room.
7:30 AM. Nurses still in the room caring for patient, bringing him linens and such.

Review of the medical record revealed Patient #8 arrived via EMS on 04/24/2025 at 7:55PM with a chief complaint of pain all over for two weeks. Documented vital signs on arrival were, oral temperature was "37.8" degrees Celsius [100.0 degrees Farenheight], pulse:100 beats per minute, respiratory rate: 18 breaths per minute. His blood pressure was 108/60, his oxygen saturation was 100% on room air, and his pain intensity was two out of ten. At 8:06 PM a medical screen was completed by an APRN and revealed "no relevant medical history presents to ED today with complaints of bilateral hip pain after suffering a fall today prior to arrival. Patient stated that he lives alone but appears to be a poor historian. He says he gets around on an electric scooter and a walker but can not tell me why he needs a walker or a scooter to ambulate. When asked how long he was on the floor he replied, "not for long" and he also stated that the pain has eased up a bit." At 8:17PM a hip Xray was ordered and at 8:32PM the hip Xray revealed negative for hip fracture. Patient #8 was reevaluated by the APRN at 8:27 PM with an "Unchanged" assessment. Patient #8 was discharged home at 8:41PM. No reevaluation of vital signs or pain prior to discharge and no administration of medication.

Review of policy "Patient Rights and Responsibilities" effective 02/2024, revealed "patients have a right to privacy regarding medical care, pain management, and reasonable responses to reasonable request of service".

During an interview on 05/15/2025 at 9:30 AM, the CNO (Chief Nursing Officer) stated yes, I agree the APRN assessed him in the lobby in front of other people and it looks as if he did not even assess the him like he said he did. He should not have done that, there is no privacy there.

Based on video footage, medical record review, facility policies, and interviews conducted, the facility failed to ensure the basic right to respect, dignity and comfort for 1 (Patient #8) of 20 sampled. Failure to ensure respect, dignity and comfort resulted in an incomplete assessment, and patient pain and suffering for 10 hours spent sitting outside of the Emergency Department (ED) untreated.

Findings included:

Review of video footage revealed:
7:49 PM Patient#8 brought in by EMS (Emergency Medical Service) via stretcher.
7:50 PM brought to nurses' station then immediately to fast track (a designated area or system designed to provide rapid care for patients with less severe conditions, allowing them to be seen and treated efficiently without taking up resources needed for more critical cases)
7:51 PM brought to lobby moved from stretcher to wheelchair.
7:53 PM EMS talking with Staff B, Medic to registered him.
7:55 PM Patient #8 registered.
7:57 PM Staff B, Medic took patients temp.
7:58 PM EMS hands patient an emesis bag and a tissue.
8:00 PM EMS in ED waiting room. APRN in waiting room, walks outside
8:01 PM APRN back inside the waiting room.
804 PM APRN in waiting room behind screen talking to patient. Hands in pockets.
8:05 PM APRN to triage room
8:08 PM Staff A, RN comes to patient in lobby. Gets patient and brings him to Fast track Room 1.
8:14 PM Radiology picks up patient.
8:28 PM back from radiology to Room 1, staff in full PPE.
8:34 PM Registration inside Room 1 with patient.
8:36 PM registration leaves room and talks with APRN
8:43 PM APRN walks through lobby
8:44 PM Staff A, RN goes into room1 with patient with paperwork in his hand
8:45 PM Staff A, RN walked out of room 1
8:49 PM Staff A, RN back in room.
8:50.28 PM Staff A, RN brings Patient #8 out lobby doors via wheelchair, wearing mask Patient #8 has black shirt, hat and blanket over his lap.
8:50.52 PM Locks wheelchair and returns to the lobby and to the back of the ED (out of sight)
8:51.33 PM Patient #8 seen outside lobby doors on the right side, leaning forward in wheelchair.
8:51.49. PM Patient #8 slumped over, head leaning down with head down, Staff A, RN goes outside with paper in his hand to talk to patient, Paper given to patient.
8:52.07 PM Lobby doors open again due to Staff A, RN in proximity of doors, patient seen slumped over in chair. Patient seen slouched and reading papers,
8:53 PM patient seen on video moving blanket, slouched over.
9:02 PM A person from outside in black scrubs noted to get behind patient and moved him via wheelchair to lobby and met by Staff B, Medic in lobby. Staff B, Medic pushes patient back outside.
906 PM Staff D, CN and 2 male RNs seen in lobby heading to lobby doors. Staff D, CN and 1 male nurse (possibly Staff B, Medic) go outside to see patient.
9:06.19 PM Staff D, CN noted standing to right of patient with hands of hips.
9:11 PM larger female nurse seen walking out talking to patient.
9:12 PM Nurse leaves patient and comes into ED, talks with Staff B, Medic and then returns to back of ED
9:15 PM Staff B, Medic went out the lobby doors and moved the patient to the left side outside the lobby doors, outside of camera view.
9:28 PM white male patient brought outside lobby doors on the right side by female tech.
9:29 PM white male patient picked up by vehicle
9:33 PM Staff B, Medic seen going outside lobby doors and returning to desk to grab gloves and going back outside, returning to desk art 9:34PM.
9:36 PM purple hair nurse seen leaving through lobby doors. 9:38 came back in with food.
9:43.15 PM Staff D, CN brings bottle of water outside to patient. Comes back into ED lobby and speaks with Staff Medic.
9:55 PM security noted to be talking with patient outside and then comes into lobby
10:03 PM Staff B, Medic leaves, and the new nurse takes over new Medic.
10:20 PM female black-haired nurse seen walking through lobby doors to outside, past patient,
10:48 PM Medic seen going outside to get empty wheelchair and bring it into the ED for an incoming patient, no contact noted with Patient #8.
10:55 PM Staff D, CN seen double masked going outside. She walks to the left where patient #8 is, looks like she walks past the patient. Appears to stand with hands on her hips. Then came back in at 10:57 PM and talked to Medic.
11:00 PM closing fast track, multiple staff members seen come to lobby leave.
11:31 PM Medic went outside the lobby doors to get a wheelchair.
11:34 PM Staff D, CN seen coming out to lobby picking up a different patient and taking her to the back.
11:50 PM Medic leaves and dark long hair staff takes over,
11:52 PM Can see patient #8 movement - can see through window patient moves blanket into view and then unable to see further

04/25/2025
6:51 AM Medic went outside,
6:57 AM Staff F, CN, went outside.
6:58 AM Patient wheeled in by Staff F, CN. Pointing at bottom of wheelchair.
6:59 AM Taken to the bathroom. PCT with her.
7:01 AM Staff C, CN came to the outside and looked at where patient had been sitting.
7:16 AM Patient #8 brought out of bathroom via wheelchair by nurse and tech, into room 6
7:18 AM Patient placed in bed and wheelchair removed from room.
7:30 AM. Nurses still in the room caring for patient, bringing him linens and such.

Review of the medical record revealed Patient #8 arrived via EMS on 04/24/2025 at 7:55PM with a chief complaint of pain all over for two weeks. Documented vital signs on arrival were, oral temperature was "37.8" degrees Celsius [100.0 degrees Farenheight], pulse:100 beats per minute, respiratory rate: 18 breaths per minute. His blood pressure was 108/60, his oxygen saturation was 100% on room air, and his pain intensity was two out of ten. At 8:06PM a medical screen was completed by an APRN and revealed "no relevant medical history presents to ED today with complaints of bilateral hip pain after suffering a fall today prior to arrival. Patient brought in by EMS. Patients stated that he lives alone but appears to be a poor historian. He says he gets around on an electric scooter and a walker but can not tell me why he needs a walker or a scooter to ambulate. When asked how long he was on the floor he replied, "not for long" and he also stated that the pain has eased up a bit. Appearance/Presentation: Hygiene poor." At 8:17PM a hip Xray was ordered and at 8:32PM the hip Xray revealed negative for hip fracture. Patient #8 was reevaluated by the APRN at 8:27PM with an "Unchanged" assessment. Patient #8 was discharged home at 8:41PM. No reevaluation of vital signs or pain prior to discharge and no administration of medication.

Review of policy "Patient Rights and Responsibilities" effective 02/2024, revealed "patients have a right to privacy regarding medical care, pain management, and reasonable responses to reasonable request of service".

During an interview on 05/15/2025 at 9:30 AM, the CNO (Chief Nursing Officer) stated yes, I agree the APRN assessed him in the lobby in front of other people, and it looks as if he did not even really assess the hip. He should not have done that; there is no privacy there.

Based on hospital video footage, medical record review, interviews, and facility policy, the facility failed to protect the patients' right to be free from neglect for one (Patient #8) out of 20 sampled patients.

Findings included:

