Trinitas Regional Medical Center

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 47131 Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure that vital signs and pain assessments are performed for all patients in the emergency department in accordance with the facility’s established timeframe. Findings include: Facility document titled, “Plan for Provision of Care: Assessment, Planning and Education-Appendix 1” (no date) stated, “... Department: Emergency Department; Assessment/Reassessment: ... Assessment of patient is a head to toe survey and a focused: physical assessment ...vital signs ... pain assessment ... The Triage RN and the ED Main treatment RN will reassess patients based on the category and individual patient needs/acuity, a minimum of every 120 minutes.” On 8/12/25 at 12:50 PM, upon review of Patient (P)1’s medical record, in the presence of S3, the following was revealed: P1 had a documented past medical history including diabetes, hyperlipidemia (high cholesterol), and hypertension (high blood pressure) who arrived at the ED on 07/10/25 at 1759 (5:59 PM) with complaint of “blurry vision.” The arrival complaint was updated at 18:02 (6:02 PM) as “Blurred Vison, Headache.” The patient’s vital signs were as follows, Temperature: 97.8F (Fahrenheit); Heart Rate: 75; Respirations: 16; Blood Pressure: 149/74; oxygen saturation: 99% on room air. There was no pain assessment documented in the patient’s triage note. Upon further review, a pain assessment was completed by S11 at 1956 (7:56 PM) and documented that P1’s pain was zero (no pain). The patient was discharged from the ED on 07/10/25 at 22:16 (10:16 PM). There was no other vital signs or pain assessment documented in the medical record. The medical record lacked documentation that P1’s vital signs and pain were assessed every 120 minutes between 19:56 (7:56 PM) and 22:16 (10:16 PM), in accordance with the facility’s “Plan for Provision of Care” established timeframe. During an interview with S5 on 8/12/25 at 1:40 PM, he/she confirmed vital signs should be documented every two hours. S3 confirmed this finding at the time of the discovery.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 43214 Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure that a restraint order was obtained after a patient was placed in restraints in one of two medical records reviewed (Patient (P)3). Findings include: Facility Policy titled, Restraints - Violent and Non-Self-Destructive Procedure, effective on 9/19/2024, states, “...3. Procedure: Performed by LP [Licensed Practitioner]... Supplemental Guidance The need for restraint may occur so quickly that an order cannot be obtained prior to the application of restraint. In these emergency application situations, the order must be obtained either during the emergency application or immediately (within a few minutes) after the application.” On 7/17/2025 at 11:49 AM, a review of P3’s medical record was conducted and revealed the following: The ED Note from 7/5/25 at 4:49 PM, stated, “Patient is AAOx3 [awake, alert, and oriented times three]. Brought in by EMS found unconscious on the train. 4 of Narcan given in the field. Patient refusing to be treated stating [he/she] wants to get home, [he/she] lives in Pennsylvania and doesn’t know how [he/she] got her [sic]. Patient was trying to leave, DR [name] at bedside evaluating patient, patient refusing to answer questions. Patient attempted to leave security called and patient placed in restraints.” The ED Provider Note from 7/6/25 at 7:21 AM, stated, “ ... Date of Service 7/5/2025 at 4:35 PM ... History of Present Illness ... [He/she] is belligerent to staff, refusing to provide any information and demanding to leave ... ED Course & MDM [medical decision making] ... patient awoke and became belligerent ... Patient initially refused to answer any questions and demanded to leave. And due to [his/her] attempting to leave without my evaluation of [his/her] having capacity, and concern for possible ICH [intracranial hemorrhage] as cause of agitation and belligerence, patient was momentarily restrained. Patient restrained for approximately 3 minutes.” At 1:50 PM, an interview was conducted in the Emergency Department (ED) with Staff (S)3. When asked if a patient was restrained for a minute or two, would he/she need to obtain a restraint order from the doctor, S3 stated, “yes, you need an order, it doesn’t matter how long the restraints are on, the doctor needs to assess the patient.” The medical record lacked evidence of a restraint order. On 7/17/2025 at 11:52 AM, all of the above findings were confirmed with S1.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49174 Based on medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to implement interventions necessary to provide a safe setting for the care of three suicide-risk patients per facility policy (A0144). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patients. On December 12, 2024 at 1:09 PM, an IJ was identified. On December 12, 2024 at 2:39 PM, the IJ template was presented to the administration and an acceptable removal plan was accepted on December 13, 2024 at 11:07 AM. On December 13, 2024, verification of the IJ removal plan was conducted and included the following: review of staff re-education, sign in-sheets, and staff interviews regarding the facility’s process for placing patients on 1:1 observation. The IJ was lifted on December 13, 2024 at 12:12 PM. Cross Reference: 482.13(c)(2) Patient Rights: Care in a Safe Setting”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 43214 Based on medical record review, staff interviews, and review of facility policy and procedure, it was determined that the facility failed to ensure the patient’s rights to have their pain assessed, managed, and maintained in four of four medical records reviewed (Patient (P) 2, P4, P9, and P19). Findings include: Facility Policy titled, “Implementation of Patient Rights” (reviewed 12/2023), states, “ ... PURPOSE: To ensure that: ... 