Erlanger Medical Center

“Stories: 8 Constructed: 1938 Building Drawings Available: Yes Sprinklered: Yes Licensed Beds: 582 A Life Safety Code Complaint Investigation #TN00077580 was conducted by the State of Tennessee Health Facilities Commission on 04/08/2026. During this life safety survey, Erlanger Health System was found to be in substantial compliance with the requirements for participation in Medicare/Medicaid with Title 42 CFR Subpart 482, Life Safety from Fire, and the related National Fire Protection Association (NFPA) standard 101-2012 Edition. The requirements at 42 CFR, Subpart 482.41(b) are MET as evidence by: During the Life Safety Life Safety Code Complaint Investigation #TN00077580 conducted on 04/08/2026, no deficiencies were cited under Title 42 CFR Subpart 482.41(b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) standard 101, 2012 Edition.”

“CONTENT OF RECORD: COMPLICATIONS CFR(s): 482.24(c)(4)(iv) [All records must document the following, as appropriate:] Documentation of complications, hospital acquired infections, and unfavorable reactions to drugs and anesthesia. This Standard is not met as evidenced by: 51389 Based on facility policy review, review of medical records, review of facility documentation and interviews, the facility failed to document a complication that occurred during an EGD (Esophagogastroduodenoscopy - using a cameral to look into the esophagus, stomach, and first part of the small intestines) procedure on 12/15/2025 and failed to document a follow up plan of care related to the complication for 1 patient (Patient #1) out of 3 patients reviewed. The findings include: Review of the facility’s policy titled, “Disclosure Guideline,” revised 7/2025, revealed “...policy outlines the process for disclosing unanticipated events and outcomes to patients and their family members...this guideline should not prevent or delay communication with families but provide support for the disclosure process...when a health care injury occurs, the patient and the family...are entailed to a prompt explanation of how the injury occurred and the long term effects...Attending Physician...primarily responsible for the care and treatment of a patient...the Disclosing Physician will document each discussion with the patient and/or patients family including disclosure of the a Disclosable Event...documentation in the medical record should include: time, place, and date of the meetings...identity of all attendees...the medically significant facts disclosed...next steps or changes in the treatment that were discussed...the patient’s and/or the patient’s family’s understanding of the situation and decisions regarding the patient’s plan of care...” Patient #1 was admitted to the facility on 12/15/2025 for an EGD and a Colonoscopy (using a camera to look into the bowels). Medical record review of a Procedural Note by the physician (Provider A) dated 12/15/2025 at 9:29 AM, revealed the EGD started at 8:30 AM and the overall impression of the procedure showed “...Z-line regular [visible, zigzag-shaped boundary where tissue of the esophagus meets the tissue of the stomach]...normal cardia [the part of the stomach that is closest to the esophagus]...gastric fundus [upper dome part of stomach]...gastric body [middle part of stomach]...antrum [lower part of stomach]...and pylorus [the valve between the stomach and the small intestine]...biopsied...” Medical record review of the Provider Notes revealed there was no documentation by Provider A stating there was a complication of a residual piece of tissue that came out during the EGD and there was no documentation of a follow up plan for Patient #1 Medical record review of an Anesthesia Note dated 12/15/2025 at 9:30 AM, revealed “...no notable events...” Medical record review of Laboratory Results dated 12/15/2025, revealed a CRP for Hepatitis C [C Reactive Protein - is usually high in Hepatitis C), Hepatitis B Surface Antigen (a protein on the surface of the hepatitis B virus that indicates an active infection), Hepatitis C (virus that spreads through close person-to-person contact and eating contaminated food or drink), and HIV 1 and 2 (Human Immunodeficiency Virus) were obtained via a blood sample after Patient #1’s procedure, and they resulted as negative. Review of facility documentation within an Internal Report revealed the hospital received a complaint from Patient #1’s insurance company on 12/17/2025, stating the “...patient reported having an EGD and Colonoscopy on 12/15/2025 and after the procedure, she was told by the Physician the scope used had some residual tissue in it and this caused her to possibly be exposed to someone else’s fluids...” The hospital started an investigation and during their interviews with the staff and Provider A they determined “...when the physician pushed the forceps [an instrument for grasping] in the scope to obtain a biopsy, a fragment of unknown substance exited into the patient...while in the stomach...it was immediately withdrawn...new scope was inserted and the procedure was completed...[Registered Nurse A] notified the Manager at 9:00 AM, and the Scope Cleaning Report from when the scope was last cleaned was pulled...” The IP (Infection Prevention) Department was notified, and they went to the department to speak to the staff. Provider A spoke to Patient #1 and the spouse regarding the situation and labs were drawn. The facility report revealed a copy of the scope processing ticket prior to the case and the report stated “...this is the first patient that used the same scope (2470665)...scope was pulled and sent to the [manufacturer]...” Further review of the Facility’s Internal Report revealed the event and the results of the manufacturer’s inspection of the scope were discussed in the Patient Safety Team. On 1/14/2026, the Manager of the GI (Gastrointestinal) Lab reported “...Mandatory Education for all the employees who performed scope processing will be completed by the representative from (Manufacturer) on 1/20/2026.” The Internal Report failed to reveal anyone contacted Patient #1 after her discharge to follow up on any testing Patient #1 would need to do in the future due to the tissue exposure during the EGD. Interview on 2/3/2026 at 10:30 AM, with the Quality and Safety Director verified there was not any documentation about the complication that occurred during the EGD or the follow up post exposure plan for Patient #1. Interview on 2/3/2026 at 12:15 PM, with RN A revealed she was the RN during the procedures for Patient #1. She stated her role was a “circulator for the room...I document things about the procedure...the Doctor decided to do a biopsy...the Tech opened the forceps...they were sterile...and gave them to the Doctor...he ran it down the scope...it pushed some tissue out...I saw the tissue...it was pinkish in color...[Physician A] said does everyone else see that...we all said yes...” Interview on 2/3/2026 at 12:20 PM, with the GI Lab Manager, revealed the Physician inserted the biopsy forceps into the scope and something came out of the end of the scope. The Physician withdrew the scope and got another scope to complete the procedure. “...The nurse contacted me immediately...I contacted IP and they came and talked with the patient...I also went and talked to her...I told the patient what happened and she had an understanding of what happened...I gave her my business card...she had my number to call if she needed anything...I told her we had to do the blood work per our hospital policy and that she could look on MyChart (the hospital’s patient portal online) to get the results...she denied having any questions...” The Manager shared the Manufacturer’s Inspection results. She explained “...there was some wrinkles in the boot of the scope or some bending that looks like a wrinkle...this is from normal wear and tear...this is inside the scope and you cannot see it...the [manufacturer] rep [representative] told me that it probably had a little wrinkle on the boot and a piece of tissue could have lodged behind the wrinkle...” The Manager described the cleaning process of a scope including after it is manually cleaned it is placed in the Disinfection Machine to disinfect the scopes and once it is cleaned the machine creates a ticket. The ticket is attached to the scope and hung in the “Scope Room” storage cabinets. The Manager stated the machine has a memory and she can go back and pull a report at any time. The GI Lab Manager denied contacting Patient #1 after her discharge for any follow up needed due to the tissue exposure during the EGD. Interview dated 2/3/2026 at 12:30 PM, with GI Technician A (GI Tech A) revealed she was in the room when the occurrence happened. She stated “I opened the forceps and he placed it in the scope and and pushed it down in the scope...I was able to see the monitor...he [Physician A] asked us, do you all see this? Tell me this is not what we see...it was a pinkish tissue-like substance...” Interview dated 2/3/2026 at 12:35 PM, with Physician A revealed he remembered Patient #1 somewhat and did remember the event. He stated “...I pushed in the forceps to get a biopsy and then as it reached the end, a piece of tissue came out...I ended the procedure and started over with a new scope...I did talk to the patient after the procedure in the recovery room...I said there was some tissue in the scope from before...I do not remember my exact words...I did say you could be exposed to some tissue from the patent the scope was used on before...I told her that we clean the scopes each time it is used per a protocol...” Physician A denied contacting Patient #1 after her discharge for any follow up needed due to the tissue exposure during the EGD. Interview on 2/3/2026 at 1:05 PM, with IP Nurse A and IP Nurse B revealed they “... were called down about a retained tissue...they pulled the scope out of use...thought maybe something broke inside...we didn’t speak to the patient at first...we decided to do some serological testing first...they were going to send the scope off to be tested...the doctor came over to us and asked if we were ready to talk to the patient...we usually do not talk to the patient...we explained to the patient that they use a special straw to access the hole in the scope...something came out of the hole...I explained we would need some blood work to make sure she was safe...I explained this was potential evidence it wasn’t as clean as we thought...I cannot tell you what you would be exposed to...” IP Nurse A and B denied contacting Patient #1 after her discharge for any follow up needed in the future due to the tissue exposure during the EGD. They stated this would need to come from the physician.”

“A Life Safety Code Complaint Investigation #TN00076338 was conducted by the State of Tennessee Health Facilities Commission on 6/30/2025. During this life safety complaint survey, Erlanger Medical Center was found in substantial compliance with the requirements for participation of Medicare/Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) standard 101-2012 Edition. The requirements at 42 CFR, Subpart 482.41(b) are MET as evidence by: During the life safety complaint survey, #TN00076338, conducted on 6/30/2025, no deficiencies were cited under 42 CFR PART 482.41, Requirements for Hospitals.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 51701 Based on the review of the facility policy, review of facility documentation, medical record review, and interview, the facility failed to report an occurrence resulting in injury and failed to report an allegation of abuse to the proper authorities for 1 patient (Patient #1) of 3 patients reviewed. The findings include: Review of the facility policy, “Abuse, Neglect, and Rape Reporting,” dated 11/2023, showed “...if a hospital patient demonstrates any of the criteria for abuse, Care Management or the House Supervisor should be notified for the proper referral notification...” Review of the facility policy, “Occurrence Reporting” dated 11/2022, showed “...All events should be reported into the electronic safety software...as soon as possible after detection by the employee or by the healthcare provider most closely involved in the situation...Event should be reported timely and ideally no later than the end of the scheduled shift of duty...” Review of facility documention showed an occurrence report was entered by Risk Management on 1/16/2025, 4 days after an incident with injury occurred on 1/12/2025. The report was entered into the facility’s electronic reporting system after a social media outlet posted information related to the incident. Medical record review showed Patient #1 was seen in the facility’s ED on 1/12/25 and left Against Medical Advice (AMA) at 9:22 PM. The patient was returned to the ED by ambulance on 1/12/25 at 11:24 PM, due to being injured when hospital security officers drug him to a bus stop. Medical record review of Patient #1’s triage record revealed the second visit, dated 1/12/25 at 11:24 PM, showed Registered Nurse (RN) #1, recorded Patient #1 a 56-year-old male, arrived by Emergency Medical Services (EMS) with a complaint of foot injury, related to dragging his feet while being escorted to the bus stop by security officers. The chief complaint noted was Foot Injury, Abrasion of Right Foot, and Abrasion of Knee Bilateral. During a telephone interview with RN #1 on 1/24/25 at 10:30 AM, she stated she was working as the triage nurse for the ambulance patients on 1/12/25. Interview confirmed she triaged Patient #1 on 1/12/25 at 11:24 PM, and documented his complaint was a foot injury. RN #1 stated she was told in report Patient #1 received his injuries as he was being dragged off hospital property by security officers. RN#1 stated she did not report the injuries on the foot, knees, and hands to anyone, including the House Supervisor. Interview confirmed RN #1 did not not complete an occurrence report and had not followed the abuse policy. During a telephone interview with the RN Clinical Director of Emergency Services on 2/22/25 at 2:37 PM, she confirmed RN#1 did not complete an Occurrence Report and she was not notified of the suspected abuse, and neither was the House Supervisor or Care Management. During a telephone interview with Paramedic #1 and Paramedic #2 on 2/28/25 at 9:06 AM, Paramedic #1 stated when they arrived on scene for the “traumatic injury 911 call” Patient #1 was sitting on the bench with one shoe. His feet were swollen and he had scratches all over his feet. Paramedic #1 said Patient #1 stated “the police did it.” Paramedic #1 stated she gave report to the facility ED staff. A telephone interview on 2/28/25 at 11:50 AM, with the physician treating Patient #1, confirmed he remembered seeing the patient and he stated he had seen Patient #1 “earlier in the day.” Interview revealed as the physician examined the patient, Patient #1 stated his wounds were from being dragged and confirmed he didn’t know if anyone in nursing reported the allegation of abuse.”