Review of the hospital video footage revealed:
7:49 PM Patient#8 brought in to the Emergency Department (ED) by EMS (Emergency Medical Service) via stretcher.
7:50 PM brought to nurses' station then immediately to fast track (a designated area or system designed to provide rapid care for patients with less severe conditions, allowing them to be seen and treated efficiently without taking up resources needed for more critical cases.)
7:51 PM brought to lobby moved from stretcher to wheelchair.
7:53 PM EMS talking with Staff B, Medic to registered him.
7:55 PM Patient #8 registered.
7:57 PM Staff B, Medic took patients temp.
7:58 PM EMS hands patient an emesis bag and a tissue.
8:00 PM EMS in ED waiting room. Advanced Practice Registered Nurse (APRN) in waiting room, walks outside.
8:01 PM APRN back inside the waiting room.
8:04 PM APRN in waiting room behind screen talking to patient. Hands in pockets.
8:05 PM APRN to triage room
8:08 PM Staff A, Registered Nurse (RN) comes to Patient #8 in lobby. Gets patient and brings him to Fast track Room 1.
8:14 PM Radiology picks up patient.
8:28 PM back from radiology to Room 1, staff in full PPE.
8:34 PM Registration inside Room 1 with patient.
8:36 PM registration leaves room and talks with APRN
8:43 PM APRN walks through lobby
8:44 PM Staff A, RN goes into room 1 with patient with paperwork in his hand
8:45 PM Staff A, RN walked out of room 1
8:49 PM Staff A, RN back in room.
8:50.28 PM Staff A, RN brings Patient #8 out lobby doors via wheelchair, wearing mask Patient #8 has black shirt, hat and blanket over his lap.
8:50.52 PM Locks wheelchair and returns to the lobby and to the back of the ED (out of sight)
8:51.33 PM Patient #8 seen outside lobby doors on the right side, leaning forward in wheelchair.
8:51.49. PM Patient #8 slumped over, head leaning down with head down, Staff A, RN goes outside with paper in his hand to talk to patient, Paper given to patient.
8:52.07 PM Lobby doors open again due to Staff A, RN in proximity of doors, patient seen slumped over in chair. Patient seen slouched and reading papers,
8:53 PM patient seen on video moving blanket, slouched over.
9:02 PM A person from outside in black scrubs noted to get behind patient and moved him via wheelchair to lobby and met by Staff B, Medic in lobby. Staff B, Medic pushes patient back outside.
9:06 PM Staff D, CN and 2 male RNs seen in lobby heading to lobby doors. Staff D, Charge Nurse (CN) and 1 male nurse (possibly Staff B, Medic) go outside to see patient.
9:06.19 PM Staff D, CN noted standing to right of patient with hands of hips.
9:11 PM larger female nurse seen walking out talking to patient.
9:12 PM nurse leaves patient and comes into ED, talks with Staff B, Medic and then returns to back of ED
9:15 PM Staff B, Medic went out the lobby doors and moved the patient to the left side outside the lobby doors, outside of camera view.
9:28 PM white male patient brought outside lobby doors on the right side by female tech.
9:29 PM white male patient picked up by vehicle
9:33 PM Staff B, Medic seen going outside lobby doors and returning to desk to grab gloves and going back outside, returning to desk art 9:34
9:36 PM purple hair nurse seen leaving through lobby doors. 9:38 came back in with food.
9:43 .15 PM Staff D, CN brings bottle of water outside to patient. Comes back into ED lobby and speaks with Staff Medic.
9:55 PM security noted to be talking with patient outside and then comes into lobby
10:03 PM Staff B, Medic leaves, and the new nurse takes over new Medic.
10:20 PM female black-haired nurse seen walking through lobby doors to outside, past patient,
10:48 PM Medic seen going outside to get empty wheelchair and bring it into the ED for an incoming patient, no contact noted with Patient #8.
10:55 PM Staff D, CN seen double masked going outside. She walks to the left where Patient #8 is, looks like she walks past the patient. Appears to stand with hands on her hips. Then came back in at 10:57 and talked to Medic.
11:00 PM closing fast track, multiple staff members seen come to lobby leave.
11:31 PM Medic went outside the lobby doors to get a wheelchair.
11:34 PM Staff D, CN seen coming out to lobby picking up a different patient and taking her to the back.
11:50 PM Medic leaves and dark long hair staff takes over,
11:52 PM Can see patient #8 movement - can see through window patient moves blanket into view and then unable to see further

04/25/2025
06:51 AM Medic went outside,
6:57 AM Staff F, CN, went outside.
06:58 AM Patient wheeled in by Staff F, CN. Pointing at bottom of wheelchair.
6:59 AM Taken to the bathroom. PCT with her.
0701 AM Staff C, CN came to the outside and looked at where patient had been sitting.
07:16 AM Patient #8 brought out of bathroom via wheelchair by nurse and tech, into room 6
7:18 AM Patient placed in bed and wheelchair removed from room.
7:30 AM. Nurses still in the room caring for patient, bringing him linens and such.

Review of the medical record revealed Patient #8 arrived via EMS on 04/24/2025 at 7:55 PM with a chief complaint of pain all over for two weeks. Documented vital signs on arrival were, oral temperature was "37.8" degrees Celsius [100.0 degrees Fahrenheit], pulse:100 beats per minute, respiratory rate: 18 breaths per minute. His blood pressure was 108/60, his oxygen saturation was 100% on room air, and his pain intensity was two out of ten. At 8:06PM a medical screen was completed by an APRN and revealed "no relevant medical history presents to ED today with complaints of bilateral hip pain after suffering a fall today prior to arrival. Patient brought in by EMS. Patients stated that he lives alone but appears to be a poor historian. He says he gets around on an electric scooter and a walker but can not tell me why he needs a walker or a scooter to ambulate. When asked how long he was on the floor he replied, "not for long" and he stated that the pain has eased up a bit. Appearance/Presentation: Hygiene poor." At 8:17PM a hip Xray was ordered and at 8:32PM the hip Xray revealed negative for hip fracture. Patient #8 was reevaluated by the APRN at 8:27PM with an "Unchanged" assessment. Patient #8 was discharged home at 8:41 PM. There was no reevaluation of vital signs or pain prior to discharge and no administration of medication.

An interview was conducted on 5/12/25 at 4:00PM with Staff A, Registered Nurse (RN). He said he has worked here for about a year and a half. Staff A, RN said Patient #8 came in by EMS and he was working in the Fast Track area and he heard across the radio Patient #8 was going to be in Fast Track. On arrival Patient #8 was placed in a wheelchair and he had a very bad odor to him and there was another patient in the chair next to him, so Staff A, RN requested Patient #8 be placed in a private room due to the odor and there being a patient next to him. Staff A, RN said the patient next to Patient #8 was not complaining he just requested the move to a private room because he is familiar with Patient #8 and he does not bathe properly and is at times homeless but, this particular visit Patient #8 said he had a home and EMS said they picked him up at an apartment. Staff A, RN said "at one point I did offer him a gown to take home because of his foul odor, and we do not have an area to bathe him. [Patient #8] declined the gown." Staff A, RN said Staff D, ED Charge Nurse (CN) advised him to put Patient #8 outside and Patient #8 agreed to it so, he was placed out front of the ED shortly before the Fast Track area closed down at 9:00 p.m. Staff A, RN said he does not recall going back outside to check on him. Staff A, RN said at midnight, when he left, he walked past Patient #8 still sitting in his wheelchair still outside of the ED. He said next time they should not leave the patient outside.

An interview was conducted on 5/12/25 at 4:23 PM Staff B, Paramedic. He said he was working triage the night Patient #8 came into the ED. EMS brought Patient #8 through the back and brought him up front in the stretcher and placed him in a wheelchair in the Fast Track area. EMS told him Patient #8 was there for pain all over. Staff B, Paramedic said Patient #8 was in obvious pain the way he was moaning. Staff B, Paramedic said he obtained vitals off the EMS machine because he was not used to EMS coming up to the front with a patient on a stretcher. Staff B, Paramedic said there were a couple people checking into the ED and they had made a comment about the smell and Patient #8 had body odor that was spreading throughout the emergency room so Staff A, RN called the charge nurse and got approval to put Patient #8 in a room due to the body odor plus he was moaning in pain. Staff B, Paramedic said Staff A, RN took the patient back to the room and he said he stayed at the front of the ED where he was stationed and did not see Patient #8 until Staff A, RN wheeled him outside and placed him by the ED doors. Staff B, Paramedic said he checked on Patient #8 outside about three times and he was presenting the same as when he came in. "He was out there and there seemed like something was wrong with him. and I kept telling Staff D, ED CN he ' s still sitting out there and he ' s making noises, she said she was calling the supervisor to get him a ride. Staff D, Paramedic said if the patient would have stayed in the back of the ED where EMS originally brought him in and not come to the Fast Track area he would've gotten a more thorough workup with labs, gown, intravenous (IV) line but he doesn't know why Patient #8 came up to the Fast Track area. He said the charge nurse assigns the patients location. He then said when he was checking Patient #8 in there were two past file records for him and he chose the first file because Patient #8 looked at the file and confirmed the address but the file that was chosen did not have his updated medical history in it which he did not found out till later.

During a group interview on 05/12/2025 at 4:47PM, the CEO (Chief Executive Officer), CNO (Chief Nursing Officer), VPQ (Vice President of Quality), Director of Patient Safety, ED Director, ED Manager, and Staff C, ED CN confirmed the patient was not worked up properly, was not stable for discharge and was not provided a safe discharge. Allowing a patient to sit outside the ED entrance all night, approximately 10 hours, in a wheelchair is not ok.

An interview was conducted on 5/12/25 at 4:49 PM with the ED Director. He said Patient #8 came in for a fall and was discharged. He was placed outside of the ED doors in a wheelchair and that is where he remained until his car service was actually coming, on 4/25/25 at 6:00AM. The day shift nurses brought him back to clean him up before he got into the car service and that is when his coccyx wounds were discovered, and he was weak, so he was readmitted and that is when they discovered how sick he actually was.

An interview was conducted on 5/12/25 at 5:00PM with Staff C, ED CN. She said she has worked at the facility for six years and she said she was familiar with Patient #8. She said she got to work about ten minutes to 6:00AM and Patient #8 was sitting in a wheelchair outside of the ED doors, she said good morning to him and he said hello. She said her and Staff D, ED CN were doing report and Staff D, ED CN said Patient #8 was waiting for a car service and the Staff E, House Supervisor could not provide a car service for him so they were waiting for the day shift supervisor to come on to order him a car service. Staff D, ED RN told her Patient #8 needed to be cleaned up and he had clean scrubs. She said she did not know why night shift did not clean up Patient #8. Staff F, RN and a Patient Care Technician (PCT) brought Patient #8 back to the ED bathroom and he was very weak and could not get on or off the toilet or hold himself up while they cleaned him and when they wiped his backside there was blood so Staff F, RN said she needed a doctor and the doctor came to the bathroom and said lets get him to a bed and assess him. It was difficult getting him back into the wheelchair because of his weakness. But they brought him to the bed, finished getting him cleaned up, and that is when they realized he had wounds to his coccyx.

A phone interview was conducted on 5/13/25 at 1:49 PM with Staff D, ED CN. She said she has worked as the ED charge nurse for almost 3 years. She said she received a call from EMS and Patient #8 was originally called in as female with generalized body aches and pains. That night was busy, and she had a provider out in the Fast Track area, so she sent Patient #8 to the Fast Track. When he arrived, EMS added he had hip pain, and she asked Patient #8 what his pain was, and he said it was a two [minimal pain] all over. So, she sent him to the Fast Track area because she had several people being admitted "upstairs" and if he needed to come to the back of the ED he could. Once he was in Fast Track and the ED staff requested to put him in room two and they might need to get him changed because he smelled. Staff D, ED CN said he wasn't there to originally be seen long "I think he was there about an hour" and the provider let her know he was being discharged, and he might need a ride. "The nurse [Staff A, RN] asked if I wanted to leave Patient #8 in the room and I said no because I have to shut down rooms one through five because Fast Track was closing." Staff D, ED CN said Patient #8 wanted to go outside because he was complaining it was cold in the room. So, because he wanted to go outside, he was placed outside the ED in a wheelchair with a blanket. She said after a couple of hours of him being outside she called the house supervisor and told her Patient #8 said his sister was coming but "she's not here can we get a [Car Service] and the supervisor said she would get back to me." Staff D, ED CN said it was probably another hour or two hours, and she was having difficulty with the computer, but she was trying to get him a car service but it's normal not to have a car service available at night because of the hospital being in a small town. She said the House Supervisor brought Patient #8 scrubs to change into. She said when she left that morning at 6:00AM she told Patient #8 they were trying to get him a car service and Staff D, ED RN said to Patient #8 "you good? He said I'm good." and then she left.