5. Patients have their pain assessed as outlined in the pain management policy. ... PATIENT RIGHTS ... Pain Management. Activities are planned/coordinated to ensure pain is recognized/addressed appropriately in accordance with care/treatment/services including: Assessing for pain. Educating all relevant providers about assessing/managing pain. Educating patients/families about their roles in managing pain and potential limitations and side effects of pain treatments. ...” Facility Policy titled, “Pain Management and Assessment” (revised 12/2022), states, “ ...POLICY: All patients have the right to pain assessment and management as an important part of their care, therefore: 1. All patients will have an assessment of pain upon admission. ... PROCEDURE: A. Assessment of Patients ...1. Screen for the presence of pain at the time of admission by eliciting a pain response regarding the current presence of pain or pain experienced in the last few weeks. On 12/11/24, a review of P2, P4, P9, and P19’s medical record review, revealed the following: On 11/11/24 at 11:49 AM, P2 arrived in the Emergency Department (ED) with complaints of chest pain. On 11/11/24 at 11:53 AM, P2’s vital signs assessment at triage included a temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation. On 11/11/24 at 12:03 PM, P2 had an electrocardiogram (ECG) performed. On 11/11/24 at 1:58 PM, P2’s ED Disposition was set to “LWBS (left without being seen) after triage.” P2’s medical record lacks documented evidence that a pain assessment was performed during P2’s ED visit. On 10/7/24 at 8:03 PM, P4 arrived in the ED with complaints of generalized chest pain to the right side of his/her neck that was getting gradually worse. On 10/7/24 at 8:24 PM, P4’s vital signs assessment at triage included a temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation. On 10/7/24 at 8:45 PM, P4 was seen by an ED physician and orders were placed. On 10/7/24 at 8:46 PM, the patient’s first pain assessment was documented when P4 was given IV Toradol (a pain medication). P4’s medical record lacked documented evidence that a pain assessment was completed during triage. On 11/1/24 at 12:25 AM, P9 arrived in the ED with complaints of knee pain. On 11/1/24 at 12:28 AM, P9’s vital signs assessment at triage included a temperature, heart rate, respiratory rate, blood pressure and oxygen saturation. On 11/1/24 at 5:20 AM, P9’s ED Disposition was set to “LWBS after triage.” On 12/12/24 at 12:23 PM, S4, confirmed the medical record lacked evidence of a pain assessment or re-assessment. When questioned if P5 should have been re-assessed during his/her wait, S4 stated, “yes.” P9’s medical record lacked documented evidence that a pain assessment was performed during P9’s ED visit. On 10/1/24 at 6:29 PM, P19 arrived in the ED with complaints of chest and abdominal pain. On 10/1/24 at 6:32 PM, P19’s vital signs assessment at triage included a temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation. On 10/1/24 at 7:53 PM, P19 was seen by an ED physician. On 10/1/24 at 10:54 PM, P19’s ED Disposition was set to “Eloped.” P19’s medical record lacked documented evidence that a pain assessment was performed during P19’s ED visit. On 12/12/24 at 10:08 AM, during an interview with S4, (ED Director of Nursing), he/she stated that in the ED pain is assessed during the second part of triage, unless the patient comes in with a complaint of pain then the pain should be assessed right away.”

“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: 48414 Based on observation, medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to implement policies and procedure for the care of suicidal patients presenting to the Emergency Department (ED) in four of four medical records (Patient (P)13, P23, P24, and P25). Findings include: Facility policy titled, “Patient Safety Watch Policy” last effective on 10/17/2024 states, “ ... 1. Policy Statement: POLICY: Based on a patient risk assessment for potential for harm to self/and or others, the RN will place patients determined to be a danger to themselves or others or at risk for self or other injury on the appropriate patient watch level until an evaluation can be obtained by a LIP [Licensed Independent Practitioner] .... Law Enforcement Officers, family members, or visitors cannot be assigned responsibility to monitor the patient if an order for patient watch is in place. ...One-to-One Observation: For patients exhibiting behaviors that present a danger to self or others as evidenced by ...verbalizing suicide ideation with a plan and/or an overt suicide attempt ...a one-to-one observation is necessary ... 3. Every 15/30 Minute Check: requires that the patient be observed by a staff member at least once every 15/30 minutes as prescribed by the LIP for the duration of the order.” Facility policy titled, “Suicide Risk Assessment, Care and Referral” reviewed on 12/2022, states, “... II. Policy Definition: 1. ... Definitions ...b. 1:1 Observations: any staff member performing 1:1 Observation must remain within arm’s length of patient, unless otherwise directed ...The on-going observation/assessment must be documented on the Observation Flow Sheet ... III. [facility name] - Emergency Department (ED): 1. Adult and Pediatric Patients a. All [facility initials] patients are screened for suicide ideation using the [ED] Screen version of the Columbia-Suicide Severity Rating Scale (C-SSRS), as part of the initial triage process. If the patient is unable to answer the question, ask the parent, guardian, or significant other ... i. High Risk: Initiate 1:1 observation and safety precautions...” On 12/10/24 at 10:47 AM, a tour of the Transitional Care Unit (TCU) was conducted with Staff (S)1 (Director of Quality, Infection Prevention, and Patient Safety). During an interview, S1 indicated that the TCU is a locked 6-bed unit, for behavioral health patients that need further evaluation. The TCU was observed to have two staff members present which included, one Registered Nurse (RN) and one Security Officer. The unit had a census of three patients (P23, P24, and P25). During the tour, all three patients were observed without a staff member performing 1:1 observation within arm’s reach. On 12/10/24 at 10:49 AM, during an interview with S21 (RN), when questioned concerning the procedure for a suicidal patient in the TCU, S21 stated that the ratio in the TCU is 6:1 (6 patients per 1 RN). S21 explained there is also one Patient Care Technician (PCT) who is responsible for documenting the 15-minute observations for every patient, and one security guard. When questioned on the process if a patient was ordered a 1:1 observer, S21 stated that the one PCT in the TCU will be the 1:1 observer for all patients within the TCU. On 12/11/24, a review of P25’s medical record revealed the following: P25 presented to the ED on 12/9/24 at 10:09 PM, with an arrival complaint of psych eval [psychiatric evaluation] and C-SSRS score indicated “High Risk.” The RN Triage Note stated, “Patient