Uofl Health - Jewish Hospital and Mary & Elizabeth 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: 28734 Based on observation, interview, policy review, and record review, the allegation that the facility failed to protect one (1) of nine (9) sampled patients from physical abuse was substantiated. Patient (P)5 suffered physical abuse by Security Officer (SO)3. The findings include: A review of the facility’s policy, titled “Patient Rights and Responsibilities” dated 10/2021 stated, “4. The patient has the right to be free from all forms of abuse or harassment ...” A review of the facility’s policy titled, “Protection of Patients from Abuse by a Staff Member” dated 09/24/2024 stated, “Purpose: To ensure protection of patient of University of Louisville (UofL) Health from any form of actual or alleged maltreatment, including abuse, neglect, exploitation, and misappropriation of property. To establish guidelines for the recognition, reporting and management of allegations of patient abuse by a staff member ...Abuse is defined by the Centers for Medicare and Medicaid Services (CMS) as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish ...” A review of Patient’s (P)5’s Face Sheet revealed the facility had admitted him on 07/26/2025. Review of the “Psychiatric (PSYCH) Assessment, dated 07/28/2025, revealed, “ ...he states he had an argument with his mom that started two (2) days ago when she asked him to help his brothers clean their room. The patient got upset, did not want to help his brothers, ended up getting his phone taken away ...mom was trying to get him to take his medications. Has not taken it in the past two (2) days since the argument, states he does not need to take medications ...mom ended up taking siblings out of the house in order for him to calm down ...family reports they ended up speaking with him through the camera in their home. That is when P5 stated that he was going to kill himself, so she ended up calling the police ...” Diagnoses: disruptive mood dysregulation disorder, major depressive disorder, oppositional defiant disorder, conduct disorder, post-traumatic stress disorder (PTSD), migraines, bradycardia, and asthma ...Treatment goal is to attain euthymic mood, gain better insight into problems, and to learn better coping skills.” An observation and review of video surveillance provided by the facility revealed on 07/29/2025 at 6:35 PM, SO3 approached the outside doorway to P5’s room. The patient was observed standing right outside of the doorway to his room. The officer was observed to have moved in close to the patient and grab onto the patient’s left upper arm and push him back into his room. The patient could be observed to recover from the push and as he walked back towards his bedroom door. The officer was then observed to push the patient back into his room with both of his arms placed just below the patient’s chest. Continued review of the footage revealed the patient landed onto the bed mattress and the security officer landed upon the patient’s chest area. A review of a “Consult Note” dated 07/30/2025 at 1634 by a provider revealed, “Right hand pain, P5 is being seen for his complaints of right-hand pain. Says “security hurt my hand.” Says he was in his room trying to leave and security would not let him leave his room. Says during this interaction, he scratched his hand and hurt his right middle finger ...Skin: three (3) millimeter (MM) superficial abrasion to the right fifth knuckle on the lateral aspect of the knuckle. No bruising or swelling of the middle finger. Ordering bacitracin twice daily for three (3) days. Cover with a band-aid. Review of the facility’s “Witness Statement/Investigation Notes Form” dated 07/29/2025 revealed Security Officer (SO)3 reported that during a code situation he had been asked by nursing to ensure P5 stayed in his room because he, and another patient were going “to jump” another patient when they were being walked to the Quiet Room. SO3 had revealed that P5 had taken a step out of his room, and “he reports he put a hand on P3’s left arm and said “please, stay in your room.” The SO stated, “the patient said no and pushed him in the chest. He notes putting his arm up towards the patient, protecting himself. He reports P5 took a step back, blading his body, pulled his pants up, and balled his fist. He states he genuinely thought this patient was about to attack him so he tried to initiate a single person holding before the patient could start throwing punches. He notes P5 went back, and they both went down on his bed ...” Review of another “Witness Statement” dated 07/30/2025 with SO2 revealed, “He was in the hallway ...when he looked around and saw P5 with his hand on SO3’s chest. He states he then saw SO5 go into P5’s room, so he ran over to help. He notes when he arrived at the patient’s room, he saw the patient in a kind of prone position on the bed with SO5 over him with the patient’s arm crossed. He reports saying that they need to get the patient off the bed and in a supine position, so they transitioned ...” A review of P5’s “Witness Statement” dated 07/30/2025 revealed that he was in his room for room restriction on something that had occurred a few days ago. He states one of his peers kept running into his room, and team members caught him. He states that one of the nurses had asked one of the security guards to watch him and his peer because they kept going into each other’s rooms. He reports attempting to go out of his room to the restroom, and the security guard pushed him. He states he then tried to walk around him with the security guard pushing him harder. He notes slapping the security guards hand away. He reports the security guard pushed him hard and they both fell on the bed with the security team member on top of him causing an abrasion to his right hand and a small bruise on his right middle finger. He states the team members said, “we can’t keep him like this” so they pushed him off the bed and onto the floor and put him in a “real holding” He notes being put back on room restriction for this altercation and he did not do anything until he was pushed down.” A review of the “Circumstantial Evidence” in the investigative report stated SO5 stated, “he did not see the initiation of the incident, however, responded to P5’s room when he saw numerous peers go in. He states that when he entered the room, he saw SO3 on top of P5. He notes re-directing SO3 to get off the patient’s back. He stated he was not sure if pressure pushed, or if the patient did it to himself, but the patient fell to the floor. He notes they were then able to initiate and approved Crisis Prevention Institute (CPI) holding.” An interview, 04/08/2026 at 1:02 PM with Risk Analyst2 revealed once the allegation had been made by P5, the facility had conducted an investigation, and the facts were then presented in a Risk Management Meeting which included members of various departments within the facility. She went onto state there had been a lot of open discussion about the case. The Risk Analyst stated the Security Department had a lot of input and had not felt like SO3 had intentionally physically abused P5 because the officer had felt threatened by the patient. She revealed the Risk Management Team never made the final decision on whether to substantiate or unsubstantiate an allegation of abuse. A telephonic interview with the Security Director on 04/10/2026 at 8:32 AM revealed the process of investigation at the facility had been completed by the Risk Management Team and then presented to the security team along with other administrative members. He revealed members do have opportunities to offer their opinion whether they agree or disagree with presented evidence but the ultimate decision on whether to substantiate or unsubstantiate an allegation of abuse had not been made by the security team. He went onto state he would need to review the video on the alleged incident that occurred between SO3 and P5 before he continued the interview with the surveyor. An interview, on 04/10/2026 at 8:55 AM with the former Director of Human Resources Organizational Effectiveness revealed she had become involved with this case at the point of the Risk Meeting. She revealed she recalled there had been quite a bit of vocal discussion about the actions of SO3. She went onto state the facility now had more involvement now with security, and use of force. Interview on 04/10/2026 at 9:11 AM with the Director of Patient Safety revealed he had watched the video of the incident between