Singing River Gulfport

“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: 31935 Based on medical record review, staff interviews, and policy and procedure review, the facility failed to follow its policy and procedure related to reassessment of patients waiting for a Medical Screening Exam (MSE) in the Emergency Department (ED). This practice affected four (4) of 20 medical records reviewed, Patients #1, # 2, # 4, and #9. Findings Include: Review of facility policy titled, “Emergency Department Waiting Room”, approved 05/15/2023, documented, “Purpose/Objective: The purpose of this policy is to initiate care while patients are in the waiting room, prior to provider involvement. Scope: For use with Emergency Department (ED) patients that have been triaged by a RN [Registered Nurse] and are waiting to be roomed in the ED, and have not had care initiated by a provider in the ED ...All ESI [Emergency Severity Index] level 1 or 2 patients should be roomed immediately.” Review of facility policy titled, “Against Medical Advise Discharge and Elopement” approved on 08/22/2022, revealed “ Singing River Health System (‘Singing River’) believes that patient care is compromised when patients leave... the patients are unavailable to receive monitoring of care, diagnostic, studies, treatments, and examinations by the primary team and consulting physicians. Patients admitted to Singing River are to be discharged pursuant to a physician’s order. Some patients, however, leave or are found to have left the premises without having been discharged. Medical and nursing staff should act in the best interest of any patient who has an unscheduled departure. Definition: 2. Elopement - a patient who leaves an inpatient unit or the Emergency Room (after the admission decision is made) without communicating their intention to leave shall be designated as an elopement until proven otherwise. 3. Left without being seen (“LWOBS”) - a patient who leaves prior to medical assessment and/or recommended treatment plan. Procedure: Elopement: 1. When a patient is identified as missing: a. Search nursing unit and common areas, b. Attempt to contact the patient via their cell phone, c. Page patient overhead, requesting return to room, d. Notify physician and Patient Care Supervisor that the patient is missing ... 3. If the patient is NOT found, notify the patient’s emergency contact and the Singing River campus police. The Singing River campus police should document and determine the need to notify assisting law enforcement agency (Local police department for welfare check or Chancery Court). 4. Submit an incident report (Safety Net).” Exit conference was held on 05/01/2026 at 10:35 a.m. During the exit conference the survey team discussed the findings, answered questions and no other documents were presented to the survey team by the facility. 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: 31935 Based on medical record review, staff interview, and policy and procedure review, the facility failed to provide reassessments of patients waiting in the Emergency Department (ED) waiting room per facility policy and procedure for four (4) of 20 medical records reviewed, Patient #1, #2, #4, and #9. Findings Include: Review of the hospital medical record for Patient #1 confirmed the patient arrived at the Emergency Department (ED) on 04/09/2026 at 7:16 p.m., with complaints of vaginal bleeding and approximately six (6) weeks pregnant. Patient #1 was triaged at an Emergency Severity Index Level (ESI) two (2) at 7:22 p.m. Registered Nurse #1’s note revealed Patient #1 believed she was six weeks pregnant and started bleeding four (4) days ago, Saturday (04/04/2026), and was evaluated at another facility and diagnosed with antepartum bleeding. Patient states she is having abdominal cramping as well and has an appointment with an Obstetrician on Monday. Vital signs were obtained at 7:24 p.m. Only one set of vital signs were documented for this ED visit. Patient #1 was discharged on 04/10/2026 at 1:01 a.m. Patient #1 was triaged as ESI level two (2) and was not seen by an attending physician for a Medical Screening Exam (MSE) until 11:43 p.m., almost five (5) hours later. Facility policy for Emergency Severity Index level (ESI) two (2) is classed as emergent and patients were to be transported to a treatment room as soon as possible with minimal to no delay with reassessment and vital signs every 15 - 30 minutes. An interview on 04/28/2026 at 2:13 p.m. with the Administrator confirmed only one (1) set of vital signs for Patient #1 who had been in the emergency department for over five (5) hours was not appropriate. Review of medical