to the ED with concerns of suicidal ideation after being found sitting in [his/her] vehicle with exhaust pipe covered and looping back to the inside of the vehicle. Patient per EMS [Emergency Medical Services] ‘Was caught cheating on wife’ prior to attempting to harm self. Patient denies attempt and states ‘they broke into my car’ -Patient in no distress.” On 12/10/24 at 1:50 AM, P25’s C-SSRS reassessment indicated “High Risk.” The ED Physician Note from 12/10/24 at 2:32 AM, stated, “Discussed case with psychiatric resident who spoke with [his/her] attending [name]- they advise patient will ultimately need to be transferred to [facility initials] for full psychiatric evaluation but cannot be sent until labs are obtained.” P25’s medical record lacked documented evidence P25 was placed on 1:1 observation due to suicidal ideation/suicide attempt. On 12/11/24 at 2:07 PM, upon interview, S1 stated that during the unit tour on 12/10/24, the TCU did not have a staff member assigned for 1:1 observation for P25. S1 confirmed that there should have been a 1:1 observation ordered for P25. S1 confirmed the Patient Care Technician [PCT] assigned to the unit ran to the lab at the time of the tour, and upon returned he/she sat at the nurse’s station, not within arm’s reach of P25. On 12/12/24, a review of P13, P23, and P24’s medical record revealed the following: P13 arrived at the ED by ambulance on 12/3/24 at 7:44 PM with complaints of suicide attempt (Tylenol ingestion). At 7:50 PM, P13 was triaged and screened high risk for suicide using the Columbia Suicide Severity Rating Scale [C-SSRS]. The ED provider evaluated the patient at 7:56 PM. P13’s nurse performed two additional C-SSRS screenings at 8:22 PM and 8:33 PM, to which P13 scored “high risk.” P13 was given activated charcoal and acetylcysteine. P13 was transferred to a higher level of care at 11:07 PM. On 12/12/24 at 10:45 AM, P13’s medical record was reviewed with S3 (ED Chairman). Upon interview S3 stated, “I would have a 1:1 on [P13].” At 12:25 PM, S4 (Director of Nursing - DON) stated that patients who are deemed high risk are placed on 1:1 observation, changed into paper scrubs, and have their belongings searched. S4 then confirmed P13’s medical record lacked documented evidence that P13 was placed on a 1:1 observation due to suicidal ideation. P23 arrived at the ED on 12/10/24 at 2:15 AM, with arrival complaint of drug use. At 2:18 AM the triage note stated, “Pt [patient] to the ed [Emergency Department] with [town name] EMS [Emergency Medical Services] and PD [Police Department] under arrest after being found ‘passed out’ int he [sic] passenger side of the car. Patient denies using drugs today - patient noted to have white substance on the nose.” At 2:21 AM, the “Suicide Screen - CSSRS [Columbia Suicide Severity Rating Scale” was documented as “unable to assess.” At 3:01 AM, naloxone (Narcan) injection 0.1 mg [milligrams], intravenous was given. At 3:13 AM, the ED Notes stated, “pt receives [sic] sleeping, in pd [police department] custody, reacting only to sternal rub. Narcan given intravenously. Pt responsive immediatlhy [sic] When asked what substances where [sic] used tonight, pt replied ‘I don’t know I just wanted to die’.” At 3:20 AM, the ED Provider Note stated, “ ...ED Course note: After administration of Narcan, patient exhibits suicidal ideation. [He/She] reports [he/she] wants to kill [himself/herself] remains in PD custody. ... Plan Patient is placed in ED observation pending psychiatric evaluation. They remain medically cleared for psychiatric evaluation and will be re-assessed throughout their course in the ED.” At 4:00 AM, the ED RN Updates documentation stated, “pt to TCU accompanied by [Local Police Department] left arm handcuffed to bed rail.” On 12/12/24 at 10:01 AM, upon interview, S4 stated the C-SSRS is completed on the initial assessment and should be reassessed at the RN’s discretion, if there is a change in patient status, if patient was unable to answer and becomes more alert, or if they make a suicidal statement. S4 then stated that a patient who came in for overdose will remain in the main ED until awake, once awake patient will be reassessed for the need for 1:1 (observation). S4 confirmed that the Police cannot be the 1:1 [sitter]. During the medical record review, P23’s medical record lacked evidence that 15-minute observations were completed every 15 minutes per facility policy. P23’s medical record lacked evidence that P23 was provided a 1:1 observer due to suicidal ideation. During a tour on 12/10/24, P23 was observed without a 1:1 observer within arm’s reach. On 12/12/24 at 10:41 AM, these findings were confirmed with S1 and S2 (Vice President Chief Medical Officer). P24 arrived at the ED on 12/9/24 at 12:14 PM, with a complaint of “psych [psychiatric] evaluation.” At 12:14 PM, the ED triage note stated, “Pt presents to ED aaox3 [awake, alert, and oriented], in no distress, c/o [complaining of] self-harm. Pt reports SI [suicidal ideation] with no plan denies HI [homicidal ideation] or auditory hallucinations. Pt states ‘I don’t want to live anymore, I’m tired of it all.’ Hx [history] of depression states compliant with psych meds.” At 12:18 PM, a C-SSRS was completed, resulting in a “Moderate Risk.” At 12:37 PM, the Patient Safety Checklist was completed. At 12:46 PM, an order for Nursing - Patient monitoring safety checks every 15 minutes was placed. At 12:56 PM, the ED RN documentation stated, “ ... Received pt in TCU-5, alert and oriented. Arrived tearful and crying a little. Had come to hospital for post-discharge follow-up and had told provider [he/she] was under a lot of stress and wanted to die. No plan.” At 2:55 PM, the Clinical summary note stated, “ ...Cardiology, Psychiatry, Neurology consults placed, patient on cardiac monitoring, one-to-one observation and decision was made to admit for further care and management.” Upon review, P24’s medical record lacked documented evidence that the order for 1:1 observation was implemented. P24’s medical record lacked evidence that 15-minute observations were completed every 15 minutes per facility policy. On 12/11/24, P1 confirmed that the 1:1 observation and the “Every 15 Minute Check” documentation should have been completed in the electronic medical record. S1 indicated that staff previously documented observations on the paper form but switched to electronic documentation as of September. During a tour on 12/10/24, P24 was observed without a 1:1 observer within arm’s reach.”