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 30553 Based on review of facility policy, observation, and interview, the facility failed to ensure medications were stored appropriately, for 1 of 2 nursing computer carts. The findings include: Review of the facility policy, “Medication Storage and Security Including Controlled Substances,” revised 7/2024, showed “...drug storage throughout the hospital are under the supervision of the Senior Director of the Pharmacy or his/her pharmacy designee...medications stored in locked storage areas will be stored under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security...” Observation on 2/19/2025 at 3:55 PM, in the Emergency Department (ED) triage area, showed 1 prepackaged injectable syringe of 40 milligrams (mg) of Lovenox (medication used to prevent blood clots) and 1 bottle of Nitroglycerin (medication used to treat chest pain) 0.4 mg, which were lying unsecured on the nursing computer cart. The cart was located in the hallway of the triage area. There were 3 patients observed on stretchers located in the area and no ED staff members were present. During an interview on 2/19/2025 at 4:00 PM, the ED Director confirmed the medications were stored on the nursing computer cart and were not secured.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 49485 Based on medical record review and interview, the hospital’s governing body failed to protect each patient’s right to be free from abuse and failed to provide medical care in a safe environment for 4 patients (Patients #10, #5, #2 and #11), failed to ensure medical and health risks were explained for 2 patients (Patients #12 and #13) so each patient could make informed medical decisions prior to discharging Against Medical Advice (AMA), failed to establish a process for prompt resolution and ensure an effective grievance process for 1 patient (Patient #13) and failed to provide an effect discharge planning process, consistent with the patient’s goals for care and their treatment preferences, to ensure an effective transition of the patient from hospital to post-discharge care for 3 patients (#6, #12 and #13) of 15 patients reviewed. The hospital’s non-compliance placed all patients in serious and immediate threat, placing them in Immediate Jeopardy (IJ). The findings include: Patients #10, #5, #2 and #11 were noted to be verbally and/or physically abused by the hospital’s contracted security company while receiving medical care in the hospital emergency room. Refer to A-0115 and A-0144. Review of the hospital record for patient #12, an 82-year-old female admitted to the emergency room (ER) on 5/20/2024 at 8:40 PM, after she had fallen on the ground during a syncopal episode (sudden loss of consciousness due to a drop in blood flow to the brain), hitting her head and had abnormal blood work/lab results. Patient #12 was not provided with an explanation by the medical staff of the risks associated with leaving without treatment as per the hospital’s policy. Review of ER clinical notes for Patient #13, a 39-year-old male, showed he was admitted on 6/30/2024 with a diagnosis of Sepsis (a life-threatening reaction to infection that can damage organs and tissues). Medical record review revealed Patient #13 was not provided with the explanation by the medical staff, the risks associated with leaving without treatment as per the hospital’s policy. Refer to A-0115, A-0144 and A-0799. Medical record review revealed Patient #6 was admitted to the ER via ambulance on 4/21/2024 at 5:53 PM, and discharged at 7:43 PM, on 4/21/2024. Interview on 9/11/2024 at 11:05 AM, with Registered Nurse (RN) K revealed Patient #6 was homeless and unable to walk on her own, needed a wheelchair (w/c) to get around and her w/c was at the community kitchen where she lived, 8 blocks from Hospital #1. Interview revealed RN K was the discharging nurse for patient #6. He did have a chance to review patient #6’s medical record, did not remember patient #6 well, but had some recollection of patient #6. He was the person who discharged Patient #6 on 4/21/2024, after being treated in the emergency room for Cellulitis. During the interview, RN K stated “...Sometimes I just push the homeless patients in the ER breezeway and let them figure out how they are going to get to where they stay...” Interview with Officer J, with the local City Police Department on 9/11/2024 at 3:40 PM, revealed he was a supervisor with a police crisis response team which deals with social and criminal issues in the city and on 4/22/2024 at 4:30 PM, one of his officers responded to a call that a person was found crawling in the street outside on the emergency room at [Hospital #1]. The officer found Patient #6 on the street indicating that she wanted to die and that was the reason she was crawling in the street. According to the responding officer, Patient #6 explained she was seen in Hospital #1 ER the previous day (4/21/2024) and was taken by wheelchair to a bench outside the ER by a nurse and was left on a bench. Refer to A-0144. The Patient Experience Director confirmed the grievance for Patient #13 had not been addressed to date and the letter sent, inaccurately, assured the complainant appropriate action was taken by the unit manager when it had not been. Refer to A-0118.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49485 Based on facility policy review, facility documentation, medical record review and interview, the hospital failed to protect each patient’s right to be free from abuse and provide medical care in a safe environment for 4 patients (Patients #10, #5, #2 and #11) and failed to ensure medical and health risks were explained prior to discharge for 2 (Patients #12 and #13) of 15 patients reviewed. The hospital’s non-compliance placed all patients in a serious and immediate threat and placed them in Immediate Jeopardy (IJ). The findings include: Review of the hospital policy titled, “Leaving Against Medical Advice” revised 07/2023, revealed “...This policy provides guidance for [Hospital#1] in addressing situations where a patient or his or her decision maker states the desire to leave the facility against medical advice in a manner that both promotes patient safety and honors patient rights...[Hospital #1] responds appropriately to all requests for treatment. When a patient or his or her parent/legal guardian/surrogate takes action for the patient to leave Against Medical Advice (AMA), a record should be made of the circumstances. Staff members and the physician should also attempt to educate the patient/parent/legal guardian/surrogate about the consequences of leaving without approval...A. As soon as any staff member becomes aware of the patient’s desire to leave the facility AMA, the attending physician should be called. The attending physician, nurse, and/or assigned patient caregiver should attempt to determine the reason(s) for the desire to leave AMA. B. The staff member should then notify the unit nurse manager and House Supervisor or designee of the desire to leave AMA. C. The patient’s nurse should document the intent to leave AMA and any actions taken to leave AMA in the patient’s medical record. D. If it is possible to address the concerns voiced by the patient or parent/legal guardian/surrogate, every reasonable attempt should be made to do so. If it is not possible to change the patient/parent/legal guardian/surrogate’s decision to leave AMA, the charge nurse should speak to the patient/parent/legal guardian/surrogate to explain that the attending physician/designee should speak with them prior to their leaving the facility. E. The charge nurse should inform the patient/parent/legal guardian/surrogate that his/her insurance company may not pay for the hospitalization if the patient leaves AMA...G. If the attempts to discourage the patient from leaving AMA are unsuccessful, the patient’s nurse or attending physician should document the following: I. The nurse and/or physician explained to the patient/parent/legal guardian/surrogate the risks associated with leaving without treatment and should document the explanation in the patient’s medical record. The nurse and/or physician/designee should also document in the medical record all attempts made to address the patient/parent/legal guardian/surrogate’s concerns and actions taken by the medical staff to encourage the patient/parent/legal guardian/surrogate to stay at the facility. ii. The patient/parent/legal guardian/surrogate is requested to sign the “Release of Responsibility” form (#38543). The release may be signed by the patient if 18 years of age or older without decision-making capacity. iii. A notation should be made in the nurses’ notes by the nurse, stating that “the patient/parent/legal guardian/surrogate was informed about the medical concerns related to leaving AMA and has chosen to leave the hospital.” iv. A notation should be made in the medical record by the attending physician indicating the events that occurred and reasons (if known) for the patient/parent/ legal guardian/surrogate deciding to leave AMA. The attending physician is also required to sign the “Release of Responsibility” section of the form. v. If the patient/parent/legal guardian/surrogate refuses to sign the “Release of Responsibility” form, the nurse or attending physician should complete and document the patient’s refusal on the form and place the form in the patient’s medical record. Place the “Release of Responsibility” form in the patient’s chart with or without the patient/parent/legal guardian/surrogate’s signature. vi. The patient’s nurse completes an electronic occurrence report regarding the AMA situation. vii. The patient’s nurse completes the Nursing Discharge assessment.” Review of the hospital policy titled, “Patient Related Complaint and Grievance Resolution” revised 9/2023, stated “...For grievances requiring a clinical investigation, The Patient Experience Office will send an acknowledgement letter to the complainant within 7 business days of receiving the complaint indicating that their concern(s) are under review and that they will receive follow-up within a specific time period. In those cases, a member of the Patient Experience Office will send a final written resolution response letter within the 30-day (business days) time frame. These final closure letters should also state that an investigation was performed, what steps were taken, results, the organization’s contact person and date of completion...A grievance is considered resolved when the patient is satisfied with the actions taken on their behalf...” Review of the hospital policy titled, “Patient Rights” dated 8/2024, revealed “...You, the patient, have the right to...Be safe from abuse or harassment...It is your responsibility to...Accept that bad language or bad behavior will not be tolerated...” Review of the hospital policy titled, “Abuse Reporting” dated 11/2024, revealed “...All patients have the right to be free from all acts of violence...from staff...The hospital will ensure that patients are free from all forms of abuse...All allegations of abuse...will be investigated thoroughly and will begin immediately once the allegation has been made...If the allegation is against a...care giver for the patient, the caregiver will be removed from caring for the patient...Education is provided during new employee orientation...annual training...on abuse...including reporting requirements, prevention, intervention, and detection...The investigation will include interviews of all persons involved...Incidents of abuse...harassment will be reported...analyzed with appropriate corrective, remedial, or disciplinary actions taken in accordance with applicable local, State, or Federal law...Reports of suspected abuse...harassment shall be made to Senior Leadership or the Risk Manager immediately...The caregiver affected by the allegation will be placed on administrative leave during the investigation...If the allegations are substantiated, the employee will be terminated and the appropriate agencies will be notified...” Review of a written statement from Staff Member B, dated 8/17/2022, revealed “...Walked into the unit @ [at] 625 am [6:25AM] Saw pt [Patient #10] in bed 8 being restrained. Offered assistance. Help [Patient Care Technician/PCT] U hold left arm to assess...IV [intravenous] was bad so we took off [specialized pressure bandage...and tried to take off the tape. While this was happening, [Staff Member B] was at the right arm of the pt. I [Staff Member B] heard the pt say, “that hurts, my arm hurts, it feels like you are going to break it!” I heard [Licensed Practical Nurse/LPN] V say, “wait his arm is at an angle, let go, that doesn’t look right.” I looked up and saw his [Patient #10’s] arm bent at an angle toward the head of the bed. After iv [intravenous needle] was wrapped up, I left to answer call lights. I heard another commotion and came back into the room. Pt [Patient #10] was kicking his legs. I [Staff Member B] was to the foot of the bed and grabbed the pt’s legs and slammed them down on the bed and yelled very loudly at the pt “STOP RIGHT NOW!” [Staff Member B] held the pt’s legs down while someone else retied the leg restraints. The restraints were reassessed and found to be to [too] tight...” Review of the facility’s document titled “eSAFE” incident report dated 8/17/2022, revealed “...While multiple staff were attempting to restrain the patient [Patient #10] to allow performance of an EKG, [electrocardiogram] [Staff Member B] entered room to assist and became physically aggressive towards...