record for Patient #2 revealed the patient presented to the Emergency Department (ED) on 04/09/2026 at 2:41 p.m. with a complaint of abdominal pain with an onset of three (3) days ago and multiple episodes of emesis and diarrhea. Patient #2 reported one episode of blood-tinged emesis two weeks ago. Triage at 2:52 p.m. with Emergency Severity Index level (ESI) three (3) assigned and vital signs documented. Patient #2 left without being seen (LWBS) after triage at 7:51 p.m. after waiting for approximately five (5) hours for a medical screening exam (MSE). No documented evidence facility followed its policy and procedure for reassessment of vital signs every 30 to 60 minutes per Emergency Services Index Level policy. Patient #2 returned to the ED later in the evening on 04/09/2026 at 11:50 p.m. with complaints of right abdominal pain and vomiting for two weeks. Patient #2 reported symptoms start in the mornings and get better as the day goes on and he vomited blood two weeks ago but that has resolved. Triage assessment at 11:55 p.m., with vital signs documented and ESI level three (3) assigned. The medical record documented ED disposition left without being seen (LWBS) on 04/10/2026 at 1:46 a.m. after waiting approximately two (2) hours for an MSE. There was no documentation of the reassessment of vital signs every 30 - 60 minutes in the medical record per Emergency Services Index level policy. Review of medical record for Patient #4 (age 7) revealed the patient was accompanied by mother and entered the Emergency Department (ED) on 04/06/2026 at 4:13 a.m. with complaints of eye drainage. Parent states the patient woke up this morning with her eyes crusted shut and left sided ear pain with sore throat - onset this morning. Triage assessment at 4:22 a.m., with vital signs documented and triage ESI level four (4) assigned. Documentation reveals Patient #4 was discharged at 8:42 a.m. with no documentation of procedure and treatment carried out due to patient leaving prior to being seen by health care provider after waiting approximately four (4) and one half (1/2) hours for a MSE. There was no documentation of reassessment or vital signs after two (2) hours per Emergency Services Index level policy. No documentation of attempt to education guardian on risk of leaving without being seen. Review medical record for Patient # 9 revealed patient arrived at the ED on 03/09/2026 at 8:01 a.m. with a complaint of pelvic pain, vaginal bleeding that started last night, and reports she is 12 weeks pregnant. Triage assessment at 8:06 a.m. with an ESI level of three (3) and vital signs documented. Documentation reveals Emergency Department disposition was set to “Eloped” at 10:38 a.m., approximately two (2) and one half (1/2) hours after arriving at the ED for treatment. No documentation of reassessment or vital signs every 30 to 60 minutes per Emergency Services Index Level policy. Additionally, there was no documentation the hospital followed its policy for “Against Medical Advice Discharge and Elopement.” In an interview with the Chief Medical Officer on 05/01/2026 at 10:11 a.m. and again at 10:13 a.m., it was confirmed ED staff did not follow the hospital’s policy and procedure for reassessment of Patient #2, Patient #4 and Patient #9. Review of facility policy titled “Triage: Emergency Severity Index CPG”, approved 08/2025, documented “Policy: This Emergency Severity Index (ESI) guideline outlines the nursing responsibilities for the nursing management of patients presenting to the Emergency Department [ED] and requesting treatment. Definitions: Triage: A method of evaluation of all patients entering the Emergency Department. ESI Triage yields rapid, reproducible and clinically relevant stratification of patients into five groups, from level 1 (most urgent) to level 5 (least urgent.) ...Emergency Severity Index (ESI): A five-level triage algorithm used in emergency departments (EDs) to prioritize patients based on severity of their condition and the resources they need ...ESI Level 2 (Emergent) 1. Classify as Level 2, any patient with high risk of deterioration or signs of a time-critical ...ESI Level 3 (Urgent) 1. Classify as Level 3, all patients not meeting criteria for Level 1 or 2, stable, with many types of resources needed to investigate or treat (e.g., lab tests, imaging). The patient requires medical attention, but some delay in treatment will not result in loss of life or limb. Reassessment as defined for Level 3 patients is required ...ESI Level 4 (Less Urgent) 1. Classify as Level 4, all patients not meeting criteria for Level 1 or 2, but only one resource will be used in the treatment of this patient ...Reassessment: 1. Reassess all patients remaining in the waiting room area after triage and before room assignment, based upon chief complaint and classification. 