Rochester General Hospital

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 48506 Based on policy review, observation, and interview, the hospital failed to ensure all staff utilize personal protective equipment (PPE), perform hand hygiene, and carry out daily cleaning of isolation rooms according to recognized standards of practice. Reference: 482.42(a)(3): Infection Control, Surveillance, Prevention”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 48506 Based on policy review, observation, and interview, the hospital failed to ensure all staff utilize personal protective equipment (PPE), perform hand hygiene, and carry out daily cleaning of isolation rooms according to recognized standards of practice. Findings include: Review of the policy “Infection Prevention- Hand Hygiene,” dated 01/2025, revealed it is expected that all staff will clean hands as they enter and leave a patient’s room, even if nothing was touched while in the room. Review of the policy “Infection Prevention- Standard precautions,” dated 02/2025, revealed standard precautions will be used by all persons having contact with or providing care to a patient in any area of the health system, regardless of the patient’s diagnosis or presumed infection status. Standard Precaution components include hand hygiene; PPE such as gloves, gowns, aprons, masks, eye protection, and resuscitation devices. PPE should not be worn in the hallways, unless staff is following standard precautions due to a perceived risk of exposure or if they must physically assist a patient who has a multidrug resistant organism. Gloves must be changed and hand hygiene performed between patients. Remove the gown and perform hand hygiene before leaving the patient’s environment. Review of the policy “Isolation Patient Room Discharge and Terminal Cleaning,” dated 10/2024, revealed whenever it’s possible that you’ll have contact with infectious material, body fluids, or hazardous chemicals, use appropriate PPE. No matter what type of cleaning you’re doing, wear gloves when performing any cleaning procedures, and change your gloves frequently during the day. Gloves must be changed after each room and should also be changed if the integrity of the glove becomes torn or compromised. After removing gloves, clean your hands. When possible, you should clean isolation patient rooms last because isolation rooms may require special PPE, and it is easiest to handle these rooms after you’ve cleaned all other patient rooms. Minimal contact isolation PPE requirements include gloves and gown. “Caution, Wet Floor” signs should only be in place long enough for the floor to dry. Once you put the right PPE on for the job, position your cart near the doorway so you can reach supplies without having to leave the room once you start cleaning. Before cleaning the room, remove trash and anything that is contaminated. For a terminal clean, if a room has curtains, they must be removed to be cleaned and replaced with clean curtains after the room is disinfected. Clean the isolation room with a five-zone system. One cloth is needed to clean each zone. You may end up using more than one cloth per zone, but you’ll always need five cloths at a minimum. Zone one is the entire bed including the footboard, headboard, mattress, and the frame. Zone two is patient contact items including over-bed table, bedside table, telephone and cord, nurse’s call button and other instruments attached to the wall, including cords, and the tv remote and cord. Zone three contains ledges, edges, trash cans, and furniture. Zone four contains the sink and shower in the restroom. Zone five contains the toilet flush valve, toilet bowl, and the outside of the toilet seat. Once the wet floor signs are placed, all isolation rooms must be mopped with a disinfectant solution. Start mopping at the back of the room and work toward the door, mopping under and behind furniture and replacing furniture to its standard room set-up placement. After cleaning the five zones, make sure the room is ready for the next patient. The room should look like it’s been prepared with care. At the end of the cleaning procedures, use one additional cleaning cloth to disinfect equipment that was brought into the room period for protective isolations, you will have also disinfected equipment before entering the room put all the disinfected equipment back on your cart. Remove any PPE using the inside out method to avoid touching contaminated surfaces and dispose of it all in the plastic trash liner. Tie all liners individually for proper disposal. Perform hand hygiene and proceed to the next room. Observation on 12/09/25 at 10:59 AM to 11:14 AM on the Medical Intensive Care Unit revealed Staff (G), Housekeeper, who was cleaning room #527 (a contact plus isolation room). Staff (G) parked the cleaning cart and garbage bin in front of the doorway to room #527. Staff (G) performed hand hygiene and gloves were applied. With gloved hands, Staff (G) used the broom and dustpan from the cart to quickly sweep the area in the hallway in front of doorway. Staff (G) returned the broom/dustpan back to the cleaning cart and adjusted their hair away from their face with the same gloves on. Staff (G) put a gown on, repositioned the cleaning cart, and removed the garbage bag from the cleaning cart. Staff (G) walked into room #527, removed the garbage bag from the trash can, placed the new garbage bag in, exited into the hallway, and put the full garbage bag into the garbage bin. Staff (G) returned to room #527 to change the bathroom garbage, exited the room, and put the garbage bag into the garbage bin. Staff (G) touched the cleaning cart to obtain a cloth soaked in Oxycide (disinfectant) but did not change their gloves prior to touching the cleaning cart. Staff (G) walked back into room #527 with the cleaning cloth soaked in Oxycide and wiped down the rails of the bed. Staff (G) walked into the hallway, put the cleaning rag into the soiled linen bag in the cleaning cart, and obtained a mop head soaked in oxycide. Staff (G) removed their gown, but did not remove their gloves, walked down the hallway, picked up a “wet floor” sign, and placed the sign in front of room #527. Staff (G) removed their gloves and reapplied a new set of gloves without performing hand hygiene and putting on another gown. Staff (G) attached the mop pad to the mop, walked into room #527 and mopped the floor. Staff (G) walked to the cleaning cart, detached mop pad from pole, and placed it in the dirty linen bag on the cart. Staff (G) gathered supplies from the cart and touched hair with gloves on. Staff (G) removed their gown, placed the mop handle back on the cart, removed the boom and dustpan, and swept the hallway in front of the room. The dustpan was emptied into the garbage bin and Staff (G) removed their gloves and performed hand hygiene. Staff (G) did not disinfect the door handles. Interview on 12/09/25 at 10:59 AM to 11:14 AM with by Staff (E), Environmental Services Day Director, and Staff (M), Environmental Service Supervisor, verified that Staff (G), Housekeeper, should have removed their gown and gloves when exiting the room, and reapply gloves/gown when re-entering the room. Gloves should not have been worn when touching Staff (G) ’ s hair and door handles should have been disinfected. Additionally, the isolation room was cleaned out of order. Staff (E) stated all non-isolation rooms should have been cleaned prior to the isolation rooms, and Staff (G) did not do this.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49205 Based on policy review, document review, medical record review, video review, and interviews, the hospital failed to protect and promote the rights of all patients. Specifically, clinical and security staff failed to identify Patient #1 was at risk for elopement/absconding and potential self-harm and/or harm to others and did not implement safety measures to monitor Patient #1. Reference: 482.13(c)(2): The patient has the right to receive care in a safe setting.”