An interview was conducted on 5/13/25 at 2:34 PM with Staff B, Paramedic he said when Patient #8 arrived he thought he needed a bed in the back not in the Fast Track. You could tell by looking at him he needed a more thorough work up than just a Fast Track work up. He said he had been a paramedic, for about 30 years with fire rescue and had hospital experience. He said EMS did not do a good job giving us a history on him. "Staff A, RN and I both agreed he needed to go in the back for a more thorough work up but the charge nurse [Staff D, ED CN] makes the calls, she ' s in charge, [Staff D, ED CN] likes it done her way so we were only able to put him in a Fast Track room." Staff B, Paramedic said after Patient #8 was discharged, Staff B, Paramedic said he saw Staff A, RN bring Patient #8 outside of the ED, so he asked Staff A, RN "what's that about and he said I ' m just doing what I was told." Staff B, Paramedic said he called the charge nurse three times that night and told her he had concerns because Patient #8 was moaning and still sitting outside, and she just said she called the supervisor and to "just leave him out there."

An interview was conducted on 5/13/25 at 3:31 PM with Staff A, RN he said at the time the patient arrived to the ED he did not smell like feces he smelled of "body odor" and he had poor hygiene. He said as soon as he arrived at the check-in area the Fast Track area immediately started to smell. He said the Fast Track area is a room that has chairs in it with little "dividers" in between each chair. He said when patients arrive, the charge nurse assigns the location of where the patients are placed and Staff D, ED CN assigned Patient #8 to chair two in the Fast Track area but there was a patient already in chair one and with only the divider in between the two the chairs he said he called the charge nurse to see if he could move the patient to room 1 which is a room just off the Fast Track area that is normally utilized for procedures that require more privacy than just a divider. He said Staff D, ED CN said "if that ' s what you want to do that's fine" so Staff B, RN moved Patient #8 into room one. Staff B, RN said he noticed Patient #8's clothes were dirty so he offered him a gown "because we don ' t have extra clothes, but the patient said he wanted to wear his clothes and didn't want the gown." Staff B, RN said once Patient #8 was discharged, Staff B, RN told Staff D, ED CN Patient #8 may need a ride but with his odor a car service may decline the ride because they don't want to put him in their car. He said Staff D, ED RN was the person who gave him directive to place the patient outside. Staff B, RN said he did not know why she told him to put Patient #8 outside, but he can only "speculate because the Fast Track area was closing."Staff B, RN said Staff D, ED CN does have a reputation for not being the nicest but that was not his experience, but he does know some nurses feel that way.

A phone interview was conducted on 5/13/25 at 3:37PM with the ED Medical Director. He said for someone who comes into the ED with generalized pain he would ask if there were a joint in particular that is bothering them that made them come to the ED and ask about chronic disease process to determine a history of arthritis. He said he would try to narrow down the pain, palpate and perform range of motion. He said he does not necessarily expose the skin unless during palpation he feels an abnormality or displacement or if someone complains of a wound. He said if someone is having tenderness to their hip on palpation and they are wheelchair bound or use a walker he would invert and evert the hip and start with an order for a hip Xray then he may or may not provide pain control. He said if the Xray comes back negative, he would reassess in terms of pain control. A lot of times patients come to the ED to determine if a bone is broken or not and once, they find out the bone is not broken they feel comfortable to go home with a primary care physician follow up and over the counter medications for pain.

A phone interview was conducted on 5/13/25 at 8:08PM with Staff E, House Supervisor. She said she remembered Patient #8 and she was filling in as the House Supervisor that night, which she had done before, but she was normally a night shift Intensive Care Unit (ICU) nurse. She said she was rounding in the ED around 9:00PM and Staff D, ED CN told her Patient #8 was discharged and outside waiting for his ride, but he may need a car service. She told Staff D, ED CN "okay let me know" and she went outside to see Patient #8. She said Patient #8 was sitting in his wheelchair, awake, alert, and appeared to be talking to someone on the phone. She asked him if he needed a ride and he said his sister was going to come and get him and she told him okay let them (ED staff) know if you need anything. She said she did not see him anymore that night. She said it was not until about 2:00AM when Staff D, ED CN called her and asked if she was able to get a car service and she said she didn't know she needed to get him one, so she tried to log into the car service account and she could not get into it so she called Staff D, ED CN back and told her she couldn't log into the system and since it was so close until the day shift supervisor was supposed to come in she said she would "keep trying and let the day shift supervisor know." Staff E, House Supervisor said when the day shift supervisor arrived, she told her Patient #8 needed a car service and the day shift supervisor said its normal to not be able to get a car service at night and the day shift house supervisor was able to order him a car service and she left.

An interview was conducted on 5/14/25 at 10:55 AM with Staff F, RN. She said she was working 6:00AM to 6:00PM on 4/25/25 and she overheard the two charge nurses Staff D, ED CN and Staff C, ED CN doing report. She overheard Staff D, ED CN telling Staff C, ED CN "there was a patient outside because he was "dumping" feces all over because he wanted to stay because his family could not take care of him." Staff F, RN said she heard Staff D, ED CN telling Staff C, ED CN he had a car service coming "but he was dumping [urine] and [feces] everywhere so he needs to be cleaned up before the [Car Service] comes here" and Staff D, ED CN gave Staff C, ED CN some scrubs. She overheard Staff C, Ed CN on the headset ask for someone to bring Patient #8 back inside and Staff F, RN said she was not doing anything so she said she would help. She went outside and when she approached him she saw he was sitting outside of the ED doors next to the bench with the wheelchair locked from the back. When she went to unlock his wheelchair, she saw there was dry "poop" on the back of the wheelchair where his back was resting and there was "poop" dripping from the back of the wheelchair onto the pavement. Staff F, RN said she went into "mom nurse mode" and said to Patient #8 "hey I'm going to bring you inside to get you cleaned up" and she began to wheel him into the bathroom in the ED, and she asked another employee to help her. She said when she got the patient into the bathroom he was "covered in poop" to the point there was poop in his shoes, up his back, it had soaked through his jean shorts and it had crusted onto the wheelchair so when we tried to lift him to assist him off of the wheelchair his legs were stuck on the chair because the "poop on his legs had dried onto the wheelchair." She said at that point they placed a towel on the toilet so he could sit down, and she said she is not normally a loud person but she was so mad at the way the patient was treated and how he was presenting she called over the headset she needed help now and get the ED Medical Director! She said when the other nurses and the doctor came into the bathroom she said, "This is [explicit] ridiculous who left him like this?" She said at that point the doctor said let's take him back into a room and get him looked at.

An interview was conducted on 5/14/25 at 11:30AM with Staff G, RN she said the night shift "absolutely" knew the patient was soiled but they were waiting until the ride was coming before they changed him. She said Staff D, ED CN told the other staff to place the patient outside and he stayed outside until the day shift staff came in and ordered him a ride and got him changed and that's when it was discovered how sick he really was.

A phone interview was conducted with the ED Director on 5/14/25 at 4:30 PM he said Patient #8 came in, was discharged, they let him sit outside, they went to clean him up for his ride in the morning and he had "poop" all over him and he had wounds. They were working him up for sepsis. The ED Director said he stopped and saw the patient when he walked through the ED in the morning. He said Patient #8 asked for a drink of his water, he handed him his water, he said he didn't even know that was Patient #8 who asked for water. The ED Director said Staff C, ED CN told him "oh this guy his hemoglobin was 2.3 lactic acid was 16 so we are going to transfer him out for a possible GI bleed." The ED Director said the ED Manager and Staff C, ED CN told him about the concerns they had about Patient #8 ' s care at the safety huddle at 8:45 AM. The ED Director said the concern was they felt "they [night shift staff]" just left the patient outside all night. He said he reviewed part of the video footage until 12:00AM because he had to go home early that day. He said at 9:00PM that is a pretty busy time for their ED and it was pretty common to place a patient outside while they wait for a ride. He said for a Fast Track patient with pain, the nurse should do a focused assessment. For hip pain the nurse should palpate, ask if they can ambulate, do range of motion. He said patients who come into the ED should have vitals taken and he was very disappointed when he heard Patient #8 did not have vitals or follow up vitals taken. He said normal vitals are pulse less than 100, blood pressure 170 to 180 over 90 and a temperature of 97 to 99 degrees.

Review of facility policy "Abuse, Neglect, Exploitation" effective 08/2023 states "the purpose of the policy is patients have the right to be free from mental, physical, mental, sexual, and verbal abuse, neglect and exploitation. It is the policy of this facility to protect patients from real or perceived abuse, neglect to exploitation from anyone, including staff members, students, volunteers, other patients, visitors or family members..... Medical Neglect- the failure to seek, obtain, or to follow through with medical care for the person, with the failure resulting in an observable, material impairment to the growth, development ad /or functioning of the person."

Review of facility event log on 04/25/2025 patient event entered by staff was described as "We were told a patient was outside waiting for a ride service and made need to be changed prior to ride service arrival. There were scrubs waiting at the nurse's station."

Based on review of hospital video footage, medical record review, facility documents, facility policies and interviews conducted, the facility failed to properly evaluate 1 (Patient #8) of 20 patients sampled.