2. Reassessment of vital signs based on ESI level ...ESI Acuity Rating 2 Every 15-30 minutes, ESI Acuity Rating 3 Every 30-60 minutes, ESI 4/5 Recheck abnormal v/s [vital signs] at discharge or if patient remains in ED after 120 minutes.” Exit conference was held on 05/01/2026 at 10:35 a.m. During the exit conference the survey team discussed the findings, answered questions and no other documents were presented to the survey team by the facility. Cross Refer to A2400.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47684 A-0115 / 482.13 Based on staff interviews, review of medical record, review of the facility incident report, and review of the facility policy and procedures the facility failed to follow its policy and procedure for de-escalation and placing restraints on with nonviolent methods, failed to identify hitting a patient in the face as physical abuse, and failed to follow the facility policies for the reporting, investigation and enforcement of actual violence against a patient resulting in placing all patients requiring de-escalation of behavior or needing restraints to be placed at risk when Campus Police are required for assistance for one (1) of three (3) medical records reviewed. Findings Include: An interview conducted with Campus Police Officer (CPO) #2 on 10/15/2025 at 2:20p.m. confirmed, Campus Police Officer #1, who inappropriately abused Patient #1 is currently employed at this facility. CPO #2 stated, “ ...We investigated and decided he didn’t do anything wrong. The patient hit him, and he hit him back. What else was he supposed to do?” CPO #2 also confirmed Campus Police Officers are mostly retired police officers and they received training on the use of physical force at the police academy and the training at this facility is called Satori Alternatives to Managing Aggression (SAMA) and “Staying Ahead of Crisis De-escalation for Safer Care.” CPO #2 also stated “ ...They focus more on verbal de-escalation here ...and campus security does not participate on hands on training in de-escalating combative patients at the facility ...”. An interview with the Director of Campus Police on 10/15/2025 at 3:00 p.m. confirmed the Director stated, “CPO #1 did not do this right ...he was assaulted and reacted to defend himself ...We assessed the whole incident and what to do better ...we need a better plan on removal of restraints for stretcher to bed transfers ...”. The interview also confirmed Campus Police Officers receive training on SAMA (Satori Alternatives to Managing Aggression), de-escalation in crisis management system for professionals, on orientation and annually thereafter with physical staff training as well. An interview with the Human Resources (HR) Director on 10/16/2025 at 10:15 a.m. confirmed, the House Supervising Manager for the department determines if an employee is sent home in the event of an incident. She also confirmed that CPO #1 remained at work for the rest of his shift after the incident. The HR Director also confirmed when an investigation is complete, HR guides managers on policies. The managers decide what steps will be taken regarding the employee at fault. The incident was reported to the Director of Accreditation on 10/13/2025 as well as the Chief Legal Officer. They met and discussed that the employee would not be reprimanded for the abuse accusation/confirmation. An interview with Registered Nurse (RN) #2 on 10/16/2025 at 11:00 a.m., confirmed his recall of the incident on 10/12/2025. RN #2 stated “ ....CPO #1 tried to get the patient back into the bed, the patient hit CPO #1, and CPO #1 pushed patient back while going into the bed ...CPO #1 was holding the patient upper body and CPO #4 was holding the lower body. While the patient was laying on the hospital bed, CPO #1 “hit patient”. “I couldn’t see him hit the patient; I was able to see him draw back his elbow ... CT (computed tomography) scan was performed and the laceration above the right eyebrow was sutured ...” An interview with CPO #1 on 10/16/2025 at 2:15 p.m., confirmed the Emergency Department Charge Nurse received a call from the Emergency Medical Technicians (EMT’s) that the patient coming into the Emergency Department (ED) was combative, he called Security Officer #4 to come to the ED. The patient was taken into room five (5) by the EMT’s. CPO #1 said security needed to look through the patient’s bag, but the patient said no. He said he explained to the patient he was only looking for weapons, nothing else. CPO #1 stated “ ...the patient jumped off the bed and knocked my arm away; I put my left hand on his ribs to redirect him back to his bed ...the patient was demanding his bag ...”