“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: 49205 Based on policy review, document review, medical record review, video review, and interviews, the hospital failed to protect and promote the rights of all patients and ensure care was received in a safe setting. Specifically, clinical and security staff failed to identify Patient #1 was at risk for elopement/absconding and potential self-harm and/or harm to others; the registered nurse did not triage and/or conduct a suicide assessment for Patient #1, police refused to stay and monitor Patient #1; and measures to safely monitor Patient #1 were not implemented. The hospital failed to implement constant or close observation measures despite the patient’s history of violence, suicidal/homicidal risk, and being placed in a yellow gown (indicating elopement risk); the noncompliance resulted in Patient #1 eloping/absconding from the Emergency Department while still medically and psychiatrically uncleared, necessitating a hospital lockdown and a subsequent police search, which directly jeopardized the patient’s safety and the security of the hospital environment. Findings include: Review of the policy “Identification, Assessment and Planning Care for Individuals at Risk for Suicide,” revised February 2024, revealed patients at risk of suicide include patients who are diagnosed with a primary or secondary emotional or behavioral illness; patients admitted after a suicide attempt; patients admitted with an injury that appears to be self-inflicted or unexplained origin; patients expressing or demonstrating symptoms of severe depression or mania; and patients at identified at risk after completion of suicide screen. The ultimate goal is to ensure the safety of patients in the hospital. Patients who present for medical stabilization after a suicide attempt or express intent to harm themselves may need to be assessed by psychiatry or transferred to another facility for psychiatric evaluation. Patients who present at risk of harming themselves are placed in a safe environment with continuous observation, until a physician deems the patient is no longer at risk. All patients 13 years old and older entering the ED who present at risk for intentional harm to themselves or others, will receive an age-appropriate psycho-behavioral and suicide screening. The ED provider will assess the patient in more detail and determine any necessary interventions needed to mitigate any potential patient self-harm risks and place an order for the appropriate level of monitoring. All patients and circumstances are unique. In the event there are individualized patient care concerns, a care conference should be held with the care team to discuss the situation and plan for the patient. (No policy was found specifically addressing criteria for a risk assessment for violence and/or homicidal). Review of the policy “Security Risk Observation Policy for Patient Care,” effective May 2024, revealed the purpose of this policy is to provide the appropriate observation and safety measures and to ensure a safe environment to all patients, staff and visitors. Clinical assessments for potential disruptive behaviors will be made by the physician or nurse, who may request assistance from security personnel when necessary. For patients who are under constant observation in the ED, the registered nurse (RN) will evaluate each patient during the triage assessment for any potential security risks. Security will be notified and be present to search for harmful objects, as well as to provide aid in observation until released by the RN in the ED. Review of the policy “Emergency Medicine Unit Structure Standard,” last revised August 2024, revealed the triage/nurse inputs the patient’s chief complaint, documents significant physical, relevant recent medical and surgical, psychological history in the triage note related to the chief complaint. The triage/nurse will complete relevant/required screening tools to facilitate rapid staff awareness and expedite patient care. The triage/nurse determines the priority for treatment based upon the initial assessment and classifies the patient per the “Emergency Severity Index-ESI.” The triage/nurse communicates priority needs of Category ESI 1 and 2 to the Clinical Nurse Leader (CNL), charge nurse and/or provider. The triage/nurse will assign in collaboration with the CNL/charge nurse the patient to an open room and/or send the patient with a nurse or patient care technician (PCT) to the clinical area for placement. The role of Emergency Medical Services (EMS) triage in the adult ED is to collaborate with ED provider team to flow psychiatric patients to the Crisis Intervention Unit (CIU) in an expeditious manner while maintaining client and staff safety. Triage in conjunction with CNL or charge nurse initiates crisis intervention when warranted. The hospital will provide a safe and secure environment for all patients presenting with psychiatric emergencies. Any patient expressing lethality issues or in acute psychiatric distress are to be immediately escorted to an appropriate bed either in the psychiatric area or CIU, or to a medical bed. The ED shall take custody of these patients from the moment of contact by requiring a 1:1 observation by a staff member or placed on close observation as necessary. This may include security, a technician, or nursing staff. The ED provider evaluates all psychiatric or behavioral health patients in order to medically screen and medically clear the patient prior to the patient being seen by a psychiatrist or their designee. (No policy was found specifically addressing criteria for a risk assessment for absconding/elopement). Review of the policy “Comprehensive Emergency Management Plan Annex 8 Missing Patient Plan,” reviewed January 2025, revealed patient elopement can be defined as the unauthorized absence of an admitted patient from the boundaries of the care unit, including the Emergency Center, without staff knowledge. An appropriate plan includes mitigation activities to reduce the potential for elopement and actions to improve the prospect for a quick resolution to a missing patient incident. Criteria for patients with elopement potential include those with a previous history of elopement, attempted elopement, wandering, patients who are resistant to admission, or those that develop wandering tendencies. Once a patient has been identified as being high risk for elopement, appropriate interventions will be implemented. In the ED, all attempts are made to place them in a room that they can’t leave without being seen. If additional supervision is necessary, they are put on 1:1 for safety. Review of the policy “Incarcerated Patient,” revised May 2025, revealed hospital patients, who by nature of their incarceration in any jail or prison, are considered potentially dangerous will be accompanied by law enforcement officers at all times during their stay. The law enforcement officer is expected to sit inside the patient’s room, except when