Cox Medical Center Branson

“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: 51264 Based on policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#12) of 31 Emergency Department (ED) records reviewed from 10/30/24 through 03/31/25. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). Findings included: Review of the hospital’s policy titled, “EMTALA,” dated 01/12/24, showed appropriate MSEs were provided to individuals who requested examinations or treatment. MSEs consisted of an assessment and ancillary tests based on the patient’s presenting symptoms or chief complaint, as necessary, to determine the presence of absence of an EMC. Assessments could be a brief history and physical or could require complex ancillary studies and monitoring, such as an EKG. If EMCs were discovered as the result of an MSE, the patient was provided stabilizing treatment until the EMC resolved or appropriate transfer was facilitated. Individuals were stabilized when their condition was assured, within reasonable medical probability, not to materially deteriorate; or when the treating physician determined, within reasonable clinical confidence, that the EMC was resolved. Please refer to 2406 for further details.”

“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: 51264 Based on policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#12) of 31 Emergency Department (ED) records reviewed from 10/30/24 through 03/31/25. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). Findings included: Review of the hospital’s policy titled, “EMTALA,” dated 01/12/24, showed appropriate MSEs were provided to individuals who requested examinations or treatment. MSEs consisted of an assessment and ancillary tests based on the patient’s presenting symptoms or chief complaint, as necessary to determine the presence of absence of an EMC. Assessments could be a brief history and physical or could require complex ancillary studies and monitoring, such as an EKG. If EMCs were discovered as the result of an MSE, the patient was provided stabilizing treatment until the EMC resolved or appropriate transfer was facilitated. Individuals were stabilized when their condition was assured, within reasonable medical probability, not to materially deteriorate; or when the treating physician determined, within reasonable clinical confidence, that the EMC was resolved. Review of Patient #12’s ambulance report, dated 01/16/25, showed paramedics noted abdominal distention and pain throughout his abdomen, sides and lower back. His vital signs (VS, measurements of the body’s most basic functions) were within normal limits (WNL), except his blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80), which ranged from 209/113 to 220/119. He was transported to Cox Medical Center Branson (CMCB). Review of Patient #12’s medical record, dated 01/16/25, showed: - At 6:45 PM, a 53-year-old man presented to the ED with complaint of constipation, abdominal pain and nausea (a feeling of sickness with an urge to vomit). His pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) was eight. - His medical history included kidney failure with weekly dialysis (process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions) treatments. - The physician ordered blood tests, an abdominal x-ray (test that creates pictures of the structures inside the body-particularly bones) and a computed tomography (CT, a combination of x-rays and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) of his abdomen. CT results indicated liquid stool, then a large amount of hard stool, within the colon and rectum. No small bowel obstruction (a partial or complete blockage in the small or large intestine that prevents food, fluid, or stool from passing through) was present. - At 9:45 PM, VS showed tachycardia (abnormally rapid heart rate, greater than 100 beats per minute [bpm]). His heart rate was 102 bpm. - At 9:48 PM, he received ondansetron (medication used to treat nausea) and hydromorphone (medication used to treat severe pain). - At 10:30 PM, his heart rate was 118 bpm, his blood pressure was 260/126. - At 10:45 PM, he received hydromorphone and hydralazine (medication used to treat high blood pressure). - At 11:11 PM, he received prochlorperazine (medication used to treat nausea). - At 11:18 PM, his final pain score was six. - At 11:30 PM, his heart rate was 140 bpm, his blood pressure was 184/97. - On 01/17/25 at 00:20 AM, he received diltiazem (medication used to lower blood pressure and to reduce the workload of the heart). - At 00:57 AM, a physician order for discharge was placed. - At 1:20 AM, staff removed stool manually and an enema was performed. - At 1:28 AM, he received lactulose (medication used to treat constipation). - At 1:30 AM, nursing documentation indicated that Patient #12 was allowed to remain at the hospital until his dialysis appointment later that morning. - At 1:45 AM, his heart rate was 124 bpm, his blood pressure was 119/112. - At 2:31 AM, he received clonidine (medication used to lower high blood pressure and heart rate). - At 4:30 AM, the patient slept. - At 5:45 AM, final VS showed his heart rate was 120 bpm. - At 6:04 AM, discharge instructions were provided. He was to return if conditions worsened or persisted. It was recommended that he follow-up with a physician. Instruction included tips on the management of nausea and constipation symptoms. He was escorted to his dialysis appointment. Review of Patient #12’s ambulance report dated 01/17/25, showed he was transported to Hospital B, and complained of an elevated heart rate, that he