“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: 48414 Based on medical record review, review of video surveillance, staff interviews, and review of facility documents, it was determined the facility failed to ensure that local authorities were notified of an assault incident per facility policy. Findings include: Facility policy titled, “Nonviolence in the Workplace” effective 6/30/23, states, “ ...This policy defines what constitutes violent acts and threats, identifies potential warning signs, and processes for reporting and possible actions to be taken to ensure everyone’s safety and well-being/recovery post-event. [Facility name] is committed to providing a safe, secure environment for its employees, patients, physicians, visitors, vendors, and volunteers. To that end, [facility name] works with its employees to maintain an environment that is free from violence, harassment, intimidation, threats or other disruptive behavior. [Facility name] will not tolerate such behavior and all employees are expected to report, using verge, any prohibited/disruptive behavior as described in the policy. All reported behaviors/events will be promptly reported by the person receiving the information. If substantiated, appropriate action(s) will be taken which may include ...notifying outside authorities. ...Definitions: Physical Assault: An act which inflicts bodily/emotional harm or unwanted hostile physical contact of a non-sexual or sexual nature (e.g. ...pushing, shoving ...). ...Prohibited Behaviors ...Any type of physical contact to cause harm to another or one’s self (e.g. ..shoving ...) ...” On 12/11/24, medical record review revealed Patient (P)1 presented to the Emergency Department (ED) on 11/10/24 at 9:18 AM, with a chief complaint of aggressive behavior. At 9:18 AM, the ED Provider Note stated, “ ...[P1] is a 65 y.o. [year old] [male/female] with a PMHX [past medical history] of dementia, schizophrenia, HTN [hypertension], and COPD [chronic obstructive pulmonary disease], and HLD [hyperlipidemia], who presents to ED [emergency department] from [facility name] nursing home for psych [psychiatric] evaluation. Per report, patient began displaying aggressive behavior after a lover’s quarrel. ...Upon ED arrival, patient is still aggressive and refusing to cooperate ...”. At 9:28 AM, P1’s CSSRS (Columbia Suicidal Severity Rating Scale) risk was “No Risk.” At 10:08 AM, an order was placed for 1:1 observation for suicide and elopement precautions. At 5:56 PM, the ED RN (Registered Nurse) Updates, stated, “ ...Patient assisted to the floor as [he/she] continued violently swinging at staff members, patient then lifted to stretcher, ER MD [medical doctor] at bedside ordered restraints and medication.” At 10:00 PM, the restraints were removed. On 11/11/24 at 1:26 AM, the ED RN Note stated, “Patient is belligerent, uncooperative and aggressive. Pt [patient] was screaming and attempting to punch and swing at staff. Pt stumbled and fell backwards striking head on ground. Pt placed back in bed. MD at bedside. Multiple attempts made to de-escalate the patient and defuse the situation. Pt was resistant to all attempts to defuse. A code gray was called and the patient was placed in 4 point mechanical restraints. Medicated per MD orders. CT [computed tomography] scan ordered. All safety precautions maintained per facility protocol. Monitoring ongoing.” On 11/11/24 at 7:43 AM, the CT Head final results were, “Trace acute subarachnoid hemorrhage in a right frontal sulcus.” On 11/12/24 at 8:24 AM, a repeat CT of the head results stated, “ ... Previously noted subarachnoid hemorrhage has resolved.” On 12/11/24 at 10:00 AM, the facility investigation of the incident was reviewed with S1. The incident involving P1 occurred on 11/11/24 at 1:26 AM. The facility reported this event to the Department of Health on 11/11/24 at 9:35 AM. An interview was conducted with S1, who stated that the incident was not reported sooner due to the staff involved, S24 (Security Officer), S25 (PCT), and S26 (RN) reporting the incident as a patient fall. Review of the statements from S25 and S26 revealed both staff reported P1 fell. S1 indicated once the video surveillance was reviewed of the incident it was determined that S24 pushed P1, causing P1 to fall and sustain an injury. S1 confirmed S24 worked the remainder of his/her scheduled shift on 11/11/24, because it was not known at the time that S24 pushed P1. S1 confirmed that on 11/12/24, S24 was furloughed pending the facilities investigation and on 11/25/24, S24 was terminated. S1 explained that S25, was required to complete education prior to returning to work but he/she never completed the education or returned to work, and therefore was terminated. S1 confirmed that S26, was not present during the incident, that he/she exited the unit, but documented as if he/she was present. S1 provided S26’s Handle with Care re-education. S1 provided documentation that S26 had a meeting with leadership and was educated about documenting accurately and how to document if he/she is not a first-hand witness. On 12/11/24 at 10:52 AM, review of the video surveillance for the Transitional Care Unit (TCU) within the ED was conducted in the presence of S1 and S23 (Security Director). The video surveillance reviewed did not have any audio recording and was not time stamped. S23 confirmed the video surveillance was from the incident involving P1 on 11/11/24. Video surveillance review revealed: P1 and S24 were observed to be standing in front of the nurse’s station facing each other. S25 (Patient Care Technician [PCT]) was observed to be standing behind the nurse’s station. P1 appeared to be disheveled, with his/her scrub top half off. S25 then came around the nurse’s station and stood behind P1. P1 then appeared to hit S24 in the upper chest area. S24 then pushed P1. P1 then appeared to hit S24 again. S24 then forcefully pushed P1, causing him/her to fall to the ground. At 11:03 AM, the police investigation report dated 11/11/24 was reviewed with S1 and S23. The report lacked evidence that the facility reported to the police that S24 