[Patient #10]...” During an interview on 9/12/2024 at 10:10 AM, Registered Nurse (RN) D stated she was working in the emergency room on 8/17/2022 when she witnessed Patient #10 being placed in 4-point (all four extremities) restraints. RN D stated she saw staff members around Patient #10. The patient started kicking his feet, Staff Member B picked up Patient #10’s feet and aggressively slammed the patient’s feet down on the bed and tightened the restraints too tight. Staff Member B was yelling at the patient to stop kicking. RN D stated she had never seen Staff Member B so aggressive with a patient before. Medical record review revealed Patient #5 arrived at the facility by ambulance on 6/22/2024 for a right arm laceration. Patient #5 was treated for the right arm laceration and discharged home on 6/22/2024. Review of the facility’s document titled “eSAFE” incident report dated 6/27/2024, revealed an incident between a contracted security officer (Security Officer-SO Q) and Patient #5 occurred on 6/22/2024. The incident report read “...[Patient #5]...brought in on 6/22/2024 for a severe circumferential arm laceration...[Patient #5] was...held on the EMS [Emergency Medical Service] stretcher...in front of the charge desk the patient’s arm was bumped the patient sat up on the stretcher and screamed in pain. When this happened...[SO Q] approached the patient grabbing him by the head and slammed him backwards and held the patient’s face by under the chin pushing upwards and the top of the head pushing down so the patient could not open his mouth...[Registered Nurse-RN AA] came from the back side of the charge desk...around to where the incident was occurring [SO Q] had removed his badge and was holding it in the patient’s face saying ’...this is my ER [explicit language]’...[RN AA] attempted to diffuse the situation and [SO Q] would not stop...[RN AA] stepped away to ask someone to call for more help and when I [writer of the report] returned to the patient’s side [SO Q] eventually let go but kept arguing with the patient...antagonizing the patient...” Medical record review revealed Patient #2 presented to the ED on 7/5/2024 with a self-inflicted gunshot wound (GSW) to the head. Further review revealed Patient #2 was hemodynamic stable, alert and oriented, with combative behaviors. On initial evaluation, Patient #2 was extremely anxious, refused to answer questions about self-inflicted GSW, and quickly became agitated upon further questioning. Patient #2’s blood alcohol level was 244 mg/dL (milligrams/deciliters-units of measure). Patient #2 was placed on suicide precautions; 1:1 observation with sitter to bedside; placed in a yellow gown; and was placed on Certificate of Need (CON-emergency psychiatric commitment) hold due to posing a potential harm or danger to self and others. Review of the facility’s document titled, “eSAFE” incident report dated 7/5/2024, revealed “...ED [Emergency Department] bed 7 was brought in as a self-inflicted GSW to the head. Shortly after arrival, pt [patient] was placed on a CON d/t [due to] SI [suicidal ideation] and attempted suicide. [Registered Nurse-RN W] responded to [Patient #2’s] room after hearing screaming. Upon entry, [Patient #2] was removing bedside monitoring equipment, agitated and asking to leave. [RN W] alerted [Medical Doctor-MD Y] of [Patient #2’s] behavior. [MD Y] gave a verbal order for IV [intravenous] Ativan [a sedating medication] and soft wrist restraints. [Patient #2] was placed in wrist restraints and medication was administered as prescribed. [Patient #2] was found again, out of bed, with restraints removed. [RN W] entered the room to find [Patient #2] agitated with several...security officers at bedside. [Patient #2] was visually upset and attempting to leave the ED. [RN W] alerted [MD Z] of [Patient #2] behavior and increased agitation. [MD Z] gave a verbal order for IM [intramuscular] medications and violent wrist restraints. [RN W] left the room to grab restraints, upon returning to the room, [Patient #2] was found being placed in the bed by 4 security guards. Security was attempting to move [Patient #2] in the bed when one of them verbalized being kicked. [SO X] then hit [Patient #2] with a closed fist on his chest. [RN W] was unable to reach...[Patient #2] d/t the number of security officers at the bedside. [Patient #2] was thrashing during the attempt to restrain him. During the events...[Patient #2] became agitated and was grabbing at security. [SO X] stated “I’m going to punch you if you touch my officers again.” [SO X] then proceeded to hit the pt [Patient #2] several more times with a closed fist in the chest and abdomen...[SO X]...turned to [MD Z] and stated, ‘I had to punch him, he grabbed my guys.’...[Patient #2] was placed in violent restraints...intermittently sat up...was agitated. IM [intramuscular] medications were administered...[Patient #2] was hit with a closed fist several more times by [SO X] after med administration...” Medical record review of Patient #11, dated 8/28/2024 at 11:15 PM, revealed “... CO [corrections officer] attempted to put mobility chains [immobilizes upper extremities] on Patient #11 due to patient being able to move hands freely. During this encounter, Patient #11 reached for off-duty officer’s gun. Security at bedside to subdue. Patient spitting blood onto security guards. Patient laughed and stated that ‘it’s funny because I have AIDS.’ Blood is on security guard’s skin and clothing. House supervisor made aware...CO requesting more officers to assist with patient...” Review of a facility incident report for Patient #11 dated 9/11/2024, revealed “...On 09/11/24, while reviewing the combative patient report, which I [Security Director] review daily, I [Security Director] saw [Security Officer O] antagonized and bully an almost incoherent patient. PT [Patient] I [Security Director] [Patient #11] was brought into the ER [emergency room] by the...County Sheriff’s Office, by Corrections Officer. The PT [Patient #11] had been violently beaten by other inmates while incarcerated and had open bleeding wounds on his face and in his mouth. [Security Officer O] reported a violent individual who was hitting and punching police officers, and at one point even trying to take officer firearm. In the footage I [Security Director] observed [Security Officer O] stalking the PT [Patient #11], who 99% of the time was sitting still and compliant. I watched the incident unfold with [Security Officer O] taking a hair net from the nurse’s station, placing it over the PT’s [Patient #11] head, and pulling it tight sneakily coming up behind the PT [Patient #11]. In the footage, [Security Officer O] is grinning. [Security Officer O] was not asked to assist and should have no dealings with a guarded...County Inmate. [Security Officer O] again grabbed the patient by the face, without being asked to assist, and violently shoved the patient’s head down into a bed with no regard for the open wounds on his face and in his mouth and not knowing if there was a neck injury or any kind of head injury. [Security Officer O] later takes a towel, which he was constantly fixated on for some reason on the PT [Patient #11] spitting, in which the video shows he never spit on anyone and told another officer to help him with this guy who is spitting and places the towel over the PT’s [Patient #11] face and holds his head immobile with heavy pressure. [Security Officer O] continues to get involved and gets into the face of the PT [Patient #11] cursing him and lunging at the PT [Patient #11], when the PT [Patient #11] leaned forward [Security Officer O] violently strikes the PT [Patient #11] again in his face, still not knowing if he could have further injury or killed the PT [Patient #11]. The...County deputy had to get between [Security Officer O] and the PT [Patient #11] and move him out of the way. [Security Officer O] stated he was spat on that was why he hit him, but video footage shows no blood coming from the PT’s [Patient #11] mouth or on [Security Officer O]. [Security Officer W] witnessed the incident and stated the blood came from [Security Officer O] slapping the Pt [Patient #11] with open wounds and made the blood splatter all over everyone. The report written by [Security Officer O] has him pressing charges on the PT [Patient #11] and charging him with Aggravated Assault...” During an interview on 9/19/2024 at 12:55 PM, the Patient Safety Quality Manager, stated she was made aware on 9/19/2024 of the events that took place involving Security Officer O and Patient #11 on 8/28/2024. The Patient Safety Quality Manager could not explain why 21 days elapsed before she was made aware of the patient abuse that occurred on 8/28/2024 until the morning of 9/19/2024. She stated she and the abuse teams reviewed the video footage of Security Officer O interacting with the Patient #11 and deemed Security Officer O’s interactions were abusive. The Patient Safety Quality Manager stated she contacted the Chief of Security and asked Security Officer O be removed from the hospital and not be allowed to return. During interview on 9/19/2024 at 1:10 PM, the Director of Security stated he was employed by the hospital’s contracted security company and had been the Director of Security since 4/1/2024. The Director of Security stated Security Officer O was the night shift supervisor and he had noticed most of the aggressive behavior documented had been on the night shift and by officers supervised by Security Officer O. Security Officer O was terminated from the hospital’s contracted security company because of his abusive actions taken against Patient #11. Medical record review revealed Patient #12, an 82-year-old female, was admitted to the ER on 5/20/2024 at 8:40 PM, after she had fallen on the ground during a syncopal episode (sudden loss of consciousness due to a drop in blood flow to the brain), hitting her head. Continued record review revealed she initially had experienced mild confusion after the fall. Patient #12 had a medical history of Atrial Fibrillation (irregular and often very rapid heart rhythm), Arthritis, Asthma, Claustrophobia (fear of confined spaces) and Hypertension. An ER review of laboratory results for Patient #12, dated 5/20/2024, revealed “Abnormal” laboratory results without defining or providing the normal and abnormal reference ranges or the specific results for Patient #12. Creatinine (blood test to measure how kidneys are performing and filtering waste)-results “Anormal”; Urea Nitrogen (blood test for a marker of kidney function)-results “Abnormal”; Glucose (blood test of a simple sugar the body uses for energy)-results “Anormal”; Hematocrit (blood test to determine the percentage of red blood cells in the blood)-results “Abnormal”; Basic Metabolic Panel (a blood test to check for kidney health, blood sugar, electrolytes and acid base balance in the blood)-results “Abnormal”; Complete Blood Count (CBC) with differential (a blood to measure red and white blood cells to test for anemia and infections, some heart diseases, autoimmune disorders)-results “Abnormal”; continued review of laboratory results on 5/21/2024 revealed Ferritin (a protein that stores iron)- results “Abnormal”; Folate (important in red blood cell formation)- results “Abnormal”; Iron (mineral vital to the proper function of hemoglobin, a protein needed to transport oxygen in the blood)- results “Abnormal”; Total Iron Binding (test to measure the blood’s ability to bind to iron and carry it through the body)- results “Abnormal.” Review of hospital documentation titled, “Emergency Care (ED) Timeline” revealed Patient #12 was discharged on 5/22/2024 at 10:11 AM, with intravenous fluids (IV) discontinued at 10:12 AM. Continued record review revealed there was no documentation for Patient #12 as per the hospital’s AMA policy to reflect, “...a record should be made of the circumstances, or the physician was notified or the notification of the unit nurse manager or the House Supervisor or designee” of Patient # 12 desire to leave AMA. Further record review revealed Patient #12 was not provided with an explanation by “the nurse and/or physician, the risks associated with leaving without treatment...” and no documentation “all attempts made to address the patient...concerns and actions taken by the medical staff to encourage patient...to stay at the facility” per the hospital’s AMA policy after Patient #12 suffered a head injury resulting from a fall and without documented assessment and/or treatment for the noted “Abnormal” laboratory results. Review of hospital documentation titled, “Leaving the Hospital Against Medical Advice” dated 5/24/2024, revealed “Patient #12 had signed the document stating, “ This will certify that I, the undersigned, [patient #12’s name] A patient in the above named medical center, having requested discharge and removal from the medical center against the advices of my attending physician(s), hereby release [name of hospital], its physicians, officers and employees, severally and individually, from any and all liability of any nature whatsoever for any injury or harm or complication of any kind that may result directly or indirectly, by reason of my terminating my stay as a patient as [name of hospital] and my departure from said medical center, and hereby waive any and all rights f action I many now have or later acquire as a result of my voluntary departure from said medical center and the termination of my stay as a patient therein. This /release is made with the full knowledge of the danger that may result from the action I am taking.” The document was signed by the patient and witnessed, along with the signature of the nurse. However, the physician signature was noted to not be signed and was blank where the physician was to sign. Medical record review revealed Patient #13, a 39-year-old male, was