. CPO #1 said he hugged the patient and went down onto the hospital bed with the patient after he shoved the officer’s hand. CPO #1 reported the patient hit his face on the bed when the security guard pushed the patient down on the hospital bed. CPO #1 said the patient swung his fist at him and “I hit him ...Once he was restrained, I lifted the head of the bed, and he started spitting blood ...I broke his nose”. Document review of Patient #1’s of the Medical Doctor’s progress note in the medical record revealed: “ ...The patient was brought to the ED for evaluation of homicidal ideations. On arrival patient was agitated and aggressive. Patient requires physical and chemical restraint. While being physically restrained the patient sustained laceration to his right eyebrow and a nasal bone fracture. The patient is hemodynamically stable in status post chemical sedation. Workup showed Methamphetamine and marijuana use. The patient was ultimately cleared for Customer Identification Program (CIP). Discharge plan is to discharge on 10/13/25 pending CIP evaluation, Ear Nose and Throat (ENT) follow up for nasal bone fracture and return to ED in 7 days for suture removal ...”. Review of the incident report dated 10/12/2025 revealed “ ...”Restraints were removed, and patient became violent striking the Campus Police officer in the face ... Campus police officer responded to the physical assault resulting in the patient being struck in the face ...”. Review of the facility policy, “Patient Rights and Responsibility”; dated 03/2011, revised 12/2023 reveals “ ...Health System is committed to upholding and respecting the rights of our patients ...”You have the right to: ... 13. Receive are in a safe setting, free from mental, physical, sexual or verbal abuse and neglect ...15. Safe implementation of restraints or seclusion by trained staff ...”. Review of the facility policy, “Workplace violence,” dated 05/2019, revised 04/2024 reveals “ ...Workplace violence - “Any act of aggression, physical assault ... that occurs on facility Property and/or that causes physical or emotional harm that may impact the individual or other’s safety at facility. Violence also includes, but is not limited to, the following: Emotional Physical, or Verbal Abuse ...A. Reporting - Employees are required to report any indirect or direct threat of violence, incidents of actual violence, and suspicious individuals or activities directed against ...patient ...B. Responding: ...investigates all reports and takes whatever action is deemed appropriate to protect employees, patients ...will promptly and thoroughly investigate all reports of threats of violence or incidents of actual violence and of suspicious individuals or activities. To maintain workplace safety and the integrity of its investigation, ...may suspend employees suspected of workplace violence or threats of violence, either with or without pay, pending investigation ...C. Enforcement: Anyone found to be responsible for threats of or actual violence or other conduct that is in violation of these guidelines will be subject to prompt corrective action up to and including termination of employment ...Plan for implementation: Staff will be educated on the policy upon hire and as needed with updates. Employees whose job duties include responding to alarms or other notifications of incidents will receive additional, interactive training that is specific to confronting or controlling person’s exhibiting aggressive or violent behaviors ...”. Review of the facility policy, “Use of Force,” dated 06/01/2018, revised 02/20/2025 reveals “ ...Policy: “Protecting innocent human life is the most important mission ... while officer discretion is critical, the need for accountability and control of police activities is necessary to limit abuses of authority ... Force, non-deadly force, or less-lethal force ... Compliance techniques may include: ... use of restraints, forced movement, or using other forms of pain compliance or control ...” Review of the facility policy, “Abuse or Neglect of a Vulnerable Adult or Child,” dated 02/2002, revised 05/2025 reveals “ ...Definitions: 1. Abuse- The commission of a willful act. Or the willful omission of the performance of a duty, which act, or omission contributes, tends to contribute to, or results in the infliction of physical pain, injury or mantal anguish on or to a vulnerable person, ... Abuse includes, but is not limited to, a single incident. Review of the facility policy, “Standard of Behavior,” dated 2006, revised 9/2024 reveals “ ...expects staff members to conduct themselves in a manner that protects the interest and safety of patients, staff members ...”. See A-0144/482.13(c)(2) and A-0145/482.13(c)(3) for additional information. Exit conference on 10/17/2025 at 3:15p.m. with the Director of Accreditation and Safety, Quality Assurance and Infection Control, Registered Nurse, the Director of Campus Police, Human Resources representative, Risk Department representative, and the Administrator. Reviewed the findings of the survey and no further documentation was provided for review.”