patient is in isolation, in the operating room or during the birth of an infant. Should the law enforcement officer need a personal relief break, the officer must obtain their own coverage. No Rochester Regional Health personnel are to ever replace a law enforcement officer. Review of the emergency department medical record for Patient #1 revealed the following: On 09/15/25: -The “Emergency Medical Service-EMS,” document revealed at 10:30 PM, EMS arrived at a local police department to find Patient #1 in a holding cell. Police requested a 9.41 mental health transport ((New York State Mental Hygiene Law that allows police/peace officers to take into custody a person who appears to be mentally ill and likely to cause serious harm to themselves or others) for evaluation. The police officer advised EMS that Patient #1 had over 20 pending charges and was acting “bizarre” earlier in the day. This “bizarre” behavior resulted in police having to tase Patient #1 multiple times. The only complaint that Patient #1 reported to EMS was pain and swelling to the right hand. Police officers reported that the injury to the right hand could have been caused by Patient #1 banging their hand on glass windows (in the jail cell). At 10:43 PM, Patient #1 was transported to the hospital with their left hand secured to the gurney via handcuffs. The EMS examination revealed Patient #1 was alert, with no neurological deficits noted. A review of body systems were within expected limits, except for swelling and pain noted to the right hand. At 10:45 PM, EMS documented Patient #1’s vital signs as a temperature of 98.1 degrees (normal range 96-99 degrees) Fahrenheit, a heart rate of 66 (normal range 60-100) beats per minute, respirations of 16 (normal range 12-20) breaths per minute, a blood pressure of 152/96 (normal range 90-140/60-90) millimeters of mercury, an oxygen saturation of 99 (normal range 93-100) percent, and a pain level of 10/10 (0-no pain, 10-worst pain ever). At 11:01 PM, EMS arrived at hospital with Patient #1. Patient #1 was registered and triaged. At 11:15 PM, Patient #1 was moved to room #18 by EMS, but there was no bed in the room. At 11:30 PM, a bed arrived in the room. The handcuffs were removed by police. Patient #1 moved over to the hospital bed and patient care was transferred from EMS to hospital staff. -At 10:53 PM, the “Mental Health Transport 9.41,” paperwork documented by police revealed at 09:00 PM, police officers arrived at the residence of Patient #1 for a follow-up visit. Patient #1 became manic and would not listen to police officers’ commands. Patient #1 grabbed a large knife in their vehicle, threatened the police officers, before running through an apartment complex, and into the woods. Once police officers located Patient #1, they would not follow verbal commands and kept yelling for police officers to “shoot” them. Patient #1 was then tased and taken into police custody. Patient #1 was manic the entire time and was not making any sense. Patient #1 placed themselves in a dangerous situation, was unable to care for self, made verbal and physical threats, attempted to hurt/kill self/others, and had a weapon (butcher knife). -At 11:05 PM, Patient #1 arrived in the ED via ambulance and police escort for a 9.41 mental hygiene law evaluation and complaints of right-hand pain. -At 11:06 PM, Staff (M), RN documented a triage note indicating EMS reported Patient #1 was placed under a mental health evaluation by police for acting strange and punching the glass in their cell with right fist. EMS reported Patient #1 would remain in police custody. -At 11:08 PM, vital signs were a temperature of 98.1 degrees (normal range 96-99 degrees) Fahrenheit, heart rate of 66 (normal range 60-100) beats per minute, respirations of 16 (normal range 12-20) breaths per minute, blood pressure of 152/96 (normal range 90-140/60-90) millimeters of mercury an oxygen saturation of 99 (normal range 93-100) percent, and a pain score of 10 (scale 0-10, 0= no pain-10= worst pain ever). (The vital signs documented are the same vital signs taken by EMS at 10:45 PM). -At 11:09 PM, triage documentation by Staff (M), RN, revealed Patient #1’s airway, breathing, circulation and disability were all “within defined limits (met all established criteria for what is considered normal or acceptable).” The triage suicide screen (assess the severity of suicide risk) was performed. Patient #1 denied feeling down, depressed, or hopeless over the past two weeks. Patient #1 denied having thoughts of killing themselves and harming others in the last two weeks. Patient #1 denied ever attempted to kill themselves. An emergency severity index (assesses patient acuity, needed resources, and level of urgency) score of 2 (high-risk). (Staff (M) verified that they did not interview Patient #1 for triage or the suicide screening stating information was received from EMS). -At 11:16 PM, Patient #1 was moved to ED Room #A17 located across the hallway, in direct view of the nurse’s station. -At 11:19 PM, Staff (P), Secretary documented “please contact [local police department] police sergeant prior to release.” -At 11:20 PM, Staff (N), Physician, documented a medical screening examination that indicated Patient #1 presented to the ED under arrest by police. Patient #1 was a former police officer who had prepared a list of individuals they intended to kill. Patient had confronted someone and was subsequently arrested. Patient #1 was brought to the ED after they reportedly voiced homicidal and suicidal thoughts. It was also reported that Patient #1 had been hitting their hand against glass. Patient #1 reported they did not know why they were arrested. Patient #1 was not hallucinating, was not delusional, and did not appear to be intoxicated. Patient #1 denied having suicidal or homicidal thoughts. Patient #1 was not psychotic, manic, delusional, or responding to internal stimuli (experiences, thoughts, and physiological changes that originate within an individual). There were abrasions noted on the head of Patient #1, which Patient #1 was unaware of how they occurred. Patient #1’s only complaint was pain to the right hand. -At 11:26 PM, Staff (N), Physician, ordered laboratory tests and imaging (procedure that creates detailed images of internal structures in the body) of the right hand and head. (At approximately 11:45 PM, police leave the hospital per security report). -At 11:58 PM, Staff (O), RN, documented a psychosocial assessment that revealed Patient #1 appeared disheveled, fearful, and exhibiting anxious behaviors. Patient #1 was alert and oriented to person, place, time, and their affect (immediate expression of emotion) was appropriate for the circumstances. However, Patient #1 was also restless and had a rapid speech pattern. On 09/16/25: -At 12:05 AM, Staff (O), RN, documented Patient #1 was calm and cooperative. Patient #1 was resting in bed with monitoring ongoing. -At 12:33 AM, the urine drug and cannabinoid screens resulted negative. -At 01:08 AM, Staff (O), RN, documented Patient #1 was not in their room. Patient #1 was observed by nearby staff following the emergency exit signs. There was an ongoing search for Patient #1 with security. (There is no documentation of when police left the hospital, no interventions were ordered/implemented to monitor Patient #1 due to the absconding risk and/or risk for harm to self or others). Review of the video surveillance, dated 09/15/25 to 09/16/25, revealed the following: -At 11:03:59 PM, Patient #1 was wheeled into the ED through the EMS entrance on a stretcher, with their left wrist handcuffed to the side rail of the stretcher with two EMS providers, five security officers, and one police officer, to the triage area. -From 12:44:16 AM to 12:47:22, Patient #1 was pacing in the hallway, on a cell phone, in a yellow gown with a blanket in his arms across from the nurse’s station. -At 12:47:22 AM, Patient #1 hung up the phone and started walking down the hallway. There were no staff in the hallway. Two staff members in the nurse’s station across from Patient #1’s room, both had their backs facing Patient #1’s room as Patient #1 walked down the hallway. -From 12:47:37 AM to 12:51:13, Patient #1 leaves the area of their room and was seen walking down hallways until they opened an exterior door of the hospital next to a parking garage in their yellow gown and a blanket draped over their shoulders and exited the hospital, walking down the sidewalk, and exiting the parking garage. Review of the emergency department medical record for Patient #1 dated 09/16/25 (visit #2-returned to the ED after absconding) revealed at 01:28 PM, Patient #1 arrived at the ED in the custody of police officers for a mental health examination. A suicide assessment indicated Patient #1 was at high risk, and a psychiatric consult was ordered and performed at 02:47 PM. Patient #1 was placed on 9.37 mental hygiene law (involuntary inpatient admission of an individual at substantial risk of harm to themselves of others) status and was transferred to an outside, secure inpatient psychiatric facility at 08:30 PM. Police stayed with Patient #1 the entire time. Review of the “Department of Safety and Security Report,” by Staff (AA), Security Officer, dated 09/15/25 at 11:35 PM, revealed at around 11:00 PM, security was made aware that Patient #1, a mental health transport, was arriving with a police officer. At about 11:06 PM security met Patient #1 at the emergency medical services triage area. Patient #1 was handcuffed to the stretcher and was cooperative with medical staff and security. Patient #1 was assigned to Room #17 and the handcuffs were removed. Patient #1 was changed into a yellow gown. Staff (AA) asked the police officer if they were going to stay with Patient #1 as there were 15 pending charges stemming from the encounter that led to the mental health transport. The police officer stated that they would not be staying due to not having enough police officers that night. Extra rounds were conducted to check on Patient #1 periodically. The last rounding was on 09/16/25 at 12:40 AM. Review of the “Department of Safety and Security Control Access Lockdown Report,” by Staff (W), Security Supervisor, dated 09/16/25 at 02:41 AM, revealed on 09/15/25 at 11:06 PM, Patient #1 arrived at the ED escorted by police officers. At 11:19 PM, Patient #1 was triaged and changed into a yellow gown. Patient #1 was placed in room #17. At 11:35 PM Staff (W) and Staff (Z), Security Officers confirmed the police officer would not be staying with Patient #1. At 11:45 PM, the police officer left. On 09/16/25 at 12:37 AM, a medical incident occurred in Room #18. At 12:40 AM, Staff (AA), Security Officer saw Patient #1 standing in the doorway of room #17 requesting to use the bathroom. Staff (AA) escorted Patient #1 back to room #17 after they used the bathroom. At about 12:46 AM, staff notified security that Patient #1 was missing from their room. At 12:51 AM, video review confirmed Patient #1 exited the building through a door near the parking garage. At 01:20 AM, police were notified and arrived at the hospital at 01:45 AM. At 02:15 AM, Staff (W) ordered a hospital lockdown. At 03:41 AM, the Incident Command Center was formally established to coordinate the response and search operations. Review of the “Department of Safety and Security Missing Patient/Elopement Attempt Report,” by Staff (AA), Security Officer, dated 09/16/25 at 01:05 AM, revealed Patient #1 was a 911 contact (contact the police department when the patient is discharged from the hospital) and was not in their assigned room. Security dispatch was immediately notified and started a camera/video review to locate Patient #1’s last known location. Security started searching the immediate area and was unable to locate Patient #1. Police officers arrived to assist in the search for Patient #1 as they had pending charges against Patient #1 and their recent conduct that made them a danger to society. The building was put on lockdown. After video review, it was determined that Patient #1 was last seen heading towards the parking garage at 12:51 AM in their yellow gown and a blanket. Interview on 09/22/25 at 01:00 PM with Staff (N), Physician, revealed that on 09/15/25, Patient #1 was under arrest for threatening police officers and family. Patient #1 hurt their right hand and needed to be evaluated. The police officers who brought Patient #1 into the hospital did not stay with them and they told staff that he was a 911 contact. Usually, the police officers stay with patients who are a high risk. Constant observation was not ordered as Patient #1 denied homicidal and suicidal ideations and was calm and cooperative. After a long discussion with the psychiatric assessment officer who was aware that Patient #1 was threatening others, it was mutually decided that Patient #1 did not need psychiatric care (no evidence of conversation found in medical record). Patient #1 absconded from the ED while Staff (N) was caring for a critical patient in the room next to Patient #1. Patient #1 was in a yellow hospital gown indicating that they were an elopement risk. Interview on 09/22/25 at 03:40 PM with Staff (M), Registered Nurse, revealed that they were the triage nurse for Patient #1 on 09/15/25. Patient #1 arrived at the ED handcuffed to the stretcher with emergency medical services (EMS) and a police officer due to a right-hand injury from punching a wall while in jail. All of the information for the triage assessment was from the EMS team. Staff (M) never spoke directly with Patient #1. At the time of triage, the 9.41 paperwork was not available, and Staff (M) did not speak to the police officer. The homicidal and suicidal screen were completed based on information from the EMS team. Security took Patient #1 into the bathroom and did a weapon search and had them change into a yellow gown. Patient #1 was put into Room #17 which was directly across from the nurse’s station. Staff (M) thought that the police officer was staying with