admitted to the Emergency Room (ER) on 6/30/2024, with a diagnosis of Sepsis (a life threatening reaction to infection that can damage organs and tissues). Patient #13 had a medical history of Cervical Vertebrae (C4-C5) Spinal Injury following a fall and resulting Paraplegia complicated by neurogenic bladder, neurogenic bowel, stage IV left ischial decubitus ulcer status post (excision and flap closure in 12/2023), and Deep Vein Thrombosis (DVT). Review of laboratory results for patient #13, dated 7/3/2024, revealed an elevated White Blood Count (CBC) (a measurement of the number of white blood cells in the body and can detect infection). The normal range for the hospital’s WBC was noted to be 10*3/uL (microliters) with patient #13 results at 17.1 and flagged as being “out of range.” Review of hospital documentation titled “Progress Notes” dated 7/3/24 at 6:03 PM, revealed RN N documented, “Patient ready to leave AMA, as he feels urology, and wound care have ignored him. Pulled out his foley and is currently getting dressed. Notified MD.” According to” Care Timeline” on the progress note, Patient #13 was discharged at 7:21 PM. Review hospital documentation titled “Progress notes” dated 7/3/2024 at 6:03 PM, revealed Patient #13 was discharged AMA. Continued record review revealed no documentation for Patient #13 as per the hospital’s AMA policy to reflect, “... a record should be made of the circumstances, or the physician was notified or the notification of the unit nurse manager or the House Supervisor or designee” of Patient # 13 desire to leave AMA. Further record review revealed Patient #13 was not provided with the explanation by “the nurse and/or physician, the risks associated with leaving without treatment...” and no documentation “all attempts made to address the patient...concerns and actions taken by the medical staff to encourage patient...to stay at the facility” per the hospital’s AMA policy after patient #13 was diagnosed with Sepsis and an elevated WBC. Review hospital documentation titled, “eSAFE” dated 7/5/2024, revealed a complaint/grievance was filed with the hospital for event dates 6/30/2024 on behalf of Patient #13. A follow up to the complainant was in the form of a letter dated, July 11, 2024. The letter revealed, “...An investigation was performed by the Office of Patient Experience...The nurse manager over the unit has reviewed this file and is taking appropriate action to address this. Please be assured that we are committed to identifying opportunities for improving the care delivered to our patients and taking appropriate action when necessary...Our investigation is now complete...” During an interview on 9/11/24 at 4:01 PM, Registered Nurse (RN) M, who discharged Patient #13 on 7/3/2024 at 7:21 PM, stated he was not aware of the hospital’s policy for AMA. When asked if RN M explained the risks of leaving AMA to Patient #13, he stated, “No, he [Patient #13] was very kind, but he said he felt like he was not getting the care that he needed here.” Upon further interview with RN M, he revealed he was not aware of the AMA policy and had not been in-serviced on the AMA policy. RN M further stated he did not provide Patient #13 with risks to his health when he left AMA. He further stated Patient #13 left before the doctor could see the patient. Interview confirmed RN M did not provide Patient #13 with risks regarding his diagnosis of Sepsis and/or elevated WBC. Interview on 9/12/24 at 11:25 AM, revealed RN N discharged Patient #12 on 5/22/2024, and she stated she was not aware of the hospital’s policy for AMA, only that an “AMA form is provided to the patients if they want to leave, and it lets them know of their risks if they decide to leave and the patient signs the AMA form.” When RN N was asked if she explained the risks of leaving AMA to Patient # 12, she stated “No.” Upon further interview with RN N, it was revealed she not seen the AMA policy and had not been in-serviced on the AMA policy. During an interview on 9/12/2024 at 11:30 AM, the hospital’s attorney stated, “It’s on them [patients] when they sign out AMA. They understand the risks when they sign the AMA form.” Refer to A-0144, A-0145, and A-0799.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 49485 Based on hospital policy review, medical record review and interview, the hospital failed mitigate risks and protect patients from abuse, provide a safe environment, provide appropriate discharges and ensure patient rights by not demonstrating evidence of a Quality Assurance and Performance Improvement (QAPI) associated with the provisions of the said Condition of Participation and Standards of Care for 7 of 15 patients reviewed. The hospital’s non-compliance placed patients in a serious and immediate threat and placed them in an Immediate Jeopardy (IJ). The findings include: Patients #10, #5, #2 and #11 were noted to be verbally and/or physically abused by the hospital’s contracted security company, while receiving medical care in the hospital’s emergency room. Refer to A-0115, A-0144 and A-0144. Medical record review of Patient #12, an 82-year-old female, showed she was admitted to the emergency room (ER) on 5/20/2024 at 8:40 PM, after she had fallen on the ground during a syncopal episode (sudden loss of consciousness due to a drop in blood flow to the brain), hitting her head and has abnormal laboratory results. Patient #12 was not provided with the explanation by the medical staff, the risks associated with leaving without treatment as per the hospital’s policy. Medical record review of hospital emergency (ER) clinical notes for Patient #13, a 39-year-old male, revealed he was admitted to the ER on 6/30/2024 with a diagnosis of Sepsis (a life threatening reaction to infection that can damage organs and tissues). Interview and record review revealed Patient #13 was not provided with the explanation by the medical staff, the risks associated with leaving without treatment as per the hospital’s policy. Refer to A-0115, A-0144, and A-0799. Medical record review revealed Patient #6 was admitted to the ER via ambulance on 4/21/2024 at 5;53 PM and discharged at 7:43 PM, on 4/21/2024. Interview with Registered Nurse (RN) K revealed Patient #6 was homeless and unable to walk. Patient #6 explained that she was not able to walk on her own, needed a wheelchair to get around and her wheelchair was at the community kitchen where she lived 8 blocks from Hospital #1. During the interview, RN K stated “...Sometimes I just push the homeless patients in the ER breezeway and let them figure out how they are going to get to where they stay...” Review of police records revealed Patient #6 was found the following day by the police on the sidewalk outside the hospital ER without a wheelchair. The responding officer found Patient #6 crawling on the street, indicating that she wanted to die. According to the responding officer, he stated Patient #6 explained that she had been seen in Hospital #1 ER the previous day (4/21/2024) and was taken to a bench outside the ER in a wheelchair by a nurse and was left on the bench. Refer to A-0144. The Patient Experience Director confirmed the grievance for Patient #13 had not been addressed to date and the letter sent inaccurately assured the complainant that appropriate action was addressed by the unit manager when it was not. Refer to A-0118”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 49485 Based on policy review, medical record review and interview, the hospital failed to have an effective discharge planning process when Patient #6, a non-ambulatory homeless patient, was discharged from the Emergency Room (ER) to a bench outside of the ER without a wheelchair and transportation to a safe location, and the hospital failed to provide the risks to the health, safety, and welfare for Patient #12 and Patient #13 when they left Against Medical Advice (AMA) of 15 patients reviewed for discharge. The hospital’s non-compliance placed all discharged patients in a serious and immediate threat and placed them in Immediate Jeopardy (IJ). The findings include: Review of facility’s policy titled, “Case Management-Transition Management, Discharge Planning, and Patient Choice,” dated 6/2021, revealed “...Transition Management-the process of assessing...reassessing the patients for post-hospital needs...developing...implementing a plan to coordinate those services identified as necessary for the patient when they leave the hospital. The process includes a mechanism for a Case Management [CM] Registered Nurse [RN]or Social Worker [SW] to identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge or transfer if there is inadequate planning...as outlined in the routine nursing assessment. A discharge planning evaluation by the CM/SW may be requested...Transition management will be conducted in accordance with all legal mandates while supporting the patient’s ethical and moral directives. Case Management discharge planning services are available to all patients regardless of age, sex, national origin, race, and sexual orientation...All discharge evaluations and discharge plans are recorded in [electronic medical record] by the RN/SW Case manager... results are discussed with the patient or individual acting on his or her behalf...” Review of the facility’s hospital policy titled, “Leaving Against Medical Advice [AMA]” dated 7/2023, revealed “...provides guidance...in addressing situations where a patient or...decision maker states the desire to leave the facility against medical advice in a manner that both promotes patient safety and honors patient rights...When a patient or...parent/ legal guardian/surrogate takes action for the patient to leave Against Medical Advice, a record should be made of the circumstances. Staff members and... physician should also attempt to educate...patient/parent/legal guardian/surrogate about the consequences of leaving without approval...As soon as any staff member becomes aware of the patient’s desire to leave the facility AMA, the...physician should be called. The...physician, nurse...assigned patient caregiver should attempt to determine the reason(s) for the desire to leave AMA...staff member should then notify the unit nurse manager...House Supervisor or designee of the desire to leave AMA...The patient’s nurse should document the intent to leave AMA...any actions taken to leave AMA in the patient’s medical record...If...possible...address...concerns voiced by...patient or parent/legal guardian/surrogate, every reasonable attempt should be made to do so. If...not possible to change the patient/parent/legal guardian/surrogate’s decision to leave AMA, the charge nurse should speak to the patient/parent/legal guardian/surrogate to explain that the...physician/designee should speak with them prior to their leaving the facility...The charge nurse should inform the patient/parent/legal guardian/surrogate that...insurance company may not pay for the hospitalization if the patient leaves AMA...If...attempts to discourage the patient from leaving AMA are unsuccessful, the patient’s nurse or...physician should document the following:..explained...the risks associated with leaving without treatment...document the explanation in the patient’s medical record...document in the medical record all attempts made to address the patient/parent/legal guardian/surrogate’s concerns and actions taken by the medical staff to encourage the patient/parent/legal guardian/surrogate to stay at the facility...The patient/parent/legal guardian/surrogate is requested to sign the “Release of Responsibility” form...The release may be signed by the patient if 18 years of age or older without decision-making capacity...notation should be made in the nurses’ notes by the nurse, stating...’the patient/parent/legal guardian/surrogate was informed about the medical concerns related to leaving AMA and has chosen to leave the hospital’...A notation should be made in the medical record by the...physician indicating the events that occurred...reasons (if known) for the patient/parent/ legal guardian/surrogate deciding to leave AMA. The...physician is also required to sign the “Release of Responsibility” section of the form...If the patient/parent/legal guardian/surrogate refuses to sign the “Release of Responsibility” form, the nurse or...physician should complete and document the patient’s refusal on the form and place the form in the patient’s medical record. Place the “Release of Responsibility” form in the patient’s chart with or without the patient/parent/legal guardian/surrogate’s signature...The patient’s nurse completes an electronic occurrence report regarding the AMA situation...The patient’s nurse completes the Nursing Discharge assessment...” Medical record review for Patient #6 revealed the patient was admitted to Hospital #1 on 4/21/2024 at 5:53 PM, “...Means of arrival, ambulance...66 yo [year old] F [Female] hx [history] of homelessness, Chronic Obstructive Pulmonary Disease [COPD], Diabetes Mellitus [DM], and Hypertension [HTN] presents for bilateral lower extremity pain and hip pain. Patient tearful on interview. Patient reports last Wednesday she started to notice some left hip pain as well as lower extremity pain. Patient denies any recent fever, chest pain, or shortness of breath. Patient does report some chills ...” Review of discharge summary from Hospital #1 dated 4/21/2024 7:43 PM, [less than 2 hours after admission] “...Please continue your home medications. Continue the Doxycycline that was prescribed by previous providers to complete the course of antibiotics. There was no acute fracture of your L hip seen on your Hip Xray. Please follow up with your primary care physician. Please return to ED if you develop any new or worsening symptoms ...” During an interview on 9/11/2024 at 11:05 AM, Registered Nurse [RN] K stated he had worked at the facility for 3.5 years and was the discharging nurse for Patient #6 on 4/21/2024, after being seen and treated in the facility’s emergency department for Cellulitis. RN K stated he could not recall specifics related to Patient #6 but noted she was wheelchair bound and was not able to walk on her own. He stated the facility’s emergency department has a case manager to assist patients with transportation needs during the hours of 8:00 AM-4:30 PM. When Patient #6 was discharged on 4/21/2024 at 7:43 PM, there was no case manager available. RN K further stated Patient #6 was homeless and typically, (hired transportation by private individuals) would be called for patients who do not have transportation. Patient #6 was wheelchair dependent and would have required a van with a lift. RN K stated he “...wasn’t sure if [Hospital] would pay for a lift ...” RN K stated “...Sometimes I just push the homeless patients in the ER breezeway and let them figure out how they are going to get to where they stay...”