Saint Joseph Hospital

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 44396 Based on interview, record review, review of the facility’s job description, and review of the facility’s policies, the facility failed to ensure patients were protected from abuse by staff for 2 of 11 sampled patients, Patient (P) 1 and P11. On 04/13/2025, Patient Care Assistant (PCA) 1 was observed to exhibit aggressive, inappropriate behavior toward P11. PCA1 was suspended and completed a part of the mandated remediation addressing his behavior before returning to work on 04/17/2025. On 05/20/2025, PCA1 completed a one-on-one remediation with the Security Manager. On 08/03/2025, PCA1 was observed to again exhibit aggressive, inappropriate behavior toward P1. PCA1 was terminated on 08/03/2025. The findings include: Review of the facility’s policy titled, “Alleged Abuse IN-FACILITY by Employees or Non-Employees Identification, Investigation and Reporting,” dated 07/2021, revealed its purpose was to ensure protection of patients from any form of actual or alleged maltreatment, including abuse, neglect, exploitation, and misappropriation of property. Further review revealed for any report of alleged abuse, the priority was the safety and well-being of the patient, and the alleged perpetrator shall be removed from duty until the investigation had been completed. It also stated the alleged perpetrator should not return to the facility until instructed by the designated leader. Continued review revealed any employee or physician who knew or reasonably suspected that a patient had been abused by an employee, medical staff member, or other patient must immediately escalate the concern. Additional review revealed Charge Nurses/Department Managers and House Managers were the first notification, and after ensuring the safety of the victim and removal of the alleged perpetrator, the House Manager or department leader would escalate the chain of command and coordinate escalation to the Administrator on-call. Then, the Administrator on-call was expected to escalate the incident to the Risk Manager and senior leadership. Further review revealed the Risk Manager was responsible to coordinate an initial meeting with key leadership including, but not limited to, Human Resources, Executive Clinical leadership, Quality leadership, key Department leadership, and the Grievance Coordinator to review allegations/assign tasks. Review of the policy revealed the team would then validate the safety of the patient, any other potential victims, work status of the perpetrator, communication to the patient’s attending physician, occurrence report entry, and establish key contacts for the investigation. The Risk Manager and Quality team would conduct a thorough, timely, and objective investigation of the allegation. Review of the facility’s policy titled, “Abuse, Neglect, Exploitation of Patients and Reporting,” adopted May 2017, revealed the purpose of the policy was to ensure patients were free from all forms of abuse, neglect, harassment, or exploitation from staff, volunteers, other patients or visitors. Continued review of the policy revealed any person having reasonable cause to suspect that a patient who was a vulnerable adult (defined as a person eighteen (18) or older who, because of mental or physical dysfunction, was unable to manage his or her own resources, carry out the activity of daily living, or protect himself or herself from neglect, exploitation, or a hazardous or abusive situation without assistance from others, and who might be in need of protective services) or child had suffered abuse, neglect, or exploitation shall report or cause a report to be made in accordance with the state’s law. Finally, policy review revealed an oral or written report shall be made to the Cabinet for Health and Family Services (CHFS) immediately upon knowledge of suspected abuse, neglect, or exploitation. Review of the facility’s policy titled, “Patient Rights and Patient Responsibilities,” last reviewed 12/2022, revealed under all circumstances, a patient had the right to always receive fair and compassionate care. Further review revealed patients had a right to receive comfort, respect and recognition of personal dignity, values, and beliefs, including cultural, psychosocial, and spiritual. Continued review revealed patients had the right to be treated equally and receive the same level of care or treatment regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation or gender identity, or expression. Additional review revealed patients had the right to receive treatment in a safe environment free from neglect, exploitation, and abuse. Review of the facility’s policy titled, “Patient Care Assignments,” last revised 07/2024, revealed caregiver clinical skills would be taken into consideration before making assignments or floating personnel to other areas. Review of the “Resource Patient Care Assistant (PCA)” job description, last edited 3/25/2025, revealed the PCA aided in transporting, transferring, lifting, and performed patient care duties to support the care giving team as delegated and with associated competencies. Further review revealed the essential PCA functions included reporting changes in patient status promptly to licensed staff, performing as patient care companion when needed, and communicating with patient, family, physicians, and unit personnel and peers in an accurate, courteous, and professional manner. Review of the facility’s policy titled, “Patient Restraints and Seclusion: [Facility’s Name],” last revised 06/2025, revealed the policy applied to health care professionals operating within the organization’s facilities that had responsibility for ordering, assessing, care planning, restraining, or monitoring the restrained patient. Further review revealed staff would demonstrate competency in monitoring the physical and psychological well-being of a patient who was restrained or secluded, including skin integrity. Review of the facility’s policy titled, “[The Organization’s] Health Administrative Policy,” effective date 02/02/2023, revealed employees were expected to perform satisfactorily, follow standards of conduct that protected the safety of patients, and conduct themselves with a level of professionalism that promoted a productive work environment. Further review revealed substandard performance or workplace conduct that was contrary to the organization’s health policies or expectations, whether directed toward fellow employees, patients, or any person, violated policies and expectations and would be addressed appropriately. Continued review revealed corrective action could utilize coaching, documented verbal warning, written warning, final written warning, suspension, and separation of employment. Additional review revealed the organization might follow a process in utilizing certain types of warnings before moving to separation of employment. However, per the policy, nothing created a guarantee of a particular escalation process, and separation of employment might occur prior to the issuance of any prior corrective action when deemed appropriate. Review of the facility’s policy titled, “Standards of Conduct,” last reviewed 11/2022, revealed the purpose of the policy was to ensure optimum patient care by promoting a safe, cooperative, and professional healthcare environment by defining a code of conduct. Further review revealed every employee was subject to conditions of behavior, including treating all staff, patients, and visitors with courtesy and respect. Review of PCA1’s Performance Measure Action Plan: “Workplace Violence (WPV) and De-Escalation,” last revised 4/15/2025, revealed he was to complete a one-on-one with the Security Manager for de-escalation techniques. Further review revealed he was to complete the education and then read and sign an attestation for understanding of content for the “Standards of Conduct” policy, “Patient Restraints and Seclusion” policy, and “Patient Rights and Responsibilities” policy. 1. Review of P11’s medical record revealed the facility admitted the patient on 04/11/2025 with a diagnosis of sepsis. He was discharged on 05/09/2025 after an Esophagogastroduodenoscopy and Percutaneous Endoscopic Gastrostomy Tube (G-tube) Placement were performed. P11 also received treatment for sepsis/infection management with administration of intravenous (IV) antibiotics. He experienced issues with confusion and was restrained after self-removal of lines and telemetry leads. During telephone interview with PCA4 on 08/13/2025 at 3:29 PM, she stated she was orienting with PCA1 as a new employee in April 2025. She further stated a patient (P11) was restrained due to pulling out his gastric tube and was nonverbal. She stated she, PCA1, and Nurse 2 had gone to his room to check on him due to an alarm and found he had pulled off his restraints and telemetry leads. She stated immediately PCA1 was aggressive, stating “we’re not going to do this tonight” and “I’m not in the mood for this.” She stated P11 could follow commands but was clearly disoriented, and PCA1 treated P11 like he was aware of his actions. PCA4 stated PCA1 restrained the patient so that P11’s wrists were up by his ears. She stated she saw blood on P11’s right arm when PCA1 was reapplying the restraints. She stated she told Nurse 2 they needed to get help, and she and Nurse 2 left the room. She further stated Charge Nurse (CN) 1 came in the room after they went for help, leaving P11 alone with PCA1. She stated CN1 assessed P11, changed restraints, and bandaged the patient’s arm. She stated she knew she should have stayed with the patient but was so new she went with her instinct to get help. She stated she thought PCA1 would settle down after she told him his behaviors were unacceptable, but he was laser focused on being aggravated with the behaviors P11 exhibited. She also stated she could not understand why he was so upset because she and Nurse 2 were in P11’s room with him, so he did not have to insert himself in anything. PCA4 stated PCA1 was very angry, but P11 had not given them any problems earlier in the shift. She stated P11 had pulled his telemetry leads all night long but was not combative and was more harmful to himself than others. During telephone interview with Nurse 2 on 08/13/2025 at 4:44 PM, she stated she was not P11’s primary nurse but was in P11’s room with PCA4, who was orienting with PCA1. She stated they went to P11’s room because the telemetry monitor looked like he was in asystole. Upon entering the room with PCA4, she stated PCA1 was already there, and they observed P11 had pulled the telemetry leads off. She stated PCA1 pushed P11 down, held him down by his forehead and was screaming at him while the patient was telling him to stop. She stated P11 was sitting up in bed, and PCA1 was pushing him down. She stated P11 sustained a right forearm skin tear, which they documented and put a photo of it in P11’s chart. She stated she left the room to get the charge nurse and did not recall PCA4 being with her. She stated she did not know where the primary nurse was, but she came after the charge nurse and House Supervisor were involved. She stated then PCA1 left the room and went to the nurse’s station while they went to the break