Patient #1 since they were in custody. Handoff was given to Staff (O), Registered Nurse, who assumed care of Patient #1. When the 9.41 paperwork was available Staff (M) scanned it into Patient #1’s chart. Interview on 09/22/25 at 04:00 PM with Staff (W), Security Supervisor, revealed that the police officer called the hospital before Patient #1 arrived and requested to meet them upon their arrival. The police officer alerted them that Patient #1 was tased after threatening police officers with a knife and had many other charges pending. Staff (W) had asked the police officer if they were staying with Patient #1 and were told that they were short staffed and could not stay, but to call when Patient #1 was discharged so they could pick them up. Security Officers then escorted Patient #1 to the rest room for Patient #1 to change into a yellow gown and collect personal items. Patients who are in yellow gowns are at risk of wandering or elopement, such as patients with dementia or psychiatric/behavioral problems. Security staff do not sit with patients who are in police custody and the police officer is to stay with the patient. Staff (W) knew Patient #1 was not able to leave the facility as they had not been medically cleared and were there on a 9.41. 911 was called to alert police Patient #1 absconded. A lockdown of the hospital was called. Video footage revealed Patient #1 left the building out of an exit door that led to a parking garage. Interview on 09/22/25 at 04:26 PM with Staff (A), Senior Director Regulatory Compliance, revealed that all patients of the ED receive a suicidal and homicidal ideation screen. It is a requirement that the RN ask the patient the screening questions directly. If a patient is on a 9.41 and not medically cleared, they cannot leave the hospital. There is not a policy for when a police officer leaves a patient in the ED alone without anyone watching them. Interview on 09/23/25 at 08:00 AM with Staff (O), Registered Nurse, revealed that they were the nurse assigned to Patient #1 on 09/15/25. Patient #1 was brought in by the police. Patient #1 was in police custody due to being arrested for warrants, threatening police with a knife, and being tased. While in police custody Patient #1 punched the wall in the jail cell and injured their right hand. Security was also with Patient #1 and assisted with a weapon search, changing into a yellow gown, and locking up their belongings. Even though Patient #1 was in police custody, the police officer left Patient #1 alone. Security was not assigned to sit with Patient #1 when the police officer left. If a police officer needs to leave, security would need to delegate a staff member to stay with the patient and collaborate with the charge nurse. Staff (O) and security were checking in on Patient #1 frequently. The patient in the room next to Patient #1’s had an emergency. That is when Patient #1 was found to not be in their room. Staff (O) spoke to security, and they immediately began to search for Patient #1. Interview on 09/23/25 at 09:30 AM with Staff (X), Security Officer, revealed they were working when Patient #1 arrived at the ED on 09/15/25. The police officer called and alerted security that Patient #1 was coming to the ED for evaluation and wanted Staff (W), Security Supervisor, to meet them on arrival. Staff (X) was present when Patient #1 arrived at the ED in handcuffs attached to the gurney. The police officer told security that Patient #1 had 15 charges against them. Patient #1 was calm and cooperative, triaged, searched for weapons, and changed into a yellow gown. Patient #1 was then put into Room #17. The police officer told security that they were not staying with Patient #1 due to being short-staffed and to call when Patient #1 was discharged. Staff (W) told the police officer that they did not have anyone to sit with Patient #1. If a patient is brought into the ED in police custody, they are to have a police officer always stay with them. If a patient goes into the CIU (crisis intervention unit- locked psychiatric area of the emergency department) the police officer can leave the premises. The CIU was full at the time. Patient #1 was brought into the medical ED. Nursing staff called security once when they realized that Patient #1 was missing. Interview on 09/23/25 at 010:00 AM with Staff (Y), Nurse Supervisor, revealed that they were not told about Patient #1 until 09/16/25 at 02:29 AM when the ED was going on lockdown. Security should have told them about Patient #1 and how the police were refusing to stay with Patient #1. Staff (Y) would have escalated the situation to the police officer’s supervisor notifying them an officer would have to stay with Patient #1. Interview on 09/23/25 at 01:11 PM with Staff (Z), Security Officer, revealed that Patient #1 came into the ED in police custody. When the police officer said that they could not sit with Patient #1 Staff (Z), told the police officer that they needed to stay with the patient. The police officer refused to stay due to them being short staffed. The police officer told Staff (Z) and Staff (W), Security Supervisor to call when Patient #1 was discharged. Interview on 09/23/25 at 01:30 PM with Staff (AA), Security Officer, revealed that Patient #1 came in on 09/15/25 in police custody handcuffed to the gurney under a 9.41. The police officer requested to speak to Staff (W), Security Supervisor, as they were not able to stay with Patient #1 and wanted the hospital to call when Patient #1 was discharged. If a patient comes into the ED in police custody with charges pending, they must stay with the patient. A few minutes before Patient #1 eloped from the ED, Staff (AA) assisted Patient #1 to the bathroom and then back to Room #17. At the same time there was a critical patient in the room next to Patient #1. Patient #1 noticed this when walking back to their room. Patient #1 eloped shortly after. Interview on 09/23/25 at 04:09 PM with Staff (BB), Clinical Nurse Leader, revealed that they did not know Patient #1 was in the ED until Staff (EE), Charge Nurse made them aware that Patient #1 had absconded. Due to the immediate danger, Staff (BB) decided that the hospital needed to go on lockdown for safety. Interview on 09/23/25 at 05:43 PM with Staff (FF), Psychiatric Assessment Officer, revealed they were alerted by Patient #1’s outpatient treatment team that Patient #1 was coming to the hospital for violent behavior toward police officers. Staff (FF) communicate to Staff (W), Security Supervisor, and Staff (N), Physician that Patient #1 was being brought in on a 9.41 due to pulling a knife on police officers, was suicidal and wanted the police officer to shoot and kill him. After Patient #1 was discharged they would be going to jail. Staff (FF) followed up with Staff (N) later in the shift to see if they wanted a psychiatric workup and Staff (N) revealed that Patient #1 was not medically cleared at that time. Staff (FF) did not document any conversations as no consultation was ordered.”