contributed to the potassium chloride he received for hypokalemia (low potassium level in the blood) while in the CMCB ED. His VS were WNL, except tachycardia which ranged from 119 to 121 bpm. An electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions) recorded a regular heart rhythm. He was transported to Hospital B. Review of Patient #12’s Hospital B medical record, dated 01/17/25, showed: - At 10:27 PM, he arrived in the ED, via EMS, with history of no bowel movement for five days. He was previously seen at CMCB and stated that nothing was done, nothing helped. - Medical records from CMCB indicated that he had a CT of the abdomen that suggested constipation. He was manually disimpacted, received a soap suds enema and was unable to have bowel movement since then. His abdominal pain and distention increased. - At 10:47 PM, lab results indicated increased Troponin I High Sensitivity (a type of blood test that measures whether or not a person is experiencing, or may soon experience, a heart attack where normal is 0-15). His lab result was 600. - On 01/18/25 at 12:53 PM, a rapid response (a changing situation that requires more staff to address the current needs of the patient) was called during his dialysis treatment for irregular heart rhythms of supraventricular tachycardia (abnormal heart rhythm in which the upper chambers of the heart beat very quickly) and ventricular tachycardia (a condition in which the lower chambers of the heart [ventricles] beat very quickly). - On 01/18/25 at 3:13 AM, an abdominal CT was completed for abdominal pain and distention. The CT was compared to the CT completed on 01/16/25. Findings indicated a bowel obstruction. - At 4:21 AM, an abdominal x-ray was completed that indicated a bowel obstruction was present. - He had a nasogastric tube (NG, soft, flexible tube inserted through the nose and into the stomach to remove stomach contents, or to instill drugs, liquids, or liquid food) placed and was admitted to the hospital. During an interview on 04/02/25 at 2:18 PM, Staff R, ED Medical Director, stated that exams for constipation included physical assessments, history, blood tests and CT imaging. Treatment included manual removal of stool, enemas, and medications for pain, nausea and fluid management. Physicians reassessed patient symptoms during treatment. Patients were discharged with instructions on managing symptoms of constipation; in most cases patients continued with outpatient treatment options as they were rarely admitted for constipation. During an interview on 04/02/25 at 12:20 PM, Staff Q, Physician, stated the protocol for constipated patients included blood tests, CT images and rectal exams. Treatment took hours and included fluid management, manual removal of stool, enemas and medications. Improvement usually took days, therefore patients continued treatment after discharge. During an interview on 03/31/25 at 3:30 PM, Staff M, RN, stated that at times, providers would complete an MSE on patients before the order set testing resulted. During an interview on 04/02/25 at 12:13 PM, Staff P, RN, stated that Patient #12’s pain improved. He used the commode and was more comfortable after treatment. Patients were not always cured in the ED.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50321 Based on interview, record review and policy review the hospital failed to: - Immediately remove one staff member and one visitor from patient care after witnessed alleged abuse occurred for one current patient (#16) and one discharged patient (#19) of three allegations of abuse reviewed. (A0145) - Follow their internal policy for prompt reporting of alleged abuse for one current patient (#16) and one discharged patient (#19) of three allegations of abuse reviewed. (A0145) - Follow their internal policy for investigation of abuse and neglect and perform a timely and thorough investigation to accurately determine whether abuse had occurred for one discharged patient (#19) of three allegations of abuse reviewed. (A0145) - Timely and urgently educate staff following a patient abuse incident involving one discharged patient (#19) of two reviewed. This failed practice placed all patients admitted to the hospital at increased risk for their safety. (A0144) These failed practices resulted in the noncompliance with 42 CFR 482.13 Condition of Participation: Patient’s Rights. Please refer to A-0144 and A-0145”

“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: 50321 Based on interview, record review and policy review the hospital failed to timely and urgently educate staff following a patient abuse incident involving one discharged patient (#19) of two reviewed. This failed practice placed all patients admitted to the hospital at increased risk for their safety. Findings included: Review of the hospital’s document titled, “Allegation of Abuse, Neglect, or Harassment on Cox Health Premises,” dated 05/03/24, showed: - All forms of abuse, neglect, or harassment whether from staff, practitioners, other patients, or visitors are prohibited. - Allegations or information indicating that abuse, neglect, or harassment may have occurred will be thoroughly and promptly investigated with appropriate follow-up action taken. - Abuse is a willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. - Willful is defined as a deliberate act with intent to inflict injury or harm. Review of the hospital’s document titled, “Alleged Patient Abuse and Neglect Event (344592),” dated 06/17/24, showed: - The event occurred on 06/11/24 at 2:52 PM, the incident report was entered on 06/17/24 at 10:45 