. RN K denied he “dumped” Patient #6 on the sidewalk outside the emergency room but could not explain how Patient #6 was found the following day on the sidewalk outside the hospital ER without a wheelchair. RN K stated patients who were discharged were transported out of the ER in a wheelchair to the breezeway and were not allowed to maintain procession of the wheelchair. During an interview on 9/11/2024 at 3:40 PM, Officer J of the local city Police Department stated he was a supervisor with a police crisis response team which deals with social and criminal issues in the city. On 4/22/2024 at 4:30 PM, one of his officers responded to a call that a person was found crawling in the street outside of Hospital #1’s ER. The responding officer found Patient #6 crawling on the street, indicating that she wanted to die. According to the responding officer, he stated Patient #6 explained that she had been seen in Hospital #1 ER the previous day (4/21/2024) and was taken to a bench outside the ER in a wheelchair by a nurse and was left on the bench. Patient #6 explained that she was not able to walk on her own, needed a wheelchair to get around and her wheelchair was at the community kitchen where she lived 8 blocks from Hospital #1). The responding officer summoned an ambulance to transport Patient #6 to Hospital #2. Review of EMS transport records of [patient #6] revealed the following: “per police report: Patient was seen last night at [hospital #1] for hip pain and was discharged back to the community. Patient was taken across the street in a wheelchair and left in her own care. Patient did not have access to transport and her wheelchair and slept on the sidewalk. Patient is non-ambulatory and has severe cellulitis in her lower extremities. Patient has been non-compliant with all medications for at least one month. Police found patient on sidewalk and patient expressed suicidal ideation with a plan to crawl into traffic. Mobile crisis was called and volunteer behavioral placed patient on a 6404/con. Patient is going to [hospital #2] ED for medical clearance and inpatient psychiatric placement. Patients mental state is alert and oriented and answers all questions appropriately. Patient is calm and cooperative. Patient was found lying on sidewalk and had urinated and defecated on herself due to incontinence and inability to get to a restroom. Patient complained of feeling cold and uncomfortable with hip pain 5/10 from sleeping on sidewalk. Patients’ respiratory effort is normal. Breath sounds clear and equal bilaterally with symmetrical chest rise and fall. Patient denies substance use. Patient admits to continued suicidal ideation. Patient admits to a suicide attempt in the past and has had previous psychiatric hospitalizations. Patient feels hopeless and complains of being a burden. Patient denies auditory and visual Hallucinations. Patient feels she is in need of skilled nursing care as she is unable to care for herself”. Review of medical record from the receiving Hospital #2 for Patient #6 dated 4/22/2024, revealed the following: “Patient is a 66-year-old white female who presents to the emergency room with complaints of suicidal ideations that are mainly of a social initiation. Patient is a morbidly obese female...confined to a wheelchair and is homeless. She was brought in by EMS with a...[psychiatric commitment order]...in place. Patient has a known history of bipolar disorder, schizoaffective disorder and supposedly was in [another psychiatric hospital] about a month ago...went to live at a local homeless shelter. Earlier this week she had a fall out of her wheelchair and went to [Hospital #1] where they evaluated her and discharged her...to the street yesterday [4/21/2024]. The patient states that she...urinated and defecated on herself. According to EMS...she was covered in urine and feces...It is of note that the patient started to crawl...going to traffic in an attempt to get help and possibly kill herself. Once again, the patient presents with suicidal ideations without plan...previously in [Hospital #1 ER] and was evaluated and was prescribed an antibiotic...continued with cellulitis and still has erythematous legs. During an interview on 9/16/2024, at 10:30 AM, the Patient Safety and Quality Director with Hospital #1 stated that she was aware of the incident related to Patient #6’s unsafe discharge on 4/21/2024 and did not investigate the discharge, do an incident report on the incident, or look for a way to prevent this type of unsafe discharge from happening in the future. When asked if Patient #6’s 4/21/2024 discharge was an unsafe discharge, she confirmed “it was not an optimal discharge.” Medical record review for Patient #12, an 82 year-old female, was admitted to the ER on 5/20/2024 at 8:40 PM, after she had fallen on the ground during a syncopal episode (sudden loss of consciousness due to a drop in blood flow to the brain), hitting her head. Continued record review revealed she initially had experienced mild confusion after the fall. Patient #12 also had medical history of Atrial Fibrillation (irregular and often very rapid heart rhythm) Arthritis, Asthma, Claustrophobia (fear of confined spaces), and Hypertension. Review of laboratory results for Patient #12 dated 5/20/2024, revealed “Abnormal” laboratory results without defining or providing the normal and abnormal reference ranges or the specific results for Patient #12. Creatinine ( blood test to measure how kidneys are performing and filtering waste)- results “Abnormal”; Urea Nitrogen ( blood test for a marker of kidney function)- results “Abnormal”; Glucose (a simple sugar the body uses for energy )- results “Abnormal”; Hematocrit (blood test to determine the percentage of red blood cells in the blood)-results “Abnormal”; Basic Metabolic Panel (a blood test that checks for kidney health, blood sugar, electrolytes and acid base balance in the blood) -results “Abnormal”; Complete Blood Count ( CBC) with differential ( a blood test that measures red and white blood cells to test for anemia and infections, some heart diseases, autoimmune disorders)- results “Abnormal”; Continued review of laboratory results on 5/21/2024 revealed, Ferritin ( a protein that stores iron) - results “Abnormal”; Folate ( important in red blood cell formation)- results “Abnormal”; Iron( mineral vital to the proper function of hemoglobin, a protein needed to transport oxygen in the blood)- results “Abnormal”; Total Iron Binding ( test that measure blood’s ability to bind to iron and carry it through the body)- results “Abnormal.” Review of Hospital #1 documentation titled, “Emergency Care Timeline,” revealed Patient # 12 was discharged on 5/22/2024 at 10:11 AM, with peripheral intravenous fluids (IV) discontinued at 10:12 AM. Continued record review revealed there was no documentation for Patient #12 as per the hospital’s AMA policy to reflect “ ... a record should be made of the circumstances, or the physician was notified or the notification of the unit nurse manager or the House Supervisor or designee...” of Patient #12 desire to leave AMA. Further record review revealed Patient #12 was not provided with the explanation by “...the nurse and/or physician, the risks associated with leaving without treatment...” and no documentation “...all attempts made to address the patient...concerns and actions taken by the medical staff to encourage patient...to stay at the facility...” per the hospital’s AMA policy after Patient #12 suffered a head injury resulting from a fall and without documented treatment for the noted “Abnormal” laboratory results. Review of Hospital #1 documentation titled, “Leaving the Hospital Against Medical Advice” dated 5/24/2024, revealed Patient #12 had signed the document stating, “...This will certify that I, the undersigned, [Patient # 12 ] A patient in the above named medical center, having requested discharge and removal from the medical center against the advices of my attending physician(s), hereby release [Hospital #1], its physicians, officers and employees, severally and individually, from any and all liability of any nature whatsoever for any injury or harm or complication of any kind that may result directly or indirectly , by reason of my terminating my stay as a patient as [Hospital #1] and my departure from said medical center, and hereby waive any and all rights action I many now have or later acquire as a result of my voluntary departure from said medical center and the termination of my stay as a patient therein. This /release is made with the full knowledge of the danger that may result from the action I am taking...” The document was signed by the patient and witnessed, along with the signature of the nurse. However, the physician signature was noted to not be signed and was blank where the physician was to sign. During an interview on 9/12/24 at 11:25 AM, RN N who discharged Patient #12 on 5/22/2024, stated she was not aware of the hospital’s policy for AMA, only that an “AMA form is provided to the patients if they want to leave, and it lets them know of their risks if they decide to leave and the patient signs the AMA form.” When asked if RN N explained the risks of leaving AMA to Patient # 12, she stated, “No.” Upon further interview with RN N it was revealed she not seen the AMA policy and had not been in-serviced on the AMA policy. Medical record review for Patient #13, revealed a 39-year-old male, admitted to the ER on 6/30/2024 with a diagnosis of Sepsis (a life threatening reaction to infection that can damage organs and tissues). Patient #13 also had a medical history of Cervical Vertebrae (C4-C5) Spinal Injury following a fall and resulting Paraplegia complicated by Neurogenic Bladder, Neurogenic Bowel, Stage IV left Ischial Decubitus Ulcer status post (excision and flap closure in 12/2023), and Deep Vein Thrombosis (DVT). Review of laboratory results for Patient #13 dated 7/3/2024, revealed elevated White Blood Count (WBC) a measurement of the number of white blood cells in the body and can detect infection). The normal range for the hospital’s WBC was noted to be 10*3/uL (microliters) with Patient #13 results at 17.1 and flagged as being out of range. Review of hospital documentation for Patient #13 titled, “Progress Notes,” dated 7/03/24 at 6:03 PM, revealed RN N documented, “ ...Patient ready to leave AMA, as he feels urology, and wound care have ignored him. Pulled out his foley and is currently getting dressed. Notified MD [Medical Doctor]...” According to Care Timeline on the progress note, Patient #13 was discharged at 7:21 PM. Review hospital documentation titled, “Progress notes” dates 7/3/2024 at 6:03 PM, revealed Patient #13 was discharged AMA. Continued record revealed there was no documentation for Patient #13 as per the hospital’s AMA policy to reflect, “... a record should be made of the circumstances, or the physician was notified or the notification of the unit nurse manager or the House Supervisor or designee...” of Patient’s #13 desire to leave AMA. Further record review revealed Patient #13 was not provided with the explanation by “...the nurse and/or physician, the risks associated with leaving without treatment...” and no documentation “...all attempts made to address the patient...concerns and actions taken by the medical staff to encourage patient...to stay at the facility...” per the hospital’s AMA policy after patient #13 was diagnosed with Sepsis and with an elevated WBC. Review of the Physician’s Progress Note dated 7/3/2024 at 7:21 PM, the physician documented, “Went to PM round on patient [Patient #13], patient not in room. Informed that he has left AMA.” During an interview on 9/11/24 at 4:01 PM, RN M discharged Patient #13 on 7/3/2024 at 7:21 PM, stated he was not aware of the hospital’s policy for AMA. When asked if RN M explained the risks of leaving AMA to Patient #13, he stated, “ ...No, he [Patient #13] was very kind, but he said he felt like he was not getting the care that he needed there...” RN M confirmed he was not aware of the AMA policy and had not been in-serviced on the AMA policy. RN M further confirmed he did not provide Patient #13 with risks to his health when he left AMA. He further stated Patient #13 left before the doctor could see Patient #13. RN M confirmed he had not provided Patient #13 with the risks regarding his diagnosis of Sepsis and/or elevated WBC. During an interview on 9/12/2024 at 11:30 AM, the hospital’s attorney stated, “...It’s on them [patients] when they sign out AMA. They understand the risks when they sign the AMA form ...””