“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: 49205 Based on policy review, medical record review, video review, and interviews, the hospital failed to ensure the emergency department (ED) staff followed policies and procedures governing the care provided in the ED. Specifically: 1. Clinical staff failed to file an incident report within 24 hours of the adverse elopement event for Patient #1. 2. The Clinical Nurse Leader and Nursing Supervisor were not notified of Patient #1’s elopement (12:51 AM) timely, delaying security measures such as a hospital-wide lockdown (controlled access of all entrances/exits) until 02:15 AM, emergency department diversion (notification to Emergency Medical Services (EMS) to not to bring ED patients to the hospital) until 02:55 AM, and notification to leadership until 03:13 AM for the implementation of the incident command center until 03:41 AM. This noncompliance resulted in a signficant delay in implementing necessary security and emergency protocols, jeopardizing patient safety and hospital operations. Findings #1: Review of the “Event Reporting Policy & Procedure,” effective November 2023, revealed that all employees and staff are responsible for identification and notification of any errors, close calls or other safety events to their supervisor/manager. Errors, close calls, and other safety events are reported in the on-line event reporting system as soon as possible, but ideally no later than 24 hours after event discovery. Review of the emergency department (ED) medical record and surveillance video for Patient #1 revealed on 09/15/25 at 11:05 PM, Patient #1 arrived at the ED via ambulance and police escort for a 9.41 mental hygiene transport (New York State Mental Hygiene Law that allows police/peace officers to take into custody a person who appears to be mentally ill and likely to cause serious harm to themselves or others) evaluation and complaints of right-hand pain. On 09/16/25 at approximately 12:51 AM, Patient #1 absconded/eloped from the hospital. An interview on 09/22/25 at 04:26 PM with Staff (A), Senior Director Regulatory Compliance, revealed that no Safe Connect report (incident report) was filed by staff related to Patient #1’s absconding from the facility. Findings #2: Review of the policy “Emergency Medicine Unit Structure Standard,” last revised August 2024, revealed when a patient is discovered missing, staff must notify the charge nurse and ED attending physician. The charge nurse will inform security and the clinical evaluator, notify the nursing shift supervisor, and enter the information into Safe Connect (incident reporting system). Security will call 911. The clinical evaluator will notify the ED nurse manager and the adult ED medical director. The nursing shift supervisor will notify the administrator on call. If the patient has not been located within four hours, the administrator on call will notify the corporate risk manager and senior leadership, including the chief nursing officer and the president. When the patient is located, the above process should be repeated in reverse order to be sure that all parties are notified. Review of the policy “Comprehensive Emergency Management Plan Annex 8 Missing Patient Plan,” last reviewed January 2025, revealed patient elopement can be defined as the unauthorized absence of an admitted patient from the boundaries of the care unit, including the Emergency Center, without staff knowledge. The staff member who initially becomes aware of the missing patient is responsible for verifying that the patient did not have permission to leave and that staff members are not aware of any other reasons they may be gone. Nursing staff are to search the entire unit thoroughly. The nursing personnel will call security, give a patient description, and when the patient was last seen. Security will begin a search of the facility for the missing patient, issue a “Missing Person Alert” and contact the Administrative Clinical Coordinator, who will contact the Administrator on call. In the event a patient cannot be located, the police department may be notified by security at the discretion of the physician or Director of Nursing. If appropriate, hospital leadership will activate the Incident Command System. If the patient is not located within a reasonable amount of time, the hospital will establish the Hospital Command Center (HCC- an area set up to gather information, direct activities, and provide guidance in an emergency situation) and request appropriate team members to report. Interview on 09/22/25 at 11:00 AM with Staff (A), Senior Regulatory Compliance Officer, revealed the following timeline: On 09/15/25 at 11:05 PM, Patient #1 arrived via ambulance with police. At 11:35 PM, Patient #1 was moved to Room #17 across from the nurse’s station. At 11:45 PM, police leave the hospital. On 09/16/25 at 12:46 AM, security was notified Patient #1 was missing. At 12:51 AM, Patient #1 exited the parking garage. At 01:20 AM, the police are notified. At 01:45 AM, police onsite, assist in searching for Patient #1. At 02:15 AM, security/clinical nurse leader placed the hospital in lockdown (controlled access of all entrances/exits). At 02:29 AM, the charge nurse notified the nursing supervisor. At 02:55 AM, the nursing supervisor called 911 for emergency medical services (EMS) diversion (notification to EMS not to bring ED patients to the hospital). At 02:58 AM, the nursing supervisor contacted the administrator on call. At 03:13 AM, the administrator on call contacted hospital leadership. At 03:41 AM, the Incident Command Center was established, and a media alert was sent. At 04:08 AM, lockdown was ended. At 04:44 AM, diversion was ended. At 07:05 AM, the Incident Command Center was closed. Interview on 09/23/25 at 10:00 AM with Staff (Y), Nurse Supervisor, revealed that they were not told about Patient #1 until 09/16/25 at 02:29 AM when the ED was going on lockdown. (Patient #1 absconded/eloped at approximately 12:51 AM). They got an update from the charge nurse and security as to the events that occurred, and that Patient #1 had absconded. The decision for lockdown was between security and Staff (BB), Clinical Nurse Leader. The decision was made by Staff (Y) to go on diversion. After the hospital was put on diversion, Staff (Y) called Staff (U), Administrator on call. Staff (Y) had never had to put the hospital on diversion before this event and Staff (U) expressed that they would handle making the appropriate individuals aware. Staff (Y) called 911 to make them aware of the diversion. Security should have told them about Patient #1 and how the police were refusing to stay with Patient #1. Staff (Y) would have escalated the situation to the police officer’s supervisor notifying them an officer would have to stay with Patient #1. Interview on 09/23/25 at 04:09 PM with Staff (BB), Clinical Nurse Leader, revealed that they did not know Patient #1 was in the ED until Staff (EE), Charge Nurse made them aware that Patient #1 had absconded. Due to the immediate danger, Staff (BB) decided that the hospital needed to go on lockdown for safety. Staff (Y), Nurse Supervisor, was informed about Patient #1 absconding and the lockdown.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 49205 Based on policy review, medical record review, document review, and interview, in 1 of 15 medical records reviewed (Patient #1), nursing staff failed to adhere to the policies and procedures of the hospital. The facility failed to ensure that a pain reassessment was performed and documented within 60 minutes of receiving an as needed (PRN) pain medication. Findings include: Review of the policy titled “Pain Management Procedure”, dated October 2023, indicated “Complete reassessments will be completed within 60 minutes of administering as needed (PRN) pain medications.” “If pain is present, identify that it is “ongoing” pain and document; Location of pain; Orientation of pain (i.e. left, right, mid); Type of pain (i.e. aching, throbbing, stabbing); Is it acceptable to the patient (yes/no); Interventions used if needed.” Review of the policy titled “RRH Nursing Documentation Guidelines Policy”, dated August 2023, revealed patient pain level and “reassessment/observation” will be documented following PRN pain medication administration. Review on 01/23/25 of the medical record for Patient #1 revealed from 05/11/24 to 05/26/24, for 35 of 87 opportunities nursing staff failed to document a complete pain reassessment within 60 minutes after receiving a PRN dose of pain medication. Interview on 01/24/25 at 11:00 AM with Staff (C), Clinical Nurse Specialist, stated the expectation per policy is that a pain reassessment should be documented within 60 minutes of a patient receiving a PRN pain medication.”