AM by Staff CC, Nursing Administrative Director. - The type of event was identified as alleged physical abuse. - On 06/17/24, Staff BB, Nurse Manager, was informed by Staff CC that the event had occurred. The body camera footage was then reviewed with the assistance of Staff U, Public Safety Captain. - On 06/19/24, Staff LL was interviewed and reported that Patient #19 was confused. Security grabbed both of her hands and she dug her nails into their arms. The security officer was calm and not in distress or threatened. Without prompting she reported that she had taken a saline syringe and sprayed it into Patient #19’s face. She described it as “getting a kitten to stop being bad.” She claimed she had not spoken to anyone about the event except Staff W, Registered Nurse (RN). Staff BB added that she became aware of the event because Staff LL had spoken to Staff CC and others and appeared to “brag” and “seemed proud” of her actions. Staff LL was suspended and ultimately terminated. Staff BB documented that the events in the body camera footage did not occur as Staff LL reported during interview. - On 06/20/24, Staff CC reported that Staff LL told her on 06/13/24 that she sprayed a patient in the face in self-defense. Upon reflection she spoke to Staff BB and reviewed the body camera footage with Staff U. After the realization that the event was not in self-defense, an incident report was completed. The security team agreed that Staff LL should have been removed from the room at the time of the event. - On 06/21/24, Staff Z, Charge RN, was interviewed and reported that she did not see the event take place, only that she noticed Patient #19’s face was wet. Staff LL told her it was just water. When she returned to the nurse’s station Staff LL told her what she did. - On 06/22/24, Staff W, RN, was interviewed and reported that he was taken back by Staff LL’s actions but did not want to jeopardize their friendship. He knew he should have reported the incident immediately. Review of the hospital’s undated document titled, “Allegation of Abuse/Neglect on Cox Health Premises Fact Sheet,” showed: - When you witness or suspect an event notify your supervisor or charge nurse immediately. - The department supervisor or nursing supervisor will remove the accused staff member immediately from all patient care contact. - Abuse is a willful act and/or behavior that is deliberate with intent to inflict injury or harm. - Different forms of abuse include physical which was defined as rough handling, hitting, pushing, or corporal punishment, and emotional which was defined as humiliation, mocking behavior, or inappropriate threats of punishment. Review of the hospital’s document titled, “PCU Weekly Huddle Sign in Sheet,” dated 06/21/24, showed 11 of 38 staff signatures. A handwritten note was included that showed the initial huddle sign in sheet was not included as it was not available. Review of the hospital’s untitled document dated 08/13/24, showed an email from Staff U, Public Safety Captain, that documented a staff meeting had taken place on 06/26/24 from 5:00 PM to 6:00 PM and all but two staff members were present. Review of security staff body camera video titled, “Staff S, Security Officer (SO) - Branson 2024-06-11 14:54:32,” dated 06/11/24, showed: - At 2:55:04 PM, Staff S, SO, entered Patient #19’s room. Staff W, RN; Staff LL, Terminated RN; Staff X, SO; Staff Y, House Supervisor; and Staff Z, Charge RN, were present at Patient #19’s bedside. - At 2:55:38 PM, Staff S held down Patient #19’s right arm. Staff W then administered intravenous (IV, in the vein) Haldol (a medication used to treat mental disorders by decreasing excitement of the brain) in her left arm. Staff S then released her arm. - At 2:56:15 PM, a staff member attempted to scan Patient #19’s wristband. She then held her arms toward her body. Staff S and Staff W held down both of her arms. She told staff to “back off.” - At 2:56:19 PM, Staff LL sprayed a saline syringe in Patient #19’s face. - At 2:56:25 PM, Staff LL stated, “it was just water” as Staff S and Staff W released Patient #19’s arms. - At 2:56:33 PM, Patient #19 stated, “I don’t deserve that.” - At 2:56:34 PM, a staff member stated, “we don’t deserve that either.” - At 2:56:41 PM, Staff S asked, “are you going to calm down?” - At 2:56:49 PM, Patient #19 asked, “so you got shot in the eye with a ball, I thought you were going to calm down” and pointed to her face. - At 2:57:06 PM, Patient #19 stated, “sure, so she can shoot me in the face, you need to stay away from me” as she wiped her face with her gown. Review of Patient #19’s medical record showed: - On 06/10/24 at 9:37 PM, she was a 65-year-old female admitted for an altered level of consciousness after a fall at home. - On 06/10/24 at 10:32 PM, A physician’s note documented that she was difficult to redirect, appeared restless and anxious, and was unable to answer orientation questions. - On 06/11/24 at 1:57 PM, a violent event report documented that she refused to get on the Magnetic Resonance Imaging (MRI, test that uses a magnetic field and radio waves to create images of the organs and tissues within the body) table and was brought back to her room. She proceeded to become verbally aggressive. She was confused and felt she was a hostage. When staff attempted to administer medications, she began to throw her arms and threaten staff. Security assistance was requested, and medications were administered with her agreeance. - On 06/11/24 at 11:45 PM, a nursing note documented that after she returned from an MRI, she was anxious and