Findings included:

Review of hospital video footage revealed:
7:49 PM Patient#8 brought in by EMS (Emergency Medical Services) via stretcher.
7:50 PM brought to nurses' station then immediately to fast track (a designated area or system designed to provide rapid care for patients with less severe conditions, allowing them to be seen and treated efficiently without taking up resources needed for more critical cases.)
7:51 PM brought to lobby moved from stretcher to wheelchair.
7:53 PM EMS talking with Staff B, Medic to registered him.
7:55 PM Patient #8 registered.
7:57 PM Staff B, Medic took patients temperature.
7:58 PM EMS hands patient an emesis bag and a tissue.
8:00 PM EMS in ED waiting room. APRN (Advanced Practice Registered Nurse) in waiting room, walks outside.
8:01 PM APRN back inside the waiting room.
804 PM APRN in waiting room behind screen talking to patient. Hands in pockets.
8:05 PM APRN to triage room
8:08 PM Staff A, Registered Nurse (RN) comes to patient in lobby. Gets patient and brings him to Fast track Room 1.
8:14 PM Radiology picks up patient.
8:28 PM back from radiology to Room 1, staff in full PPE (Personal Protective equipment).
8:34 PM Registration inside Room 1 with patient.
8:36 PM registration leaves room and talks with APRN
8:43 PM APRN walks through lobby
8:44 PM Staff A, RN goes into room 1 with patient with paperwork in his hand
8:45 PM Staff A, RN walked out of room 1
8:49 PM Staff A, RN back in room.
8:50.28 PM Staff A, RN brings Patient #8 out lobby doors via wheelchair, wearing mask Patient #8 has black shirt, hat and blanket over his lap.
8:50.52 PM Locks wheelchair and returns to the lobby and to the back of the ED (out of sight)
8:51.33 PM Patient #8 seen outside lobby doors on the right side, leaning forward in wheelchair.
8:51.49. PM Patient #8 slumped over, head leaning down with head down, Staff A, RN goes outside with paper in his hand to talk to patient, Paper given to patient.
8:52.07 PM Lobby doors open again due to Staff A, RN in proximity of doors, patient seen slumped over in chair. Patient seen slouched and reading papers,
8:53 PM patient seen on video moving blanket, slouched over.
9:02 PM A person from outside in black scrubs noted to get behind patient and moved him via wheelchair to lobby and met by Staff B, Medic in lobby. Staff B, Medic pushes patient back outside.
906 PM Staff D, Charge Nurse (CN) and 2 male RNs seen in lobby heading to lobby doors. Staff D, CN and 1 male nurse (possibly Staff B, Medic) go outside to see patient.
9:06.19 PM Staff D, CN noted standing to right of patient with hands of hips.
9:11 PM larger female nurse seen walking out talking to patient.
9:12 PM nurse leaves patient and comes into ED, talks with Staff B, Medic and then returns to back of ED
9:15 PM Staff B, Medic went out the lobby doors and moved the patient to the left side outside the lobby doors, outside of camera view.
9:28 PM white male patient brought outside lobby doors on the right side by female tech.
9:29 PM white male patient picked up by vehicle
9:33 PM Staff B, Medic seen going outside lobby doors and returning to desk to grab gloves and going back outside, returning to desk art 9:34 PM
9:36 PM purple hair nurse seen leaving through lobby doors. 9:38 came back in with food.
9:43.15 PM Staff D, CN brings bottle of water outside to patient. Comes back into ED lobby and speaks with Staff Medic.
9:55 PM security noted to be talking with patient outside and then comes into lobby
10:03 PM Staff B, Medic leaves, and the new nurse takes over new Medic.
10:20 PM female black-haired nurse seen walking through lobby doors to outside, past patient,
10:48 PM Medic seen going outside to get empty wheelchair and bring it into the ED for an incoming patient, no contact noted with Patient #8.
10:55 PM Staff D, CN seen double masked going outside. She walks to the left where patient #8 is, looks like she walks past the patient. Appears to stand with hands on her hips. Then came back in at 10:57 and talked to Medic.
11:00 PM closing fast track, multiple staff members seen come to lobby leave.
11:31 PM Medic went outside the lobby doors to get a wheelchair.
11:34 PM Staff D, CN seen coming out to lobby picking up a different patient and taking her to the back.
11:50 PM Medic leaves and dark long hair staff takes over,
11:52 PM Can see patient #8 movement - can see through window patient moves blanket into view and then unable to see further

04/25/2025
6:51 AM Medic went outside,
6:57 AM Staff F, CN, went outside.
6:58 AM Patient wheeled in by Staff F, CN. Pointing at bottom of wheelchair.
6:59 AM Taken to the bathroom. PCT with her.
701 AM Staff C, CN came to the outside and looked at where patient had been sitting.
7:16 AM Patient #8 brought out of bathroom via wheelchair by nurse and tech, into room 6
7:18 AM Patient placed in bed and wheelchair removed from room.
7:30 AM. Nurses still in the room caring for patient, bringing him linens and such.

Review of medical record revealed Patient#8 checked into the ED (Emergency Department) on 04/24/2025 at 7:55 PM with a chief complaint of pain all over for two weeks. Documented vital signs on arrival were oral temperature was "37.8" degrees Celsius [100.0 degrees Fahrenheit], pulse:100 beats per minute, respiratory rate: 18 breaths per minute. His blood pressure was 108/60, his oxygen saturation was 100% on room air, and his pain intensity was two out of ten. A medical screen was completed by an APRN and revealed "no relevant medical history presents to ED today with complaints of bilateral hip pain after suffering a fall today prior to arrival. Patient brought in by EMS. Patients stated that he lives alone but appears to be a poor historian. He says he gets around on an electric scooter and a walker but can not tell me why he needs a walker or a scooter to ambulate. When asked how long he was on the floor he replied, "not for long" and he also stated that the pain has eased up a bit. Appearance/Presentation: Hygiene poor." A nursing assessment revealed steady gait, ambulates independently, skin warm, dry, intact, no complaints of lesions, rash, wounds, bruises, petechiae or abrasions. No reassessment of Patient #8 vital signs or assessment prior to discharge home/outside in wheelchair.

Review of medical record revealed on 04/25/2025 at 07:15 AM, Patient #8 was brought back into the ED by the ED staff for check in. Chief complaint states "patient arrived to ED via ambulance last night- patient was seen and discharged, patient was waiting outside in a wheelchair; when nurse went outside patient was severely weak, unable to stand and covered in feces; significant wounds are noted to patient's bottom with active bleeding, states he is just "in so much pain". Per ED MD note, "62 yr old man with a past medical history of ostomy reversal and current urostomy here complaining of generalized weakness and diarrhea over past several days. Patient states he has had pain all over his body for the past week or so and was seen at this facility last night where he was determined to have no acute traumatic injury and discharged home. While waiting for ride, patient developed urinary and fecal incontinence and was struggling to care for himself. He was not able to ambulate by himself without a wheelchair. Patient stated he lives alone and has no one to help are for him. Nursing assessment revealed unstageable wound on coccyx, alert and awake, skin is cool and diaphoretic, tachycardic (having an abnormally fast heart rate), unable to stand by himself. Lab results revealed hemoglobin (an iron-rich protein in red blood cells that carries oxygen from the lungs to the rest of the body) 2.4 (normal levels 13.7-17.5) and lactic acid (indicating whether body tissues are receiving enough oxygen. Elevated levels can suggest tissue hypoxia, shock, sepsis, heart failure, or liver disease.) 17 (normal levels 0.4- 2.0). Patient admitted and transferred to [another hospital] for severe anemia (a condition where the body has an abnormally low level of red blood cells (RBCs) or hemoglobin, the protein in RBCs that carries oxygen) and septic shock (a life-threatening condition that occurs when the body's immune system overreacts to an infection, leading to widespread inflammation and organ damage).

An interview was conducted on 5/12/25 at 4:00PM with Staff A, Registered Nurse (RN). He said he has worked here for about a year and a half. Staff A, RN said Patient #8 came in by EMS and he was working in the Fast Track area and he heard across the radio Patient #8 was going to be in Fast Track. On arrival Patient #8 was placed in a wheelchair and he had a very bad odor to him and there was another patient in the chair next to him, so Staff A, RN requested Patient #8 be placed in a private room due to the odor and there being a patient next to him. Staff A, RN said the patient next to Patient #8 was not complaining he just requested the move to a private room because he is familiar with Patient #8 and he does not bathe properly and is at times homeless but, this particular visit Patient #8 said he had a home and EMS said they picked him up at an apartment. Staff A, RN said "at one point I did offer him a gown to take home because of his foul odor, and we do not have an area to bathe him. [Patient #8] declined the gown." Staff A, RN said Staff D, ED Charge Nurse (CN) advised him to put Patient #8 outside and Patient #8 agreed to it so, he was placed out front of the ED shortly before the Fast Track area closed down at 9:00 p.m. Staff A, RN said he does not recall going back outside to check on him. Staff A, RN said at midnight, when he left, he walked past Patient #8 still sitting in his wheelchair still outside of the ED and he did not say anything to Patient #8 but he was not acting "out of his normal". Staff A, RN said he was familiar with the patient and his "normal" is to yawn loudly "things like that" but he did not notice him appearing to be in any pain. He said he feels next time they should not leave the patient outside.

An interview was conducted on 5/12/25 at 4:15PM with the APRN he said he has worked for the hospital since October 2023, and he remembered Patient #8. He said Patient #8 was brought in by EMS because he had fall. The APRN asked him how he got up and Patient #8 said he gets around on a walker and a scooter, "he was kind of young, so I asked him how'd you get a walker or a scooter, and he said he has had it for a long time." The APRN asked him if he had a medical alert button, he said no he wasn't down long. Patient #8 said he has had some pain but "its easing up a bit." The APRN said he was able to narrow the pain down his hips because when he palpated his hips, he shifted and winced. The APRN said he ordered a hip Xray. He said the Xray was negative, he discharged him with extra strength Tylenol. The APRN said Patient #8 was a poor historian. He also had poor hygiene because of his smell. He said Patient #8's pulse was 100 beats per minute and he associated the high pulse with his pain. The APRN said it is not his normal practice to do a head-to-toe skin assessment for someone with hip pain and it's not his normal practice to have a patient change into a gown when they come in for a fall. He said he palpated Patient #8's hip on the side and that is when he winced and shifted. The APRN said he palpated over Patient #8 ' s regular street clothes. "I gave the discharge papers to the nurse, and I left at 9:00PM when the shift was over."

An interview was conducted on 5/12/25 at 4:23 PM Staff B, Paramedic. He said he was working triage the night Patient #8 came into the ED. EMS brought Patient #8 through the back and brought him up front in the stretcher and placed him in a wheelchair in the Fast Track area. EMS told him Patient #8 was there for pain all over. Staff B, Paramedic said Patient #8 was in obvious pain the way he was moaning. Staff B, Paramedic said he obtained vitals off the EMS machine because he was not used to EMS coming up to the front with a patient on a stretcher. Staff B, Paramedic said there were a couple people checking into the ED and they had made a comment about the smell and Patient #8 had body odor that was spreading throughout the emergency room so Staff A, RN called the charge nurse and got approval to put Patient #8 in a room due to the body odor plus he was moaning in pain. Staff B, Paramedic said Staff A, RN took the patient back to the room and he said he stayed at the front of the ED where he was stationed and did not see Patient #8 until Staff A, RN wheeled him outside and placed him by the ED doors. Staff B, Paramedic said he checked on Patient #8 outside about three times and he was presenting the same as when he came in. "He was out there and there seemed like something was wrong with him. and I kept telling [Staff D, ED CN] he's still sitting out there and he's making noises, she said she was calling the supervisor to get him a ride." Staff B, Paramedic said he was new to the facility and started in January of 2025 and he didn't know that since Patient #8 was on hospital property that he should have been brought back into the ED. "Honestly, since he didn't leave, he got the care he initially needed." Staff B, Paramedic said if the patient would have stayed in the back of the ED where EMS originally brought him in and not come to the Fast Track area he would've gotten a more thorough workup with labs, gown, intravenous (IV) line but he doesn't know why Patient #8 came up to the Fast Track area. He said the charge nurse assigns the patients location. He also said when he was checking Patient #8 in there were two past file records for him and he chose the first file because Patient #8 looked at the file and confirmed the address but the file that was chosen did not have his updated medical history in it which he did not found out till later.