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 49485 Based on facility policy review, medical record review and interview, the hospital failed to establish a process for prompt resolution of patient grievances and to ensure effective operation of the grievance process for 1 (Patient #13) of 15 patients reviewed. The findings include: Review of the hospital policy titled, “Patient Related Complaint and Grievance Resolution, revised 9/2023, stated “ ...For grievances requiring a clinical investigation, The Patient Experience Office will send an acknowledgement letter to the complainant within 7 business days of receiving the complaint indicating that their concern(s) are under review and that they will receive follow-up within a specific time period. In those cases, a member of the Patient Experience Office will send a final written resolution response letter within the 30-day (business days) time frame. These final closure letters should also state that an investigation was performed, what steps were taken, results, the organization’s contact person and date of completion...A grievance is considered resolved when the patient is satisfied with the actions taken on their behalf...” Review hospital documentation titled, “eSAFE” dated 7/5/2024, revealed a complaint/grievance was filed with the hospital for event dates 6/30/2024 on behalf of Patient #13. A follow up to the complainant was in form of a letter dated, July 11, 2024. The letter revealed, “...An investigation was performed by the Office of Patient Experience...The nurse manager over the unit has reviewed this file and is taking appropriate action to address this. Please be assured that we are committed to identifying opportunities for improving the care delivered to our patients and taking appropriate action when necessary...Our investigation is now complete...” During an interview on 9/11/2024 at 12:16 PM, the Patient Experience Director stated the nurse manager over the unit did not review or address the concern. The Patient Experience Director stated, “It was an assumption since I saw she [unit manager] was in the system and she would address it.” The Patient Experience Director confirmed the grievance had not been addressed to date and the letter sent, inaccurately assured the complainant that appropriate action was addressed by the unit manager and when it was not. Refer to A-0115.”

“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: 49485 Based on facility policy review, medical record review and interview, the hospital failed to protect each patient’s right to be free from abuse and provide medical care in a safe environment for 4 patients (Patients #10, #5, #2, and #11), and failed to be provide medical care in a safe environment for 1 patient (#6) who was wheelchair bound and homeless, without a wheelchair upon discharge, whereby Patient #6 was found by police approximately 24 hours later outside the hospital emergency room, attempting to crawl onto the road, the hospital failed to ensure medical and health risks were explained so that the individual patients could make informed medical decisions prior to discharging Against Medical Advice (AMA) for 2 patients (Patients #12 and #13) of 15 patients reviewed. The findings include: Review of hospital policy titled, “Patient Related Complaint and Grievance Resolution” revised 9/2023, stated “...For grievances requiring a clinical investigation, The Patient Experience Office will send an acknowledgement letter to the complainant within 7 business days of receiving the complaint indicating that their concern(s) are under review and that they will receive follow-up within a specific time period. In those cases, a member of the Patient Experience Office will send a final written resolution response letter within the 30-day (business days) time frame. These final closure letters should also state that an investigation was performed, what steps were taken, results, the organization’s contact person and date of completion...A grievance is considered resolved when the patient is satisfied with the actions taken on their behalf...” Review of the facility policy titled, “Patient Rights” dated 8/2024, revealed “...You, the patient, have the right to...Be safe from abuse or harassment...It is your responsibility to...Accept that bad language or bad behavior will not be tolerated...” Review of the facility policy titled, “Abuse Reporting,” dated 11/2024, revealed “...All patients have the right to be free from all acts of violence...from staff...The hospital will ensure that patients are free from all forms of abuse...All allegations of abuse...will be investigated thoroughly and will begin immediately once the allegation has been made...If the allegation is against a...care giver for the patient, the caregiver will be removed from caring for the patient...Education is provided during new employee orientation...annual training...on abuse...including reporting requirements, prevention, intervention, and detection...The investigation will include interviews of all persons involved...Incidents of abuse...harassment will be reported...analyzed with appropriate corrective, remedial, or disciplinary actions taken in accordance with applicable local, State, or Federal law...Reports of suspected abuse...harassment shall be made to Senior Leadership or the Risk Manager immediately...The caregiver affected by the allegation will be placed on administrative leave during the investigation...If the allegations are substantiated, the employee will be terminated and the appropriate agencies will be notified...” Review of a written statement from Staff Member B dated 8/17/2022, revealed “...Walked into the unit @ [at] 625 am [6:25 AM] Saw pt [Patient #10] in bed 8 being restrained. Offered assistance. Help [Patient Care Technician/PCT] U hold left arm to assess...IV [intravenous] was bad so we took off ...[specialized pressure bandage]...and tried to take off the tape. While this was happening, [Staff Member B] was at the right arm of the pt [Patient #10]. I [Staff Member B] heard the pt [Patient #10] say, “that hurts, my arm hurts, it feels like you are going to break it!” I heard [Licensed Practical Nurse/LPN] V say, “wait his arm is at an angle, let go, that doesn’t look right.” I looked up and saw his [Patient #10] arm bent at an angle toward the head of the bed...After iv [intravenous needle] was wrapped up, I left to answer call lights. I heard another commotion and came back into the room. Pt [Patient #10] was kicking his legs. [Staff Member B] was to the foot of the bed and grabbed the pts [Patient #10’s] legs and slammed them down on the bed and yelled very loudly at the pt [patient] “STOP RIGHT NOW!” [Staff Member B] held the pt’s [Patient #10] legs down while someone else retied the leg restraints. The restraints were reassessed and found to be to [too] tight...” Review of the facility’s document titled, “eSAFE” incident report dated 8/17/2022, revealed “...While multiple staff were attempting to restrain the patient [Patient #10] to allow performance of an EKG, [electrocardiogram] [Staff Member B] entered room to assist and became physically aggressive towards...[Patient #10]...” During an interview on 9/12/2024 at 10:10 AM, Registered Nurse (RN) D stated she was working in the emergency room on 8/17/2022, when she witnessed Patient #10 being placed in 4-point (all four extremities) restraints. RN D stated she saw staff members around Patient #10. The patient started kicking his feet, Staff Member B picked up Patient #10’s feet and aggressively slammed the patient’s feet down on the bed and tightened the restraints too tight. Staff Member B was yelling at the patient to stop kicking. RN D stated she had never seen Staff Member B so aggressive with a patient before. Medical record review of Patient #5 revealed he arrived at the facility by ambulance on 6/22/2024, for a right arm laceration. Patient #5 was treated for the right arm laceration and was discharged home on 6/22/2024. Review of the facility’s document titled, “eSAFE” incident report dated 6/27/2024, revealed an incident between a contracted security officer (Security Officer-SO Q) and Patient #5 occurred on 6/22/2024. The incident report read “...[Patient #5] ...brought in on 6/22/2024 for a severe circumferential arm laceration...[Patient #5] was...held on the EMS [Emergency Medical Service] stretcher...in front of the charge desk the patient’s arm was bumped the patient sat up on the stretcher and screamed in pain. When this happened...[SO Q] approached the patient grabbing him by the head and slammed him backwards and held the patient’s face by under the chin pushing upwards and the top of the head pushing down so the patient could not open his mouth...[Registered Nurse-RN AA] came from the back side of the charge desk...around to where the incident was occurring [SO Q] had removed his badge and was holding it in the patients face saying ’...this is my ER [explicit language]’...[RN AA] attempted to diffuse the situation and [SO Q] would not stop...[RN AA] stepped away to ask someone to call for more help and when I returned to the patients side [SO Q] eventually let go but kept arguing with the patient...antagonizing the patient...” Medical record review revealed Patient #2 presented to the ED on 7/5/2024, with a self-inflicted gunshot wound (GSW) to the head. Further review revealed Patient #2 was hemodynamically stable, alert and oriented, with combative behaviors. On initial evaluation, Patient #2 was extremely anxious, refused to answer questions about self-inflicted GSW, and quickly became agitated upon further questioning. Patient #2’s blood alcohol level was 244 mg/dL (milligrams/deciliters-units of measure). The patient was placed on suicide precautions; 1:1 observation with sitter to bedside; placed in a yellow gown; and was placed on Certificate of Need (CON-emergency psychiatric commitment) hold due to the potential harm or danger to self and others. Review of the facility’s document titled, “eSAFE” incident report dated 7/5/2024, revealed “...ED [Emergency Department] bed 7 was brought in as a self-inflicted GSW to the head. Shortly after arrival, pt [patient] was placed on a CON d/t [due to] SI [suicidal ideation] and attempted suicide. [Registered Nurse-RN W] responded to [Patient #2] room after hearing screaming. Upon entry, [Patient #2] was removing bedside monitoring equipment, agitated, and asking to leave. [RN W] alerted [Medical Doctor-MD Y] of [Patient #2] behavior. [MD Y] gave a verbal order for IV [intravenous] Ativan [a sedating medication] and soft wrist restraints. [Patient #2] was placed in wrist restraints and medication was administered as prescribed. [Patient #2] was found again, out of bed, with restraints removed. [RN W] entered the room to find [Patient #2] agitated with several...security officers at bedside. [Patient #2] was visually upset and attempting to leave the ED. [RN W] alerted [MD Z] of [Patient #2] behavior and increased agitation. [MD Z] gave a verbal order for IM [intramuscular] medications and violent wrist restraints. [RN W] left the room to grab restraints, upon returning to the room, [Patient #2] was found being placed in the bed by 4 security guards. Security was attempting to move [Patient #2] in the bed when one of them verbalized being kicked. [SO, X] then hit [Patient #2] with a closed fist on his chest. [RN W] was unable to reach...[Patient #2] d/t the number of security officers at the bedside. [Patient #2] was thrashing during the attempt to restrain him. During the events...[Patient #2] became agitated and was grabbing at security. [SO X] stated ‘I’m going to punch you if you touch my officers again.’ [SO X] then proceeded to hit the pt [Patient #2] several more times with a closed fist in the chest and abdomen...[SO X]...turned to [MD Z] and stated, “I had to punch him, he grabbed my guys.”...[Patient #2] was placed in violent restraints...intermittently sat up...was agitated. IM [intramuscular] medications were administered...[Patient #2] was hit with a closed fist several more times by [SO X] after medication administration...” Medical record review revealed Patient #11 was a patient in the ER on 8/28/2024 at 11:15 PM, and revealed “... CO [corrections officer] attempted to put mobility chains [immobilizes upper extremities] on Patient #11 due to patient being able to move hands freely. During this encounter, Patient #11 reached for off-duty officer’s gun. Security at bedside to subdue. Patient spitting blood onto security guards. Patient laughed and stated that ‘it’s funny because I have AIDS.’ Blood is on security guard’s skin and clothing. House supervisor made aware...CO requesting more officers to assist with patient...” Review of a facility incident report for Patient #11 dated 9/11/2024, revealed “...On 09/11/24, while reviewing the combative patient report, which I [Security Director] review daily, I [Security Director] saw [Security Officer O] antagonized and bully an almost incoherent patient. PT [Patient] I [Security Director] [Patient #11] was brought into the ER [emergency room] by the...County Sheriff’s Office, by Corrections Officer. The PT [Patient #11] had been violently beaten by other inmates while incarcerated and had open bleeding wounds on his face and in his mouth. [Security Officer O] reported a violent individual who was hitting and punching Police Officers, and at one point even trying to take officer firearm. In the footage I [Security Director] observed [Security Officer O] stalking the PT [Patient #11], who 99% of the time was sitting still and compliant. I watched the incident unfold with [Security Officer O] taking a hair net from the nurse’s station, placing it over the PT’s [Patient #11] head, and pulling it tight sneakily coming up behind the PT [Patient #11]. In the footage, [Security Officer O] is grinning. [Security Officer O] was not asked to assist and should have no dealings with a guarded...County Inmate. [Security Officer O] again grabbed the patient by the face, without being asked to assist, and violently shoved the patient’s head down into a bed with no regard for the open wounds on his face and in his mouth and not knowing if there was a neck injury or any kind of head injury. [Security Officer O] later takes a towel, which he was constantly fixated on for some reason on the PT [Patient #11] spitting, in which the video shows he never spit on anyone and told another officer to help him with this guy who is spitting and places the towel over the PT’s [Patient #11] face and holds his head immobile with heavy pressure. [Security Officer O] continues to get involved and gets into the face of the PT [Patient #11] cursing him and lunging at the PT [Patient #11], when the PT [Patient #11] leaned forward [Security Officer O] violently strikes the PT [Patient #11] again in his face, still not knowing if he could have further injured or killed the PT [Patient #11]. The...County deputy had to get between [Security Officer O] and the PT [Patient #11] and move him out of the way. [Security Officer O] stated he was spat on that was why he hit him, but video footage shows no blood coming from the PT’s [Patient #11] mouth or on [Security Officer O]. [Security Officer W] witnessed the incident and stated the blood came from [Security Officer O] slapping the Pt [Patient #11] with open wounds and made the blood splatter all over everyone. The report written by [Security Officer O] has him pressing charges on the PT [Patient #11] and charging him with Aggravated assault...” During an interview on 9/19/ 2024, at 12:55 PM, the Patient Safety Quality Manager stated she was made aware on 9/19/2024 of the events that took place involving Security Officer O and Patient #11 on 8/28/2024. The Patient Safety Quality Manager could not explain why it took 21 days for her to be made aware of the patient abuse that occurred on 8/28/2024. She stated she and the abuse teams reviewed the video footage of Security Officer O interacting with [Patient #11] and deemed Security Officer O’s interactions were abusive. The Patient Safety Quality Manager stated she contacted the Chief of Security and asked Security Officer O to be removed from the hospital and not be allowed to return, 21 days after the abuse. During interview on 9/19/2024 at 1:10 PM, the Director of Security stated he was employed by the hospital’s contracted security company and had been the Director of Security since 4/1/2024. The Director of Security stated Security Officer O was the night shift supervisor, and he had noticed that most of the aggressive behavior documented had been on the night shift and by officers supervised by Security Officer O. Security Officer O was terminated from the hospital’s contracted security company because of his abusive actions taken against the emergency room Patient #11. Medical record review of Patient #6 revealed the patient was admitted on 4/21/2024, at 5:53 PM, “Means of arrival, ambulance...hx [history] of homelessness, COPD [Congestive Obstructive Pulmonary Disease], DM [Diabetes Mellitus], and HTN [Hypertension] presents for bilateral lower extremity pain and hip pain. Patient tearful on interview. Patient reports last Wednesday she started to notice some left hip pain as well as lower extremity pain. Patient denies any recent fever, chest pain, or shortness of breath...does report some chills.” Review of the discharge summary dated 4/21/2024 7:43 PM [less than 2 hours after admission] “Please continue your home medications. Continue the Doxycycline that was prescribed by previous providers to complete the course of antibiotics. There was no acute fracture of your L [left] hip seen on your Hip Xray. Please follow up with your primary care physician. Please return to ED if you develop any new or worsening symptoms.” Interview with RN K, on 9/11/2024 at 11:05 AM, revealed RN K was the discharging nurse for patient #6 on 4/21/2024. He reviewed Patient #6’s medical record, did not remember patient #6 well, but had some recollection of Patient #6 from 4/21/2024. He discharged Patient #6 on 4/21/2024, after being treated in the emergency room for Cellulitis. Patient #6 was wheelchair bound and was not able to walk on her own. Interview revealed from 8:00 AM to 4:30 PM, there was a case manager who assists patient with transportation if the patient does not have transportation. The case manager was not on duty when Patient #6 was discharged at 7:43 PM, on 4/21/2024. He remembered Patient #6 was homeless. He stated “typically would call for a [name of taxi] if a patient does not have transportation,” but patients who are wheelchair bound would require a van with a lift and “he wasn’t sure if [Hospital #1] would pay for a lift van....Sometimes I just push the homeless patients in the ER breezeway and let them figure out how they are going to get to where they stay.” Interview continued and he denied he “dumped” Patient #6 on the sidewalk outside the emergency room, but he could not explain how Patient #6 was found the following day on the sidewalk, outside the Hospital #1’s emergency room, with no wheelchair. He state that patients are taken out of the emergency room in a wheelchair when being discharged, but do not get to keep a wheelchair from the emergency room. Interview with staff member L, on 9/11/2024 at 9:25 AM, revealed she was an ER Clinical Staff Leader and stated if a patient does not have transportation [Hospital #1] will always try to get the patient transportation to their place of residence. She stated there was a case manager available during the day to arrange transportation and the house supervisor can arrange transportation for patients after hours and [Hospital #1] will arrange transportation for patients that are wheelchair bound. Interview with Officer J, with the local City Police Department on 9/11/2024 at 3:40 PM, revealed he was a supervisor with a police crisis response team which deals with social and criminal issues in the city. On 4/22/2024 at 4:30 PM, one of his officers responded to a call that a person was found crawling in the street outside on the emergency room at [Hospital #1]. The officer found Patient #6 on the street, indicating that she wanted to die and that was the reason she was crawling in the street. Continued interview revealed Patient #6 explained she had been seen in the emergency room the previous day and was taken to a bench outside the emergency room, in a wheelchair by a nurse, and was left on a bench. Patient #6 explained she was not able to walk on her own, needed a wheelchair to get around and her wheelchair was at the community kitchen where she lived on 11th street. An ambulance was called and Patient #6 was transported to Hospital #2. Review of emergency medical services (EMS) transport records of patient #6 dated April 22, 2024, revealed, the following: “...per police report: patient [patient #6] was seen last night [4/21/2024] at [hospital #1] ...for hip pain... and was discharged back to the community. Patient was taken across the street in a wheelchair... and left in... her own care.... patient did not have access to transport or... her wheelchair and slept on the sidewalk. Patient is non-ambulatory... and has severe cellulitis in... her lower extremities. patient has been non-compliant with all medications for at least one month. Police found patient on sidewalk... and patient expressed suicidal ideation with a plan to crawl into traffic. Mobile crisis was called and volunteer behavioral placed patient on a [involuntary psychiatric commitment]. Patient is going to ... [hospital #2] ... ED for medical clearance and inpatient psychiatric placement. Patients mental state... is alert... and oriented... and answers all questions appropriately. Patient is calm and cooperative. Patient was found lying on sidewalk... and had urinated and defecated on herself due to incontinence and inability to get to a restroom. Patient complained of feeling cold and uncomfortable with hip pain ...from sleeping on sidewalk ...patient admits to continued suicidal ideation... patient admits to a suicide attempts in the past... and has had previous psychiatric hospitalizations. Patient feels hopeless... and complains of being a burden...patient feels she is in need of skilled nursing care... as she is unable to care for herself...”. Medical record review of Patient #6 after admitted to Hospital #2’s ER on 4/22/2024, revealed the following: “Patient is a 66-year-old white female who presents to the emergency room with complaints of suicidal ideations that are mainly of a social initiation. Patient is a morbidly obese female that is confined to a wheelchair and is homeless. She was brought in by EMS with a CON in place. Patient has a known history of bipolar disorder, Schizoaffective disorder and supposedly was in [Hospital #3] about a month ago. It is of note that patient was supposed to discharge from [Hospital #2] and went to live at a local homeless shelter. Earlier this week she had a fall out of her wheelchair and went to [Hospital #1] where they evaluated her and discharged her...to the street yesterday. The patient states...urinated and defecated on herself. According to EMS, she was...covered in urine and feces...It is of note that the patient started to crawl...going to traffic in an attempt to get help and possibly kill herself. Once again, the patient presents with suicidal ideations without plan. Patient was seen 4 days ago in the emergency room ...Patient still has erythematous legs..” Review of hospital policy Case Management-Transition Management, Discharge Planning, and Patient Choice, last revised 6, 2021, stated...”Transition Management” -the process of assessing and reassessing the patients for post-hospital needs and then developing and implementing a plan to coordinate those services identified as necessary for the patient when they leave the hospital. The process includes a mechanism for a Case Management Registered Nurse or Social Worker to identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge or transfer if there is inadequate planning... as outlined in the routine nursing assessment. A discharge planning evaluation by the CM/SW may be requested...Transition management will be conducted in accordance with all legal mandates while supporting the patient’s ethical and moral directives. Case Management discharge planning services are available to all patients regardless of age, sex, national origin, race, and sexual orientation...All discharge evaluations and discharge plans are recorded in EPIC by the RN/SW Case manager and the results are discussed with the patient or individual acting on his or her behalf...” During an interview with the Patient Safety and Quality Director, on 9/16/2024, at 10:30 AM, she stated that she was aware of the incident related to Patient #6’s unsafe discharge on 4/21/2024 and did not investigate the discharge, do an incident report on the incident, or look for a way to prevent this type of unsafe discharge from happening in the future. When asked if Patient #6’s 4/21/2024 was an unsafe discharge, she stated “it was not an optimal discharge.” Review of hospital documentation titled, “Leaving Against Medical Advice” revised 07/2023, revealed “This policy provides guidance for [Hospital #1] in addressing situations where a patient or his or her decision maker states the desire to leave the facility against medical advice in a manner that both promotes patient safety and honors patient rights ... [Hospital #1] responds appropriately to all requests for treatment. When a patient or his or her parent/ legal guardian/surrogate takes action for the patient to leave Against Medical Advice (AMA), a record should be made of the circumstances. Staff members and the physician should also attempt to educate the patient/parent/ legal guardian/surrogate about the consequences of leaving without approval ... A. As soon as any staff member becomes aware of the patient’s desire to leave the facility AMA, the attending physician should be called. The attending physician, nurse, and/or assigned patient caregiver should attempt to determine the reason(s) for the desire to leave AMA. B. The staff member should then notify the unit nurse manager and House Supervisor or designee of the desire to leave AMA. C. The patient’s nurse should document the intent to leave AMA and any actions taken to leave AMA in the patient’s medical record. D. If it is possible to address the concerns voiced by the patient or parent/legal guardian/surrogate, every reasonable attempt should be made to do so. If it is not possible to change the patient/parent/legal guardian/surrogate’s decision to leave AMA, the charge nurse should speak to the patient/parent/legal guardian/surrogate to explain that the attending physician/designee should speak with them prior to their leaving the facility. E. The charge nurse should inform the patient/parent/legal guardian/surrogate that his/her insurance company may not pay for the hospitalization if the patient leaves AMA...G. If the attempts to discourage the patient from leaving AMA are unsuccessful, the patient’s nurse or attending physician should document the following: I. The nurse and/or physician explained to the patient/parent/legal guardian/surrogate the risks associated with leaving without treatment and should document the explanation in the patient’s medical record. The nurse and/or physician/designee should also document in the medical record all attempts made to address the patient/parent/legal guardian/surrogate’s concerns and actions taken by the medical staff to encourage the patient/parent/legal guardian/surrogate to stay at the facility. ii. The patient/parent/legal guardian/surrogate is requested to sign the “Release of Responsibility” form (#38543). The release may be signed by the patient if 18 years of age or older without decision-making capacity. iii. A notation should be made in the nurses’ notes by the nurse, stating that “the patient/parent/legal guardian/surrogate was informed about the medical concerns related to leaving AMA and has chosen to leave the hospital.” iv. A notation should be made in the medical record by the attending physician indicating the events that occurred and reasons (if known) for the patient/parent/ legal guardian/surrogate deciding to leave AMA. The attending physician is also required to sign the “Release of Responsibility” section of the form. v. If the patient/parent/legal guardian/surrogate