SO3 and P5. He revealed he observed the SO forcefully push the patient onto the mattress and felt the officer had been physically aggressive with the patient. He stated the officer and had not been compliant with CPI. He revealed the SO had been placed on Administrative Time Off (ATO) during the course of the investigation. Interview, on 04/10/2026 at 9:25 AM with the Director of Nursing revealed after the incident, a medical provider had determined P5 had a scratch on his arm. She said she had attended the Risk Management Meeting to discuss the facts of the investigation. She stated the nursing staff preferred to work in a therapeutic manner, but it was the job of security to “secure the situation.” She went onto state she thought the way the patient had been treated by the SO was terrible, and shortly after the incident, abuse training went out to the entire hospital. She revealed the event was “the perfect storm” and thought many staff at the hospital had not agreed with the decision to unsubstantiate the allegation made by P5. She stated the facility stressed therapeutic techniques and to walk away if you had to, however, many of the patients were aggressive with staff. Interview with the Security Manager on 04/10/2026 at 9:51 AM revealed he had not felt SO3 acted with malicious intent toward P5, however, SO3 had not followed CPI. He stated it appeared to him P5 had tested the officer’s boundaries. He went onto state SO3 had stated that the patient had hit him, but he did not have any injuries. He revealed the officer should have stood at the doorway with both of his arms extended towards the patient. The Security Manager revealed all the security officers had received training and education on abuse, and patient rights. He also revealed it was his expectations that the nurse secures any requests for seclusion from the physician. An interview with the Director of Security on 04/10/2026 at 11:00 AM revealed SO3 had stated the patient had put his fists up and had a bladed stance (According to specialized dictionaries like Wiktionary and YourDictionary, a bladed stance is defined as a martial arts or tactical stance in which one foot is positioned in front of the other, with the body angled away from an opponent), however he had not see that in the video. He revealed he observed SO3 pushing P5 back into his room. He revealed when a patient became escalated or aggressive the best option would be to push your hands forward, and step backwards. He stated there were very specific rules that had to be followed with hospital security, and it could be a difficult job. The Security Director stated the security guards had to complete a 120-hour (three week) academy, and during the academy each officer received training on abuse. An interview with the Chief Executive Officer, on 04/10/2026 at 11:50 AM revealed the facility had unsubstantiated the incident between the officer and the patient as abuse, however there had been deviations from facility protocols. He went onto state it was at that time that the facility looked at global educations towards the definition of abuse, power struggles, aggressions, the investigative process, and trauma informed care. Record review revealed SO3 completed “Safety and Security Basic Officer Skills” on 07/11/2025. Conclusion: Based on observation, interview, record review and policy review, the allegation of physical abuse is substantiated.”

“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: 28734 Based on observation, interview, policy review, and record review, the facility failed to ensure patients were free of all forms of abuse or harassment from the staff for one (1) of three (3) sampled patients. Patient (P)#1 was physically abused in the Emergency Department (ED) by two (2) staff members. The incident was witnessed by other staff members, however, the staff failed to report their observations until four (4) days after the event occurred. The findings include: A review of the policy and procedure, “Abuse and Domestic Violence,” dated 10/10/2024, stated “Purpose: To provide guidelines for employees of the hospital to recognize and report incidents of abuse, neglect, mistreatment, and exploitation. (The facility) will comply with all state, federal and local laws to the reporting of suspected abuse, neglect, mistreatment or exploitation and will take immediate action to report any incident where an employee determines he or she has a reasonable cause to believe abuse, neglect, and/or mistreatment has occurred ...Contact numbers for reporting abuse, neglect, mistreatment or exploitation are listed at the end of this policy. Adult abuse: A person 18 years or older who, because of mental or physical dysfunction is unable to manage his/her own resources or carry out the activity of daily living, or protect self from neglect, exploitation or a hazardous or abusive situation without assistance from others, and who may be in need of protective services. Abuse: The infliction of injury, sexual abuse, unreasonable confinement, intimidation, or punishment that results in physical pain or injury, including mental injury. Definitions: Caretaker: An individual or institution who has been entrusted with or who has the responsibility for the care of the adult as a result of a family relationship, or who has assumed the responsibility for the care of the adult person voluntarily, or by contract, employment, legal duty or agreement. In instances of suspected, alleged or witnessed abuse of a patient ...the witnessing hospital employees must notify their immediate supervisor, utilizing the chain of command. Human Resources and Quality/Patient Safety shall also be notified immediately. Risk Management should be notified immediately if patient harm has occurred. Factual documentation of the suspected, alleged or witnessed abuse will be place in the medical record, if applicable, as well as in an Occurrence Report. Based on the progressive discipline guidelines located in the employee handbook, employees may be subject to immediate suspension.” A review of the policy and procedure, “Event Reporting,” dated 05/22/2025, revealed, “Reporting of actual and potential safety events is the responsibility of all healthcare professionals and ancillary staff. The submission of these events will be facilitated by an electric reporting system ...” Definitions: any process that led to actual harm or potential to cause harm. Unsafe Conditions: Circumstances that increase the probability of a patient ...safety event ...2. Inappropriate staff behavior. Guidelines: 1. The reporting program is made available to all system employee, physicians, and contracted services, 2. The individual discovering the event should be the person reporting the event. The event should also be reported to the appropriate parties at the time of discovery.” Review of the document titled, ED Physician Notes” dated 11/16/2023 at 22:44 revealed P1 had been evaluated in the ED with complaints of “a chemical smell in apartment is making leg pain and tremors worse.” Continued review of the document revealed P1 suffered with suicidal ideation, depression, anxiety, and agitation. P1 also had the diagnosis of Parkinson’s Disease. Review of the Glasgow Scale revealed P1 was oriented and obeyed commands. The ED notes revealed “she is at the point now where she is going to jump off a bridge.” The patient was placed on a 72-hour hold and admitted to the hospital. A review of the document, “Aggressive Patient Event,” dated 11/21/2023, revealed on 11/17/2023 at 3:10 PM revealed Paramedic1 filed a report to the facility alleging she witnessed Emergency Department Technician (EDT) 1, and 2 “trying to take the belongings of patient (P1) on a 72-hour hold, patient spit in EDT1’s face. When this happened, EDT2 grabbed P1 around their chest/neck pushed the patient down and lifted the patient’s shirt above her head.” The paramedic went onto state two (2) security guards, names unknown, and Registered Nurse (RN)4 also witnessed the event. An interview with Peer Review and Process Improvement Coordinator1(PR/PI) on 08/12/2025 at 9:30 AM revealed the alleged incident had not been reported by anyone, to anyone at the facility for four (4) days. Observation, along with PR/PI 2, of the ED video surveillance camera footage was reviewed on 08/12/2025 and on 08/13/2025. Review of the footage revealed on 11/17/2023 at 2:32 PM, the patient was placed in a bed, and the curtains were pulled. 