tearful. She did “not trust those other nurses” and felt they would “put her to sleep and she won’t wake up.” - On 06/13/24, she was discharged home. During an interview on 08/13/24 at 12:37 PM, Staff U, Public Safety Captain, stated that Staff LL’s, Terminated RN, actions were willful intimidation and retaliatory. Security staff were educated during a staff meeting on 06/27/24. She had documentation of who was present, but not the specifics of the education provided. Without immediate education there was a possibility this event could have happened again and may not have been reported properly. During an interview on 08/14/24 at 10:42 AM, Staff N, Patient Safety Officer, stated that he was aware of the event and the behavior was concerning and appeared intentional. At a minimum the behavior of Staff LL, Terminated RN, should have been reported and the house supervisor had a duty to do so. He was unsure why staff present during the event did not escalate to administration. He felt floor staff may have had a poor understanding of the abuse and neglect policy. Any report of suspected abuse or neglect should have been reported immediately. Staff had access to all policies and were expected to follow them. During an interview on 08/13/24 at 11:21 AM, Staff V, Education Manager, stated that he was responsible for inpatient and Emergency Department (ED) education. The behavior was demeaning and should have been reported. He did not provide house wide education following the event. Patient Safety was responsible for informing him of events that required house wide education. During an interview on 08/14/24 at 9:44 AM, Staff GG, Nursing Vice President (VP), stated that all staff should have been educated following the event. During an interview on 08/14/24 at 1:47 PM, Staff KK, Regulatory Affairs Director, stated that only security staff and staff on the unit in which the event occurred were educated following the event. During an interview on 08/14/24 at 12:10 PM, Staff K, Nurse Manager, stated that he was aware of the event, but no new education was provided to his staff. During an interview on 08/13/24 at 10:40 AM, Staff Y, House Supervisor, stated that she did witness the event and felt it was unnecessary. She was stunned but did not report the event. She received formal coaching after the event and an email was sent that contained the abuse and neglect policy sometime the following week. During an interview on 08/13/24 at 10:23 AM, Staff Z, Charge RN, stated that she was present during the event but did not see it happen. Staff LL, Terminated RN, did tell her what she did later that shift. She did not report the event. During a telephone interview on 08/13/24 at 11:11 AM, Staff W, RN, stated that Staff LL’s, Terminated RN, behavior was demeaning and abusive. He was educated during a formal coaching after the event because he was a witness and did not follow policy. He was not aware of any group education provided to other staff. During an interview on 08/13/24 at 10:50 AM, Staff X, Security Officer, stated that Staff LL’s, Terminated RN, actions were unnecessary and she assumed her behavior would be addressed after the event by the supervisor who was present. She did have a conversation with her supervisor following the event and her captain addressed the policy in their staff meeting later that month. During a telephone interview on 08/13/24 at 2:20 PM, Staff S, Security Officer, stated that he did not see the event take place, but he would consider Staff LL’s, Terminated RN, actions to be an inappropriate and intentional infliction of distress. He would have reported her behavior if he had seen it. He did receive education the following Monday or Tuesday during a shift huddle. 49489 50496”

“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: 50496 Based on interview, record review and policy review, the hospital failed to: - Immediately remove one staff member and one visitor from patient care after witnessed alleged abuse occurred for one current patient (#16) and one discharged patient (#19) of three allegations of abuse reviewed. - Follow their internal policy for prompt reporting of alleged abuse for one current patient (#16) and one discharged patient (#19) of three allegations of abuse reviewed. - Follow their internal policy for investigation of abuse and neglect and perform a timely and thorough investigation to accurately determine whether abuse had occurred for one discharged patient (#19) of three allegations of abuse reviewed. These failed practices placed all patients admitted to the hospital at increased risk for their safety. Findings included: Review of the hospital’s document titled, “Allegation of Abuse, Neglect, or Harassment on Cox Health Premises,” dated 05/03/24, showed: - All forms of abuse, neglect, or harassment whether from staff, practitioners, other patients, or visitors are prohibited. - Allegations or information indicating that abuse, neglect, or harassment may have occurred would be thoroughly and promptly investigated with appropriate follow-up action taken. - Abuse was a willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. - Willful was defined as a deliberate act with intent to inflict injury or harm. - Immediately means at the time of witnessing conduct or receiving an allegation of misconduct. - The identification of abuse by staff would include those who are witnesses to threats, abusive, or neglectful behavior, or violence toward the patient. - Employees who witness, or suspect abuse, neglect, or harassment shall report the alleged incident to their