room. She stated PCA1’s behavior was unjustifiable, and she wrote an IRIS (the facility’s online reporting system) report about it, but he was not fired. She stated she reached out to managers and human resources (HR) about how important it was they took the situation seriously. Nurse 2 stated that was new behavior from PCA1. She stated she had witnessed PCA1 to have a short temper, that he could get mad easily, such as if somebody asked him to retake a blood pressure or to get a blood sugar in the middle of the night. However, she stated he had fussed about these things but had not been aggressive with patients. During interview with Nurse 6, P11’s primary nurse, on 08/15/2025 1:57 PM, she stated P11 was confused, and staff had to place P11 in restraints the night of the incident. She also stated she was not in the room when the incident happened and was not aware of what was going on until she entered the room to administer an intravenous (IV) antibiotic. She stated Nurse 2 and PCA4 left the room as she entered. She stated she noticed P11 was bleeding and did not recall a wound earlier in the night. She stated PCA1 told her P11’s skin tear happened while he was combative. She stated she left the room to get dressing supplies and felt something was amiss, so she took another nurse with her when she returned. She further stated she dressed the wound and photographed it to document it in P11’s chart. She also stated CN1 and the House Supervisor came in to talk to P11 while she was administering the antibiotic. She stated CN1 instructed PCA1 not to be back in the room, then she did not see him the rest of the night and for a few nights after the incident. She stated she did not receive instruction not to leave PCA1 alone with P11. During telephone interview with CN1 on 08/13/2025 at 2:33 PM, she stated she received a report from Nurse 2 and PCA4 of the incident with P11, so she reported it to the House Supervisor, and it went up the line from there. She stated she assessed the patient and ensured he was safe. She stated Nurse 2 came to her to assess the situation involving P11. She stated she called the House Supervisor, who came to the floor. She stated when she went to P11’s room, she talked to PCA1 and told him not to go back in the room. She stated she thought she remembered the House Supervisor sent PCA1 home. She stated PCA1 was a float who came to their floor regularly, and she had not observed or received reports of his similar behaviors in the past. 2. Review of P1’s medical record revealed he was admitted on 07/26/2025 with the presenting problem of altered mental status. P1 was discharged on 08/06/2025 with diagnoses of severe sepsis, acute cholecystitis, delirium, and acute metabolic encephalopathy. Continued review revealed, after computed tomography-guided cholecystostomy tube placement on 07/30/2025 and treatment with intravenous (IV) antibiotics, he was transferred out of the Intensive care unit (ICU) and had issues with ongoing delirium. During interview with PCA1 on 08/13/2025 2:50 PM, he stated it was Sunday, 08/03/2025, and he was a sitter for P1, who had a history of violence. He stated P1 was by the sink, he thought to wash his hands, and P1 started chanting, “I’m going to get what I want.” PCA1 stated when he asked P1 what he wanted, he picked up a box of gloves and started walking toward him, while he was sitting. PCA1 stated P1 stopped responding when asked what he could do for the patient, and P1 tried to hit him with the box of gloves. He stated when P1 lunged at him, he gave P1 a push toward the bed while holding on to him. He stated he went to the hallway to see if anyone was around, then when he turned back to P1’s room, P1 threw a Sequential Compression Device (SCD) pump at him. PCA1 stated he pushed P1 into bed, then pushed the “Code Gray” button (a Rapid Response Team code for a patient with combative or aggressive behavior), and the charge nurse came to the room. PCA1 stated security and the House Supervisor came to the room, and he reported to them what happened and wrote a statement. PCA1 also stated he reported the incident to police. He further stated Human Resources (HR) called the next day and twisted his statement around against him. He stated less than 24 hours later, he was terminated for cussing and being too aggressive toward the patient. PCA1 stated every single nurse and PCA were on his side, that nobody liked and said he did what he had to do to not get injured. He stated he had training on de-escalation but it was geared from the Crisis Prevention Institute (CPI) to create a distance between self and the aggressive patient, to get out, and to find help. He stated he pushed the Code Gray button and was screaming for help. He denied having been in an investigation about his behavior before this one. During interview with Nurse 5 on 08/14/2025 at 3:50 PM, he stated he was in P1’s room five to ten minutes before the Code Gray and had taken his vital signs. He stated P1 was sitting up in a chair and was mildly agitated. However, he stated P1’s behavior did not seem to require further intervention, and he was just complaining that he wanted to go home. Nurse 5 stated he heard the Code Gray, and it was one of his rooms, so he directly went to P1’s room. He stated he had been at the far end of the hall and had not heard PCA1 shout for help prior to the Code Gray. He also stated when he responded to the code, he saw PCA1, who was obviously upset, walk away. He stated PCA1 reported to him that P1 had thrown the SCD pump at his head or had tried to. Nurse 5 stated when he entered P1’s room, P1 was back in bed. He stated he was subsequently notified PCA1 was going home. During telephone interview with Nurse 4 on 08/13/2025 at 5:05 PM, she stated she went to P1’s room in response to the Code Gray alert, so she did not witness the incident. She stated the sitter, PCA1, described what happened, but it did not completely match what CN2 told her. She also stated he had her read his statement, which also did not match. She stated CN2 told her PCA1 had his fist drawn back like he was going to hit P1, but PCA1 did not report that to her. She stated if PCA1 had bruising or a mark on his face from the pump, it was not noticeable to her. She stated the House Supervisor was already there as well as security, both in the room and outside in the hall. During interview with CN2 on 08/13/2025 at 4:31 PM, she stated PCA1 activated a Code Gray and she responded. She stated PCA1 screamed at P1, “Sit the fuck down,” and grabbed him by the arm. She stated she had to tell PCA1 to leave the room three or four times before he would leave. She stated PCA1 reported P1 threw a SCD pump and knocked his glasses off. She stated she observed the pump in the floor by P1’s feet, and PCA1’s glasses were on. CN2 stated, later in the room with the House Supervisor, PCA1 told them he had not been hit by the SCD pump. She stated P1 was scared, and she got him back to bed and did a head-to-toe assessment, finding no marks on P1. She stated P1 required a one-to-one sitter, and the sitter had to be male, because a couple of days before he had grabbed a female sitter. During telephone interview with CN2 on 08/14/2025 at 3:58 PM, she stated PCA1 had his right arm pulled back with his fist in a ball when she entered the room. She stated he was shouting, “Sit the fuck down!” She stated she grabbed PCA1 by one of his arms and told him to go take a walk and to leave the room. She stated she had to say it three or four times. She stated PCA1 did back away but did not leave the room at first; then when he did leave, P1 did not follow him out. She further stated she was standing between the patient and the sink/door. She stated she observed the patient was breathing hard/heavy, and she took his vital signs. She stated the House Supervisor had arrived, and he squatted down by P1 to talk to him. She stated P1 held her hand, and they did a head-to-toe assessment which was negative for adverse findings. She stated the police came up to the window in the nurse’s station later. She stated they asked for her and told her PCA1 had filed an assault charge, but she stated she told them she would not talk to them without her supervisor. She stated the House Supervisor arrived, and he took it from there. She stated the Staffing Office made the decision for assignments, including who was going to be the sitter for a patient who required one. She stated when PCA1 arrived to start the shift, he seemed to focus on P1’s potential behavior. The assignment had been made earlier and PCA1 was very hyper anyway, so she stated she had not thought anymore about it. During telephone interview with the House Supervisor on 08/13/2025 at 4:08 PM, he stated Code Gray was called on P1. He also stated CN2 responded first and reported seeing PCA1 bending over P1 with his arm cocked back like he was about to strike the patient. He stated she was the only witness. He stated PCA1 told him that PCA1 was cussing at the patient but not that he was going to hit the patient. He stated PCA1 had called the Code Gray apparently due to the patient throwing a SCD pump at him, and that was what threw PCA1 off. He stated PCA1’s exact words were that he “lost it.” He stated PCA1 acknowledged he was angry and yelling/cussing at P1 because of the SCD pump. He also stated the nursing staff reported it happened in a different area than where it was originally reported. The House Supervisor stated when the Code Gray was called, he responded, as he always would, but by the time he arrived, P1 was already in bed with CN2 talking to him. He further stated he did not see a mark, bruise, or cut on PCA1 after the SCD pump allegedly hit him. The House Supervisor stated all the staff reports matched except CN2 thought PCA1 was going to hit the patient. He stated CN2 described to him that she grabbed PCA1’s arm to direct him out of the room but did not see him hit the patient. The House Supervisor stated he collected written statements from PCA1 and CN2, went over details with security, and made the determination to send PCA1 home shortly after the event. Then, he stated he escalated the incident up the chain of command. He also stated Risk Management, the Chief Nursing Office (CNO) and HR took over after he gave them the rundown of everything. The House Supervisor stated he had sent PCA1 home about four months ago for holding a patient down in bed. He stated he reported that incident up the chain of command as well. During interview with the Market Manager for Flex Team on 08/15/2025 at 10:03 AM, he stated he was the first line supervisor for the flex team, which was also known as the float pool, and PCA1 was assigned to the team. He stated, based on HR recommendations, PCA1 had to complete the online education modules before he went to the in-person security class, and believed he had to complete them before coming back to work on 04/17/2025, after suspension. He stated he had several phone conversations with PCA1 about expectations for what he had to do to return to work, including ways to de-escalate without being aggressive, not taking patient comments to heart as they were ill, and/or they might have dementia. He further stated he coached on escalating to leadership for assistance, including