2:34 PM The patient was placed in the Trendelenburg position; 2:39 PM P 1 raised up in the bed, and EDT 1, and 2 grab the patient by her neck and posterior head and violently pushed her down onto a pillow. At 6:53 PM, EDT1 was observed to argue with the patient. At 8:04 PM, P1 was transferred to floor 3A. Telephonic interview on 08/12/2025 at 2:39 PM with EDT2 revealed he did not want to speak about the incident, and if needed, the surveyor could talk with his lawyer. Telephonic interview on 08/12/2025 at 2:40 PM with EDT1 revealed she left employment at the facility in 2023. She revealed on 11/17/2023 she was one of the caregivers for P1, and her responsibility was to basically sit with the patient as a “safety sitter” because the patient may have harmed herself. The EDT continued to state P1 was aggressive at times, and wanted to get out of the bed, and the patient had not liked being told what to do. She stated the nurse had told her to undress the patient and put her into a gown. She revealed when she tried to assist the patient to undress, the patient spit in her eye, and she and other staff ended up putting a blue mask on the patient’s face. EDT1 stated she did not remember P1 being pushed down onto the pillow by her neck. The EDT went onto state she had received some training on how to deal with aggressive patients, but it had been a terrible class, and revealed she did not feel like she had been trained appropriately on how to deal with these types of patients. Interview with RN4, on 08/13/2025 at 10:06 AM revealed he was one of the caregivers for P1, and he did not recall anyone holding onto the patient’s throat, and staff could only gently hold a patient’s extremities down if needed for aggressive behaviors and any type of restraint had to be ordered by a physician. RN4 stated staff had to complete abuse training modules at least once or twice a year. He revealed any time a patient became combative, staff should distance themselves from the patient, keep their cool, and notify security. Telephonic interview with Paramedic1 on 08/13/2025 at 8:59 AM revealed she did recall an instance that occurred in the ED where staff attempted to get P1 to lay back on her bed, and EDT2 pushed her back onto the bed by her neck. The paramedic revealed she felt compelled to report the incident to the facility, and she also had a duty to report abuse. She went on to state she had not been afraid to report it, but it had not been in EDT2’s character to be abuseful with a patient. She stated she wrestled with reporting the incident because maybe the EDT had not meant to be so aggressive towards P1. Paramedic1 revealed anytime abuse had been witnessed, it should be reported to a supervisor while the details were still on your mind. An interview with the Head of Security 1, on 08/12/2025 at 1:54 PM, revealed he had gone to the ED on 11/17/2023 because the patient had been placed on a 72-hour hold, and the nurse requested security pick up and log her personal belongings. He stated he had stepped back from P1 because staff were engaged with her. He revealed the level of aggression was over the top between the patient and staff. The patient had been very vocal, and the staff were aggressive towards her. He stated he did not observe the EDT’s put the patients head to the pillow, but he had heard a commotion. The next thing he observed were the two (2) EDT’s holding the patient down onto the bed. The Head of Security went on to state P1 was in the facility’s ED a lot, and verbal de-escalation had worked with her in the past. He stated the next day; after watching the video, he reported his observations to Risk Management and filled out an incident report. He stated, in the video, he observed EDT2 used excessive force with his hand on the patients’ neck to push her down onto the pillow while EDT2 just appeared to have a nasty attitude. Interview with the Security Dayshift Supervisor1 on 08/12/2025 at 2:09 PM revealed P1 had a history of hitting and spitting, and was a regular patient in the ED. He stated he had received annual training through the Crisis Prevention Institute on advanced physical techniques along with other safety techniques. He stated in his experience with the patient an argument with staff usually escalated her behaviors. He revealed staff could deal with aggressive patient by appeasement within reason such as offering the patient food, and drink. The supervisor stated “deadly force” should never be used with a patient by grabbing their neck. He defined “deadly force” as force used where you feel for your life. A telephonic interview with Security Officer 1 on 08/12/2025 at 2:45 PM revealed he knew P1 well, and on that specific day, he observed the patient holding and shaking her walker at staff because she wanted to go to the restroom, and call her son, however, the staff snatched her cellphone out of her hand. He revealed he had, at that time, tried to counsel staff on effective ways to handle P1, but was ignored by all. The security officer went onto state staff could have had better results if they had talked nice to her. An interview with Occupational Therapist 1 on 08/13/2025 at 9:30 AM revealed staff received mandatory training on abuse on the Knowledge Hub. She went on to state if she witnessed something that looked like abuse, she would definitely go up the chain of command and report it. She revealed any suspected instances of abuse should be reported right away to a supervisor in order to keep the patients safe. Interview with Registered Dietician 1 on 08/13/2025 at 8:36 AM revealed abuse could be verbal, physical, sexual, neglect or emotional. She stated she would immediately report anything that appeared to be abuse to a supervisor. She stated abuse incidents should be reported immediately because it was a patient safety issue, and all patients could be a potential risk for harm. A telephonic interview on 08/13/2025 at RN5 revealed anytime possible abuse was witnessed the first thing to do was stop the abuse, talk with the staff, talk with the patient, and notify the house supervisor as well as complete an Event Report. Telephonic interview with the Workplace Violence Coordinator1 on 08/13/2025 at 12:05 PM revealed he provided education to staff on crisis management and de-escalation skills as well as mitigating risks and to be intentional with their own behaviors. He revealed the facility offered on-line courses, classroom courses as well as advanced courses on crisis management. The coordinator stated it was important for staff to address the root cause of undesirable behaviors. Telephonic interview with Physician2, on 08/13/2025 at 1:16 PM revealed he currently served as the Assistant Medical Director in the ED and his expectations from staff were that they followed all the protocols the facility had in place to protect the safety of all patients. He stated staff were educated and trained yearly on safety, and if he observed something abuseful towards a patient he would immediately report it to the charge nurse, remove the staff from the situation, start an investigation, and send the staff member home. He went onto state staff involved in the investigation were either re-educated on abuse or terminated. The doctor revealed any instances of abuse had to reported to a supervisor right away for the immediate safety of all the patients. He stated staff that abused patients could have mental health issues or be under the influence of something. Interview with the Chief Nursing Officer (CNO)1, on 08/13/25 at 1:00 PM revealed there were different types of abuse such as physical abuse, restraints, and verbal abuse. She stated all staff received mandatory training on patient rights and abuse through the KNOW module, and frequent audits were completed to ensure all staff received the training. She stated the Quality/Risk Management meetings were monthly and were attended by the Chief Medical Officer, Chief Nursing Officer, and Physicians as well as other department heads. Her expectations from the staff were that any issues which involved possible abuse, or abuse be reported immediately so the abuse did not happen again. A review of the document titled, “Hands on Crisis Prevention Interventions” dated 2023 revealed RN4 completed training on 12/11/2023. A review of the document titled, “Student and Group Transcript Report revealed EDT1 completed training on Non-Violent Crisis Intervention on 06/09/2023, Working with Difficult and Combative People on 03/19/2022, Crisis Prevention on 03/13/2022, Workplace Violence Safety Survey on 08/01/2022, Patient Rights and Abuse on 08/01/2023. A review of the document titled, “Student and Group Transcript Report, revealed EDT2 completed training on Non-Violent Crisis Intervention on 03/28/23, and Crisis Prevention Institute on 03/31/2022, Patient Rights and Abuse on 10/22/2023, and Workplace Violence Safety on 08/03/2022.”