During an interview on 05/12/2025 at 4:45 PM, VPQ (Vice President of Quality) stated when we were made aware of the incident, I did an RCA (Root Cause Analysis). The RCA was for the patient requesting to sit outside because the lobby was cold. The results of the RCA concluded with all ED staff receiving education on no patient is allowed to be left outside unattended, all ED staff must complete mandatory education Compassionate Connected Care, Chain of Command, and EMTALA.

During a group interview on 05/12/2025 at 4:47PM, the CEO (Chief Executive Officer), CNO (Chief Nursing Officer), VPQ, Director of Patient Safety, ED Director, ED Manager, and Staff C, ED CN confirmed the patient was not worked up properly, was not stable for discharge and was not provided a safe discharge. Allowing a patient to sit outside the ED entrance all night, approximately 10 hours, in a wheelchair is not ok.

An interview was conducted on 5/12/25 at 4:49 PM with the ED Director. He said Patient #8 came in for a fall and was discharged. He was placed outside of the ED doors in a wheelchair and that is where he remained until his car service was actually coming, on 4/25/25 at 6:00AM. The day shift nurses brought him back to clean him up before he got into the car service and that is when his coccyx wounds were discovered, and he was weak, so he was readmitted and that is when they discovered how sick he actually was.

An interview was conducted on 5/12/25 at 5:00PM with Staff C, ED CN. She said she has worked at the facility for six years and she said she was familiar with Patient #8. She said she got to work about ten minutes to 6:00AM and Patient #8 was sitting in a wheelchair outside of the ED doors, she said good morning to him, and he said hello. She said her Staff D, ED CN were doing report and Staff D, ED CN said Patient #8 was waiting for a car service and the Staff E, House Supervisor could not provide a car service for him so they were waiting for the day shift supervisor to come on to order him a car service. Staff D, ED RN told her Patient #8 needed to be cleaned up and he had clean scrubs. She said she did not know why night shift did not clean up Patient #8. Staff F, RN and a Patient Care Technician (PCT) brought Patient #8 back to the ED bathroom and he was very weak and could not get on or off the toilet or hold himself up while they cleaned him and when they wiped his backside there was blood so Staff F, RN said she needed a doctor and the doctor came to the bathroom and said lets get him to a bed and assess him. It was difficult getting him back into the wheelchair because of his weakness. But they brought him to the bed, finished getting him cleaned up, and that is when they realized he had wounds to his coccyx. She said they put him on a telemetry monitor and his pulse was 103 beats per minute and with the wounds they initiated a sepsis alert because he had a high heart rate and because he had wounds there was a source of infection. Staff C, ED CN said Patient #8 was very difficult to get labs on, so they ended up collecting the labs when he had his intravenous line (IV) line placed. She said they ended up having to put a midline IV in because of how hard it was to get an IV on him. Staff C, ED CN said he received IV antibiotics. She said his labs came back and his lactic acid was "super high" at 17, platelets were at 7. She said when she saw the labs "it was HOLY COW!" she said she s been doing this a long time and his labs results surprised her. She said they were trying to get a hold of the Hospitalist to see if we were going to accept him at their facility, but they ended up doing an ER-to-ER transfer because they did not have a Gastroenterologist (GI) doctor on call that day.

An interview was conducted on 5/13/25 at 9:17AM with the Chief Executive Officer (CEO). He said they brought Patient #8's case to their "Division", and they only recommended to report to Department of Children and Families (DCF) therefore that ' s what they did and DCF did not accept the case. The CEO said the Chief Medical Officer (CMO) presented the case and the chart findings to peer review and when a case is presented to the peer review they either say there is no concerns with this, or "something is concerning for them" so they request to speak with the physician, or they say there are major concerns with this, and new processes need to be put in place. The CEO confirmed the peer was presented the case and they want to speak with the APRN.

A phone interview was conducted on 5/13/25 at 1:49 PM with Staff D, ED CN. She said she has worked as the ED charge nurse for almost 3 years. She said she received a call from EMS and Patient #8 was originally called in as female with generalized body aches and pains. That night was busy, and she had a provider out in the Fast Track area, so she sent Patient #8 to the Fast Track. When he arrived, EMS added he had hip pain, and she asked Patient #8 what his pain was, and he said it was a two [minimal pain] all over. So, she sent him to the Fast Track area because she had several people being admitted "upstairs" and if he needed to come to the back of the ED he could. Once he was in Fast Track and the ED staff requested to put him in room two and they might need to get him changed because he smelled. Staff D, ED CN said he wasn't there to originally be seen long "I think he was there about an hour" and the provider let her know he was being discharged, and he might need a ride. "The nurse [Staff A, RN] asked if I wanted to leave Patient #8 in the room and I said no because I have to shut down rooms one through five because Fast Track was closing." Staff D, ED CN said Patient #8 wanted to go outside because he was complaining it was cold in the room. So, because he wanted to go outside, he was placed outside the ED in a wheelchair with a blanket. She said after a couple of hours of him being outside she called the house supervisor and told her Patient #8 said his sister was coming but "she's not here can we get a [Car Service] and the supervisor said she would get back to me." Staff D, ED CN said it was probably another hour or two hours, and she was having difficulty with the computer, but she was trying to get him a car service but it's normal not to have a car service available at night because of the hospital being in a small town. She said the House Supervisor brought Patient #8 scrubs to change into. She said when she left that morning at 6:00AM she told Patient #8 they were trying to get him a car service and Staff D, ED RN said to Patient #8 "you good? He said I ' m good." and then she left.

An interview was conducted on 5/13/25 at 2:34 PM with Staff B, Paramedic he said when Patient #8 arrived he thought he needed a bed in the back not in the Fast Track. You could tell by looking at him he needed a more thorough work up than just a Fast Track work up. He said he had been a paramedic, for about 30 years with fire rescue and had hospital experience. He said EMS did not do a good job giving us a history on him. "Staff A, RN and I both agreed he needed to go in the back for a more thorough work up but the charge nurse [Staff D, ED CN] makes the calls, she ' s in charge, [Staff D, ED CN] likes it done her way so we were only able to put him in a Fast Track room." Staff B, Paramedic said after Patient #8 was discharged, Staff B, Paramedic said he saw Staff A, RN bring Patient #8 outside of the ED, so he asked Staff A, RN "what ' s that about and he said I ' m just doing what I was told." Staff B, Paramedic said he called the charge nurse three times that night and told her he had concerns because Patient #8 was moaning and still sitting outside, and she just said she called the supervisor and to "just leave him out there."

An interview was conducted on 5/13/25 at 3:31 PM with Staff A, RN he said at the time the patient arrived at the ED he did not smell like feces he smelled of "body odor" and he had poor hygiene. He said as soon as he arrived at the check-in area the Fast Track area immediately started to smell. He said the Fast Track area is a room that has chairs in it with little "dividers" in between each chair. He said when patients arrive, the charge nurse assigns the location of where the patients are placed and Staff D, ED CN assigned Patient #8 to chair two in the Fast Track area but there was a patient already in chair one and with only the divider in between the two the chairs he said he called the charge nurse to see if he could move the patient to room 1 which is a room just off the Fast Track area that is normally utilized for procedures that require more privacy than just a divider. He said Staff D, ED CN said "if that ' s what you want to do that ' s fine" so Staff B, RN moved Patient #8 into room one. Staff B, RN said he noticed Patient #8's clothes were dirty so he offered him a gown "because we don ' t have extra clothes, but the patient said he wanted to wear his clothes and didn't want the gown." Staff B, RN said once Patient #8 was discharged, Staff B, RN told Staff D, ED CN Patient #8 may need a ride but with his odor a car service may decline the ride because they don't want to put him in their car. He said Staff D, ED RN was the person who gave him directive to place the patient outside. Staff B, RN said he did not know why she told him to put Patient #8 outside, but he can only "speculate because the Fast Track area was closing." Staff B, RN said Staff D, ED CN does have a reputation for not being the nicest but that was not his experience, but he does know some nurses feel that way.

A phone interview was conducted on 5/13/25 at 3:37PM with the ED Medical Director. He said for someone who comes into the ED with generalized pain he would ask if there were a joint in particular that is bothering them that made them come to the ED and ask about chronic disease process to determine a history of arthritis. He said he would try to narrow down the pain, palpate and perform range of motion. He said he does not necessarily expose the skin unless during palpation he feels an abnormality or displacement or if someone complains of a wound. He said if someone is having tenderness to their hip on palpation and they are wheelchair bound or use a walker he would invert and evert the hip and start with an order for a hip Xray then he may or may not provide pain control. He said if the Xray comes back negative, he would reassess in terms of pain control. A lot of times patients come to the ED to determine if a bone is broken or not and once, they find out the bone is not broken they feel comfortable to go home with a primary care physician follow up and over the counter medications for pain.

A phone interview was conducted on 5/13/25 at 8:08PM with Staff E, House Supervisor. She said she remembered Patient #8 and she was filling in as the House Supervisor that night, which she had done before, but she was normally a night shift Intensive Care Unit (ICU) nurse. She said she was rounding in the ED around 9:00PM and Staff D, ED CN told her Patient #8 was discharged and outside waiting for his ride, but he may need a car service. She told Staff D, ED CN "okay let me know" and she went outside to see Patient #8. She said Patient #8 was sitting in his wheelchair, awake, alert, and appeared to be talking to someone on the phone. She asked him if he needed a ride and he said his sister was going to come and get him and she told him okay let them (ED staff) know if you need anything. She said she did not see him anymore that night. She said it was not until about 2:00AM when Staff D, ED CN called her and asked if she was able to get a car service and she said she didn't know she needed to get him one, so she tried to log into the car service account and she could not get into it so she called Staff D, ED CN back and told her she couldn't log into the system and since it was so close until the day shift supervisor was supposed to come in she said she would "keep trying and let the day shift supervisor know." Staff E, House Supervisor said when the day shift supervisor arrived, she told her Patient #8 needed a car service and the day shift supervisor said its normal to not be able to get a car service at night and the day shift house supervisor was able to order him a car service and she left.