physically assaulted P1. S1 stated, “we thought [P1] fell, and we cannot control what is written in the police report.” When asked if the police were updated on the results of the facility investigation that S24 physically assaulted P1, both S1 and S23 were unsure. At 11:10 AM, a phone interview was conducted with S5 (Administrative Director) who filed the initial police report. S5 indicated he/she filed the police report before the facility completed the investigation. When asked if S5 contacted the police after the investigation revealed that S24 assaulted P1, S5 stated, “No, I did not.” S23 then stated, that he/she will file a supplement police report immediately. At 2:00 PM, S1 stated the facility contacted the local police department, and were told the officer that took the initial report would have to do the supplemental report. S1 stated they were attempting to contact the police department supervisor to assist with completing the supplemental report. On 12/12/24, P1 confirmed that the facility filed a supplemental police report.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 48414 Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure that a restrained patient received a face-to-face evaluation within one (1) hour after the application of restraints. Findings include: Facility policy titled, “Restraints- Violent and Non-Violent Non Self Destructive Procedure” effective 9/19/24, states, “ ...1. Purpose Statement: To provide a standardized, organizational approach for the management of restraint which addresses regulatory compliance, patient dignity, and safety. ...Definitions: ...Licensed Practitioner: Any practitioner permitted by State Law and hospital policy as having authority to order restraints for patients. Physicians, APNs [Advanced Practice Nurse], and PAs [Physician Assistant] are LPs [licensed practitioners] have authority to order restraints. ...Face to Face: An LP must see the patient in person within 1 hour after the initiation of the intervention (regardless of whether the intervention has already been discontinued). The evaluation includes: the patients immediate situation, the patients reaction to the situation, the patients’ medical and behavioral condition and the need to continue or terminate the intervention.” On 12/11/24 medical record review revealed Patient (P)1 presented to the Emergency Department (ED) on 11/10/24 at 9:18 AM, with a chief complaint of aggressive behavior. At 9:18 AM, the ED Provider Note stated, “ ...[P1] is a 65 y.o. [year old] [male/female] with a PMHX [past medical history] of dementia, schizophrenia, HTN [hypertension], and COPD [chronic obstructive pulmonary disease], and HLD [hyperlipidemia], who presents to ED [emergency department] from [facility name] nursing home for psych [psychiatric] evaluation. Per report, patient began displaying aggressive behavior after a lover’s quarrel. ...Upon ED arrival, patient is still aggressive and refusing to cooperate.” On 11/10/24 at 5:56 PM, the ED RN (Registered Nurse) Updates, stated, “ ...Patient assisted to the floor as [he/she] continued violently swinging at staff members, patient then lifted to stretcher, ER MD [medical doctor] at bedside ordered restraints and medication.” P1’s medical record lacked evidence that a licensed provider conducted a face-to-face evaluation within 1 hour after initiation of restraints. On 11/11/24 at 1:53 AM, a physician order was placed for restraints. P1’s medical record lacked evidence that a licensed provider conducted a face-to-face evaluation within 1 hour after initiation of restraints. On 11/11/24 at 8:15 AM, a nurse placed an order for restraints. P1’s medical record lacked evidence that a licensed provider conducted a face-to-face evaluation within 1 hour after initiation of restraints. On 12/11/24 at 2:00 PM, these findings were confirmed with S1.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47131 Based on video surveillance review of the Psychiatric Emergency Services (PES) Room 2, staff interviews, and review of facility documents, it was determined that the facility failed to: 1) ensure safety is maintained when staff on the PES unit place a patient in a therapeutic hold and protect patients from abuse during investigation of an incident where a staff member physically assaulted a patient while the patient was being held (A0144); and 2) respond to signs of physical distress while a patient is restrained (A0202). On July 23, 2024, at 1:30 PM, an Immediate Jeopardy (IJ) finding was identified for the facility’s failure to ensure that staff on the PES unit provide care to patients in a safe setting (A0144). On July 23, 2024 at 4:33 PM, the IJ template was presented to the administration and a removal plan was requested. The facility implemented the following to address the IJ: re-education of all PES Unit mental health technicians, crisis workers, physicians, and nursing staff prior to starting their next shift. PES policy for medical emergencies was received and reviewed. Document review of staff education was conducted, and staff on other behavioral health units received re-education, verified through review of employee attestations. The IJ was removed on July 25, 2024 at 12:00 PM, after the State Survey Agency verified the full implementation of the removal plan, and Condition Level non-compliance remains (A0144). Cross Reference: 482.13(c)(2) Patient Rights: Care in Safe Setting 482.13(f)(2)(iv) Patient Rights: Safe Application and Use of All Types of Restraint or Seclusion Used in the Hospital, including Training on How to Respond to Signs of Physical and Psychological Distress (for example, positional asphyxia)”