“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: 28707 Based on interview, record review, and review of facility policies, it was determined the facility failed to comply with the Emergency Medical Treatment and Labor Act (EMTALA) provisions related to medical screening exams (MSE), that was within the hospital’s capability and capacity. The deficient practice affected Patient #1 (P1), who became aggressive and threatened violence when staff attempted to place an IV. P1 was escorted out of facility by hospital security prior to completion of the MSE. Facility provided evidence of investigation and staff education following incident. The findings include: The facility failed to provide a Medical Screening Examination (MSE) within the capability of the hospital’s emergency department (ED) for one (1) of twenty-four (24) sampled patients. Patient (P) 1 presented to the ED on 01/11/2025 with complaints of shortness of air and chest pain. Cross Refer to A2406.”

“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: 28707 Based on interview, record review, and review of facility policies, it was determined the facility failed to provide a Medical Screening Examination (MSE) within the capability of the hospital’s emergency department (ED) for one (1) of twenty-four (24) sampled patients. Patient (P) 1 presented to the ED on 01/11/2025 with complaints of shortness of air and chest pain. While present, P1 became aggressive and threatened violence when staff attempted to place an IV. P1 was escorted out of facility by security prior to completion of an MSE. Facility provided evidence of investigation and staff education following incident. The findings include: Review of the facility policy EMTALA: Treatment and Transfer of Individuals in Need of Emergency Medical Services, last reviewed 11/02/2022, revealed all facilities with a dedicated ED must provide individuals who need or seek care with an MSE within the capability of the ED to determine whether an emergency medical condition exists. Review of System Workplace Violence Prevention Committee policy, last reviewed 06/26/2023, revealed patients that are causing an unsafe/disruptive environment for staff/visitors/other patients may be discharged. Policy goes on to state all steps in outline must be met prior to discharging patient. The policy goes on to outline, for patients presenting to ED, EMTALA guidelines were to be followed, to include ensuring patient received an MSE to determine if a medical emergency existed. Review of Current Summary Aggressive Patient Event entered 01/11/2025 revealed Patient (P) 1 was known to facility. Report states P1 came by EMS and when staff attempted to insert an IV patient began cussing and drew fist back to punch staff. Staff member stopped and walked away when charge nurse came in and told patient he needed to leave. Security escorted patient out and police were notified. Email with local police dated 02/27/2025 revealed no police report was filed regarding P1 on 01/11/2025. Review of P1’s medical record revealed P1 presented to facility via EMS on 01/11/2025 at 12:22 AM with chief complaint shortness of air and chest pain on inhalation x2 years. Medical Doctor (MD) 1 put in orders at 12:40 AM for a DuoNeb (combination of bronchodilators to open airways in lungs) inhaler, a saline bolus, a COVID/Flu/RSV PCR (nasal swab) test, troponin (test for heart attack), lactic acid, CMP, CBC, an EKG, and a portable chest x-ray. EKG was completed at 12:49 AM and results were communicated to MD1 at 12:55 AM. Chest x-ray obtained at12:57 AM, compared to results of chest x-ray in system on 12/23/2024. Chest x-ray noted no pleural effusions, no pneumothorax, and no acute osseous process. Medical record notes RN1 and Paramedic (PM)1 were in P1 room at 1:19 AM discontinuing breathing treatment and attempting to start IV access (P1 had removed IV placed by EMS) when P1 became verbally aggressive and physically threatening (making a fist, attempting to strike PM1). Note states security was notified and P1 was escorted out of the ED. Medical record completed by Charge Nurse (CN) 1 goes on to reveal P1 was provided an MSE, left facility AMA after risk vs benefits were explained, and declined to sign AMA form at 1:32 AM. No documentation from MD1 in record. Interview with PM1 on 03/04/2025 at 9:00 AM stated he worked with P1 on the night of 01/11/2025. PM1 stated they got P1 back to a room, triaged him, and orders started coming in. He stated P1 was not aggressive initially, but when he went in with RN1 to get an IV line started, P1 jerked his arm away. PM1 stated he told P1 he knew an IV wouldn’t feel comfortable, but he needed to have one. PM1 stated P1 jerked his arm away again, started swearing, and drew his fist back like he was going to strike PM1. PM1 stated he asked P1 not to do that, but P1 continued to swear and act like he was going to strike him. PM1 stated at that point he left the room. PM1 stated he had seen MD1 poke his head in the room, and assumed MD1 had seen P1, as there were multiple orders in system that were more in depth than typical triage orders. Interview with RN1 on 03/04/2025 at 10:20 AM stated she was working on 01/11/2025 and was assigned to P1. She stated there were just a few patients in the department that night, and MD1 was working. She stated they did an EKG on P1, who was there maybe an hour and MD1 had put in close to 20 orders on patient. RN1 stated when she entered the room, P1 had already pulled the IV out that EMS had put in. She stated she was in the room with PM1 trying to start a new IV line and P1 was yelling, grumbling, and cursing her. She stated P1 came off the bed yelling, drew back his fist and swung at she and PM1. She stated they tried to calm him down, explaining what they were doing but he just got angrier. RN1 stated she yelled for help. Security was just outside the door, and the patient’s room was right across from the nurse’s station where Charge Nurse (CN) 1 was. RN1 stated she removed herself from the room, thinking P1 was upset with her or that she was triggering his anger, and she didn’t know what happened after that. RN1 stated she thought MD1 had been in there to see P1, as P1 had very specific orders. RN1 stated she wasn’t aware P1 had not completed a medical screening until she spoke with the Medical Director Southwest (MD SW) days later. Interview with Charge Nurse (CN) 1 on 03/04/2025 at 2:07 PM stated he was sitting at the nurse’s station on the night of 01/11/2025 when RN1 and PM1 called for security. He stated he responded with security and told P1 he had to leave. He stated P1 had orders in system, so he believed MD1 had seen P1. CN1 went on to state the facility has a zero-tolerance policy for aggression, and he was following policy when he made the judgement call and trying to keep his staff safe. CN1 stated there was no option in the system for patients escorted out by security, so he put P1’s disposition as left AMA (against medical advice). Interview with Security (S) 1 on 03/03/2025 at 3:30 PM stated he was working the night of 01/11/2025 and remembered receiving a call about a patient being aggressive. He stated he was told P1 had made a fist when staff went to stick him with an IV. S1 and S2 escorted P1 out of the ED without incident. P1 didn’t want to go to a shelter, and refused to leave, so eventually the local police were called. S1 stated when police told P1 to leave, he did. S1 stated he did not threaten or act aggressively towards security staff. Interview with S2 on 03/04/2025 at 3:46 PM stated he was working the night of 01/11/2025 and remembered the incident with P1. He stated he was in the ED talking to staff when RN1 screamed his name. S2 stated RN1 told him P1 drew a fist and acted like he was going to hit staff. S2 stated CN1 instructed him to remove the patient, and he and S1 escorted P1 out. S2 stated P1 appeared irritated at the medical staff but was cooperative with security. S2 stated they spoke with P1 for a bit, and eventually had to call local police as P1 refused to leave. He stated after police arrived they were able to convince P1 to leave. Interview on 03/05/2025 at 12:16 PM with the Emergency Department Director (ED Director) stated she reviewed the incident with P1. She stated P1 came into the ED