“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: 47684 A-0144 / 482.13(c)(2) Based on staff interviews, review of incident reporting, review of medical record, and review of facility policy and procedure review, the facility failed to ensure the facility’s staff followed standards of practice to ensure safety when attempting to restrain a patient requiring restraints to prevent harm to himself and others for one (1) of three (3) medical records reviewed. Findings Include: An interview conducted with Campus Police Officer (CPO) #2 on 10/15/2025 at 2:20 p.m. confirmed, Campus Police Officer #1, who inappropriately abused Patient #1 is currently employed at this facility. CPO #2 stated, “ ...We investigated and decided he didn’t do anything wrong. The patient hit him, and he hit him back. What else was he supposed to do?” CPO #2 also confirmed Campus Police Officers are mostly retired police officers and they received training on the use of physical force at the police academy and the training at this facility is called Satori Alternatives to Managing Aggression (SAMA) and “Staying Ahead of Crisis De-escalation for Safer Care.” CPO #2 also stated “ ...They focus more on verbal de-escalation here ...and campus security does not participate on hands on training in de-escalating combative patients at the facility ...”. An interview with the Director of Campus Police on 10/15/2025 at 3:00 p.m. confirmed the Director stated, “CPO #1 did not do this right ...he was assaulted and reacted to defend himself ...We assessed the whole incident and what to do better ...we need a better plan on removal of restraints for stretcher to bed transfers ...”. The interview also confirmed Campus Police Officers receive training on SAMA (Satori Alternatives to Managing Aggression), de-escalation in crisis management system for professionals, on orientation and annually thereafter with physical staff training as well. An interview with the Human Resources (HR) Director on 10/16/2025 at 10:15a.m. confirmed, the House Supervising Manager for the department determines if an employee is sent home in the event of an incident. She also confirmed that CPO #1 stayed at work for the remainder of his shift after the incident. The HR Director also confirmed when an investigation is complete, HR guides managers on policies. The managers decide what steps will be taken regarding the employee at fault. The incident was reported to the Director of Accreditation on 10/13/2025 as well as the Chief Legal Officer. They met and discussed that the employee would not be reprimanded for the abuse accusation/confirmation. An interview with Registered Nurse (RN) #2 (two) on 10/16/2025 at 11:00a.m., confirmed his recall of the incident on 10/12/2025. RN #2 stated “ ....CPO #1 tried to get the patient back into the bed, the patient hit CPO #1, and CPO #1 pushed patient back while going into the bed ...CPO #1 was holding the patient upper body and CPO #4 was holding the lower body. While the patient was laying on the hospital bed, CPO #1 “hit patient”. “I couldn’t see him hit the patient; I was able to see him draw back his elbow ... CT was performed and the laceration above the right eyebrow was sutured ...” An interview with CPO #1 on 10/16/2025 at 2:15p.m., confirmed that when the ER charge nurse got the call from the Emergency Medical Technicians (EMT’s) that the patient coming into the Emergency Department (ED) was combative, he called Security Officer #4 to come to the ED. The patient was taken into room 5 by the EMT’s. CPO #1 said that as security he needed to look through the patient’s bag, but the patient said no. He said he explained to the patient he was only looking for weapons, nothing else. CPO #1 stated “ ...the patient jumped off the bed and knocked my arm away; I put my left hand on his ribs to redirect him back to his bed ...the patient was demanding his bag ...” CPO #1 hugged the patient, went down onto the hospital bed with the patient after he shoved the officer’s hand. CPO #1 