“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: 47131 Based on video surveillance review and staff interviews, it was determined that the facility failed to: 1) ensure safety is maintained when staff on the Psychiatric Emergency Services (PES) unit place a patient in a therapeutic hold; and 2) protect patients from abuse during investigation of an incident where a staff member physically assaulted a patient while the patient was being held down. Findings include: On 07/23/24, during an entrance conference conducted in the presence of Staff (S)1 (VP [Vice President], Department of Behavioral Health [BH]), S2 (DON [Director of Nursing], Department of BH), and S3 (Director of Quality and Patient Safety) the following was revealed: On 07/18/24, Patient (P)1 was transferred from the hospital’s Emergency Department (ED) to the PES (Psychiatric Emergency Services) unit for a psychiatric evaluation after the ED physician medically cleared the patient. The patient was calm and cooperative upon his/her arrival to PES and the nursing admission assessment was completed without any issue. At approximately 4:30 AM on 07/18/24, a Mental Health Worker (MHW) observed that the patient appeared to be agitated and he/she alerted the Registered Nurse (RN). The RN contacted the attending psychiatrist for orders to administer medication for agitation to the patient. On 07/23/24 at 12:12 PM, review of video footage recorded on 07/18/24 from the PES unit (view from inside of PES Room 2), was conducted in the presence of S1, S3, S8 (Vice President of Support Services), and S9 (Security Manager). S3 confirmed that S1, S3, S8 and S9 had previously watched the video footage. S3 identified the patient and staff members in the video footage. S8 indicated that the timestamps in the video are two hours and 25 minutes behind actual time. The video footage review revealed the following: At 4:27 AM (Timestamp: 2:02 AM), P1 appeared to be alone in PES Room 2 and was observed to be pacing in and out of camera view. At 4:28 AM (Timestamp: 2:03 AM), S13 (Mental Health Worker [MHW]) walked into the room with P1 then left. At 4:30 AM (Timestamp: 2:05 AM), P1 appeared to be speaking to someone out of the view of the camera. The patient began pacing around the room in and out of camera view. At 4:42:03 AM (Timestamp: 2:17:03 AM), S4 (Security Officer), S5 (Security Supervisor) and S13 entered Room 2. At 4:42:13 AM (Timestamp: 2:17:13 AM), S7 (Registered Nurse [RN]), entered Room 2. At 4:42:20 AM (Timestamp: 2:17:20 AM), P1 walked towards S13 and swung (his/her) right fist towards S13 and appeared to strike the S13 on the chin. S4, S5, and S13 grabbed P1, then brought him/her face down to the floor. The patient remained face-down and was observed to be kicking his/her legs. S13 was observed to be holding P1 while lying beside the left side of the patient’s head; S5 was observed to be kneeling with his/her right knee placed in the center of P1’s spine; and S4 was knelt beside the patient’s right shoulder. At 4:43:10 AM (Timestamp: 2:18:10 AM), S4, S5, and S13 continued to restrain P1 to the floor. S4 punched P1 four times with his/her closed fist, striking the patient each time in the right side of the head. S5 and S13 continued to hold the patient while S4 punched the patient. An antenna was observed in S4’s right hand while [he/she] punched P1. After the fourth strike to the patient’s head, a walkie-talkie radio was thrown from the staff member’s right hand onto the patient’s bed. P1 was observed kicking his/her legs while still being restrained by S4, S5, and S13. S7 observed to administer an IM (intra-muscular) medication into the patient’s gluteal muscle, then moved next to the patient’s bed. At 4:43:54 AM (Timestamp: 2:18:54 AM), P 1 stopped kicking his/her legs. S4, S5, and S13 continued to hold the patient while he/she remained face down on the floor. S7 does not interact with or assess P1, who was not observed to be moving. At 4:44:17 AM (Timestamp: 2:19:17 AM), P1 kicked his/her legs then became motionless. S4, S5, and S13 continued to hold the patient face down on the floor. S7 checked the restraints on the bed and did not look towards the patient. At 4:45:22 AM (Timestamp: 2:20:22 AM), S4, S5, and S13 picked up P1’s limp body and placed the patient face down facing towards the foot of the bed. S7 stood at the head of the bed, and not observed to assess P1, who remained motionless. At 4:45:53 AM (Timestamp: 2:20:53 AM), P1 was rotated towards the head of the bed then turned to supine position onto his/her back. P1 remained motionless. Staff placed the patient’s right ankle into a restraint on the bed. At 4:45:58 AM (Timestamp: 2:20:58 AM), Staff in room consists of: S4, S5, S6 (Security Officer), S7, S13, S14 (PES Screener), S15 (Security Officer), S16 (Security Officer), S17 (RN), and S18 (RN). At 4:46 AM (Timestamp: 2:21 AM), S7 performed a sternal rub on P1 and the patient did not move. S7 repeatedly touched P1’s face and the patient remained motionless. S7 performed five chest compressions. S7 was not observed checking for the patient’s pulse. At 4:46:32 AM (Timestamp: 2:21:32 AM), P1 began convulsing, as if he/she was having a seizure. P1 was turned onto his/her right side by staff. P1 continued convulsing while staff held the patient and S7 rubbed the patient’s back. P1 continued convulsing for five minutes and 26 seconds. At 4:51:58 AM (Timestamp: 2:26:58 AM), P1 stopped convulsing. S7 removed P1’s shirt. The patient was turned onto his/her back. Facility staff resumed placing the patient’s left ankle, right wrist, and left wrist into restraints while the patient flailed his/her arms and legs. 1) On 07/23/24 at 1:05 PM, S8 confirmed that the video footage revealed that S4 struck P1 four times in the head. S8 confirmed that hospital administration had previously reviewed the video footage and was aware the staff member struck the patient. 2) On 07/23/24 At 10:50 AM, S3 confirmed that the facility’s investigation of the incident that occurred on 07/18/24 had been completed, but the final report was pending. Upon interview at 1:05 PM, S8 was asked what the expectation was when a staff member assaults a patient. S8 confirmed that S4 received a “verbal warning” and returned to work on 07/22/24 (Sunday Night) at 12:00 AM. S8 stated that S4 was “counseled by ___ [S21 (Security supervisor)] prior to returning to work on 07/22/24.” Review of the staff schedule confirmed S4 worked on 07/22/24. S8 confirmed that S4 did not receive any formal de-escalation re-education and was permitted to return to work while the incident was under investigation by the facility. The facility failed to provide a policy for investigating incidents of assault upon surveyor request.