just after midnight on Saturday 01/11/2025 by EMS with complaints of shortness of breath and chest pain x3 years. ED Director stated MD saw problems P1 presented with and started placing orders based on that, as well as likely reviewed documentation from a previous visit to a sister facility on 01/07/2025. While staff were working on following MD orders, P1 became upset when staff attempted to place an IV, started cursing at staff and posturing as if to strike staff. Staff called out for help, security and CN1 responded, with CN1 asking security to escort P1 out. ED Director stated she was reviewing incident reports the following Monday when she received a call from the Director of Compliance and Privacy (DCP) to ask if she could confirm there was a MSE on P1. She stated she reached out to the Nurse Manager (NM) and asked if she was aware if MSE had been completed on P1. ED Director stated she and NM researched the chart and interviewed staff that worked that night about the incident and MSE. ED Director stated when MD notes aren’t signed, they don’t see them in system. ED Director stated MD1 was contacted, and it was determined an MSE was not completed. Both RN1 and PM1 thought MD1 had seen P1, and CN1 wasn’t certain. ED Director stated they followed back up with DCP to let her know, and she conducted her portion of the investigation. ED Director stated all staff involved were night shift workers who had worked the weekend, which played a significant role in the investigation timeline. After determining on 01/15/2025 an MSE had not been completed, facility self-reported to state survey agency. ED Director went on to state CN1 was trained on EMTALA and CPI and sent P1 out without knowing for certain that MD had provided P1 an MSE. ED Director stated DCP did education sessions with all ED staff via Teams, providing an opportunity for staff to ask questions. ED Director shared EMTALA training had also recently (prior to incident) been assigned in computer-based learning. If an incident were to occur in future, staff know to ask provider if MSE has been completed, with security also educated to ask that question prior to escorting a patient from the ED. ED Director concluded there is no disposition on ED documentation for patients escorted out by security without receiving a MSE - it should not happen. If a patient chose to leave before receiving a MSE, it would be documented as LWBS (Left Without Being Seen). If a patient left after receiving a MSE, disposition would be eloped (if not seen by staff) or AMA (Against Medical Advice) if seen by staff and educated on risk vs benefits of leaving. ED Director stated CN1 falsified documentation by documenting P1 left AMA, and did not attempt to contact his supervisor for guidance at the time of the incident. If staff have an incident they aren’t sure how to handle, they are to contact their supervisor, ED Director, or an administrator on call. Staff could have left the room, informed MD1 P1 refused IV. ED Director stated CN1 (who worked Fridays through Sundays) was placed on administrative time off beginning Wednesday 01/15/2025 and was terminated the following week on 01/23/2025. ED Director shared MD1 was in Cambodia, as he split his time between facility and a clinic in Cambodia and was out of reach. Also, shared DCP was in Washington. Interview on 03/04/2025 at 9:15 AM with the Nurse Manager (NM) shared she saw the incident report involving P1 on Monday 01/13/2025 in the afternoon and received an email from CN1 regarding the incident with P1 and was contacted by DCP that day as well asking questions about the incident involving P1. She stated she had to reach out to CN1 as she did not see documentation that a MSE had been completed for P1. She stated, in interview with CN1, he stated he did not believe a MSE had been completed, and although he did not see what transpired involving P1, he went off report from PM1 and RN1. NM stated for almost any aggressive patient, staff are to send someone else in to try to deescalate the patient, and security can attempt to deescalate as well while staff continue to try to treat the patient. NM stated she could not recall a time since she had been NM (since 2013) that a patient had been removed prior to receiving an MSE. NM stated CN1 made a judgement call to have P1 escorted out. Continued interview with NM stated all staff know the importance of the MSE, and all staff are trained on EMTALA. She stated EMTALA education is received quarterly. NM stated in latest training (following incident) the importance of the MSE was stressed. NM stated all staff also receive non-violent crisis intervention training on hire and receive yearly refresher training, which covers de-escalation. Review of transcript EMTALA Training Session, from a TEAMS (Microsoft TEAMS, video conferencing software) meeting recorded on 01/17/2025 from 1 PM until 1:40 PM revealed Director of Compliance and Privacy (DCP) trained ED staff on EMTALA, with focus on ensuring patients receive an MSE. DCP discussed incident that occurred on 01/11/2025 with P1, noting leadership - the provider (MD1) never had an opportunity to go in and try to calm P1. Training encouraged staff to use skills learned in nonviolent crisis training, such as de-escalation or removing oneself from the situation. Also calling for help, to include security. Staff are then encouraged to talk to their lead person, charge nurse or supervisor to get them involved, as well as getting the provider involved. Emphasis of training is ensuring provider can screen patient to determine whether a medical emergency exists. In cases of extreme violence, security can call police, and police can escort patients off property AFTER an MSE has been completed. Review of email from Nurse Manager Medical Center Southwest ED (NM) to ED Director for Southwest and East (ED Director) dated 02/28/2025 titled Training, revealed all ED nurses, technicians, and paramedics had received the TEAMS training above, with completion dates ranging from 01/16/2025 to 01/31/2025, with most staff having completed training on 01/16/2025 or 01/17/2025. Interview with RN2 on 03/03/3035 at 2:54 PM stated staff were trained on how to deal with patients that present with aggressive behavior, to include verbal de-escalation and removing oneself from a situation and allowing another staff to attempt to deescalate. RN2 further shared staff received EMTALA training, and that they are required to see all patients that present to the ED regardless of what situation they may be having. RN2 shared on more recent EMTALA training, the focus was on ensuring patients receive an MSE. Interview with ER Tech on 03/03/2025 at 3:09 PM stated she had received training on de-escalation and has had to de-escalate aggressive patients in the past. She stated if not able to deescalate, she would get her charge nurse and go on up the chain from there to include security and potentially police. ER Tech stated she had also had EMTALA training, with most recent training emphasizing that all patients must receive an MSE from a provider. ER Tech stated she had been on two TEAMS meetings for education following incident involving P1. Interview with PM1 on 03/04/2025 at 9:00 AM stated he had received training on de-escalation. He stated he received EMTALA training and had a recent class that covered more specifics as it related to their facility. When asked to elaborate, PM1 stated there was no easy way to tell in the medical record if an MSE had been completed by a provider, and the MSE had to be completed when a patient presented to the ED. Interview with NM on 03/04/2025 at 9:15 AM stated everyone is trained on de-escalation, with training on hire and yearly refresher training. NM stated staff receive EMTALA training quarterly and have had a recent training emphasizing the importance of an MSE. Interview with RN1 on 03/04/2025 at 10:20 AM stated she received training on nonviolent crisis intervention every year, and EMTALA training every quarter. She stated following the incident with P1, she received additional training, a group call with more in-depth discussion on EMTALA, to include policies and procedures for dealing with aggressive patients. Interview with S2 on 03/04/2025 at 3:46 PM stated he had received nonviolent crisis intervention training. Following the incident with P1, S2 stated he met with his supervisor and was informed to ask staff in the future for any patient incident in the ED if the patient had been medically screened. Interview with the ED Director on 03/05/2025 at 12:16 PM stated staff were educated following the incident with P1, with focus on what constitutes an MSE and the importance of the MSE. ED Director stated staff were given time to ask questions during the training. If staff aren’t certain a patient has had an MSE, they are to talk to the provider. ED Director also shared security leadership was asked to train security staff to so they could ask if a patient had a medical screening exam prior to escorting a patient out of the ED.