the Rapid Response Team and the House Supervisor. He stated he just did some coaching on those things during one-on-one phone conversations. He also stated PCA1 stated he knew that he was just trying to protect himself. He stated he started his day at 6:00 AM, so he could round on night shift employees. He stated since the April 2025 incident, he recalled rounding on PCA1 a few times. He also stated float staff usually reached out on a dedicated text line with problems, and he would round on them with priority. During interview with the Market Director of Patient Flow on 08/13/2025 at 1:55 PM, she stated her department included the flex team. She also stated it had been her opinion that PCA1 should have been terminated based on the incident in April 2025. She stated the House Supervisor called her about the incident, explained the situation, sent the employee home, and had a debrief with HR, somebody from Quality, a director, the CNO, and the manager of the department. She stated, from her recollection, P11 was a confused and impulsive gentleman but pleasantly impulsive and not combative. She also recalled the manager had stated P11 had not been combative during his hospital stay. When the House Supervisor reached out, she stated a nurse and a PCA reported having witnessed PCA1 being overly aggressive with P11. She stated the nurse and the PCA reported it to CN1, who reported it to the House Supervisor, who reported it to her. The Patient Flow Director stated the House Supervisor did a really good job of collecting witness statements when fresh, before they went home from that shift. She stated PCA1 had to complete some pathways, which were online modules, repeating some that were required for onboarding and annually, but also a pathway that was a pre-requisite to the in-person Aggression Management class that he was also required to take, given by security. During additional interview with the Market Director of Patient Flow on 08/15/2025 at 9:42 AM, she stated the Market Flex Team Manager checked in with staff at the end of night shift. She further stated it was expected that they were rounding on everybody, that leaders were expected to round on staff through a shift, the nurse should be doing hourly checks on the patient, so by extension, checking on the sitter, and should be saying something if there was a problem or get help. She stated for PCA1’s Plan of Correction, the class was not available before he went back to work. She stated PCA1 had a one-on-one with the Flex Team Manager about expectations for dealing with a patient like P11 and about the plan for disciplinary action. She stated the expectation for Flex Team PCAs was that they would go to any assignment that was needed including sitting with patients. She stated the expectation with PCA1 was that he would be 100 percent capable of performing his job. She stated after the 08/03/2025 incident with P1, she remained involved by telephone due to being on vacation. She stated they got the debrief team together quickly and acted immediately. During interview with the Security Manager on 08/15/2025 at 9:11 AM, he stated he was contacted by the Market Director for Patient Flow and another manager that an employee needed remediation, but he had never had a one-on-one remediation with an employee. He stated if security knew there was a combative patient, they rounded more frequently on that unit. He stated security was called to P1’s room a couple of times, and one involved PCA1. He stated PCA1 attended the class on 05/20/2025. The Security Manager stated PCA1 participated and did everything he was supposed to, but he had a demeanor of not wanting to be there, huffing and puffing, so to speak. However, he stated as an instructor, that was not concerning since PCA1 was not declining to take part in the training. He stated PCA1 had previously been employed in the security department and was acquainted with him. He stated PCA1 was there for a few months when security was staffed by a contracted agency. He further stated they did have issues with his demeanor and behavior, such as not working well with others. He also stated there were times PCA1 exhibited too much aggression with his attitude toward people. However, he stated giving PCA1 correction would be difficult because he did not take it in stride, and he always felt like he was right and did nothing wrong. The Security Manager stated he did not recall PCA1 being terminated, but he was not a good fit and transferred to another position with the private company. He further stated he did not recall if PCA1 received documented corrective action as he was not in management then. He stated he had not given a recommendation for subsequent employment for PCA1. During interview with HR Business Partner (HRBP) 1 and HRBP2 on 08/13/2025 at 11:44 AM, HRBP1 stated they acted as consultants to management with HR Employee relations and multiple components. HRBP1 stated the HR Director ran the first investigation in the April 2025 timeframe. He stated HR was involved in determining circumstances after an incident but relied on others coming forth with information. He stated the consequences depended on the severity of the incident and on a case-by-case basis. He stated employees might go on leave pending investigation, which could involve speaking with both parties, hearing both sides of the story, taking written statements from witnesses, then relying on leadership to determine the best course of action. He stated they also relied on a progressive action track, such as first, an oral warning, then a written warning, then a final written warning, and then termination. He stated with verified abuse or neglect the actions would jump the track on the conduct policy to allow for higher responses. HRBP2 stated they had received a statement about PCA1 and reached out to him to clarify how he managed the situation. She stated they asked about his training for de-escalation, such as what techniques he learned and if he used any of those in this incident. She stated PCA1 responded with no accountability for his part in the incident, and he did not feel he was being abusive and had no explanation for why he had not done the things he had learned for de-escalation training. She stated PCA1 was providing sitter service to P1, who was at risk for falls, due to the patient’s impulsiveness for getting out of bed without assistance. She further stated, in this instance, CN2 observed from the hallway and entered the room when she witnessed PCA1 shove the patient back to bed, held his arms, and told the patient, “Stay the fuck down.” She stated there was no injury to PCA1 reported in the process. During interview with the HR Director on 08/13/2025 at 12:12 PM, she stated it was her recommendation not to terminate PCA1’s employment after the incident with P11. She stated her understanding from the Patient Safety Manager was her investigation was to determine intentional harm to the patient, and that could not be substantiated. She stated PCA1 told her it was hard to get P11 to settle down because he thought he was somewhere else. She stated PCA1 had stated P11 was working against him, and the two other people in the room were not helping him. She stated PCA1 had told her his goal was to keep P11 from falling, and he was trying to do that and reconnect the wrist restraint at the same time and by himself. She stated the other staff members spoke about feeling PCA1 was too aggressive in handling the patient, but nothing they said indicated PCA1’s purpose was to hurt P11. She stated she learned a couple of weeks later from the statewide Director of Quality and Patient Safety that this was not the standard. She stated she learned then that harm to a patient, regardless of intent, was the standard. At that point, she stated the decision had already been made not to terminate PCA1’s employment. She stated they recommended de-escalation training on workplace violence (WPV), and all staff received that in orientation and annually. She also stated the WPV training was an online module, but there was also an in-person class with security on “Techniques for Effective Aggression Management” in a classroom setting. The HR Director stated PCA1 did not provide any information about his previous employment with the security company that was contracted with the hospital. During interview with the Market Director of Risk Management on 08/15/2025 at 9:36 AM, she stated the online modules were completed in onboarding (orientation) and annually and were required by Corporate Compliance. She stated staff who did not meet those deadlines were removed from the schedule. She also stated HR checked references after the employee accepted the position. During interview with the Chief Nursing Officer/Vice President of Operations on 08/15/2025 at 2:24 PM, she stated first staff had to be trained about patient rights and to assess patients for behavioral issues. Then, she stated staff had to be trained on how to work within themselves to take care of the patients. For leaders, she stated intentional hourly rounding and education for caregivers helped to ensure patient safety and prevent some situations from escalating. She stated patient safety was also promoted when staff worked with HR to determine the path forward when an incident occurred. She stated the standard for substantiating abuse was whether the patient was harmed. She stated that related to their policy on abuse and what constituted abuse. She stated the typical response to an incident of an abuse allegation would be to remove the employee from the situation until the investigation was completed. She further stated the investigation included talking to the caregiver, the charge nurse, peers, and anyone who had provided care to the patient. She also stated the facility’s goal was to follow the corrective action policy. She stated her role was to ensure staff had followed their policy, to ensure clinical and HR partners were involved, and to ensure staff did their due diligence.