An interview was conducted on 5/14/25 at 10:55 AM with Staff F, RN. She said she was working 6:00AM to 6:00PM on 4/25/25 and she overheard the two charge nurses Staff D, ED CN and Staff C, ED CN doing report. She overheard Staff D, ED CN telling Staff C, ED CN "there was a patient outside because he was "dumping" feces all over because he wanted to stay because his family could not take care of him." Staff F, RN said she heard Staff D, ED CN telling Staff C, ED CN he had a car service coming "but he was dumping [urine] and [feces] everywhere so he needs to be cleaned up before the [Car Service] comes here" and Staff D, ED CN gave Staff C, ED CN some scrubs. She overheard Staff C, Ed CN on the headset ask for someone to bring Patient #8 back inside and Staff F, RN said she was not doing anything so she said she would help. She went outside and when she approached him she saw he was sitting outside of the ED doors next to the bench with the wheelchair locked from the back. When she went to unlock his wheelchair, she saw there was dry "poop" on the back of the wheelchair where his back was resting and there was "poop" dripping from the back of the wheelchair onto the pavement. Staff F, RN said she went into "mom nurse mode" and said to Patient #8 "hey I ' m going to bring you inside to get you cleaned up" and she began to wheel him into the bathroom in the ED, and she asked another employee to help her. She said when she got the patient into the bathroom he was "covered in poop" to the point there was poop in his shoes, up his back, it had soaked through his jean shorts and it had crusted onto the wheelchair so when we tried to lift him to assist him off of the wheelchair his legs were stuck on the chair because the "poop on his legs had dried onto the wheelchair." She said at that point they placed a towel on the toilet so he could sit down, and she said she is not normally a loud person but she was so mad at the way the patient was treated and how he was presenting she called over the headset she needed help now and get the ED Medical Director! She said when the other nurses and the doctor came into the bathroom she said, "This is [explicit] ridiculous who left him like this?" She said at that point the doctor said let ' s take him back into a room and get him looked at. She said Patient #8 was complaining of pain. When they were transferring him onto the bed "he looked like he was knocking on deaths door." She said once they got him onto the bed that is when she saw the wounds. he said he was placed on a telemetry monitor and he was tachycardic, so she called the sepsis alert. She said he had two wounds on his buttock that were open and white with tunneling and then on his buttock he had an area of red sheering. She said the stool he was sitting on in the wheelchair had actually puddled in his pants and stayed moist. She said once the sepsis alert was called they couldn't get an IV line on him so normally they would do an intramuscular injection of antibiotics but he did not want that, so she was able to convince him to have someone come down with an ultrasound and put a IV line in him. She said once they got a line on him, they drew labs, and his blood was like "water in the tube it was so thin." She said the laboratory called her and said his labs were drew wrong, draw it again. She told the laboratory they were not drawn wrong, but she did draw the labs again from his IV line. Again, the lab called and said she was doing something wrong because the labs were wrong. She said she did not do anything wrong, so the laboratory ended up sending down one of their technicians to draw blood from him and that is when his hemoglobin came back at 2.4 and he was ordered three units of blood. She said after his labs came back she was assigned to be charge nurse of the Fast Track area, but she kept checking in on Patient #8 and one time when she went to see him "This sounds weird but he was weak but his arms kept tensing up and curling in to his body." She said that is when she found out his lactic acid came back at 17, so his muscles were tensing up because the lactic acid was so high. She said he was eventually transferred out to another hospital. She said this case has really affected her because how poorly the patient was treated. Staff F, RN said the night charge nurse, Staff D, ED CN, has a reputation of treating homeless patients that way. She said she has personally experienced it where she discriminated against people like Patient #8 who are homeless, dirty, or abuse drugs and alcohol. She said, "This was not the first time [Staff D, ED, CN] has done this, this was just the worst time." She said Patient #8 was neglected and no one should have been treated the way he was treated. She said she has made many incident reports about Staff D, ED, CN behavior and how she has treated patients, and she has reported to the ED Director of her concerns related to Staff D, ED, CN's "Bullying", and she has reported to Human Resources (HR) but nothing happens. Staff F, RN said "nothing has been done except asking the staff what happened." She said there was a time when she placed a patient in an ED room who had an open head trauma and had loss consciousness and Staff D, ED CN told her the patient can't be in the room they need to go to Fast Track and Staff F, RN said the patient has a head wound and lost consciousness they need a ED room. She said no one talked to her for a month because she advocated for the patient and stood up to Staff D, ED CN.

An interview was conducted on 5/14/25 at 11:30AM with Staff G, RN she said the night shift "absolutely" knew the patient was soiled but they were waiting until the ride was coming before they changed him. Staff G, RN said Staff D, ED CN told the other staff to place the patient outside and he stayed outside until the day shift staff came in and ordered him a ride and got him changed and that ' s when it was discovered how sick Patient #8 really was. Staff G, RN said, Staff D, ED CN, has a reputation for retaliating against the staff and patients who are homeless, and abuse drugs and alcohol. Staff G, RN said the ED Director is fully aware of it an

Based on review of video footage, medical record review, facility documents, facility policies and interviews conducted, the facility failed to ensure that 1 (Patient #8) of 20 patients sampled, regardless of social status, received quality care in the emergency room to include a full assessment and treatment when needed.

Findings included:

Review of hospital video footage revealed:
7:49 PM Patient#8 brought in by EMS (Emergency Medical Services) via stretcher.
7:50 PM brought to nurses' station then immediately to fast track (a designated area or system designed to provide rapid care for patients with less severe conditions, allowing them to be seen and treated efficiently without taking up resources needed for more critical cases.)
7:51 PM brought to lobby moved from stretcher to wheelchair.
7:53 PM EMS talking with Staff B, Medic to registered him.
7:55 PM Patient #8 registered.
7:57 PM Staff B, Medic took patients temperature.
7:58 PM EMS hands patient an emesis bag and a tissue.
8:00 PM EMS in ED waiting room. APRN (Advanced Practice Registered Nurse) in waiting room, walks outside.
8:01 PM APRN back inside the waiting room.
804 PM APRN in waiting room behind screen talking to patient. Hands in pockets.
8:05 PM APRN to triage room
8:08 PM Staff A, Registered Nurse (RN) comes to patient in lobby. Gets patient and brings him to Fast track Room 1.
8:14 PM Radiology picks up patient.
8:28 PM back from radiology to Room 1, staff in full PPE (Personal Protective equipment).
8:34 PM Registration inside Room 1 with patient.
8:36 PM registration leaves room and talks with APRN
8:43 PM APRN walks through lobby
8:44 PM Staff A, RN goes into room 1 with patient with paperwork in his hand
8:45 PM Staff A, RN walked out of room 1
8:49 PM Staff A, RN back in room.
8:50.28 PM Staff A, RN brings Patient #8 out lobby doors via wheelchair, wearing mask Patient #8 has black shirt, hat and blanket over his lap.
8:50.52 PM Locks wheelchair and returns to the lobby and to the back of the ED (out of sight)
8:51.33 PM Patient #8 seen outside lobby doors on the right side, leaning forward in wheelchair.
8:51.49. PM Patient #8 slumped over, head leaning down with head down, Staff A, RN goes outside with paper in his hand to talk to patient, Paper given to patient.
8:52.07 PM Lobby doors open again due to Staff A, RN in proximity of doors, patient seen slumped over in chair. Patient seen slouched and reading papers,
8:53 PM patient seen on video moving blanket, slouched over.
9:02 PM A person from outside in black scrubs noted to get behind patient and moved him via wheelchair to lobby and met by Staff B, Medic in lobby. Staff B, Medic pushes patient back outside.
906 PM Staff D, Charge Nurse (CN) and 2 male RNs seen in lobby heading to lobby doors. Staff D, CN and 1 male nurse (possibly Staff B, Medic) go outside to see patient.
9:06.19 PM Staff D, CN noted standing to right of patient with hands of hips.
9:11 PM larger female nurse seen walking out talking to patient.
9:12 PM nurse leaves patient and comes into ED, talks with Staff B, Medic and then returns to back of ED
9:15 PM Staff B, Medic went out the lobby doors and moved the patient to the left side outside the lobby doors, outside of camera view.
9:28 PM white male patient brought outside lobby doors on the right side by female tech.
9:29 PM white male patient picked up by vehicle
9:33 PM Staff B, Medic seen going outside lobby doors and returning to desk to grab gloves and going back outside, returning to desk art 9:34 PM
9:36 PM purple hair nurse seen leaving through lobby doors. 9:38 came back in with food.
9:43.15 PM Staff D, CN brings bottle of water outside to patient. Comes back into ED lobby and speaks with Staff Medic.
9:55 PM security noted to be talking with patient outside and then comes into lobby
10:03 PM Staff B, Medic leaves, and the new nurse takes over new Medic.
10:20 PM female black-haired nurse seen walking through lobby doors to outside, past patient,
10:48 PM Medic seen going outside to get empty wheelchair and bring it into the ED for an incoming patient, no contact noted with Patient #8.
10:55 PM Staff D, CN seen double masked going outside. She walks to the left where patient #8 is, looks like she walks past the patient. Appears to stand with hands on her hips. Then came back in at 10:57 and talked to Medic.
11:00 PM closing fast track, multiple staff members seen come to lobby leave.
11:31 PM Medic went outside the lobby doors to get a wheelchair.
11:34 PM Staff D, CN seen coming out to lobby picking up a different patient and taking her to the back.
11:50 PM Medic leaves and dark long hair staff takes over,
11:52 PM Can see patient #8 movement - can see through window patient moves blanket into view and then unable to see further

04/25/2025
6:51 AM Medic went outside,
6:57 AM Staff F, CN, went outside.
6:58 AM Patient wheeled in by Staff F, CN. Pointing at bottom of wheelchair.
6:59 AM Taken to the bathroom. PCT with her.
701 AM Staff C, CN came to the outside and looked at where patient had been sitting.
7:16 AM Patient #8 brought out of bathroom via wheelchair by nurse and tech, into room 6
7:18 AM Patient placed in bed and wheelchair removed from room.
7:30 AM. Nurses still in the room caring for patient, bringing him linens and such.

Review of medical record revealed Patient#8 checked into the ED (Emergency Department) on 04/24/2025 at 7:55 PM with a chief complaint of pain all over for two weeks. Documented vital signs on arrival were oral temperature was "37.8" degrees Celsius [100.0 degrees Fahrenheit], pulse:100 beats per minute, respiratory rate: 18 breaths per minute. His blood pressure was 108/60, his oxygen saturation was 100% on room air, and his pain intensity was two out of ten. A medical screen was completed by an APRN and revealed "no relevant medical history presents to ED today with complaints of bilateral hip pain after suffering a fall today prior to arrival. Patient brought in by EMS. Patients stated that he lives alone but appears to be a poor historian. He says he gets around on an electric scooter and a walker but can not tell me why he needs a walker or a scooter to ambulate. When asked how long he was on the floor he replied, "not for long" and he also stated that the pain has eased up a bit. Appearance/Presentation: Hygiene poor." A nursing assessment revealed steady gait, ambulates independently, skin warm, dry, intact, no complaints of lesions, rash, wounds, bruises, petechiae or abrasions. No reassessment of Patient #8 vital signs or assessment prior to discharge home/outside in wheelchair.