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 47852 Based on observation, interview, record review, and review of the facility’s policy, it was determined the facility failed to ensure the safe and appropriate use of restraints and seclusion was implemented for one of 10 sampled patients, Patient 1 (P1). On 11/30/2023, Mental Health Technician 1 (MHT1) was observed, on the facility’s video camera footage, escorting P1 with the use of a physical restraint. However, the use of MHT1’s physical restraint techniques used on P1 were not per facility protocol. The findings include: Review of the facility’s policy and procedure, titled “Restraints and Seclusion”, dated 10/10/2023, revealed the policy’s purpose was to establish clear criteria in practice guidelines, practice parameters, and care protocols. Further review of the policy revealed the facility was committed to the provision of a safe, secure environment, which encompassed the patient’s physical, mental, and emotional welfare by encouraging the highest level of respect and dignity of the individual throughout the continuum of care. Continued review of the policy revealed the patient had a right to be free from mechanical, physical, or chemical restraints and/or the use of seclusion when used for the purposes of discipline or convenience. Additionally, the policy identified general staff responsibilities that qualified staff monitored and provided for the physical and psychological well-being of the patient who was restrained and/or secluded. Review of the facility’s policy and procedure, titled “Patient Rights and Responsibilities”, dated 10/2021, revealed the patient had a right to expect reasonable safety insofar as the hospital practices and environment were concerned and to be free from all forms of abuse or harassment. Further review revealed the patient had a right to considerate and respectful care at all times and under all circumstances, and the right to expect care that optimized and recognized his or her personal dignity. Closed record review revealed the facility admitted P1 on 10/12/2023 with diagnoses which included bipolar disorder, post-traumatic stress disorder (PTSD), attention deficit hyperactivity disorder (ADHD), and intellectual delay. Review of the facility’s event review, dated 11/30/2023, conducted by Risk Manager 1 (RM1), revealed during an interview with MHT1, he reported he was assisting several team members to move P1 from the fourth floor to the third floor when P1 dropped to the floor and refused to get up. MHT1 stated he pulled P1 through the door threshold to the landing, then asked her to walk down the steps, which P1 refused to do. MHT1 reported he told P1 he was going to pull her down the stairs and gently pulled her from the landing to the first step, then pulled her once more and told her to stand up, which she did, then she walked down the steps to the third floor. There was no video footage in the stairway. Continued review revealed MHT1 was current with all his required training. Additionally, the incidental findings of the investigation revealed MHT1 pulling P1 down the steps was, at best, a non-standard intervention and there was an obvious lack of recognition that pulling a patient across the floor, let alone down a flight of stairs, was not acceptable and the likelihood of injury associated with such a transport was great and the fact P1 was not cooperating with ambulating back to the unit should have precluded the use of the stairs in any event. Review of MHT1’s training record revealed he was hired on 03/06/2023 and received training on Patient Rights and Abuse on 11/07/2023 and again on 02/01/2024. Further review revealed he received training on Crisis Prevention Institute (CPI) Decision Making on 04/14/2023. Observation of video camera footage with Risk Management (RM) staff, on 12/17/2024 and 12/19/2024, revealed, on 11/30/2023 at 11:43:22, P1 was running down the hallway on the fourth floor, then tumbled to the floor; at 11:43:31, MHT1 was in the fourth-floor hallway in front of P1, who was sitting on the floor beside the stairway door, and they were talking. Further observation revealed three (3) other staff members walking toward P1 at 11:44:05; at 11:44:08, P1 got off the floor and started running in the direction of the classroom and was blocked by Teacher 1, who P1 then pushed backward; at 11:44:13, other staff members (MHT1, MHT2, and MHT3) assisted Teacher 1; at 11:44:21, MHT1 held P1’s arm and walked her toward the stairway door; at 11:44:29, P1 sat in the fourth floor hallway, at which time MHT1 grabbed P1’s right arm and pulled her across the floor while Teacher 1 opened the stairway door and MHT2 then grabbed P1’s left arm; at 11:44:37, MHT1 picked up P1’s feet and pulled P1 through the stairway door and disappeared from camera view at 11:44:39; at 11:45:04, P1 was observed walking through the stairway door on the 3rd floor holding the left side of her face; at 11:45:06, MHT1 and Teacher 1 exited the stairway door onto the third floor; at 11:45:11, P1 sat down in the hallway and MHT1 was observed walking away from P1 while Teacher 1 stayed with P1; at 11:45:16, Nurse1 entered the video with MHT1, and Nurse1 talked with staff members present, who point to the stairway door; and, at 11:46:23, Nurse1 spoke with P1, then walked away at 11:46:27, leaving P1 sitting in the hallway floor. During an interview with RM1, on 12/17/2024 at 3:10 PM, he stated the Risk Management department investigated the incident on 11/30/2023 as soon they were notified and did find MHT1 should not have transported P1 by pulling on her ankles because it did pose a risk of injury with transport. He further stated, since P1 was refusing to ambulate, the facility staff should have used the elevator instead of the stairs as staff should never try to use a hold situation on the stairs. He continued to state the use of a restraint bed or stretcher was available if the patient required a restraint during transport from the fourth floor to the third floor. During an interview with Program Coordinator 1 (PC1), on 12/18/2024 at 1:43 PM, she stated a patient should never be transported on the stairs in a hold position, and staff should use a cart on the elevator if a patient must be transported while being restrained because transporting in a hold on the stairs was unsafe. During an interview with Registered Nurse 1 (RN1), on 12/18/2024 at 2:16 PM, she stated a patient should never be transported in a stairwell in a hold position because staff might drop or hurt the patient or themself. She further stated to transport a patient in a hold position staff should use a cart or chair. During an interview with MH2, on 12/18/2024 at 2:44 PM, he stated a patient should never be transported in a hold position in a stairwell because staff do not have control in a stairwell, and it was not good for the staff or patients. He further stated he would put patients on a cart and transport by the elevator if they needed to be transported in a hold position. During an interview with MHT1, on 12/19/2024 at 9:31 AM, he stated he knew P1 from another facility prior to 11/30/2023 and “was just playing with her by swinging her legs side to side and she was laughing the whole time” during transport on 11/30/2023. He further stated after entering the stairway, P1 got up and ambulated down the stairs to the third floor. He continued to state he received abuse and restraint training annually and was taught training in the CPI, which included using the least restrictive restraint possible. Additionally, he stated he did not feel he had done anything incorrectly with the carry, “and sometimes you have to play and sometimes you have to be stern” with the patients. During an interview with RM2, on 12/19/2024 at 10:11 AM, he stated once an incident is reported to RM to investigate, they try to pull camera footage, if available, and interview any staff in the vicinity of the incident, then try to determine if there was an opportunity for abuse or improper behavior to have occurred. He further stated after an investigation was completed, the RM team discussed the incident with each other and then brought it to the Administrative team, and the team made the decision to substantiate or unsubstantiate the allegation.