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 44396 Based on interview, record review, review of the facility’s job description, and review of the facility’s documents and policies, it was determined the facility failed to ensure competent nursing care was provided for 1 of 11 sampled patients, Patient 1. P1 was placed on telesitter service, a virtual observation system, as of 08/01/2025, due to ongoing confusion. He was placed on one-to-one observation after the telesitter was insufficient, due to angry and belligerent behavior and his inappropriate behavior with attempts to grope multiple female staff members. On 08/03/2025, Patient Care Assistant (PCA) 1 was assigned to P1 as his one-to-one sitter. Although PCA1 had been educated in April 2025 and May 2025 on Abuse, Patient Rights, Standards of Conduct and Administrative Policy as well as Techniques for Effective Aggression Management, Charge Nurse (CN) 2 reported witnessing PCA1 scream at P1 while grasping P1’s arm with PCA1’s fist balled and pulled back as if to strike the patient. The findings include: Review of the facility’s policy titled, “Patient Rights and Patient Responsibilities,” last reviewed 12/2022, revealed under all circumstances, a patient had the right to always receive fair and compassionate care. Further review revealed patients had a right to receive comfort, respect and recognition of personal dignity, values, and beliefs, including cultural, psychosocial, and spiritual. Continued review revealed patients had the right to be treated equally and receive the same level of care or treatment regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation or gender identity, or expression. Additional review revealed patients had the right to receive treatment in a safe environment free from neglect, exploitation, and abuse. Review of the facility’s policy titled, “Alleged Abuse IN-FACILITY by Employees or Non-Employees Identification, Investigation and Reporting,” dated 07/2021, revealed its purpose was to ensure protection of patients from any form of actual or alleged maltreatment, including abuse, neglect, exploitation, and misappropriation of property. Further review revealed for any report of alleged abuse, the priority was the safety and well-being of the patient, and the alleged perpetrator shall be removed from duty until the investigation had been completed. It also stated the alleged perpetrator should not return to the facility until instructed by the designated leader. Review of the policy revealed the team would then validate the safety of the patient, any other potential victims, work status of the perpetrator, communication to the patient’s attending physician, occurrence report entry, and establish key contacts for the investigation. The Risk Manager and Quality team would conduct a thorough, timely, and objective investigation of the allegation. Review of the facility’s policy titled, “Patient Care Assignments,” last revised 07/2024, revealed caregiver clinical skills would be taken into consideration before making assignments or floating personnel to other areas. Review of the “Resource Patient Care Assistant (PCA)” job description, last edited 3/25/2025, revealed the PCA aided in transporting, transferring, lifting, and performed patient care duties to support the care giving team as delegated and with associated competencies. Further review revealed the essential PCA functions included reporting changes in patient status promptly to licensed staff, performing as patient care companion when needed, and communicating with patient, family, physicians, and unit personnel and peers in an accurate, courteous, and professional manner. Review of the facility’s policy titled, “Standards of Conduct,” last reviewed 11/2022, revealed the purpose of the policy was to ensure optimum patient care by promoting a safe, cooperative, and professional healthcare environment by defining a code of conduct. Further review revealed every employee was subject to conditions of behavior, including treating all staff, patients, and visitors with courtesy and respect. Review of the facility’s policy titled, “[The Organization’s] Health Administrative Policy,” effective date 02/02/2023, revealed employees were expected to perform satisfactorily, follow standards of conduct that protected the safety of patients, and conduct themselves with a level of professionalism that promoted a productive work environment. Further review revealed substandard performance or workplace conduct that was contrary to the organization’s health policies or expectations, whether directed toward fellow employees, patients, or any person, violated policies and expectations and would be addressed appropriately. Continued review revealed corrective action could utilize coaching, documented verbal warning, written warning, final written warning, suspension, and separation of employment. Additional review revealed the organization might follow a process in utilizing certain types of warnings before moving to separation of employment. However, per the policy, nothing created a guarantee of a particular escalation process, and separation of employment might occur prior to the issuance of any prior corrective action when deemed appropriate. Review of PCA1’s Performance Measure Action Plan: “Workplace Violence (WPV) and De-Escalation,” last revised 04/15/2025, revealed he was to complete a one-on-one with the Security Manager for de-escalation techniques. Further review revealed he was to complete the education and then read and sign an attestation for understanding of content for the “Standards of Conduct” policy, “Patient Restraints and Seclusion” policy, and “Patient Rights and Responsibilities” policy. Review of PCA1’s training record revealed he had completed Advanced Workplace Violence training on 05/20/2025, after originally being scheduled for 07/02/2025 but changed due to disciplinary action. Review of P1’s medical record revealed he was admitted on 07/26/2025 with the presenting problem of altered mental status. P1 was discharged on 08/06/2025 with diagnoses of severe sepsis, acute cholecystitis, delirium, and acute metabolic encephalopathy. Continued review revealed, after computed tomography-guided cholecystostomy tube placement on 07/30/2025 and treatment with intravenous (IV) antibiotics, he was transferred out of the Intensive care unit (ICU) and had issues with ongoing delirium and combativeness. During telephone interview with PCA1 on 08/13/2025 at 2:50 PM, he stated it was Sunday, 08/03/2025, and he was a sitter for P1, who had a history of violence. He stated P1 was by the sink, he thought to wash his hands, and P1 started chanting, “I’m going to get what I want.” PCA1 stated when he asked P1 what he wanted, he picked up a box of gloves and started walking toward him, while he was sitting. PCA1 stated P1 stopped responding when asked what he could do for the patient, and P1 tried to hit him with the box of gloves. He stated when P1 lunged at him, he gave P1 a push toward the bed while holding on to him. He stated he went to the hallway to see if anyone was around, then when he turned back to P1’s room, P1 threw a Sequential Compression Device (SCD) pump at him. PCA1 stated he pushed P1 into bed, then pushed the “Code Gray” button, (a Rapid Response Team code for a patient with combative or aggressive behavior), and the charge nurse came to the room. PCA1 stated security and the House Supervisor came to the room, and he reported to them what happened and wrote a statement. PCA1 also stated he reported the incident to police. He further stated Human Resources (HR) called the next day and twisted his statement around against him. He stated less than 24 hours later, he was terminated for cussing and being too aggressive toward the patient. PCA1 stated every single nurse and PCA were on his side, that nobody liked and said he did what he had to do to not get injured. He stated he had training on de-escalation but it was geared from the Crisis Prevention Institute (CPI) to create a distance between self and the aggressive patient, to get out, and to find help. He stated he pushed the Code Gray button and was screaming for help. He denied having been in an investigation about his behavior before this one. During interview with CN2 on 08/13/2025 at 4:31 PM, she stated PCA1 activated a Code Gray and she responded. She stated PCA1 screamed at P1, “Sit the fuck down,” and grabbed him by the arm. She stated she had to tell PCA1 to leave the room three or four times before he would leave. She stated PCA1 reported P1 threw a SCD pump and knocked his glasses off. She stated she observed the pump in the floor by P1’s feet, and PCA1’s glasses were on. CN2 stated, later in the room with the House Supervisor, PCA1 told them he had not been hit by the SCD pump. She stated P1 was scared, and she got him back to bed and did a head-to-toe assessment, finding no marks on P1. She stated P1 required a one-to-one sitter, and the sitter had to be male, because a couple of days before he had grabbed a female sitter. During telephone interview with CN2 on 08/14/2025 at 3:58 PM, she stated PCA1 had his right arm pulled back with his fist in a ball when she entered the room. She stated he was shouting, “Sit the fuck down!” She stated she grabbed PCA1 by one of his arms and told him to go take a walk and to leave the room. She stated she had to say it three or four times. She stated PCA1 did back away but did not leave the room at first; then when he did leave, P1 did not follow him out. She further stated she was standing between the patient and the sink/door. She stated she observed the patient was breathing hard/heavy, and she took his vital signs. She stated the House Supervisor had arrived, and he squatted down by P1 to talk to him. She stated P1 held her hand, and they did a head-to-toe assessment which was negative for adverse findings. She stated the police came up to the window in the nurse’s station later. She stated they asked for her and told her PCA1 had filed an assault charge, but she stated she told them she would not talk to them without her supervisor. She stated the House Supervisor arrived, and he took it from there. She stated the Staffing Office made the decision for assignments, including who was going to be the sitter for a patient who required one. She stated when PCA1 arrived to start the shift, he seemed to focus on P1 and potential behavior. The assignment had been made earlier and she did not have the autonomy to change it. During interview with the Market Manager for Flex Team on 08/15/2025 at 10:03 AM, he stated he was the first line supervisor for the flex team, which was also known as the float pool, and PCA1 was assigned to the team. He stated, based on HR recommendations, PCA1 had to complete the online education modules before he went to the in-person security class, and believed he had to complete them before coming back to work on 04/17/2025, after suspension. He stated he had several phone conversations with PCA1 about expectations for what he had to do to return to work, including ways to de-escalate without being aggressive, not taking patient comments to heart as they were ill, and/or they might have dementia. He further stated he coached on escalating to leadership for assistance, including the Rapid Response Team and the House Supervisor. He stated he just did some coaching on those things during one-on-one phone conversations. He also stated PCA1 stated he knew that he was just trying to protect himself. He stated he started his day at 6:00 AM, so he could round on night shift employees. He stated since the April 2025 incident, he recalled rounding on PCA1 a few times. He also stated float staff usually reached out on a dedicated text line with problems, and he would round on them with priority. During interview with the Market Director of Patient Flow on 08/13/2025 at 1:55 PM, she stated her department included the flex team. She also stated it had been her opinion that PCA1 should have been terminated based on the incident in April 2025. She stated PCA1 had to complete some pathways after a prior incident, which were online modules, repeating some that were required for onboarding and annually, but also a pathway that was a pre-requisite to the in-person Aggression Management class that he was also required to take, given by security. During interview with the Market Director of Patient Flow on 08/15/2025 at 9:42 AM, she stated the Market Flex Team Manager checked in