department supervisor or the nursing supervisor immediately. - The department supervisor or nursing supervisor would initiate the investigation immediately. - The investigation by the department supervisor or nursing supervisor includes an interview with the patient as appropriate; assessment of the patient for evidence of injury, harm, or mental distress; obtainment of written statements from the person making the allegation, witnesses, and the accused individual; and complete assessment and notification to the administrator in charge of the patient care area to decide. - Patients would not have any staff member in question caring for them or interact with any family member or visitor that may be suspect. - The accused individual may not care for or have any in-person contact with any patients while the investigation was ongoing. Review of the hospital’s document titled, “Suspected Elder (or other Vulnerable Adult) Abuse/Neglect and Assault,” dated 04/27/23, showed: - An elder was defined as any person 60 years of age or older. - Abuse was defined as the infliction of physical, sexual, or emotional injury or harm by any person, firm, corporation and bullying. - Report was defined as the communication of an allegation of abuse or neglect to the appropriate authorities. - Domestic Violence was defined as abuse by a spouse, relative or intimate partner. - Physical abuse was defined as the use of physical force. - All patients would be assessed for abuse and neglect. If staff witnesses threats, abusive or neglectful behavior, or violence toward the patient, Social Services would be notified immediately. - An injury that was not being cared for properly and pain on touching meet the criteria for possible abuse when assessing a vulnerable adult for abuse neglect, and or assault. Review of the hospital’s Incident Report titled, “Alleged Patient Abuse or Neglect Event (37928),” dated 08/13/24, showed: - On 08/04/24, Staff P, ED Charge Registered Nurse (RN), reported that Patient #16 was agitated when he received treatment in the ED. - He pulled at the bed rail with his broken arm, put his arms and legs through the bed rail, laid sideways in the bed, and had become more agitated when his wife left the room. - Staff administered Zyprexa (medication used to treat mental disorders) but he remained agitated. - A telehealth (remote delivery of healthcare services while the health care provider is at a separate location, including exams and consultations, through video and telephone communication) sitter (person assigned to continuously observe a patient within close proximity, to ensure their safety) called the ED clerk and reported that his wife had aggressively redirected his arms. She was, “slapping him on the broken arm to keep him from pulling on something, but he didn’t appear to be pulling anything.” - The clerk informed Staff R, ED RN, who went into the room, checked on the patient, and redirected the wife to be gentle with the broken arm and encouraged her to take a break. - The ED room doors were opened, and an ED technician was placed in direct line of site. - The patient became more agitated, and his wife redirected the broken arm as he reached out with it again. Staff P witnessed this and was concerned that the action was too forceful. She intervened at that time and educated her to only redirect his uninjured arm and the wife verbalized understanding. - Staff P informed Staff R about the incident and recommended he make a hotline report to Adult Protective Services. Review of Patient #16’s medical record, dated 08/03/24, showed: - On 08/03/24 at 8:40 PM, he was an 85-year-old male who presented to the ED after a fall at home and landed on his right shoulder. - Imaging showed he had a right displaced and comminuted (a bone that is broken in at least two places) proximal (closest to the central body) humerus (a long bone in the arm that runs from the shoulder to the elbow) fracture. - He was discharged home. Review of Patient #16’s medical record, dated 08/04/24, showed: - On 08/04/24 at 11:12 AM, he was an 85-year-old male who presented to the Emergency Department (ED) after a fall at home. - His physical assessment showed he had bruises on his lower back, chest and right shoulder. He had significant dementia (a loss of thinking abilities and memory) with confusion. - At 11:16 AM, Staff II, ED RN, noted that he was chronically confused and not oriented to time or place. His right shoulder was bruised, had swelling and deformity, with limited range of motion and weakness. - At 12:36 PM, a telehealth sitter provided constant remote observation in the ED. - At 4:04 PM, Staff R, RN, filed a hotline report for elder abuse. In the report he stated that the telehealth sitter called the ED clerk and reported patient #16’s spouse was “slapping him on the broken arm to keep him from pulling on something, but he didn’t appear to be pulling anything.” The Charge RN also witnessed his wife later yelled at him and pulled back the hand of his injured arm. - At 5:08 PM, a nurse told Staff DD, Social Worker (SW), and noted that she was informed that nursing had placed a hotline for Patient #16’s wife for abuse in the ED as she had pushed and hit his broken arm and that he was not safe to go home with her. The SW called the hospitalist to admit him. - At 5:38 PM, Staff DD discussed the discharge plan with his wife at the bedside. - At 6:01 PM, The ED Physician noted that a hotline was filed by nursing on Patient #16’s wife who appeared to be rough with him. - On 08/05/24 at 3:18 PM, Patient #16 was admitted to the