reported the patient hit his face on the bed when the security guard pushed the patient down on the hospital bed. CPO #1 said the patient swung his fist at him and “I hit him ...Once he was restrained, I lifted the head of the bed, and he started spitting blood ... I broke his nose”. An interview conducted with Campus Police Officer (CPO) #2 on 10/15/2025 at 2:20p.m. confirmed, Campus Police Officer #1, who inappropriately abused Patient #1 is currently employed at this facility. CPO #2 stated, “ ...We investigated and decided he didn’t do anything wrong. The patient hit him, and he hit him back. What else was he supposed to do?” An interview with the Director of Campus Police on 10/15/2025 at 3:00 p.m. confirmed the Director stated, “CPO #1 did not do this right ...he was assaulted and reacted to defend himself ...We assessed the whole incident and what to do better ...we need a better plan on removal of restraints for stretcher to bed transfers ...”. The interview also confirmed Campus Police Officers receive training on SAMA (Satori Alternatives to Managing Aggression), de-escalation in crisis management system for professionals, on orientation and annually thereafter with physical staff training as well. An interview with Registered Nurse (RN) #2 on 10/16/2025 at 11:00a.m., confirmed his recall of the incident on 10/12/2025. RN #2 stated “ ....CPO #1 tried to get the patient back into the bed, the patient hit CPO #1, and CPO #1 pushed patient back while going into the bed ...CPO #1 was holding the patient upper body and CPO #4 was holding the lower body. While the patient was laying on the hospital bed, CPO #1 “hit patient”. “I couldn’t see him hit the patient; I was able to see him draw back his elbow ... CT was performed and the laceration above the right eyebrow was sutured ...” An interview with CPO #1 on 10/16/2025 at 2:15p.m., confirmed that when the ER charge nurse got the call from the Emergency Medical Technicians (EMT’s) that the patient coming into the Emergency Department (ED) was combative, he called Security Officer #4 to come to the ED. The patient was taken into room five (5) by the EMT’s. CPO #1 said that as security he needed to look through the patient’s bag, but the patient said no. He said he explained to the patient he was only looking for weapons, nothing else. CPO #1 stated “ ...the patient jumped off the bed and knocked my arm away; I put my left hand on his ribs to redirect him back to his bed ...the patient was demanding his bag ...” CPO #1 hugged the patient, went down onto the hospital bed with the patient after he shoved the officer’s hand. CPO #1 reported the patient hit his face on the bed when the security guard pushed the patient down on the hospital bed. CPO #1 said the patient swung his fist at him and “I hit him ...Once he was restrained, I lifted the head of the bed, and he started spitting blood ... I broke his nose”. Document review of Patient #1’s medical record’s Medical Doctor’s progress note revealed: “ ...The patient was brought to the ED for evaluation of homicidal ideations. On arrival patient was agitated and aggressive. Patient requires physical and chemical restraint. While being physically restrained the patient sustained laceration to his right eyebrow and a nasal bone fracture. The patient is hemodynamically stable in status post chemical sedation. Workup showed Methamphetamine and marijuana use. The patient was ultimately cleared for Customer Identification Program (CIP). Discharge plan is to discharge on 10/13/25 pending CIP evaluation, Ear Nose and Throat (ENT) follow up for nasal bone fracture and return to ED in seven (7) days for suture removal ...”. Review of the incident report dated 10/12/2025 revealed “ ...”Restraints were removed, and patient became violent striking the Campus Police officer in the face ... Campus police officer responded to the physical assault resulting in the patient being struck in the face ...”. Review of the facility policy, “Patient Rights and Responsibility”; dated 03/2011, revised 12/2023 reveals “ ...Health System is committed to upholding and respecting the rights of our patients ...”You have the right to: ... 13. Receive are in a safe setting, free from mental, physical, sexual or verbal abuse and neglect ...15. Safe implementation of restraints or seclusion by trained staff ...”