with staff at the end of night shift. She further stated it was expected that they are rounding on everybody. In further interview, she stated for PCA1’s Plan of Correction, the class was not available before he went back to work During additional interview with the Market Director of Patient Flow on 08/15/2025 at 9:42 AM, she stated the Market Flex Team Manager checked in with staff at the end of night shift. She further stated it was expected that they were rounding on everybody. She stated for PCA1’s Plan of Correction, the class was not available before he went back to work. She stated Staffing did the preliminary staffing report, detailing such things as what unit needed a sitter. She stated they had a bed meeting and assigned for those needs, and the House Supervisor had final approval. She also stated if the unit had a different idea, they could propose it to the House Supervisor. During interview with the Security Manager on 08/15/2025 at 9:11 AM, he stated he was contacted by the Market Director for Patient Flow and another manager that an employee needed remediation, but he had never had a one-on-one remediation with an employee. He stated if security knew there was a combative patient, they rounded more frequently on that unit. He stated security was called to P1’s room a couple of times, and one involved PCA1. He stated PCA1 attended the class on 05/20/2025. The Security Manager stated PCA1 participated and did everything he was supposed to, but he had a demeanor of not wanting to be there, huffing and puffing, so to speak. However, he stated as an instructor, that was not concerning since PCA1 was not declining to take part in the training. He stated PCA1 had previously been employed in the security department and was acquainted with him. He stated PCA1 was there for a few months when security was staffed by a contracted agency. He further stated they did have issues with his demeanor and behavior, such as not working well with others. He also stated there were times PCA1 exhibited too much aggression with his attitude toward people. However, he stated giving PCA1 correction would be difficult because he did not take it in stride, and he always felt like he was right and did nothing wrong. The Security Manager stated he did not recall PCA1 being terminated, but he was not a good fit and transferred to another position with the private company. He stated he had not given a recommendation for subsequent employment for PCA1 and would not have if he had been called. During interview with the HR Director on 08/13/2025 at 12:12 PM, she stated it was her recommendation not to terminate PCA1’s employment after the incident in April 2025. She stated her understanding from the Patient Safety Manager was her investigation was to determine intentional harm to the patient, and that could not be substantiated. She stated PCA1 told her it was hard to get P11 to settle down because he thought he was somewhere else. She stated PCA1 had stated P11 was working against him, and the two other people in the room were not helping him. She stated PCA1 had told her his goal was to keep P11 from falling, and he was trying to do that and reconnect the wrist restraint at the same time and by himself. She stated the other staff members spoke about feeling PCA1 was too aggressive in handling the patient, but nothing they said indicated PCA1’s purpose was to hurt P11. She stated she learned a couple of weeks later from the statewide Director of Quality and Patient Safety that this was not the standard. She stated she learned then that harm to a patient, regardless of intent, was the standard. At that point, she stated the decision had already been made not to terminate PCA1’s employment. She stated they recommended de-escalation training on workplace violence (WPV), and all staff received that in orientation and annually. She also stated the WPV training was an online module, but there was also an in-person class with security on “Techniques for Effective Aggression Management” in a classroom setting. The HR Director stated PCA1 did not provide any information about his previous employment with the security company that was contracted with the hospital. During interview with the Market Director of Risk Management on 08/15/2025 at 9:36 AM, she stated the online modules were completed in onboarding (orientation) and annually and were required by Corporate Compliance. She stated staff who did not meet those deadlines were removed from the schedule. She also stated HR checked references after the employee accepted the position. During interview with the Chief Nursing Officer/Vice President of Operations on 08/15/2025 at 2:24 PM, she stated first staff had to be trained about patient rights and to assess patients for behavioral issues. Then, she stated staff had to be trained on how to work within themselves to take care of the patients. For leaders, she stated intentional hourly rounding and education for caregivers helped to ensure patient safety and prevent some situations from escalating. She stated patient safety was also promoted when staff worked with HR to determine the path forward when an incident occurred. She stated the standard for substantiating abuse was whether the patient was harmed. She stated that related to their policy on abuse and what constituted abuse. She stated the typical response to an incident of an abuse allegation would be to remove the employee from the situation until the investigation was completed. She further stated the investigation included talking to the caregiver, the charge nurse, peers, and anyone who had provided care to the patient. She also stated the facility’s goal was to follow the corrective action policy. She stated her role was to ensure staff had followed their policy, to ensure clinical and HR partners were involved, and to ensure staff did their due diligence.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 44396 Based on interview, record review, review of the facility’s policies and documents, and review of local law enforcement officer (LEO) documents, the facility failed to ensure that all patients presenting to the Emergency Department (ED) received a Medical Screening Examination (MSE) for one (1) of 20 sampled patients, Patient 1 (P1). P1 presented to the ED on 06/03/2025 for an examination following an alleged sexual assault. However, the facility did not have a Sexual Assault Nurse Examiner (SANE) available at that time and did not complete an appropriate MSE during the encounter. The findings include: Cross Refer to 2406.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 44396 Based on interview, record review, review of the facility’s policies and documents, and review of local law enforcement officer (LEO) documents, the facility failed to ensure that all patients presenting to the Emergency Department (ED) received a Medical Screening Examination (MSE) for one (1) of 20 sampled patients, Patient 1 (P1). P1 presented to the ED on 06/03/2025 for an examination following an alleged sexual assault. However, the facility did not have a Sexual Assault Nurse Examiner (SANE) available at that time and did not complete an appropriate MSE during the encounter. The findings include: Review of the facility’s policy titled, “EMTALA Examination, Treatment and Transfer of Individuals Who Come to the Emergency Department,” last reviewed 06/2024, revealed EMTALA obligations were activated when an individual requested examination or treatment of a medical condition within a dedicated emergency department (DED), or an individual requested examination or treatment for an emergency medical condition (EMC) while on hospital property other than a DED, or when a prudent layperson would recognize that an individual on hospital property, other than in a DED, required examination or treatment of an EMC even without a request for same. Further review revealed the facility provided to any individual who came to the ED an appropriate MSE within the capabilities of the DED, including ancillary services routinely available to the DED, to determine whether an EMC existed, regardless of the ability to pay. The policy also stated the MSE would be conducted by an individual determined qualified by Hospital Medical Staff Bylaws or Rules and Regulations. Continued review revealed the policy applied to all individuals who sought or needed an examination and/or treatment for a medical condition. Review of the facility’s policy titled, “Management of Suspected Assault Victims to Include Sexual Assault,” last revised 11/2024, revealed acute medical screening shall be performed according to EMTALA and could be performed by the ED physician or designee, which could include the mid-level provider or the patient’s attending physician. The review also revealed the primary nurse shall stay with the patient throughout the examination and collect any external evidence by using the Sexual Assault Evidence Collection Kit for exams that took place within 96 hours of the assault. Continued review revealed, for an examination following an acute incident, defined as less than 96 hours, an ED physician or mid-level provider must perform a medical screening exam, provide care for any medical injury, and notify the rape crisis center. Additional review revealed for verification of the SANE on call, staff utilized the Sexual Assault Forensic Examination (SAFE) algorithm for contact information. Review of the facility’s algorithm “Care for Sexual Assault Patient,” undated, revealed a step-by-step guide to follow when a patient presented to the facility following a sexual assault. Further review revealed when a patient wanted a SAFE and was reporting an alleged sexual assault, staff called the local law enforcement dispatch and requested a police officer and SANE, and the document contained the number. Continued review revealed if a SANE was not available, the facility completed the SAFE exam. Review of the “SANE Call-Out Roster” revealed there was not a nurse on-call after 12:00 AM on 06/04/2025 and noted that each hospital was responsible for their own examinations. Review of the “Sexual Assault Nurse Examiner Program Agreement,” effective 01/01/2025, between the local city and county government (Government) and the facility, revealed the Government provided skilled clinical personnel to operate the SANE program, and the facility agreed to provide a clinical area for the Government to implement its SANE program. Further review revealed the Government, through its SANE program, provided SANEs, on an as available basis to the facility, to perform the services, as appropriate, including performance of medical forensic evaluations, interviewing of patients who made a complaint of sexual assault, explanations of medical forensic care to patients, and collection of the patient consent forms from the patient before providing any medical forensic care. Other services included identification, packaging, and preservation of forensic evidence; creation of records of the medical forensic examination; and the maintenance of confidentiality for all such records, within the parameters specified and communication with law enforcement officers and other agencies as needed. Continued review revealed the understanding that nothing in the