hospital. - On 08/07/24 at 1:52 PM, 08/08/24 at 9:53 AM, and 08/09/24 at 8:39 AM, his wife was noted to have been at his bedside with staff. - At 4:00 PM, the case manager met with the patient, patient’s spouse and Senior Protective Services to review the discharge plan. The family was provided with SNF data and discussed choices for long term care placement. During an interview on 08/13/24 at 1:45 PM, Staff R, ED RN, stated that he made the hotline report. He did not witness any suspicious or abusive behaviors from Patient #16’s wife. He was notified by the ED clerk that the Staff FF, Patient Safety Assistant (PSA), reported that his wife had slapped his broken arm to prevent him from reaching for something. He notified the Charge RN, opened the patient’s door, and made sure staff had direct visual access of the patient at all times. He was then informed by Staff P, Charge RN, that she witnessed his wife grab his injured arm and directed him to file a hotline report. He did not believe the Charge RN reported the incident to the house supervisor or a manager but stated that either of them could have. He filed an incident report on 08/09/24, his next scheduled shift. He was unsure if the event was abuse, but he was concerned. Staff R described abuse as willful infliction of harm on a person with the intention to cause harm. He believed that Patient #16’s wife intended to help him, and her presence seemed to calm him. He stated that letting her stay with the patient was making an exception to the hospital’s abuse policy. After review of the policy, he stated he would not have expected his wife to stay at his bedside due to the suspicion of abuse. During an interview on 08/13/24 at 3:45 PM, Staff DD, SW, stated that she was made aware that Patient #16’s wife had pushed and hit his injured arm. She stated that she was not able to speak to the abuse policy and whether she considered this abuse because “policies are vague.” After review of the abuse and neglect policy, she believed the second time the wife intentionally pulled on his arm was considered abuse. The expectation for staff would be to follow policy, notify a supervisor, and call security. If she had seen the abuse, she would have reported it. During an interview on 08/13/24 at 1:15 PM, Staff P, ED Charge RN, stated that she was the charge RN on 08/04/24. The patient was disoriented, and his wife had to continuously redirect him. He kept taking off his sling, reached for things with his broken arm, and grabbed at his medical lines. When they were notified by the telehealth sitter of the concerning behavior his door remained opened, and staff kept continuous watch of the patient. She witnessed one instance where his wife grabbed him with what she considered too much force. Staff P coached his wife to not touch his injured arm and his wife verbally expressed understanding. His wife did not seem to be aggressive with him, but she did seem frustrated with the situation. Staff encouraged her to take a break. When she stepped away to the bathroom the patient became even more agitated and continuously asked for her. Staff P stated that she encouraged Staff R to file a hotline report because of the telehealth sitter’s report and the event that she witnessed. She believed his wife might not have been capable of taking care of him at home and wanted to make sure there would be follow up if he was discharged. She did not consider his wife to be actively abusive and did not escalate a report of this situation to the house supervisor or have security remove his wife. She did not conduct a formal investigation as she was not assigned to do so. She stated that the procedure when staff suspected abuse was to remove the abuser immediately and inform the house supervisor and social worker. Next, she would file a report, however, she believed in this situation his wife provided significant comfort to him and it would be more detrimental to remove her. His wife was receptive to coaching and complied with the direction of the ED staff. Staff P acknowledged that the hotline report indicated the ED staff had a suspicion of abuse and according to their policy the abuser should be removed until an investigation could be conducted. Staff P stated she errored on the side of caution by placing an in-person sitter at the patient’s bedside to help watch him and his wife and had the ED RN call the abuse hotline. She then stated a sitter was put in place for redirection of him only. During an interview on 08/13/24 at 11:38 AM, Staff N, ED Manager, stated that she was not made aware of the incident until 08/12/24. She stated that Staff R cared for the patient on 08/04/24 but did not file an incident report until 08/09/24. She stated that if the visitor of a patient inflicted harm she would expect them to be removed, and she would expect the staff to notify the house supervisor so that the patient could also be monitored. Staff should report suspected abuse immediately to a supervisor who would begin the investigation process. During an interview on 08/12/24 at 4:00 PM, Staff L, ED Charge RN, stated that when abuse was suspected by a visitor, the visitor would be removed from the patient’s room and allowed to visit if the patient gave permission. Those who witness the abuse event were expected to file the incident report within the shift the event was witnessed. During an interview on 08/14/24 at 1:47 PM, Staff KK, Regulatory Affairs Director, stated that staff who were present during the event should have escalated their concerns. After the alleged abuse event, the wife should have been