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(iv) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (iv) The safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia). This Standard is not met as evidenced by: 47131 Based on review of video surveillance of the Psychiatric Emergency Services (PES) unit Room 2, staff interview, and review of facility policy, it was determined that the facility staff failed to respond to signs of physical distress while a patient is restrained. Findings include: Reference: Policy titled “Restraint/Seclusion Use of, In Acute Care” (Reviewed 12/23) states, “ ...V. Personnel Training: Staff will receive training in the implementation and use of the restraint/seclusion. ...E. Training content includes: ...8. Monitoring of the physical and psychological wellbeing of the patient who is restrained or secluded, including, but not limited to: a. Respiratory and circulatory status. ... .” On 7/23/24 at 12:12 PM, review of video footage from the PES unit (view from inside of Room 2, [Patient (P)1’s room] directed towards bed) recorded on 7/18/24, was conducted in the presence of Staff (S)1 (Vice President of Behavioral Health Department), S3 (Director of Quality and Patient Safety), S8 (Vice President of Support Services), and S9 (Security Manager). S3 confirmed that S1, S3, S8 and S9 had previously watched the video footage. S3 confirmed the identity of P1 and identified the staff members observed in the footage from 07/18/24 PES Room 2. S8 indicated that there is a two hour and 25-minute difference between the video surveillance timestamp and the ‘correct’ time. The video footage revealed the following: At 4:42:03 AM (Timestamp: 2:17:03 AM), S4 (Security Officer), S5 (Security Supervisor) and S13 (Mental Health Worker) enter PES Room 2. At 4:42:13 AM (Timestamp: 2:17:13 AM), S7 (Registered Nurse [RN]), enters Room 2. At 4:42:20 AM (Timestamp: 2:17:20 AM), P1 walks towards S13 and swings (his/her) right fist towards S13 and appears to strike him/her on the chin. S4, S5, and S13 grab P1, and bring him/her face down to the floor. The patient remains face down and is observed to be kicking his/her legs. S13 is observed to be holding P1 beside the left side of the patient’s head; S5 is observed to be kneeling with his/her right knee placed in the center of P1’s back; and S4 is kneeling beside the patient’s right shoulder. At 4:43:10 AM (Timestamp: 2:18:10 AM), S4, S5, and S13 continue to restrain P1 face down to the floor. S4 punches the patient four times with his/her closed fist, striking the patient each time in the right side of the head. An antenna was observed in S4’s right hand while [he/she] punched P1. After the fourth strike to the patient’s head, a walkie-talkie radio was thrown from S4’s right hand onto the patient’s bed. P1 continued to kick his/her legs while still being restrained by S4, S5, and S13. S7 appeared to administer an IM (intra-muscular) medication into the patient’s gluteal muscle, then moved next to the patient’s bed. At 4:43:54 AM (Timestamp: 2:18:54 AM), P 1 stopped kicking his/her legs. S4, S5, and S13 continued to hold the patient while he/she remained face down on the floor. S7 does not interact with or assess P1, who was not observed to be moving. At 4:44:17 AM (Timestamp: 2:19:17 AM), P1 kicked his/her legs then became motionless. S4, S5, and S13 continued to hold the patient face down on the floor. S7 was not observed to look towards the patient and began to check the restraints secured to the bed. At 4:45:22 AM (Timestamp: 2:20:22 AM), S4, S5, and S13 pick up P1’s limp body and place the patient face down towards the foot of the bed. S7 was not observed to assess P1, who remained motionless. At 4:45:53 AM (Timestamp: 2:20:53 AM), P1 is rotated towards the head of the bed then turned onto his/her back. P1 remains motionless. At 4:46 AM (Timestamp: 2:21 AM), S7 performs a sternal rub on P1, the patient did not move. S7 repeatedly touches P1’s face and the patient remained motionless. S7 places his/her hands on P1’s chest and performs five chest compressions. S7 was not observed to check for the patient’s pulse. At 4:46:32 AM (Timestamp: 2:21:32 AM), P1 begins convulsing, as if he/she was having a seizure. P1 is turned onto his/her right side. S7 observed to be rubbing the patient’s back. P1 continues convulsing. At 4:50:58 AM (Timestamp: 2:25:58 AM), P1 stops convulsing and observed to be moving. S7 removes P1’s shirt. The patient is turned onto his/her back. Facility staff begin to place restraints on the patient’s ankle and wrists. S7 is observed to be wiping P1’s face. At 4:52:57 AM (Timestamp: 2:27:57 AM), S7 climbed on top of P1 and lays across the patient’s upper legs while staff placed the patient’s left ankle, left wrist, and right wrist into restraints. S7 then climbs off of P1. At 4:53:20 AM (Timestamp: 2:28:20 AM), S7 walks around P1’s bed and appears to check the restraints. All staff members except S13 exit Room 2. S13 is sitting in a chair away from the side of the patient’s bed while P1 remained in four-point restraints. P1 was observed to be moving. Upon interview with S7 on 07/24/24 at 2:51 PM, it was confirmed that he/she was the nurse that cared for P1 during the incident on 07/18/24. When asked at what time he/she realized P1 was unresponsive, S7 stated, “I administered the medication to the patient and immediately checked the restraints on the bed. After that, I noticed the patient was not moving and told them (S4, S5, and S13) to put the patient on the bed. I checked the patient and (he/she) wasn’t breathing. I panicked. I’ve never had a patient have a seizure before. The patient was combative and tried to bite me when (he/she) came out of the seizure, and we put (him/her) in restraints. I know I messed up.” On 07/23/24 at 12:25 PM, S3 confirmed that S7 did not respond to signs of patient distress or assess the patient when he/she was motionless on the floor after being placed in a physical hold by staff.”