Review of medical record revealed on 04/25/2025 at 07:15 AM, Patient #8 was brought back into the ED by the ED staff for check in. Chief complaint states "patient arrived to ED via ambulance last night- patient was seen and discharged, patient was waiting outside in a wheelchair; when nurse went outside patient was severely weak, unable to stand and covered in feces; significant wounds are noted to patient's bottom with active bleeding, states he is just "in so much pain". Per ED MD note, "62 yr old man with a past medical history of ostomy reversal and current urostomy here complaining of generalized weakness and diarrhea over past several days. Patient states he has had pain all over his body for the past week or so and was seen at this facility last night where he was determined to have no acute traumatic injury and discharged home. While waiting for ride, patient developed urinary and fecal incontinence and was struggling to care for himself. He was not able to ambulate by himself without a wheelchair. Patient stated he lives alone and has no one to help are for him. Nursing assessment revealed unstageable wound on coccyx, alert and awake, skin is cool and diaphoretic, tachycardic (having an abnormally fast heart rate), unable to stand by himself. Lab results revealed hemoglobin (an iron-rich protein in red blood cells that carries oxygen from the lungs to the rest of the body) 2.4 (normal levels 13.7-17.5) and lactic acid (indicating whether body tissues are receiving enough oxygen. Elevated levels can suggest tissue hypoxia, shock, sepsis, heart failure, or liver disease.) 17 (normal levels 0.4- 2.0). Patient admitted and transferred to [another hospital] for severe anemia (a condition where the body has an abnormally low level of red blood cells (RBCs) or hemoglobin, the protein in RBCs that carries oxygen) and septic shock (a life-threatening condition that occurs when the body's immune system overreacts to an infection, leading to widespread inflammation and organ damage).

An interview was conducted on 5/12/25 at 4:00PM with Staff A, Registered Nurse (RN). He said he has worked here for about a year and a half. Staff A, RN said Patient #8 came in by EMS and he was working in the Fast Track area and he heard across the radio Patient #8 was going to be in Fast Track. On arrival Patient #8 was placed in a wheelchair and he had a very bad odor to him and there was another patient in the chair next to him, so Staff A, RN requested Patient #8 be placed in a private room due to the odor and there being a patient next to him. Staff A, RN said the patient next to Patient #8 was not complaining he just requested the move to a private room because he is familiar with Patient #8 and he does not bathe properly and is at times homeless but, this particular visit Patient #8 said he had a home and EMS said they picked him up at an apartment. Staff A, RN said "at one point I did offer him a gown to take home because of his foul odor, and we do not have an area to bathe him. [Patient #8] declined the gown." Staff A, RN said Staff D, ED Charge Nurse (CN) advised him to put Patient #8 outside and Patient #8 agreed to it so, he was placed out front of the ED shortly before the Fast Track area closed down at 9:00 p.m. Staff A, RN said he does not recall going back outside to check on him. Staff A, RN said at midnight, when he left, he walked past Patient #8 still sitting in his wheelchair still outside of the ED and he did not say anything to Patient #8 but he was not acting "out of his normal". Staff A, RN said he was familiar with the patient and his "normal" is to yawn loudly "things like that" but he did not notice him appearing to be in any pain. He said he feels next time they should not leave the patient outside.

An interview was conducted on 5/12/25 at 4:15PM with the APRN he said he has worked for the hospital since October 2023, and he remembered Patient #8. He said Patient #8 was brought in by EMS because he had fall. The APRN asked him how he got up and Patient #8 said he gets around on a walker and a scooter, "he was kind of young, so I asked him how'd you get a walker or a scooter, and he said he has had it for a long time." The APRN asked him if he had a medical alert button, he said no he wasn't down long. Patient #8 said he has had some pain but "its easing up a bit." The APRN said he was able to narrow the pain down his hips because when he palpated his hips, he shifted and winced. The APRN said he ordered a hip Xray. He said the Xray was negative, he discharged him with extra strength Tylenol. The APRN said Patient #8 was a poor historian. He also had poor hygiene because of his smell. He said Patient #8's pulse was 100 beats per minute and he associated the high pulse with his pain. The APRN said it is not his normal practice to do a head-to-toe skin assessment for someone with hip pain and it's not his normal practice to have a patient change into a gown when they come in for a fall. He said he palpated Patient #8's hip on the side and that is when he winced and shifted. The APRN said he palpated over Patient #8's regular street clothes. "I gave the discharge papers to the nurse, and I left at 9:00PM when the shift was over."

An interview was conducted on 5/12/25 at 4:23 PM Staff B, Paramedic. He said he was working triage the night Patient #8 came into the ED. EMS brought Patient #8 through the back and brought him up front in the stretcher and placed him in a wheelchair in the Fast Track area. EMS told him Patient #8 was there for pain all over. Staff B, Paramedic said Patient #8 was in obvious pain the way he was moaning. Staff B, Paramedic said he obtained vitals off the EMS machine because he was not used to EMS coming up to the front with a patient on a stretcher. Staff B, Paramedic said there were a couple people checking into the ED and they had made a comment about the smell and Patient #8 had body odor that was spreading throughout the emergency room so Staff A, RN called the charge nurse and got approval to put Patient #8 in a room due to the body odor plus he was moaning in pain. Staff B, Paramedic said Staff A, RN took the patient back to the room and he said he stayed at the front of the ED where he was stationed and did not see Patient #8 until Staff A, RN wheeled him outside and placed him by the ED doors. Staff B, Paramedic said he checked on Patient #8 outside about three times and he was presenting the same as when he came in. "He was out there and there seemed like something was wrong with him. and I kept telling [Staff D, ED CN] he's still sitting out there and he's making noises, she said she was calling the supervisor to get him a ride." Staff B, Paramedic said he was new to the facility and started in January of 2025 and he didn't know that since Patient #8 was on hospital property that he should have been brought back into the ED. "Honestly, since he didn't leave, he got the care he initially needed." Staff B, Paramedic said if the patient would have stayed in the back of the ED where EMS originally brought him in and not come to the Fast Track area he would've gotten a more thorough workup with labs, gown, intravenous (IV) line but he doesn't know why Patient #8 came up to the Fast Track area. He said the charge nurse assigns the patients location. He also said when he was checking Patient #8 in there were two past file records for him and he chose the first file because Patient #8 looked at the file and confirmed the address but the file that was chosen did not have his updated medical history in it which he did not found out till later.

During an interview on 05/12/2025 at 4:45 PM, VPQ (Vice President of Quality) stated when we were made aware of the incident, I did an RCA (Root Cause Analysis). The RCA was for the patient requesting to sit outside because the lobby was cold. The results of the RCA concluded with all ED staff receiving education on no patient is allowed to be left outside unattended, all ED staff must complete mandatory education Compassionate Connected Care, Chain of Command, and EMTALA.

During a group interview on 05/12/2025 at 4:47PM, the CEO (Chief Executive Officer), CNO (Chief Nursing Officer), VPQ, Director of Patient Safety, ED Director, ED Manager, and Staff C, ED CN confirmed the patient was not worked up properly, was not stable for discharge and was not provided a safe discharge. Allowing a patient to sit outside the ED entrance all night, approximately 10 hours, in a wheelchair is not ok.

An interview was conducted on 5/12/25 at 4:49PM with the ED Director. He said Patient #8 came in for a fall and was discharged. He was placed outside of the ED doors in a wheelchair and that is where he remained until his car service was actually coming, on 4/25/25 at 6:00AM. The day shift nurses brought him back to clean him up before he got into the car service and that is when his coccyx wounds were discovered, and he was weak, so he was readmitted and that is when they discovered how sick he actually was.

An interview was conducted on 5/12/25 at 5:00PM with Staff C, ED CN. She said she has worked at the facility for six years and she said she was familiar with Patient #8. She said she got to work about ten minutes to 6:00AM and Patient #8 was sitting in a wheelchair outside of the ED doors, she said good morning to him, and he said hello. She said her Staff D, ED CN were doing report and Staff D, ED CN said Patient #8 was waiting for a car service and the Staff E, House Supervisor could not provide a car service for him so they were waiting for the day shift supervisor to come on to order him a car service. Staff D, ED RN told her Patient #8 needed to be cleaned up and he had clean scrubs. She said she did not know why night shift did not clean up Patient #8. Staff F, RN and a Patient Care Technician (PCT) brought Patient #8 back to the ED bathroom and he was very weak and could not get on or off the toilet or hold himself up while they cleaned him and when they wiped his backside there was blood so Staff F, RN said she needed a doctor and the doctor came to the bathroom and said lets get him to a bed and assess him. It was difficult getting him back into the wheelchair because of his weakness. But they brought him to the bed, finished getting him cleaned up, and that is when they realized he had wounds to his coccyx. She said they put him on a telemetry monitor and his pulse was 103 beats per minute and with the wounds they initiated a sepsis alert because he had a high heart rate and because he had wounds there was a source of infection. Staff C, ED CN said Patient #8 was very difficult to get labs on, so they ended up collecting the labs when he had his intravenous line (IV) line placed. She said they ended up having to put a midline IV in because of how hard it was to get an IV on him. Staff C, ED CN said he received IV antibiotics. She said his labs came back and his lactic acid was "super high" at 17, platelets were at 7. She said when she saw the labs "it was HOLY COW!" she said she s been doing this a long time and his labs results surprised her. She said they were trying to get a hold of the Hospitalist to see if we were going to accept him at their facility, but they ended up doing an ER-to-ER transfer because they did not have a Gastroenterologist (GI) doctor on call that day.


A phone interview was conducted on 5/13/25 at 1:49 PM with Staff D, ED CN. She said she has worked as the ED charge nurse for almost 3 years. She said she received a call from EMS and Patient #8 was originally called in as female with generalized body aches and pains. That night was busy, and she had a provider out in the Fast Track area, so she sent Patient #8 to the Fast Track. When he arrived, EMS added he had hip pain, and she asked Patient #8 what his pain was, and he said it was a two [minimal pain] all over. So, she sent him to the Fast Track area because she had several people being admitted "upstairs" and if he needed to come to the back of the ED he could. Once he was in Fast Track and the ED staff requested to put him in room two and they might need to get him changed because he smelled. Staff D, ED CN said he wasn't there to originally be seen long "I think he was there about an hour" and the provider let her know he was being discharged, and he might need a ride. "The nurse [Staff A, RN] asked if I wanted to leave Patient #8 in the room and I said no because I have to shut down rooms one through five because Fast Track was closing." Staff D, ED CN said Patient #8 wanted to go outside because he was complaining it was cold in the room. So, because he wanted to go outside, he was placed outside the ED in a wheelchair with a blanket. She said after a couple of hours of him being outside she called the house supervisor and told her Patient #8 said his sister was coming but "she's not here can we get a [Car Service] and the supervisor said she would get back to me." Staff D, ED CN said it was probably another hour or two hours, and she was having difficulty with the computer, but she was trying to get him a car service but it's normal not to have a car service available at night because of the hospital being in a small town. She said the House Supervisor brought Patient #8 scrubs to change into. She said when she left that morning at 6:00AM she told Patient #8 they were trying to get him a car service and Staff D, ED RN said to Patient #8 "you good? He said I'm good." and then she left.