agreement shall be interpreted as to require the Government to ensure that it shall have SANEs available to perform any and all services referenced in the Agreement 24 hours of each day of the calendar year. Further review revealed nothing in the Agreement shall be interpreted as to remove any obligation of the facility to perform sexual assault nurse examinations in compliance with all applicable state law, where and when applicable. Review of local law enforcement’s “Standard Report, JC-3,” dated 06/03/2025, revealed P1 had called for assistance on 06/03/2025 after the ex-boyfriend had physically and verbally assaulted her. She also reported he had sexually assaulted her on 06/02/2025 as well as 06/01/2025 in her home. Further review revealed P1 wanted to have a SANE exam, and law enforcement officer (LEO) 1 took her to the only available facility, which was Saint Joseph Hospital, but they did not have the nurse available, and P1 planned to return the following day. During telephone interview with LEO1 on 06/09/2025 at 10:12 AM, he stated there were four SANEs who rotated call, and the police department had an agreement with them to provide SAFE exams in a dedicated space at the facility. Review of the local law enforcement’s “Department Case Report,” dated 06/06/2025, revealed P1 requested a SAFE and went to the facility with LEOs but a SANE was not on duty, and P1 did not wish to stay at the hospital for one to respond. It stated P1 planned to return the following day. Further review of the report, authored by LEO2, revealed upon arrival to the facility, he made contact with P1 while waiting for the SAFE and eventually was informed by a nurse at the facility that they did not have the staffing to perform the SAFE at that time, and P1 would have to wait in the hospital for approximately eight to nine hours until they had a nurse available. Continued review revealed LEO1, who served as an interpreter, and LEO2 informed P1 of this and offered to take her to another facility for the SAFE to be done there or have her come back later to the facility if she did not want to wait. Continued review revealed P1 chose to return later, and LEO2 was informed at approximately 3:30 PM on 06/04/2025 that P1 had returned to the facility. Review of P1’s ED record revealed she presented to the facility’s ED on 06/03/2025 at 11:55 PM with the arrival complaint of SANE exam and with ED Physician 1 assigned as her provider. Further review revealed the procedure and treatment was not carried out due to P1 leaving prior to being seen by the health care provider. Continued review revealed no evidence of an acuity being assigned or an appropriate MSE being completed, and P1 was dismissed at 12:40 AM. During continued telephone interview with LEO1 on 06/09/2025 at 10:12 AM, he stated he brought P1 to the facility on the night of 06/03/2025 around midnight and had been assigned to assist as an interpreter also because she spoke only Spanish. He stated P1 reported she had been physically assaulted and sexually assaulted twice in the past few days. He stated from the ED lobby, she was only gone five to 10 minutes in triage before she returned to the lobby. He stated he was told the facility could not do the exam because there was no SANE on duty. He stated P1 was already a sexual assault victim in an ED, and he felt she should have been seen. He stated there was already a person waiting for a SANE exam, so staff could not see P1. However, he stated ED staff never told them the circumstances. He stated he and LEO2 offered to take P1 to another facility to see if they could do it, but P1 chose to return to the facility’s ED the following day. During telephone interview with LEO2 on 06/11/2025 at 11:58 AM, he stated the facility was the go-to facility. He stated when he arrived, P1 was already in the lobby. He stated staff took P1 back to triage. He also stated when she returned, the nurse took them aside and told them the facility already had a patient, P3, waiting for a SAFE, and the facility did not have the staff to do a SAFE on P1. He stated the nurse told them she was not kicking P1 out, and P1 could have a bed while waiting, but she could not receive the exam until the morning. He stated the LEOs told P1 the options, which included waiting, going to a different facility, or go home and come back for the exam. He stated he believed LEO1 emphasized they could take her to another hospital, but LEO2 did not speak Spanish well enough to confirm. He stated P1 made the choice to go home and return and did return to the hospital later for the exam. He stated this was the first time someone was turned away for a SAFE in his experience, and he had been in this unit for nearly a year. He stated he felt P1 should have been able to get the SAFE, and he wanted to do the interview with the SANE present, so the patient did not have to repeat the details multiple times. During interview with RN1 on 06/09/2025 at 4:20 PM, he stated he had triaged P1 when she returned the second time. He stated P1 told him she had been to the ED the previous night, and there had not been a nurse available to do the exam. He stated the typical process was to take the patient to a room immediately, get labs, get the medical clearance completed, and then call the SANE. He stated medical clearance entailed getting labs and consulting with the provider. He stated the assigned nurse followed with the provider either by system message or spoke face-to-face, and the provider would determine clearance status after labs results were posted. He stated the process was started at check-in to contact the patient advocate, and the SANE was supposed to be contacted after clearance. He stated there was a dedicated number for SANE call out. He stated P1 had told him during triage that she wanted the SAFE exam. He stated if there was not a SANE on call, then the patient could choose to wait for a SANE, or the ED provider and nurse did the exam. During telephone interview with RN2 on 06/10/2025 at 12:28 PM, she stated she was a day shift charge and worked Wednesday, 06/04/2025. She stated on that morning, the night charge nurse reported to her that the shift had been a super busy night, and there was not a SANE nurse overnight. She stated she did not have much exposure with P1, but P1 was not medically cleared until 3:45 PM, and the SANE was off call after 4:00 PM. Therefore, RN2 stated P1’s SAFE was completed by APP1, RN3, and RN4. RN2 stated the priorities for a sexual assault victim were to get the patient to a room, get medical clearance, call the crisis center, police, and then the SANE after the patient was medically cleared. She stated in the absence of a SANE, the ED primary nurse and another nurse carried out the nursing portion of the exam. During interview with RN3 on 06/10/2025 at 2:25 PM, she stated she and RN4 completed the nurse portion of P1 SAFE on 06/04/2025, and APP1 did the pelvic portion with evidence collection. She stated she had performed SAFE examinations before, and she had orientation on SANE at a previous job. She stated the process for sexual assault patients was they brought the patient to triage, then room the patient, and the provider did an MSE and ordered labs. She stated when the patient was medically cleared, the facility offered the SAFE. She stated she was not aware of the SANE schedule, and the Charge Nurse contacted them to see if a SANE was on call. If a SANE was on call, she stated they came to the facility once the patient was medically cleared, and if not, then ED staff did the exam. She stated she was aware of this process prior to the incident. She stated the SAFE should be done within 72 hours to get useful evidence; otherwise evidence could be decayed or gone. During interview with RN4 on 06/10/2025 at 2:44 PM, she stated the expectation for sexual assault patient care was triage first, room the patient, then the provider did the MSE, and labs were drawn. She stated after medical clearance, a SAFE followed if the patient wanted it. She stated staff must call for the SANE that was on call, but if no SANE was available, the ED staff must complete the examination. She stated the nurses did questioning and paperwork, then the provider did the pelvic exam, collecting samples for evidence. She stated this was the first time she had participated in a SAFE. She stated she understood that a SAFE exam must be done within four days. She stated this was important for evidence collection, and if delayed, the evidence would be gone. During interview with RN5 on 06/10/2025 at 4:02 PM, she stated her understanding was if a patient asked for a SAFE exam, they must inform the patient if there would be a long wait for the SANE nurse and offer that the exam could be done by ED staff. She stated the process was the patient went to a room fairly quickly, staff discussed what to expect as far as testing, and staff informed the patient there was a forensic nurse who would come to complete the kit should they choose to do so. She stated once the patient was cleared medically, staff found out when to expect the SANE, or if no SANE was available, they informed the patient the SAFE could be completed by the ED nurses and provider. She stated the facility had the SANE coordinator come in to provide education in the past, and the Educator had done smaller educations on this. During interview with the ED Charge Nurse (CN) on 06/10/2025 at 7:39 AM, she stated she was working on the night that P1 came for a SAFE. She stated she knew now what she did was wrong and had been educated since for how to do better. She stated the ED was unusually busy the night of 06/03/2025, and she precepted an orientee for her first night. She stated by the time P3 [another alleged sexual assault victim] and P1 arrived, she had lost a nurse at 9:00 PM, two more nurses at 11:00 PM, and another nurse was due to end the shift at 3:00 AM. She also stated she had called the House Supervisor to determine if they could get extra help, but that did not occur. She stated shortly before midnight P1 arrived, and P3 was already waiting, both needing a SAFE, and the SANE was going off call at midnight. She stated she was thinking about how to get P3’s SAFE completed because the 3:00 AM nurse had never done a SAFE. Then, she stated when P1 arrived, she panicked about what to do to manage both. She stated she had an initial conversation with ED Physician 1 who suggested she should just complete the first one in an hour. However, she stated a SAFE required far more time, and especially with a nurse who had not done one before. She stated she then met P1 in triage, explained what she thought were the options, including there was another patient ahead of her, and it might be until morning before she could have the exam. She stated she knew now P1 should have gotten the MSE by the provider, and also she did not specifically remember there being a midlevel provider on duty. She stated she did let ED Physician 1 know about the conversation she had with P1, and it was felt if they did the labs now, P1 might have to have them repeated by morning. She stated she told P1 she was welcome to stay, but she would have to wait overnight, or she could go home and return. She stated she told LEO1 she was not turning her away, and