. Review of the facility policy, “Workplace violence,” dated 05/2019, revised 04/2024 reveals “ ...Workplace violence - “Any act of aggression, physical assault ... that occurs on facility Property and/or that causes physical or emotional harm that may impact the individual or other’s safety at facility. Violence also includes, but is not limited to, the following: Emotional Physical, or Verbal Abuse ...A. Reporting - Employees are required to report any indirect or direct threat of violence, incidents of actual violence, and suspicious individuals or activities directed against ...patient ...B. Responding: ...investigates all reports and takes whatever action is deemed appropriate to protect employees, patients ...will promptly and thoroughly investigate all reports of threats of violence or incidents of actual violence and of suspicious individuals or activities. To maintain workplace safety and the integrity of its investigation, ...may suspend employees suspected of workplace violence or threats of violence, either with or without pay, pending investigation ...C. Enforcement: Anyone found to be responsible for threats of or actual violence or other conduct that is in violation of these guidelines will be subject to prompt corrective action up to and including termination of employment ...Plan for implementation: Staff will be educated on the policy upon hire and as needed with updates. Employees whose job duties include responding to alarms or other notifications of incidents will receive additional, interactive training that is specific to confronting or controlling person’s exhibiting aggressive or violent behaviors ...”. See A-0115/482.13 and A-0145/482.13(c)(3) for additional information. Exit conference on 10/17/2025 at 3:15p.m. with the Director of Accreditation and Safety, Quality Assurance and Infection Control, Registered Nurse, the Director of Campus Police, Human Resources representative, Risk Department representative, and the Administrator. Reviewed the findings of the survey and no further documentation was provided for review.”

“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: 47684 A-0145 / 482.13(c)(3) Based on staff interviews, review of medical record, and review of facility policy and procedure the facility failed to ensure the facility patients were free from abuse and failed to ensure facility staff were able to identify and report abuse based on the policy and procedures for one (1) of three (3) medical records reviewed. Findings Include An interview conducted with Campus Police Officer (CPO) #2 on 10/15/2025 at 2:20 p.m. confirmed, Campus Police Officer #1, who inappropriately abused Patient #1 is currently employed at this facility. CPO #2 stated, “ ...We investigated and decided he didn’t do anything wrong. The patient hit him, and he hit him back. What else was he supposed to do?” CPO #2 also confirmed Campus Police Officers are mostly retired police officers and they received training on the use of physical force at the police academy and the training at this facility is called Satori Alternatives to Managing Aggression (SAMA) and “Staying Ahead of Crisis De-escalation for Safer Care.” CPO #2 also stated “ ...They focus more on verbal de-escalation here ...and campus security does not participate on hands on training in de-escalating combative patients at the facility ...”. An interview with the Director of Campus Police on 10/15/2025 at 3:00 p.m. confirmed the Director stated, “CPO #1 did not do this right ...he was assaulted and reacted to defend himself ...We assessed the whole incident and what to do better ...we need a better plan on removal of restraints for stretcher to bed transfers ...”. The interview also confirmed Campus Police Officers receive training on SAMA (Satori Alternatives to Managing Aggression), de-escalation in crisis management system for professionals, on orientation and annually thereafter with physical staff training as well. An interview with Registered Nurse (RN) #2 on 10/16/2025 at 11:00 a.m., confirmed his recall of the incident on 10/12/2025. RN #2 stated “ ....CPO #1 tried to get the patient back into the bed, the patient hit CPO #1, and CPO #1 pushed patient back while going into the bed ...CPO #1 was holding the patient upper body and CPO #4 was holding the lower body. While the patient was laying on the hospital bed, CPO #1 “hit patient”. “I couldn’t see him hit the patient; I was able to see him draw back his elbow ... CT was performed and the laceration above the right eyebrow was sutured ...” An interview with CPO #1 on 10/16/2025 at 2:15 p.m., confirmed that when the ER charge nurse got the call from the Emergency Medical Technicians (EMT’s) that the patient coming into the Emergency Department (ED) was combative, he called Security Officer #4 to come to the ED. The patient was taken into room five (5) by the EMT’s. CPO #1 said that as security he needed to look through the patient’s bag, but the patient said no. He said he