“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: 49203 Based on policy review, document review, interviews, and observations, clinical staff did not verify the policies and procedures governing medical care provided in the emergency service or department are established by and are the continuing responsibility of the medical staff. Specifically, nursing staff failed to properly secure insulin (injectable medication used to maintain blood sugar) per the facility’s policy. Findings include: Review on 10/31/2024 of the policy “Medication Administration,” effective September 2024, indicated “Medications are to be removed from the automated medication dispensing cabinet and administered for one patient at a time. All medications may be retrieved for same time administration. Medications are not to be transported to bedside “in your pocket”. All medications must remain in secure storage until administered to the patient by authorized personnel. The nurse draws up the required dose and returns the insulin vial back to the appropriate drawer in ADC (Automated Dispensing Cabinet). Observation on 10/30/24 at 03:00 PM with Staff (D), Regulatory revealed a multidose insulin vial, admelog (lispro) 100 units/milliliters (fast-acting mealtime medication used to maintain blood sugar) was observed on the A-side nursing station counter, and supervision was alerted. The insulin vial was immediately removed. Staff (D) stated the insulin identified was not stored in accordance with the facility’s policy and procedure. Interview on 10/30/24 at 10:58 AM, with Staff (J), Clinical Pharmacist Specialist stated they work in the emergency department to restock medications in the Omnicell. Staff (J) stated insulin is kept inside the Omnicell and should be removed as needed and immediately returned to the Omnicell. Interview on 10/30/24 at 11:40 AM with Staff (L), Registered Nurse stated insulin is typically removed from the Omnicell and sometimes put back in the Omnicell immediately and sometimes it is not. Interview on 10/30/24 at 2:12 PM with Staff (N), Registered Nurse stated insulin is typically removed from the Omnicell and put back immediately however if the paper is out the vial is taken to the bedside to administer the medication and it is returned to the Omnicell after the medication pass. Interview on 10/31/24 at 11:45AM with Staff (E), Director of Nursing, stated being aware of a multidose insulin vial, admelog (lispro) 100 units/milliliters was observed on 10/30/24 at 03:00 PM on the A-side nursing station counter. Staff (E) verified the emergency department staff were not following the policy “Medication Administration,” that included all medications must not be left at the bedside and must remain in secure storage until administered to the patient by authorized personnel. The nurse draws up the required dose and returns the insulin vial back to the appropriate drawer in ADC (Automated Dispensing Cabinet).”

“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: 32261 Based on medical record review, document review, policy review, and interview, the facility failed to ensure all patients are free from all forms of abuse, neglect, and harassment for 1 of 20 patients (Patient #1). Specifically, facility staff failed to ensure Patient #1 was assessed by a medical provider following their allegation of abuse and the facility staff failed to report Patient #1’s allegation of abuse per facility policy. Findings include: Review of policy “Patient Abuse Policy,” last revised February 2024, revealed “Hospital team members will report suspected instances of physical abuse, mistreatment and neglect of hospital patients in accordance with the Patient Abuse Reporting Law (Public Health Law Section 2803-d). All incidents must be reported immediately to the Department Manager or designee and Administration for appropriate investigation and follow up. For situations involving non-employees, contact Security. Any patient who is suspected of, or who has reported being abused or mistreated will be assessed by a Physician, Resident, or Advanced Practice Provider immediately. Refusals should be documented in the Medical Record. The suspected abuse will be entered in the safety event reporting system. Further investigation and follow-up will be coordinated by the Department Manager and the appropriate administrator for the area. The staff in the Risk Management Department will assist with the investigation and follow-up. RRH (Rochester Regional Health) Clinical and/or Operational leadership will report substantiated incidents to the New York State Department of Health, or licensing entities, when required. A root cause analysis will be conducted on all serious incidents.” Review of policy “Event Reporting Procedure”, last reviewed November 2023, revealed “All employees/staff are responsible for identification and notification of any errors, close calls or other safety events to their supervisor/manager. Errors, close calls, and other safety events are reported in the on-line event reporting system by any staff member as soon as possible, but ideally no later than 24 hours after event discovery. Provider/Nurse Manager/Supervisor will: ensure those involved in the error, close call, or other event are assessed for injury or harm, are safe and that emergent medical care is provided as indicated by the incident; Ensure necessary immediate actions/interventions are taken to prevent additional error/close call. For patient events, notify the attending physician or provider most closely associated with the error/close call; Ensure that appropriate clinically relevant documentation of the incident is entered in the medical record of all patients involved or impacted by the incident. However, do not record in the medical record that a safety event was entered in the event reporting system. Appropriate follow up should focus on the impact of the event and what was done to minimize the likelihood that the incident will reoccur. This should include the following elements: An explanation of the circumstances surrounding the event; An updated assessment of the effects of the incident on the patient; A summary of current patient status including follow up care provided and post incident diagnosis; A chronology of steps taken to investigate the incident that identifies the date(s) and person(s) or committee(s) involved in each review activity; The identification of all findings and conclusions associated with the review of the incident; A summary of all actions taken to correct identified problems, to prevent recurrence of the incident and/or to improve overall patient care. It is the director’s ultimate responsibility to ensure thorough and timely follow up for events in his/her assigned areas”. Review on 08/03/24 of “Mandatory Compliance Education Core Content”, dated 01/2023, revealed the annual education includes a section on reporting incidents. Staff are educated on using the facility’s online event reporting process to report incidents which include but is not limited to alleged assaultive behaviors. Depending on the nature of the event, different degrees of investigation will be conducted. If an error causes serious