it was her choice. She stated the SAFE was important to gather the evidence, obtain the labs, and give the medications. During telephone interview with the House Supervisor on 06/10/2025 at 5:33 PM, she stated she did not recall getting a call about the two alleged sexual assault patients [P1, P3] that night [06/03/2025]. In further interview, she stated when there was no SANE available, it became the ED staff’s responsibility to conduct the exam. During telephone interview with Advanced Practice Provider (APP) 1 on 06/10/2025 at 11:43 AM, she stated she cared for P1 the day she did have her MSE and SAFE [06/04/2025]. She stated every ED patient should get a medical screening exam. She stated she was told P1 had seen the triage nurse only and not by a physician or APP the night before. She stated the importance of timeframes with SAFE for obtaining DNA examples, evidence collection, and the patient’s health. She stated there was no reason a SAFE should be delayed. She stated the ED providers, with nursing, were expected to perform the SAFE in the absence of a SANE. She stated she was never a SANE nurse but had training about policies for EMTALA and SAFE. She stated the policies and training had been in place since she had been there and before this incident. She stated with this incident, she did not know whether they ran it by the provider, but she thought ED staff should have known the SAFE needed to be done immediately. During telephone interview with ED Physician 1 on 06/10/2025 at 2:09 PM, she stated she was covering the ED on Tuesday night, 06/03/2025. She stated her expectation for patients reporting sexual assault was that they were brought to a room, the police were called if the patient wished to file a report, the Patient Advocate was called, and the SANE was contacted. She stated if there was a SANE on call, they came to do the exam, and if not, the Charge Nurse would step in. She stated she did pelvic swabs and offered labs and prophylaxis medications. She stated P3 was back in the room around midnight on 06/03/2025, but there was no longer a SANE on call. She stated she did not have time to do a full exam, and the Charge Nurse reported she did not have time due to losing a nurse at 3:00 AM. Therefore, she stated she instructed the Charge Nurse she needed to see P3 first, before the nurse left. She stated she was fully prepared to see P1 but had a very sick pulmonary edema patient at the same time. She stated later the Charge Nurse reported P1 was not sure about staying/waiting for the SANE and asked if she could get labs done and return later. ED Physician 1 stated there was a concern that if P1 returned, she might have to have labs repeated. She stated the ED staff was getting closer to single coverage by then, but she was not informed the patient had decided to leave, so she did not have the opportunity to speak with P1 and had planned to encourage her to stay. She stated she did not know the second patient (P1) chose to leave. She stated the time required for a SAFE was one to two hours, and she also looked for major injury. She stated the timeframe was important to preserve evidence and to prevent the alleged victim from having to wait in the ED for a long time. During telephone interview with ED Physician 2 on 06/11/2025 at 10:31 AM, he stated he assumed responsibility for P3 after the change of shift, after she had been there overnight. He stated all the labs and medications had been done by the time he assumed care. He stated they were just waiting for the SANE nurse to arrive and once that happened, P3 was discharged to her. He stated the process for treating sexual assault patients was providers see the patient, do the MSE, get labs and medications ordered, and discharge to the SANE once arrived. He stated when a sexual assault patient presented, providers talked to them, determined if any imaging or other tests needed to be done, then offered the SANE. He stated, if the patient wanted the SANE, staff must make sure a report had been filed with law enforcement and call the SANE. He stated if the SANE was unavailable, he would perform the exam. He stated for documentation, which was handled by nursing, once evidence was collected, law enforcement was present, and law enforcement would let him know if anything else was needed. If there was a SANE, he stated the SANE handled all of that, and the patient would be discharged to the SANE. He stated he had received education for managing sexual assault patients before and had since had to review the policies and attest by signature that he had done so. During telephone interview with SANE1 on 06/09/2025 at 11:01 AM, she stated she did a SAFE for P3, who had waited about nine hours overnight for the exam. She stated P3 had been at the ED since 10:00 PM the night before, and she came on duty at 8:00 AM that morning. She stated the facility’s ED staff told P1 they could not see her in the ED, even though staff usually saw the patient in the ED for medical clearance first before the SANE intervention. She also stated P1 was told they did not have anybody to do her exam, and she would have to come back. When she was called by the Charge Nurse (CN) about P1 that afternoon, she stated she asked why she had not had medical clearance, and the CN told her the facility had not had anybody to do the exam. She stated the policy was, in the absence of a SANE, that a midlevel or physician completed the exam. She stated there was always a nurse present to assist with the kit/collection and maintain the chain of custody. She stated her big concern for P1 was the assault had already happened a couple of days earlier. She stated the ED staff, in conjunction with the MSE, provided the STD and HIV prophylaxis and the Plan B prophylactic treatment (for pregnancy prevention). She stated there was a 72-hour window for that treatment. She stated P1 was barely in the window for this treatment from the first assault, and it would have been better if this had happened when she first presented. She stated, after 72 hours, the medications were not deemed effective and were not given after that timeframe. She stated there was 96 hours post assault for the exam, but the longer they waited, the greater the chance that definitive exam samples could not be collected. During telephone interview with SANE 2 on 06/11/2025 at 12:15 PM, she stated she was the program manager for the local SANE program. She stated she sent out a document to the SANEs and detectives with the schedule. She stated she had provided education to staff for probably the third time since they started with the facility and did it two different days each time. She also stated she developed the algorithm when they started the program with the facility. She stated she was contacted by the LEOs about this incident, asking whether patients could be turned away, and there was already somebody who was waiting for nine hours. She stated she contacted the facility about it, but her biggest concern was that the one turned away might have gotten a life sentence of a pregnancy added to the most traumatic thing that ever happened to her. She stated with HIV prophylaxis, they only had 72 hours to administer the medicine for it to be effective. Plus, she stated P1 was not given the proper attention she needed, which made it seem unimportant, and the delay could have hindered the prosecution. She stated she emphasized in education that staff was not judge and jury, and the sexual assault patients needed the same attention that any patient received. During additional telephone interview with SANE 2 on 06/11/2025 at 6:02 PM, she stated she wanted to emphasize that the agreement outlined SANE coverage was provided as available and that, in the absence of a SANE on duty, providers and midlevel providers were able and expected to provide forensic exams. She stated a concern was the delay for a patient who was already traumatized, thus extending the trauma. She also stated SAFE was a long exam, and for the SANE, one case could require as much as six hours from beginning to end. During interview with the Market ED Director on 06/06/2025 at 1:30 PM, she stated for sexual assault patients, they received an MSE in the ED, which addressed any injuries; labs drawn for sexually transmitted diseases (STD), human immunodeficiency virus (HIV), and pregnancy if they wanted; and prophylaxis medications if they wanted. She stated, after the MSE, labs, and medications, if there was a SANE on duty, the patient discharged from the ED to the SANE in Room 19 who performed the SAFE. She stated the patient was under the SANE’s care. She stated the SANE was contracted with the local government. She stated this process worked when there was a SANE on duty. She stated, if there was not a SANE on duty, the facility’s ED physician or mid-level provider performed the exam with primary nurse assistance. She stated they maintained the chain of custody for collection of evidence until the local LEO arrived to collect the evidence. During additional interview with the Market ED Director on 06/10/2025 at 12:14 PM, she stated she had been covering the ED while the assigned manager was on extended leave. She stated she called the CN each morning to see how the night went. When she called the morning following the incident, she stated the charge nurse reported she might have done the wrong thing, and she immediately talked through the process, the details of the policy, and what should have happened. The ED Director stated her reaction was the desire to fix this to avoid any confusion. She stated P1 should have had an MSE and should have been seen by a provider. She further stated her expectation was that the SAFE would have been done by a provider and assisted by a nurse. She stated she did remember about staffing regarding call offs, but did recall the nurse who worked 7:00 PM to 3:00 AM on 06/04/2025 was a day shift nurse who picked up extra hours. She also stated the nurse orientee was new to the hospital but was an experienced ED nurse. She stated the typical patient load was four patients to one staff member. She stated she thought the total volume of patients that night was 17 or 18. She stated their core staffing after 11:00 PM was usually four nurses and a technician, but that night after 3:00 AM there were two paramedics and two nurses, one of whom was on orientation, and one was the charge nurse. She stated the timeframe for completion of the SAFE was so important because the evidence might degrade as well as a possible injury that could go untreated. During telephone interview with the Medical Director on 06/10/2025 at 11:30 AM, he stated he expected the SANE nurse would come in, and the facility’s provider would get an MSE. He stated he was disappointed their staff got to the point of this situation. He stated ED staff did “a crazy amount” of training on EMTALA. He stated he expected the SAFE to be completed, and if necessary, the SAFE to be performed by the facility’s provider/midlevel in the absence of a SANE. He stated whomever was covering in the ED would perform the exam. He stated the expectation for the timeframe was the SAFE was done as soon as possible. He stated he would expect the SANE would start the SAFE in an hour and so would the ED staff. He stated he talked to ED Physician 1, and she was aware of his dissatisfaction about the incident. He stated she reported she had a really sick patient that required extra attention. Also, he stated a SAFE was a lengthy exam. He stated if no SANE was available, then the bulk of the exam was done by the nurse, with the provider doing the genitourinary exam and overall forensic collection of evidence. He stated for preservation and protection of evidence, it was important to collect it as soon as possible. He stated performing the MSE was important because it was not known what else was going on with the patient, with the possibilities that the patient could have hemorrhage or internal damage that should be assessed.