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 29137 Based on review of facility Patient Rights policy, review of facility video and investigation, record review, review of the Behavior Protocol, and interviews, it was determined the facility failed to protect and ensure patient rights for care in a safe setting were provide for one (1) of thirteen (13) sampled patients, Patient #6. Patient #6 sustained a raised area to the head and an abrasion to his/her upper lip in an incident with Behavioral Health Unit (BHU) Program Coordinator (PC) #1. The findings include: Review of the Welcome Guide for Patients and Visitors, no date, revealed the facility had a zero-tolerance policy for physical abuse, which included holding or restraining someone. Review of the Program Coordinators job description, revised 08/30/2021, revealed functions included providing leadership and guidance to unit staff, assisted in providing leadership to maintain a safe environment for patients utilizing proactive techniques to de-escalate an individual. Review of the facility’s “Restraints and Seclusion” policy, reference number 600-0368, last reviewed 10/10/2023, revealed the facility was committed to providing a safe, secure environment. Review of the Behavior Protocol, revised 07/03/2023, revealed when a patient was in Time-out, staff were to speak to patients in a calm manner and not to argue with patients. Review of the 3 Lourdes Unit Handbook, (Patient #6’s Unit) dated 04/2022, revealed the safety of all patients and staff was a priority. A patient could be encouraged to take a “self-time-out”, which was not a consequence but an opportunity for the patient to remove themselves from the milieu (social environment) to practice coping skills, process with a staff member or have quiet time alone. Review of the facility policy titled “Precaution Levels”, reference number 11271004, reviewed 06/26/2022, revealed each patient would be assessed upon admission for behavioral indicators, using the established guidelines. Review of the guidelines for suicide precautions-level I (SP1) revealed the criteria was based on a history of passive suicidal ideation (SI), or SI with a plan that would not be feasible while hospitalized. The facility admitted Patient #6 on 10/02/2023 from a group home. Admitting diagnoses included increased aggression of attacking peers and staff, and property destruction. Patient #6 denied suicidal ideation (SI), but staff reported threats to harm self prior to admission. Patient #6 endorsed previous suicide attempts by tying a hoodie around his/her neck. Patient #6 was assigned a Suicide Precaution level of one (1) (SP1) on admission. Review of Physician orders dated 10/02/2023 revealed Patient #6 was assessed as SP1 on admission. Continued review of Physician orders revealed #6 remained SP1 during hospitalization. Review of the facility’s investigation revealed Leadership (includes the Unit director of Nursing, Chief Nursing Officer), reviewed the video footage, dated 10/25/2023, from the incident between Patient #6 and Program Coordinator (PC) #1. Additional review revealed that on 10/25/2023, Patient #6 was assessed and treated, notifications were made to Physician, Unit Manager, DCBS (Guardian), House Supervisor, Risk Management and Administrator on Call of the incident, and the allegation of abuse. Also, on 10/25/2023, Risk Management initiated the internal abuse protocol. This included reviewing the video footage of the incident, and interviewing Patient #6, RN(s) #1 and #2 and PC #1; Child Protective Services (CPS) was notified of the abuse allegation and the on-going internal investigation by Risk Management. Risk Management Report #3756675 was generated on 10/25/2023 at 3:38 PM. Continued review revealed that on 10/26/2023 Leadership met to review the video footage, from which a deviation of a non-standard physical restraint was identified (the way PC #1 initiated the sitting cradle hold), the findings of the internal abuse investigation and consulted with the Regional Director of Quality. The decision was made to substantiate the abuse allegation on 10/26/2023. Leadership terminated PC #1 on 10/27/2023 due to gross misconduct. Attempts to contact PC#1 were unsuccessful. Review of the video footage (no audio) of the incident between Patient #6 and PC#1, dated 10/25/2023, by the State Survey Agency (SSA) Surveyor, with Lead Investigator #1, revealed that on 10/25/2023 at 8:05:54.835 AM, Patient #6 was escorted to 3 Lourdes (3L) Unit dayroom for a Time-out to calm self, by a staff member that was not able to be identified because of camera angles, for disruptive school behaviors. Patient #6 was wearing a tee-shirt and sweatpants. Continued review revealed that at 8:06:10.210 AM, Patient #6 sat in his/her assigned seat in the dayroom. The sweatshirt was visible under the seat and Patient #6 started playing with the sweatshirt. At 8:06:34.885 AM, the staff member left the dayroom. Per Lead Investigator #1, PC #1 was out of the frame but was outside the door, able to keep eyes on Patient #6 while in the dayroom. This information could not be verified related to PC #1 not returning voice mail to return phone calls. Also, Lead Investigator #1 stated that Patient #6 was in the dayroom for Time-out because the quiet room was in use. Further review revealed that from 8:06:51 AM to 8:22:39.22 AM, Patient #6 became disruptive in the dayroom by playing with the sweatshirt, making a ball with it, and removing sweatpants (gym shorts underneath) to play with also. He/she was observed to be dancing and doing pinwheels around the room, throwing, and retrieving the shirt ball. Per Lead Investigator #1, Time-out did not begin until a patient was able to be calm. Further review of the facility video footage revealed Patient #6 and PC #1 were observed at 8:22:39.221 AM to leave the dayroom. Patient #6 was carrying the shirt ball and sweatpants. At 8:22:55.778 AM, both were observed to enter the quiet room, and Patient #6 used the sweatshirt and pants to make a pillow and put him/herself on the bed, PC #1 was at the foot of the bed. Body language by PC #1 suggested he was speaking to Patient #6. Lead Investigator #1 stated that it would be at this point that PC #1 would have asked for the sweatshirt and pants because of ligature risk and Patient #6’s history of suicidal ideation (SI). At this point, Patient #6 was observed to get up and stand to the right of the head of the bed. PC #1 moved to the left side of the bed. Further review revealed PC #1 stepped on the bed and Patient #6 moved to dead center of the bed, under the window. Additional review of the video footage revealed that at 8:22:58.058 AM, PC #1 caught up with Patient #6 and his left hand was observed to contact the neck of Patient #6’s tee-shirt. At 8:22:59.709 AM, Patient #6 was observed to slap PC #1 and his (PC#1) head snap to the right side. Continued review at 8:23:00.028 AM, revealed PC #1’s open left hand came up face-level with Patient #6. Contact was unable to be verified at that time. Additional review of the video revealed that at 8:23:00.440 AM, contact was made. At 8:23:01.327 AM, PC #1 was observed to initiate a step-by-step transition of his right hand away from Patient #6’s face to gain control of Patient #6’s left forearm to be able to obtain control of Patient #6’s right forearm with his (PC #1) left hand to initiate a standing cradle assist (an approved children’s control position-medium hold). At 8:23:05.364 AM, PC #1 transitioned patient #6 to a sitting cradle assist. Further review of the video footage revealed that at 8:23:17.645 AM, two (2) additional nurses entered the room, assessed Patient #6 and the video ended. While interviewing Registered Nurse (RN) #1, (Charge Nurse that day) on 11/02/2023, at 3:36 PM, she stated that she did not witness the incident; another patient called her attention to the incident, and she went to investigate. During continued interview, RN #1 stated she observed PC #1 to be transitioning Patient #6 to a sitting cradle hold. She stated she heard Patient #6 verbally contract for safety and he/she was released from the hold. She added that RN #2 had entered the room and assessed Patient #6 for injuries. As the interview continued, RN #1 stated RN #2 escorted Patient #6 to the nurses’ station to treat Patient #6’s