removed from the patient’s room or off the property by security immediately. She wouldn’t have expected the staff to allow Patient #16’s wife to stay after there was an allegation of abuse. She would have expected the Charge RN who witnessed the event to file an Incident Report herself. During an interview on 08/14/24 at 12:40 PM, Staff JJ, PSA, stated that the previous telehealth sitter, Staff FF, PSA, told her to keep an eye on the patient for alleged abuse by his wife. Staff JJ witnessed his wife “smack” his broken arm. When the PSA saw his wife strike his arm, Staff FF said to her, “Hey, don’t do that, that’s the one that is broken,” and then his wife stepped away from the bedside for a few minutes. Later, she saw his wife and an in-person sitter at the bedside. During an interview on 08/14/24 at 12:25 PM, Staff II, ED RN, stated that he never witnessed any rough behaviors from his wife, but he recalled she was tired and showed signs of compassion fatigue. She told Staff K that it was time to get additional help at home for the patient as it was the second fall in less than 24 hours. He advised her to take a break. He stated he was not aware of any abuse or suspicion of abuse to Patient #16 by his wife. During an interview on 08/14/24 at 12:10 PM, Staff K, Nurse Manager, stated that any allegation of suspected abuse should have been escalated right away and whoever witnessed the abuse should fill out an incident report in real time. During an interview on 08/14/24 at 10:43 AM, Staff HH, Patient Safety Officer, stated that he was unsure why staff present during either event did not remove the person suspected of abuse or why it was not escalated to administration. He felt floor staff may have had a poor understanding of the abuse and neglect policy. Any report of suspected abuse or neglect should have been reported immediately. He expected everyone involved with the incident to complete an incident report before the end of their shift. Staff had access to all policies and were expected to review, refer to and follow them. It was not acceptable to keep a caregiver suspected of abuse with the patient to help keep them calm and provide comfort for the convenience to the staff. During an interview on 08/14/24 at 9:45 AM, Staff GG, Nursing Vice President (VP), stated that she expected staff who witnessed suspected abuse to file an incident report but only one incident report was necessary. She would have expected the Charge RN to have put in the incident report immediately. A non-disruptive person suspected of abuse should have been removed from the patient’s room to the waiting room and separated from the patient until the investigation was completed. She expected the house supervisor to remove a person suspected of abuse and begin the investigation. She expected the sitter to have reported the incident and to have followed the abuse and neglect policy. During an interview on 08/14/24 at 9:05 A, Staff FF, PSA, stated that she was the telehealth sitter for Patient #16 the day of the incident and saw his wife hit him on his broken arm. She immediately spoke over the speaker and told his wife, “Let’s keep our hands to ourselves.” Staff FF then reported what she saw to her lead and two other telehealth sitters to help watch his wife while she in his room. Staff FF told Staff JJ, PSA, during report about Patient #16’s wife’s actions. Staff FF had been trained to report suspicions of abuse to the RN caring for the patient, her supervisor, and to complete an incident report immediately. Staff FF did not file an incident report. After Staff FF reviewed the abuse and neglect policy, she stated that hitting or slapping was considered abuse. Review of the hospital’s document titled, “Alleged Patient Abuse and Neglect Event (344592),” dated 06/17/24, showed: - The event occurred on 06/11/24 at 2:52 PM, the incident report was entered on 06/17/24 at 10:45 AM by Staff CC, Nursing Administrative Director. - The type of event was identified as alleged physical abuse. - On 06/17/24, Staff BB, Nurse Manager, was informed by Staff CC that the event had occurred. The body camera footage was then reviewed with the assistance of Staff U, Public Safety Captain. - On 06/19/24, Staff LL was interviewed and reported that Patient #19 was confused. Security grabbed both of her hands and she dug her nails into their arms. The security officer was calm and not in distress or threatened. Without prompting she reported that she had taken a saline syringe and sprayed it into Patient #19’s face. She described it as “getting a kitten to stop being bad.” She claimed she had not spoken to anyone about the event except Staff W, RN. Staff BB added that she became aware of the event because Staff LL had spoken to Staff CC and others and appeared to “brag” and “seemed proud” of her actions. Staff LL was suspended and ultimately terminated. Staff BB documented that the events in the footage did not occur as Staff LL reported during interview. - On 06/20/24, Staff CC reported that Staff LL told her on 06/13/24 that she sprayed a patient in the face in self-defense. Upon reflection she spoke to Staff BB and reviewed the body camera footage with Staff U. After the realization that the event was not in self-defense, an incident report was completed. The security team agreed that Staff LL should have been removed from the room at the time of the event. - On 06/21/24, Staff Z, Charge RN, was interviewed and reported that she did not see the event take place, only that she noticed Patient #19’s face was wet. Staff LL told her it was just water. When