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 46710 Based on observation, interview, record review, review of the Language Line Service Log, and review of the facility’s policies, the facility failed to inform each patient of his/her rights in a language and a manner the patient could understand for 2 of 8 patients investigated for language services, Patient (P) 1 and P6. The findings include: Review of the facility’s policy titled, “Patient Rights and Patient Responsibilities,” revised 12/2019, revealed patients had a right to receive information including risks, benefits, and reasonable alternatives in a language they understood pertaining to their health status, current diagnosis, treatment plan, and prognosis in order to give informed consent or to refuse consent. Review of the facility’s policy titled, “Provision of Services for Limited English Proficient, Deaf/Hard of Hearing, and Blind/Visually Impaired Individuals,” revised 03/2020, revealed patients at the facility were to receive services in their preferred language by qualified, approved interpreters utilized during the delivery of all significant health care services. Further review revealed significant health care services included: obtaining financial and insurance information, obtaining informed consent, and during treatment and testing. Continued review revealed staff was not permitted to rely on an adult accompanying the patient for interpretation services unless there was an imminent threat to the safety or welfare of an individual when there was no qualified interpreter present. Additionally, staff was required to use a qualified interpreter to verify a family member’s translation to confirm complete and accurate communication with the patient. 1. Review of P1’s “Face Sheet” revealed the facility admitted and discharged the patient on 11/07/2024 with no primary diagnosis listed. Further review revealed P1’s primary language was Chinese. Continued review revealed no phone number, email address, or physical address were listed. Review of P1’s “Emergency Department [ED] Timeline,” dated 11/07/2024, revealed P1 entered the ED at 12:48 PM and received an electrocardiogram (EKG, a measurement of the electrical function of the heart) at 1:13 PM. Further review revealed no further treatment was documented until 4:50 PM, when P1 received a dose of haloperidol (an antipsychotic agent that could be used to treat agitation) 5 milligrams (mg) and lorazepam (an antianxiety agent) 1 mg. Per the timeline, P1 had blood samples drawn at 6:13 PM; however, no urine sample was listed on the timeline. Continued review revealed P1’s primary diagnosis was aggressive behavior. Additionally, no interpreter information was found in the “ED Timeline.” Per interview with the Market Director of Quality on 12/16/2024 at 4:35 PM, the interpreter information would appear in the “ED Timeline” if it was documented. Review of the “Language Line Service Log,” for 11/07/2024, revealed a Mandarin Chinese translator was only in use from 1:00 PM to 2:53 PM for that day. Observation and interview with P1 was not possible due to the patient no longer being at the hospital, and no contact information was listed. In an interview on 12/17/2024 at 11:45 AM, the ED Unit Clerk (EDUC) stated she believed P1 spoke English because he/she cursed at the staff in English. She further stated the staff attempted to use the approved interpretation application on the tablets at the beginning of P1’s ED encounter, but the patient was noncompliant with use of the interpreter line, so she did not believe they used it for each conversation with P1. In continued interview, the EDUC stated while RN1 collected a urine sample via urinary catheter from P1, P1 kept repeating “What the [expletive], man?” In an interview on 12/18/2024 at 10:01 AM, Registered Nurse (RN) 5 stated she used the interpreter applications on the electronic tablet in the ED when she was caring for a patient who did not speak English fluently. In further interview, RN5 stated she was in P1’s room several times during his/her ED course of treatment and never saw the interpreter electronic tablet in the room, including while RN1 was attempting to obtain a urine sample via catheterization. In an interview on 12/18/2024 at 10:51 AM, RN1 stated she used the interpreter application on the electronic tablet when speaking with P1, but he/she was confused and noncompliant with use of the interpreter. She further stated P1 became agitated and violent immediately following urinary catheterization for sample collection. Per interview, the lab was unable to process the specimen, which RN1 believed was the reason the “ED Timeline” did not reflect the event. In an interview on 12/19/2024 at 9:54 AM, the Language Services Lead (LSL) stated she educated nursing management and staff to always contact the hospital language services line to set up an in-person interpreter for confused patients. She further stated the interpreter services on the electronic tablets could be used while waiting for an in-person interpreter to arrive. She stated if staff had called her when P1 was in the ED on 11/07/2024, she could have contacted an in-person interpreter to see if they were available for Mandarin Chinese interpretation. Additionally, the LSL stated the language services page on the hospital intranet had communication boards with pictures and written Mandarin Chinese that could have been used as a tool to attempt to communicate with P1. The LSL stated it was unacceptable for hospital staff to attempt to insert a urinary catheter on P1 with no interpreter on the line because the patient had a right to know what was happening to them and to refuse the procedure if he/she desired. In an interview on 12/18/2024 at 2:27 PM, the Market Director for Emergency Services stated she believed the staff used the approved interpreter services for P1, but the patient’s dialect was difficult for the interpreter to understand. She stated this made communication with P1 difficult. The Market Director stated staff signed they read the hospital policy on interpreter services as re-education following P1’s stay in the ED, but the re-education did not include a post test to check for understanding of the policy. 2. Review of P6’s “Face Sheet” revealed P6 arrived to the ED on 12/12/2024 with a chief complaint of back pain. Further review revealed P6’s primary language was Spanish. Observation on 12/12/2024 at 11:19 AM revealed Patient Advocate Representative (PAR) 1 spoke to P6, who was Spanish speaking, through Family Member (F) 1 as an interpreter. Further observation revealed no approved interpreter was used. In an immediate interview, F1 stated hospital staff offered an interpreter, but it was the family preference that F1 did the interpreting for P6. In an interview on 12/20/2024 at 10:37 AM, PAR1 stated she did not typically work in the ED. She further stated she usually used the tablet application to contact an approved interpreter, but if a patient’s family member stated they preferred to act as the patient’s interpreter, she honored that preference and did not call an approved interpreter to verify the family member’s interpretation. Further observation on 12/12/2024 at 11:57 AM revealed an electronic tablet marked for language services. The observation revealed Emergency Department Technician (EDT) 1 was not able to open the language line application on the tablet without assistance. In an immediate interview, EDT1 stated she did know how to access the interpreter application on the tablet, but she had been on vacation. She further stated she did not recognize the log in screen that initially displayed on the tablet because it was for a secondary interpretation application that she did not use, and she had been unable to utilize the technology to navigate to the primary interpretation application. In an interview on 12/18/2024 at 10:01 AM, RN5 stated hospital staff was expected to use an approved interpreter, usually on the electronic tablet, for every conversation with a patient with limited English proficiency. She further stated staff should use the electronic tablet interpreter as a means of verifying family language interpretations to ensure the accuracy of the information conveyed to the patient. In an interview on 12/18/2024 at 3:18 PM, the Emergency Department Supervisor (EDS) stated her expectation for use of interpreter services in the ED was for staff to get an interpreter on the line via the electronic tablets and to keep that interpreter on the line with that patient until the patient was sent home or admitted to a floor upstairs. She further stated it was her expectation that staff kept an approved interpreter on the line, even if the patient’s family member was also interpreting, to verify the family member gave the patient accurate information. In an interview on 12/18/2024 at 4:48 PM, the Emergency Department Manager (EDM) stated staff needed to use an approved interpreter to accurately determine the needs of the patient. He further stated if the patient wanted to use a family member to interpret, staff needed to have an approved interpreter on the electronic tablet verify the family member’s interpretation of what was said. In an interview on 12/12/2024 at 11:32 AM, the Market Director for Emergency Services stated there was no in-person interpreter services available at the hospital. She further stated she expected staff to use the interpreter applications on the electronic tablet to interpret each conversation with patients with limited English proficiency. Per interview, if a patient requested a family member to interpret, the Market Director expected staff to use the approved interpreter application to verify the accuracy of the family member’s translation. In an interview on 12/20/2024 at 9:33 AM, the Market Director for Patient Access and Patient Logistics stated she expected staff to use an approved interpreter for each interaction with a patient with limited English proficiency. She further stated the facility had an obligation to attempt to get an in-person interpreter for a confused patient. In an interview on 12/20/2024 at 12:47 PM, the interim Chief Nursing Officer (CNO) stated her expectation for interpretation with limited English proficiency patients was for staff to utilize available language services to ensure the patient had a clear understanding of what was happening. She further stated it was important to have a clear path of communication back and forth with the patient to ensure staff met the needs of the patient.”