injuries while she and the Unit Manager escorted PC #1 off the floor and to Nursing Services. RN #1 stated that at the time, Patient #6 did not formally state an allegation of abuse, that it was more like a casual statement that PC #1 had hit his/her head on the wall. During an interview, on 11/07/2023, at 4:32 PM, with RN #2, he stated there were no additional witnesses to the incident. He stated he did not observe a “hoodie” in the room, only what he thought was two (2) sweatshirts. He continued the interview by stating that hoodies were not allowed on the Units at all, and patients were not allowed clothing that was not being worn, for ligature risk safety (Patient #6 had been admitted with a suicide precaution (SP) Level 1). RN #2 continued by stating that he had assessed Patient #6 in the room for injuries. He further stated that he observed a scant amount of blood on a front tooth of Patient #6. Continuing the interview, he stated Patient #6 had a split lip that was not actively bleeding and a raised area on his/her head. Treatment consisted of ice to the lip and Motrin. RN #2 stated he ensured appropriate notifications were made and that was the extent of his involvement. While interviewing the Risk Manager (RM), on Wednesday, 11/08/2023, at 9:03 AM, he stated it was felt there was not a systemic/procedural failure for the incident, it was not an education failure; Program Coordinator (PC) #1 had made a conscious choice to handle the incident the way he did. The interview continued by the RM stating that PC#1 had received additional training for the Program Coordinator job, had been a former instructor for crisis prevention interventions (CPI) (teaches staff how to safely and effectively respond to individuals whose behavior is escalating). During the interview, the RM stated PC #1 had the tools to handle the incident but chose not to call for help when there was no crisis at that time. Patient #6 was in a contained environment with no chance of hurting him/herself or others at that time, PC #1 could have called for help to diffuse the situation. On Wednesday, 11/08/2023, at 10:18 AM, the RM reported to the State Survey Agency (SSA) Surveyor that while he was being interviewed by the SSA Surveyor at 9:03 AM, he became aware there had been a Global Nurse Managers’ meeting (scheduled every Wednesday) and one of the topics was a presentation given by the Quality Director regarding hands-on versus de-escalation. On 11/08/2023, at 9:28 AM, while interviewing Quality Analyst/Lead Investigator #1 (LI #1), he stated that prior to working in the Risk Department, he had been a Program Coordinator (PC) and had trained PC #1, he knew PC #1 was well trained. LI #1 continued by stating it was determined through his investigation that it had been an individual failure and not a systemic failure. Additionally, the completed investigation was then sent to the Quality Patient Safety (QPS) Committee for final decision and disposition. The core members of the group (also called Leadership) included the Director Nursing (DON) of the Unit, the Unit Manager (UM) of the Unit, Director of Quality and/or the Chief Executive Office, Chief Operating Officer, and the Chief Nursing Officer. Other individuals were added as necessary. While interviewing the UM of 3 Lourdes (3L), (the unit Patient #6 was on), she stated that if an incident occurred on her Unit, she would be included in the QPS meeting. Regarding the incident involving Patient #6 and PC #1, she stated she was made aware of the incident while in the Global Nurse Manager meeting, she left the meeting and went to the Unit. On the Unit, she assessed and interviewed Patient #6, it was at this time he/she made a formal abuse allegation involving Program Coordinator (PC) #1. She stated she and the Unit DON escorted PC #1 to Nursing Services, and she (UM 3L) went to review the video with Risk department. Leadership was notified and PC #1 was put on administrative time off (ATO). During an interview, on 11/08/2023, at 12:36 PM, with the Director of Patient Safety (DPS), he stated that he is made aware of all incidents, the Management team reviewed the previous day’s events every morning. Leadership would then assign follow-up based on the criticality and the resource best suited to investigate but all events were tracked until resolved. While continuing the interview, the DPS stated since his arrival in August 2023, he had been advocating for process changes in being mechanically restraint free, that was the goal and best practice. Additionally, the DPS stated he had formulated a mechanical restraint free environment education for staff; however, the education had not been finalized and presented prior to the State Survey Agency (SSA) Surveyor entering the facility. He further stated it boiled down to performing the least restrictive physical intervention while allowing the patient the opportunity to use their own coping skills without having someone controlling them. The message is simple; don’t put hands on, have someone with you. Additionally, the DPS stated a goal is to institute the hands free physical/mechanical holds interventions and to change the mindset from “we’ve always done it this way” to focusing on de-escalation without using mechanical holds at the same time. While interviewing the Chief Nursing Officer (CNO)/Vice-President Patient Care Services, on 11/09/2023, at 9:35 AM, she stated the purpose of the QPS meetings was a collaboration with Risk and other members of the Leadership team to discuss unusual occurrences, and safety/patient concerns. Responsibilities (action items) would be assigned to the team member to investigate, follow-up, and inform QPS members or the appropriate individual. Continuing the interview, the CNO stated that crisis prevention interventions (CPI) training and certification was an on-going process based on the individual’s hire date. Further, she stated the education was presented on hire and possibly quarterly but would verify with the Educator. During the interview, the CNO stated the Director of Patient Safety (DPS) had developed and was preparing to present a staff education eschewing de-escalation without using mechanical holds at the same time at the weekly Nurse Manager meeting. The CNO stated the meeting occurred after the SSA Surveyor’s entry into the building. Further interviewing the Risk Manager on 11/09/2023, at 10:05 AM, he stated that the whole purpose of QPS was for each department to report on process improvement (PI) initiatives and do a deep dive into their own processes to identify areas for improvement. During an interview with the Professional Development Registered Nurse (RN), on 11/09/2023, at 10:09 AM, she stated that on hire, staff received two (2) full days of CPI/seclusion, restraint education, then that education is presented quarterly based on their hire date. Additionally interviewing the Director Patient Safety (DPS), on 11/09/2023, at 12:37 PM, he stated there was no failure in the process for the incident on 10/25/2023. The Program Coordinator #1 was in/near the room as per the Behavior Protocol. The failure was that PC #1 did not use an approved physical management hold per CPI. In a re-interview with the CNO, on 11/09/2023, at 12:53 PM, she stated there was no failure regarding supervision of Patient #6 on 10/25/2023. The failure was PC #1 not utilizing an approved physical management intervention. While re-interviewing the Director of Patient Safety and the Risk Manager, on 11/09/2023, at 2:02 PM, both stated that all Unit Nurse Managers randomly performed visual checks to observe for rounding being completed as documented or review video footage of things that come through on the electronic reporting system. Additionally, the Quarterly CPI education re-enforced and maintained a safe atmosphere for the patients. During an interview with the Unit Manager (UM) for 2 Lourdes (2L), a child/adolescent unit, on 11/09/2023, at 2:36 PM, she stated that right now the focus of random, monthly visual checks was to ensure that every fifteen (15) minute rounds were being completed as documented. The process was to select five (5) random patients and in conjunction with the video monitoring system, make walking rounds to ensure staff rounds were being completed and documented correctly. She continued by stating that she spent a lot of time on the Unit so that she could observe staff/patient/patient interactions in real time. Furthermore, she felt education was a major factor in providing a safe environment for the patients.”