harm, it may be considered a Serious Safety Event. A Serious Safety Event is thoroughly reviewed to identify the root cause of the error, and to identify actions that impact processes and systems for improvement. The results of Serious Safety Event investigations are reported internally to Quality Committees and Boards, and externally to federal and state regulatory agencies as needed. Safety events should be entered into the online reporting system as soon as possible, but no later than 24 hours after event discovery. Review on 07/31/24 of Patient #1’s medical record, dated 07/10/24 to present, revealed: -On 07/21/24 at 02:28 AM, Staff (H), Registered Nurse, note revealed “interpreters from the contracted interpretation services set up to come back again tomorrow morning from 08:00 AM to 12:00 PM. Patient #1 also stating they were “abused” by a community contracted interpreter (Staff V). Patient #1 claiming an interpreter was holding their hands so that they could not sign, and the interpreter was not letting people in or out of the room.” -On 7/21/24 at 10:26 AM, Staff (HH), Psychiatrist, note revealed Patient #1 “reports that they have been mistreated by tactile sign interpreter while admitted in the hospital, states that the interpreter (Staff V) held their hand and prevented them from expressing themselves.” -On 7/21/24 at 06:43 PM, Staff (K), Registered Nurse, uploaded a picture of Patient #1’s left wrist with a title of “bruising to left wrist.” The photo shows a faint blush circular area is noted on the outer aspect of Patient #1 wrist. There are several other light blue and red markings on Patient #1’s wrist and top of hand. An intravenous catheter is noted on Patient #1’s upper forearm. There is no way to determine the exact cause of the discolorations. -On 7/21/24 at 07:44 PM, Staff (K), Registered Nurse, note revealed the contracted interpretation services interpreter on the floor. There is no documented evidence in Patient #1’s medical record that they were assessed by a provider following their allegation of abuse. Review on 08/01/24 of facility adverse event reports from 07/2024 to present revealed no evidence Patient #1’s allegation of abuse was reported. Interview on 07/31/24 at 11:57 AM with Staff (J), 2800 Nurse Manager, and Staff (L), Director of Nursing, revealed Patient #1 started to complain around 07/20/24 that Staff (W), community contracted Tactile Interpreter, assaulted Patient #1. Both Staff (J) and Staff (L) went to speak to Patient #1 on 07/22/24. Patient #1 did not describe physical abuse. However, Patient #1 stated the assault by Staff (W) consisted of Staff (W) taking Patient #1’s voice by holding Patient #1’s hands to prevent signing, Staff (W) prevented Patient #1 from leaving the hospital room during the day, and Staff (W) was misinterpreting for Patient #1. Staff (J) and Staff (L) stated there was no bruising noticed on Patient #1’s wrists. Staff (L) stated no incident report was entered into the hospital system regarding the assault allegation. Interview on 07/31/24 at 02:00 PM with Staff (F), Interpreter Services Manager, revealed they were not aware of an allegation of an interpreter not letting a provider in Patient #1’s room. Staff (F) stated an e-mail was received by Patient #1 alleging abuse from the interpreter. Staff (V) was immediately removed from Patient #1’s interpretive service and Staff (F) spoke with the first interpreting company letting them know an accusation was made to which the interpreters said that did not happen. Staff (F) stated no incident report was placed. The event was reported to Staff (J), 2800 Nurse Manager, and Staff (L), Director of Nursing, met with the patient the following Monday. Interview on 07/31/24 at 01:30 PM with Staff (K), Registered Nurse, revealed an e-mail was sent to Staff (J), 2800 Nurse Manager, regarding the incident. Interviews on 07/31/24 at 02:30 PM with Staff (N), Registered Nurse and Staff (O), Registered Nurse, at 02:35 PM with Staff (Q), Registered Nurse, and Staff (R), Registered Nurse, and at 02:51 PM with Staff (I), Registered Nurse, revealed if there was an abuse allegation made by a patient, the allegation would be reported to the state, to the nurse manager, and the allegation would be reported in the Safe Connect system where they enter events such an abuse allegation. Additionally, a nursing assessment would be done, pictures could be taken, and security involvement if needed. Interview on 08/02/24 at 10:00 AM with Staff (HH), Psychiatrist, revealed Staff (HH) stated there was no escalation or reporting of the abuse allegation of holding Patient #1’s hands because it was so brief and only lasted a few seconds. If there was a suspicion of abuse, Staff (HH) stated it would be reported to supervision and the attending provider. Staff (HH) stated that if there was a suspicion of abuse, Staff (HH) stated it would be reported to supervision and the attending provider. Staff (HH) stated they did not make an incident report regarding Patient #1’s abuse allegation. Interview on 08/01/24 at 10:34 AM with Staff (B), Senior Director Regulatory Compliance, revealed there should have been a reported event entered into the hospital system when the allegations of abuse were heard by staff. Staff (B) stated there was an event placed on 07/31/24 for the bruising noted to Patient #1. Staff (B) stated Staff (L), Director of Nursing went to speak with Patient #1 after there was an allegation of an interpreter raping Patient #1. Patient #1 told Staff (L) the rape allegation was a typo so there was no concern regarding that allegation and there was no incident report made for the rape allegation. Review on 07/31/24 of Staff (K), Registered Nurse, email dated 07/21/24 at 08:56 PM to Staff (J), Nurse Manager, revealed that Staff (K) spent at least eight hours in Patient #1’s room today (07/21/24) talking with Patient #1, the interpreters and Patient #1’s friend, trying to calm Patient #1 down, trying to relieve Patient #1’s anxiety, and trying to coordinate interpreter services. Staff (K) wrote “want you (Staff J) to know that the friend that came up, is calling the for peoples with disabilities to report abuse by an interpreter that the patient (Patient #1) had earlier stated, not sure how early was, don’t know if it was Friday or earlier in the week.” An interpreter “grabbed their (Patient #1) hands and held them super tight basically cutting off their (Patient #1’s) communication. The friend also said that this interpreter declined having the doctors come in and speak with them (Patient #1) and reported that they (Patient #1) did not want fellows or other people that were training to be in the patient’s (Patient #1’s) room, which the patient (Patient #1) never said, and they (Patient #1) feels like that person didn’t properly interpret things that the providers were trying to tell them.” Staff (K) emailed that they “did tell the patient that I (Staff (K)) was going to email you (Staff J) regarding issues with the interpreters.” Interview on 08/02/24 at 10:00 AM with Staff (A), Clinical Regulatory Compliance Specialist, and Staff (B), Senior Director Regulator Compliance, confirmed these findings.”