explained to the patient he was only looking for weapons, nothing else. CPO #1 stated “ ...the patient jumped off the bed and knocked my arm away; I put my left hand on his ribs to redirect him back to his bed ...the patient was demanding his bag ...” CPO #1 hugged the patient, went down onto the hospital bed with the patient after he shoved the officer’s hand. CPO #1 reported the patient hit his face on the bed when the security guard pushed the patient down on the hospital bed. CPO #1 said the patient swung his fist at him and “I hit him ...Once he was restrained, I lifted the head of the bed, and he started spitting blood ... I broke his nose”. Document review of Patient #1’s medical record’s Medical Doctor’s progress note revealed: “ ...The patient was brought to the ED for evaluation of homicidal ideations. On arrival patient was agitated and aggressive. Patient requires physical and chemical restraint. While being physically restrained the patient sustained laceration to his right eyebrow and a nasal bone fracture. The patient is hemodynamically stable in status post chemical sedation. Workup showed Methamphetamine and marijuana use. The patient was ultimately cleared for Customer Identification Program (CIP). Discharge plan is to discharge on 10/13/25 pending CIP evaluation, Ear Nose and Throat (ENT) follow up for nasal bone fracture and return to ED in seven (7) days for suture removal ...”. Review of the incident report dated 10/12/2025 revealed “ ...”Restraints were removed, and patient became violent striking the Campus Police officer in the face ... Campus police officer responded to the physical assault resulting in the patient being struck in the face ...”. Review of the facility policy, “Patient Rights and Responsibility”; dated 03/2011, revised 12/2023 reveals “ ...Health System is committed to upholding and respecting the rights of our patients ...”You have the right to: ... 13. Receive are in a safe setting, free from mental, physical, sexual or verbal abuse and neglect ...15. Safe implementation of restraints or seclusion by trained staff ...”. Review of the facility policy, “Workplace violence,” dated 05/2019, revised 04/2024 reveals “ ...Workplace violence - “Any act of aggression, physical assault ... that occurs on facility Property and/or that causes physical or emotional harm that may impact the individual or other’s safety at facility. Violence also includes, but is not limited to, the following: Emotional Physical, or Verbal Abuse ...A. Reporting - Employees are required to report any indirect or direct threat of violence, incidents of actual violence, and suspicious individuals or activities directed against ...patient ...B. Responding: ...investigates all reports and takes whatever action is deemed appropriate to protect employees, patients ...will promptly and thoroughly investigate all reports of threats of violence or incidents of actual violence and of suspicious individuals or activities. To maintain workplace safety and the integrity of its investigation, ...may suspend employees suspected of workplace violence or threats of violence, either with or without pay, pending investigation ...C. Enforcement: Anyone found to be responsible for threats of or actual violence or other conduct that is in violation of these guidelines will be subject to prompt corrective action up to and including termination of employment ...Plan for implementation: Staff will be educated on the policy upon hire and as needed with updates. Employees whose job duties include responding to alarms or other notifications of incidents will receive additional, interactive training that is specific to confronting or controlling person’s exhibiting aggressive or violent behaviors ...”. Review of the facility policy, “Use of Force,” dated 06/01/2018, revised 02/20/2025 reveals “ ...Policy: “Protecting innocent human life is the most important mission ... while officer discretion is critical, the need for accountability and control of police activities is necessary to limit abuses of authority ... Force, non-deadly force, or less-lethal force ... Compliance techniques may include: ... use of restraints, forced movement, or using other forms of pain compliance or control ...”. See A-0115/482.13 and A-0144/482.13(c)(2) for additional information. Exit conference on 10/17/2025 at 3:15 p.m. with the Director of Accreditation and Safety, Quality Assurance and Infection Control, Registered Nurse, the Director of Campus Police, Human Resources representative, Risk Department representative, and the Administrator. Reviewed the findings of the survey and no further documentation was provided for review.”