she returned to the nurse’s station Staff LL told her what she did. - On 06/22/24, Staff W, RN was interviewed and reported that he was taken aback by Staff LL’s actions but did not want to jeopardize their friendship. He knew he should have reported the incident immediately. Review of security staff body camera video titled, “Patient #19 - Branson 2024-06-11 14:54:32,” dated 06/11/24, showed: - At 2:55:04 PM, Staff S, Security Officer, entered Patient #19’s room. Staff W, RN; Staff LL, Terminated RN; Staff X, Security Officer; Staff Y, House Supervisor; and Staff Z, Charge RN, were present at Patient #19’s bedside. - At 2:55:38 PM, Staff S held down Patient #19’s right arm. Staff W then administered intravenous (IV, in the vein) Haldol (a medication used to treat mental disorders by decreasing excitement of the brain) in her left arm. Staff S then released her arm. - At 2:56:15 PM, a staff member attempted to scan Patient #19’s wristband. She then held her arms toward her body. Staff S and Staff W held down both of her arms. She told staff to “back off.” - At 2:45:19 PM, Staff LL sprayed a saline syringe in Patient #19’s face. - At 2:56:25 PM, Staff LL stated, “it was just water” as Staff S and Staff W released Patient #19’s arms. - At 2:56:33 PM, Patient #19 stated, “I don’t deserve that.” - At 2:56:34 PM, a staff member stated, “we don’t deserve that either.” - At 2:56:41 PM, Staff S asked, “are you going to calm down?” - At 2:56:49 PM, Patient #19 asked, “so you got shot in the eye with a ball, I thought you were going to calm down” and pointed to her face. - At 2:57:06 PM, Patient #19 stated, “sure, so she can shoot me in the face, you need to stay away from me” as she wiped her face with her gown. Review of the hospital’s document titled, “Timecard,” dated 06/11/24-08/13/2024, showed: - Staff LL, Terminated RN, worked from 6:26 AM to 7:00 PM on 06/11/24 and 6:29 AM to 6:55 PM on 06/12/24. - She was placed on call for low census on 06/13/24. - She was absent on 06/19/24, 06/20/24, and 06/21/24. Review of Patient #19’s medical record showed: - On 06/10/24 at 9:37 PM, she was a 65-year-old female admitted for an altered level of consciousness after a fall at home. - On 06/10/24 at 10:32 PM, A physician’s note documented that she was difficult to redirect, appeared restless and anxious, and was unable to answer orientation questions. - On 06/11/24 at 1:57 PM, a violent event report documented that she refused to get on the Magnetic Resonance Imaging (MRI, test that uses a magnetic field and radio waves to create images of the organs and tissues within the body) table and was brought back to her room. She proceeded to become verbally aggressive. She was confused and felt she was a hostage. When staff attempted to administer medications, she began to throw her arms and threaten staff. Security assistance was requested, and medications were administered with her agreeance. - On 06/11/24 at 11:45 PM, a nursing note documented that after she returned from an MRI she was anxious and tearful. She did “not trust those other nurses” and felt they would “put her to sleep and she won’t wake up.” - On 06/13/24, she was discharged home. During an interview on 08/13/24 at 9:30 AM, Staff CC, Nursing Administrative Director, stated that Staff LL, Terminated RN, told her in passing on 06/12/24 about the event, however, she was unsure what she meant and did not investigate further. She became more concerned after reflection and spoke to Staff BB, Nurse Manager, after Staff LL had continued to tell other staff about the event. She and Staff BB requested the body camera footage. After review they became concerned and completed an incident report to start the investigation process. Staff LL did work her full shift on 06/11/24 and the following day on 06/12/24. She would consider her actions to be intentional and demeaning. During an interview on 08/13/24 at 9:42 AM, Staff BB, Nurse Manager, stated that she would consider Staff LL’s, Terminated RN, behavior demeaning and bordered on abuse. Staff LL was not remorseful and appeared to brag during her interview. She would expect her staff to report this event. During an interview on 08/13/24 at 11:21 AM, Staff V, Education Manager, stated that Staff LL’s, Terminated RN, behavior was demeaning and should have been reported. During an interview on 08/13/24 at 10:40 AM, Staff Y, House Supervisor, stated that she did witness the event and felt it was unnecessary behavior. She was stunned but did not report or investigate the event. During an interview on 08/13/24 at 10:23 AM, Staff Z, Charge RN, stated that she was present during the event but did not see it happen. Staff LL, Terminated RN, did tell her what she did later that shift. She did not report the event but would consider it abuse. During a telephone interview on 08/13/24 at 11:11 AM, Staff W, RN, stated that Staff LL’s, Terminated RN, behavior was demeaning and abusive. She was no longer violent or a threat when her arms were held down. He would submit an incident report going forward. During an interview on 08/13/24 at 10:50 AM, Staff X, Security Officer, stated that Staff LL’s, Terminated RN, actions were unnecessary and she assumed her behavior would be addressed after the event by the supervisor who was present. During a telephone interview on 08/13/24 at 2:20 PM, Staff S, Security Officer, stated that he did not see the event take place, but he would consider Staff LL’s, RN, actions to be an inappropriate and intentional infliction of distress. He would have reported her behavior if he had seen it. 49489 50321”