“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: 48414 Based on the review of one of one medical record Patient (P)1, review of facility documents, and staff interview, it was determined the facility failed to ensure all incidents of alleged abuse are investigated. Findings include: Facility policy titled, “Incident Reports” reviewed 12/2023, states, “Policy: Any unusual patient/visitor/ volunteer or student incident (i.e., injury ...) must be reported on the form entitled “Hospital Incident Report”. ...Procedure: A. Patient/Visitor Incident 1. A hospital incident report should be completed immediately following an incident; the employee involved in or observing the incident should complete the appropriate section of the report. 2. If the incident involves an injury to an inpatient, nursing personnel should arrange for the house/resident physician to examine the patient and should notify the attending physician. The house/resident physician should document physical findings in the progress notes of the medical record. ... 6. The completed incident report should be forwarded to the Risk Management within 24 hours of the incident for investigation purposes. ...”. Facility policy titled, “Implementation of Patient Rights” reviewed 12/2023, states, “ ...Internal Abuse/Neglect -To the best of its ability, the hospital will protect patients from real/perceived abuse/neglect/exploitation from anyone, including staff, students, volunteers, other patients, visitors, or other family members. -All allegations, observations or suspected cases of abuse, neglect, or exploitation that occur in the organization are investigated by the organization. ...”. On 5/21/24 at 10:45 AM, medical record review was conducted with Staff (S)5 (Director of Psychiatry, Emergency Department). P1’s medical record revealed, on 4/5/24 at 11:01 AM, that P1 presented to the main ED with a complaint of a fall. P1 had a medical history of seizures, depression, down’s syndrome, Chronic Obstructive Pulmonary Disease, and hyperthyroidism. The ED RN (Registered Nurse) Note on 4/5/24 at 11:01 AM, stated, “Chief Complaint Quote: Pt [patient] presents to the ED from [group home] via EMS [Emergency Medical Services] for evaluation of trip and fall. A hematoma is noted on the right side of forehead. ...”. On 4/5/24 at 1:00 PM, the RN Primary Assessment, stated, “ ...INTEGUMENTARY- Systems: ...Wound Type #1 hematoma Would Location #1 forehead Wound Laterality #1 right Wound Appearance #1 clean/dry ...”. The CT Scan Results from 4/5/24 at 12:48 PM, stated, “ ...Right front scalp soft tissue swelling and hematoma. ...”. P1 was discharged on 4/5/24 at 2:55 PM. On 4/11/24 at 10:47 PM, P1 presented to the Psychiatric ED, with a chief complaint of suicidal. P1 was transferred to the main ED on 4/11/24 at 11:36 PM for medical clearance. The Nursing Note from 4/11/24 at 10:47 PM, stated, “ ...Pt was noted with swelling on right side of [his/her] forehead, bruising in various stages of healing around right eye and bruises on right thigh. ... [group home employees name] reported the injuries on pt’s face and right thigh are from pt falling at the group home the previous week. ...” P1 was admitted to 6 South (Medical Unit) on 4/12/24 at 6:50 PM. The History and Physical from 4/12/24 at 9:27 PM, stated, “ ...History of Present Illness ...patient had a fall a few days ago and now has a hematoma on her right scalp ....”. On 4/18/24 at 4:55 PM, P1 was transferred and admitted to the psychiatric campus to an involuntary unit. The Psychiatric Evaluation from 4/19/24 at 3:56 PM, stated, “ ...History Present Illness Patient is a [age] [male/female] with a past psychiatric history of autism spectrum disorder, intellectual developmental delay and schizoaffective disorder bipolar type ...It was noted that the patient had a hematoma on the right-side face from a fall a few days ago. ...The patient states that [he/she] fell before coming to the hospital. [He/she refuses to answer any questions about the fall. [He/she makes [his/her] needs known by stating [he/she] wants water or needs to go to the bathroom. The Nursing Note from 5/1/24 at 12:30 PM, stated, “ ... Patient dishcharge [sic] to group home staff at 12:30 pm. During discharge, group home staff reported new bruises on [his/her] left orbital area that was not there when [he/she] came in. this writer also noted old bruises on [his/her] left orbital on upper eye lid. Staff ask patient how it happened and Patient reported “Amber” hit [him/her] when asked for help. No incident documented and there is no staff working here in D unit name Amber. Incident was notified to S6 (Nurse Manager), S9 (attending doctor), and S10 (Advanced Practice Nurse). ...”. At 11:16 AM, S3 (Quality and Patient Safety Manager), confirmed in front of S2 (Vice President of Behavioral Health), that there were no records on file of an incident report for P1. At 1:25 PM, upon interview S6 confirmed he/she was notified by S8 (RN) of the allegation of abuse made by P1. S6 stated, “I saw [P1] upon arrival to the unit and the days leading to [P1’s] discharge.” S6 indicated P1 had bruising on his/her forehead and periorbital area from the fall before admission and that it was spreading from her forehead as “expected stages of healing.” S6 stated there was no staff member named “Amber” on the unit, and P1 had not sustained any injury or fall during admission. S6 indicated since the group home staff had not visited P1 during his/her admission, the bruising may not look like what they expected it to look like. S6 indicated once he/she was made aware of the abuse allegation and alleged new bruising, he/she called and informed P1’s group home that the bruising around the eye was from P1’s previous fall and it was healing. S6 indicated the group home had no further questions. S6 stated, this conversation was not documented. When questioned, S6 confirmed he/she had not seen P1 for a couple of days prior to discharge. S6 confirmed a incident report was not completed. At 1:57 PM, S6 confirmed P1’s medical record lacked evidence of a physical examination, conducted by a physician, after P1 reported the alleged assault to S8.”