An interview was conducted on 5/13/25 at 2:34 PM with Staff B, Paramedic he said when Patient #8 arrived he thought he needed a bed in the back not in the Fast Track. You could tell by looking at him he needed a more thorough work up than just a Fast Track work up. He said he had been a paramedic, for about 30 years with fire rescue and had hospital experience. He said EMS did not do a good job giving us a history on him. "Staff A, RN and I both agreed he needed to go in the back for a more thorough work up but the charge nurse [Staff D, ED CN] makes the calls, she's in charge, [Staff D, ED CN] likes it done her way so we were only able to put him in a Fast Track room." Staff B, Paramedic said after Patient #8 was discharged, Staff B, Paramedic said he saw Staff A, RN bring Patient #8 outside of the ED, so he asked Staff A, RN "what's that about and he said I'm just doing what I was told." Staff B, Paramedic said he called the charge nurse three times that night and told her he had concerns because Patient #8 was moaning and still sitting outside, and she just said she called the supervisor and to "just leave him out there."

An interview was conducted on 5/13/25 at 3:31 PM with Staff A, RN he said at the time the patient arrived at the ED he did not smell like feces he smelled of "body odor" and he had poor hygiene. He said as soon as he arrived at the check-in area the Fast Track area immediately started to smell. He said the Fast Track area is a room that has chairs in it with little "dividers" in between each chair. He said when patients arrive, the charge nurse assigns the location of where the patients are placed and Staff D, ED CN assigned Patient #8 to chair two in the Fast Track area but there was a patient already in chair one and with only the divider in between the two the chairs he said he called the charge nurse to see if he could move the patient to room 1 which is a room just off the Fast Track area that is normally utilized for procedures that require more privacy than just a divider. He said Staff D, ED CN said "if that ' s what you want to do that's fine" so Staff B, RN moved Patient #8 into room one. Staff B, RN said he noticed Patient #8's clothes were dirty so he offered him a gown "because we don ' t have extra clothes, but the patient said he wanted to wear his clothes and didn't want the gown." Staff B, RN said once Patient #8 was discharged, Staff B, RN told Staff D, ED CN Patient #8 may need a ride but with his odor a car service may decline the ride because they don't want to put him in their car. He said Staff D, ED RN was the person who gave him directive to place the patient outside. Staff B, RN said he did not know why she told him to put Patient #8 outside, but he can only "speculate because the Fast Track area was closing." Staff B, RN said Staff D, ED CN does have a reputation for not being the nicest but that was not his experience, but he does know some nurses feel that way.

A phone interview was conducted on 5/13/25 at 3:37PM with the ED Medical Director. He said for someone who comes into the ED with generalized pain he would ask if there were a joint in particular that is bothering them that made them come to the ED and ask about chronic disease process to determine a history of arthritis. He said he would try to narrow down the pain, palpate and perform range of motion. He said he does not necessarily expose the skin unless during palpation he feels an abnormality or displacement or if someone complains of a wound. He said if someone is having tenderness to their hip on palpation and they are wheelchair bound or use a walker he would invert and evert the hip and start with an order for a hip Xray then he may or may not provide pain control. He said if the Xray comes back negative, he would reassess in terms of pain control. A lot of times patients come to the ED to determine if a bone is broken or not and once, they find out the bone is not broken they feel comfortable to go home with a primary care physician follow up and over the counter medications for pain.

A phone interview was conducted on 5/13/25 at 8:08PM with Staff E, House Supervisor. She said she remembered Patient #8 and she was filling in as the House Supervisor that night, which she had done before, but she was normally a night shift Intensive Care Unit (ICU) nurse. She said she was rounding in the ED around 9:00PM and Staff D, ED CN told her Patient #8 was discharged and outside waiting for his ride, but he may need a car service. She told Staff D, ED CN "okay let me know" and she went outside to see Patient #8. She said Patient #8 was sitting in his wheelchair, awake, alert, and appeared to be talking to someone on the phone. She asked him if he needed a ride and he said his sister was going to come and get him and she told him okay let them (ED staff) know if you need anything. She said she did not see him anymore that night. She said it was not until about 2:00AM when Staff D, ED CN called her and asked if she was able to get a car service and she said she didn't know she needed to get him one, so she tried to log into the car service account and she could not get into it so she called Staff D, ED CN back and told her she couldn't log into the system and since it was so close until the day shift supervisor was supposed to come in she said she would "keep trying and let the day shift supervisor know." Staff E, House Supervisor said when the day shift supervisor arrived, she told her Patient #8 needed a car service and the day shift supervisor said its normal to not be able to get a car service at night and the day shift house supervisor was able to order him a car service and she left.

An interview was conducted on 5/14/25 at 10:00 AM with the ED Director and the ED Manager. The ED Director said there was an issue with the initial exam the APRN did on Patient #8 because "it was not thorough." The ED Director said he thought Patient #8 was stabilized prior to discharge and The ED Manager said she did not know if Patient #8 was stabilized or not because vitals were never taken or reevaluated during his first visit. He said there has not been any education provided to his staff but there was an investigation. He said Patient #8 is not a nice person he cusses people out and calls them the "C-word." He said he sees Patient #8 driving past his house in his motorized scooter, and he hangs out by the gas station near his house, but he has not seen Patient #8 since he came to the facility's ED.

An interview was conducted on 5/14/25 at 10:55 AM with Staff F, RN. She said she was working 6:00AM to 6:00PM on 4/25/25 and she overheard the two charge nurses Staff D, ED CN and Staff C, ED CN doing report. She overheard Staff D, ED CN telling Staff C, ED CN "there was a patient outside because he was "dumping" feces all over because he wanted to stay because his family could not take care of him." Staff F, RN said she heard Staff D, ED CN telling Staff C, ED CN he had a car service coming "but he was dumping [urine] and [feces] everywhere so he needs to be cleaned up before the [Car Service] comes here" and Staff D, ED CN gave Staff C, ED CN some scrubs. She overheard Staff C, Ed CN on the headset ask for someone to bring Patient #8 back inside and Staff F, RN said she was not doing anything so she said she would help. She went outside and when she approached him she saw he was sitting outside of the ED doors next to the bench with the wheelchair locked from the back. When she went to unlock his wheelchair, she saw there was dry "poop" on the back of the wheelchair where his back was resting and there was "poop" dripping from the back of the wheelchair onto the pavement. Staff F, RN said she went into "mom nurse mode" and said to Patient #8 "hey I'm going to bring you inside to get you cleaned up" and she began to wheel him into the bathroom in the ED, and she asked another employee to help her. She said when she got the patient into the bathroom he was "covered in poop" to the point there was poop in his shoes, up his back, it had soaked through his jean shorts and it had crusted onto the wheelchair so when we tried to lift him to assist him off of the wheelchair his legs were stuck on the chair because the "poop on his legs had dried onto the wheelchair." She said at that point they placed a towel on the toilet so he could sit down, and she said she is not normally a loud person but she was so mad at the way the patient was treated and how he was presenting she called over the headset she needed help now and get the ED Medical Director! She said when the other nurses and the doctor came into the bathroom she said, "This is [explicit] ridiculous who left him like this?" She said at that point the doctor said let ' s take him back into a room and get him looked at. She said Patient #8 was complaining of pain. When they were transferring him onto the bed "he looked like he was knocking on deaths door." She said once they got him onto the bed that is when she saw the wounds. he said he was placed on a telemetry monitor and he was tachycardic, so she called the sepsis alert. She said he had two wounds on his buttock that were open and white with tunneling and then on his buttock he had an area of red sheering. She said the stool he was sitting on in the wheelchair had actually puddled in his pants and stayed moist. She said once the sepsis alert was called they couldn't get an IV line on him so normally they would do an intramuscular injection of antibiotics but he did not want that, so she was able to convince him to have someone come down with an ultrasound and put a IV line in him. She said once they got a line on him, they drew labs, and his blood was like "water in the tube it was so thin." She said the laboratory called her and said his labs were drew wrong, draw it again. She told the laboratory they were not drawn wrong, but she did draw the labs again from his IV line. Again, the lab called and said she was doing something wrong because the labs were wrong. She said she did not do anything wrong, so the laboratory ended up sending down one of their technicians to draw blood from him and that is when his hemoglobin came back at 2.4 and he was ordered three units of blood. She said after his labs came back she was assigned to be charge nurse of the Fast Track area, but she kept checking in on Patient #8 and one time when she went to see him "This sounds weird but he was weak but his arms kept tensing up and curling in to his body." She said that is when she found out his lactic acid came back at 17, so his muscles were tensing up because the lactic acid was so high. She said he was eventually transferred out to another hospital. She said this case has really affected her because how poorly the patient was treated. Staff F, RN said the night charge nurse, Staff D, ED CN, has a reputation of treating homeless patients that way. She said she has personally experienced it where she discriminated against people like Patient #8 who are homeless, dirty, or abuse drugs and alcohol. She said, "This was not the first time [Staff D, ED, CN] has done this, this was just the worst time." She said Patient #8 was neglected and no one should have been treated the way he was treated. She said she has made many incident reports about Staff D, ED, CN behavior and how she has treated patients, and she has reported to the ED Director of her concerns related to Staff D, ED, CN's "Bullying", and she has reported to Human Resources (HR) but nothing happens. Staff F, RN said "nothing has been done except asking the staff what happened." She said there was a time when she placed a patient in an ED room who had an open head trauma and had loss consciousness and Staff D, ED CN told her the patient can't be in the room they need to go to Fast Track and Staff F, RN said the patient has a head wound and lost consciousness they need a ED room. She said no one talked to her for a month because she advocated for the patient and stood up to Staff D, ED CN.

An interview was conducted on 5/14/25 at 11:30AM with Staff G, RN she said the night shift "absolutely" knew the patient was soiled but they were waiting until the ride was coming before they changed him. Staff G, RN said Staff D, ED CN told the other staff to place the patient outside and he stayed outside until the day shift staff came in and ordered him a ride and got him changed and that ' s when it was discovered how sick Patient #8 really was. Staff G, RN said, Staff D, ED CN, has