refuses to sign the “Release of Responsibility” form, the nurse or attending physician should complete and document the patient’s refusal on the form and place the form in the patient’s medical record. Place the “Release of Responsibility” form in the patient’s chart with or without the patient/parent/legal guardian/surrogate’s signature. vi. The patient’s nurse completes an electronic occurrence report regarding the AMA situation. vii. The patient’s nurse completes the Nursing Discharge assessment.” Review of hospital record review for Patient #12, an 82-year-old female was admitted to the emergency room (ER) on 5/20/2024 at 20:40 (8:40 PM EST) after she had fallen on the ground during a syncopal episode (sudden loss of consciousness due to a drop in blood flow to the brain), hitting her head. Continued record review revealed she initially had experienced mild confusion after the fall. Patient #12 also had medical history of Atrial Fibrillation (irregular and often very rapid heart rhythm) arthritis, asthma, claustrophobia (fear of confined spaces), and hypertension. Review of laboratory results for patient #12, dated 5/20/2024 revealed “Abnormal” laboratory results without defining or providing the normal and abnormal reference ranges or the specific results for Patient #12. Creatinine ( blood test to measure how kidneys are performing and filtering waste)- results “Abnormal”; Urea Nitrogen ( blood test for a marker of kidney function)- results “Abnormal”; Glucose ( a simple sugar the body uses for energy )- results “Abnormal”; Hematocrit ( blood test to determine the percentage of red blood cells in the blood)-results “Abnormal”; Basic Metabolic Panel ( a blood test that checks for kidney health, blood sugar, electrolytes and acid base balance in the blood) -results “Abnormal”; Complete Blood Count ( CBC) with differential( a blood test that measures red and white blood cells to test for anemia and infections, some heart diseases, autoimmune disorders)- results “Abnormal”; Continued review of laboratory results on 5/21/2024 revealed, Ferritin ( a protein that stores iron) - results “Abnormal”; Folate ( important in red blood cell formation)- results “Abnormal”; Iron( mineral vital to the proper function of hemoglobin, a protein needed to transport oxygen in the blood)- results “Abnormal”; Total Iron Binding ( test that measure blood’s ability to bind to iron and carry it through the body)- results “Abnormal.” Review hospital documentation titled, “Emergency Care (ED) Timeline” revealed Patient #12 was discharged on 5/22/2024 at 10:11 AM with peripheral intravenous fluids (IV) discontinued at 10:12 AM. Continued record revealed there was no documentation for Patient #12 as per the hospital’s AMA policy to reflect, “... a record should be made of the circumstances, or the physician was notified or the notification of the unit nurse manager or the House Supervisor or designee” of Patient # 12 desire to leave AMA. Further record review revealed Patient #12 was not provided with the explanation by “the nurse and/or physician, the risks associated with leaving without treatment...” and no documentation “all attempts made to address the patient...concerns and actions taken by the medical staff to encourage patient...to stay at the facility” per the hospital’s AMA policy after Patient #12 suffered a head injury resulting from a fall and without documented treatment for the noted “Abnormal” laboratory results. Review of hospital documentation titled, “Leaving the Hospital Against Medical Advice” dated 5/24/2024, revealed Patient #12 had signed the document stating, “ This will certify that I, the undersigned, [patient # 12 name] A patient in the above named medical center, having requested discharge and removal from the medical center against the advices of my attending physician(s), hereby release [name of hospital], its physicians, officers and employees, severally and individually, from any and all liability of any nature whatsoever for any injury or harm or complication of any kind that may result directly or indirectly , by reason of my terminating my stay as a patient as [name of hospital] and my departure from said medical center, and hereby waive any and all rights f action I many now have or later acquire as a result of my voluntary departure from said medical center and the termination of my stay as a patient therein. This /release is made with the full knowledge of the danger that may result from the action I am taking.” The document was signed by the patient and witnessed, along with the signature of the nurse. However, the physician signature was noted to not be signed and was blank where the physician was to sign. Medical record review revealed Patient #13, a 39-year-old male, was admitted to the Emergency Room (ER) on 6/30/2024 with a diagnosis of Sepsis (a life threatening reaction to infection that can damage organs and tissues). Patient #13 also had a medical history of Cervical Vertebrae (C4-C5) Spinal Injury following a fall and resulting Paraplegia complicated by neurogenic bladder, neurogenic bowel, stage IV left Ischial decubitus ulcer status post (excision and flap closure in 12/2023) and Deep Vein Thrombosis (DVT). Review of laboratory results for patient #13, dated 7/3/2024, revealed elevated White Blood Count (CBC) (a measurement of the number of white blood cells in the body and can detect infection). The normal range for the hospital’s WBC was noted to be 10*3/uL with patient #13 results at 17.1 and flagged as being out of range. Review of hospital documentation titled, “Progress Notes” dated 7/03/24 at 6:03 PM, revealed RN N documented, “Patient ready to leave AMA, as he feels urology, and wound care have ignored him. Pulled out his foley and is currently getting dressed. Notified MD.” According to” Care Timeline” on the progress note, Patient #13 was discharged 7:21 PM. Review hospital documentation titled, “Progress notes” dates 7/3/2024 at 6:03 PM, revealed Patient #13 was discharged AMA. Continued record revealed there was no documentation for Patient #13 as per the hospital’s AMA policy to reflect, “... a record should be made of the circumstances, or the physician was notified or the notification of the unit nurse manager or the House Supervisor or designee” of Patient #13 desire to leave AMA. Further record review revealed Patient #13 was not provided with the explanation by “the nurse and/or physician, the risks associated with leaving without treatment...” and no documentation “all attempts made to address the patient... concerns and actions taken by the medical staff to encourage patient...to stay at the facility” per the hospital’s AMA policy after patient #13 was diagnosed with Sepsis and with an elevated WBC. During an interview on 9/11/24 at 4:01 PM, RN M discharged Patient #13 on 7/3/2024 at 7:21 PM, stated he was not aware of the hospital’s policy for AMA. When asked if RN M explained the risks of leaving AMA to Patient # 13, he stated, “No, he [Patient #13] was very kind, but he said he felt like he was not getting the care that he needed there.” Upon further interview with RN M, it was revealed he was not aware of the AMA policy and had not been in serviced on the AMA policy. RN M further stated he did not provide Patient #13 with risks to his health when he left AMA. He further stated Patient #13 left before the doctor could see Patient # 13. RN M did not provide Patient #13 with risks regarding his diagnosis of Sepsis and/or elevated WBC. During an interview on 9/12/24 at 11:25 AM, revealed RN N discharged Patient # 12 on 5/22/2024, stated she was not aware of the hospital’s policy for AMA, only that an “AMA form is provided to the patients if they want to leave, and it lets them know of their risks if they decide to leave and the patient signs the AMA form.” When asked if RN N explained the risks of leaving AMA to Patient # 12, she stated, “No.” Upon further interview with RN N it was revealed she not seen the AMA policy and had not been in serviced on the AMA policy. During an interview on 9/12/2024 at 11:30 AM, the hospital’s attorney stated, “It’s on them [patients] when they sign out AMA. They understand the risks when they sign the AMA form.” Refer to A-0115, A-0145 and A-0799.”

“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: 49485 Based on facility policy review, medical record review and interview, the hospital failed to protect each patient’s right to be free from abuse for 4 patients (Patients #10, #5, #2, and #11) of 15 patients reviewed for abuse. The findings include: Review of the facility policy titled, “Patient Rights,” dated 8/2024, revealed “...You, the patient, have the right to...Be safe from abuse or harassment...It is your responsibility to...Accept that bad language or bad behavior will not be tolerated...” Review of the facility policy titled, “Abuse Reporting” dated 11/2024, revealed “...All patients have the right to be free from all acts of violence...from staff...The hospital will ensure that patients are free from all forms of abuse...All allegations of abuse...will be investigated thoroughly and will begin immediately once the allegation has been made...If the allegation is against a...care giver for the patient, the caregiver will be removed from caring for the patient...Education is provided during new employee orientation...annual training...on abuse...including reporting requirements, prevention, intervention, and detection...The investigation will include interviews of all persons involved...Incidents of abuse...harassment will be reported...analyzed with appropriate corrective, remedial, or disciplinary actions taken in accordance with applicable local, State, or Federal law...Reports of suspected abuse...harassment shall be made to Senior Leadership or the Risk Manager immediately...The caregiver affected by the allegation will be placed on administrative leave during the investigation...If the allegations are substantiated, the employee will be terminated and the appropriate agencies will be notified...” Review of a written statement from Staff Member B dated 8/17/2022, revealed “ ...Walked into the unit @ [at] 625 am [6:25 AM] Saw pt [Patient #10] in bed 8 being restrained. Offered assistance. Help [Patient Care Technician/PCT]...hold left arm to assess the...IV [intravenous] was bad so we took off...[specialized pressure bandage]...and tried to take off the tape. While this was happening, [Staff Member B] was at the right arm of the pt [Patient #10]. I [Staff Member B] heard the pt [Patient #10] say, “that hurts, my arm hurts, it feels like you are going to break it!” I heard [Licensed Practical Nurse/LPN] V say, “wait his arm is at an angle, let go, that doesn’t look right.” I looked up and saw his [Patient #10’s] arm bent at an angle toward the head of the bed. After IV was wrapped up, I left to answer call lights. I heard another commotion and came back into the room. Pt [Patient #10] was kicking his legs. [Staff Member B] was to the foot of the bed and grabbed the pts [Patient #10’s] legs and slammed them down on the bed and yelled very loudly at the pt “STOP RIGHT NOW!” [Staff Member B] held the pts [Patient #10] legs down while someone else retied the leg restraints. The restraints were reassessed and found to be to [too] tight ...” Review of the facility’s document titled, “eSAFE” incident report dated 8/17/2022, revealed “...While multiple staff were attempting to restrain the patient [Patient #10] to allow performance of an EKG, [electrocardiogram] [Staff Member B] entered room to assist and became physically aggressive towards...[Patient #10]...” During an interview on 9/12/2024 at 10:10 AM, Registered Nurse (RN) D stated she was working in the emergency room on 8/17/2022 when she witnessed Patient #10 being placed in 4-point (all four extremities) restraints. RN D stated she saw staff members around Patient #10. The patient started kicking his feet, Staff Member B picked up Patient #10’s feet and aggressively slammed the patient’s feet down on the bed and tightened the restraints too tight. Staff Member B was yelling at the patient to stop kicking. RN D stated she had never seen Staff Member B so aggressive with a patient before. Medical record review revealed Patient #5 arrived at the facility by ambulance on 6/22/2024 for a right arm laceration. Patient #5 was treated for the right arm laceration and was discharged home on 6/22/2024. Review of the facility’s document titled, “eSAFE,” incident report dated 6/27/2024, revealed an incident between a contracted security officer (Security Officer-SO Q) and Patient #5 occurred on 6/22/2024. The incident report revealed, “...[Patient #5] ...brought in on 6/22/2024 for a severe circumferential arm laceration...[Patient #5] was...held on the EMS [Emergency Medical Service] stretcher...in front of the charge desk the patient’s arm was bumped the patient sat up on the stretcher and screamed in pain. When this happened...[SO Q] approached the patient grabbing him by the head and slammed him backwards and held the patients face by under the chin pushing upwards and the top of the head pushing down so the patient could not open his mouth...[Registered Nurse-RN AA] came from the back side of the charge desk...around to where the incident was occurring [SO Q] had removed his badge and was holding it in the patients face saying “ this is my ER [explicit language]”...[RN AA] attempted to diffuse the situation and [SO Q] would not stop...[RN AA] stepped away to ask someone to call for more help and when I returned to the patient’s side [SO Q] eventually let go but kept arguing with the patient stating he could have his name and badge...antagonizing the patient...” Medical record review revealed Patient #2 was admitted on 7/5/2024, to the ED with a self-inflicted gunshot wound (GSW) to the head. Further review reveled Patient #2 was hemodynamically stable, alert and oriented, with combative behaviors. On initial evaluation, Patient #2 was extremely anxious, refused to answer questions about self-inflicted GSW, and quickly became agitated upon further questioning. Patient #2’s blood alcohol level was 244 mg/dL (milligrams/deciliters-units of measure). The patient was placed on suicide precautions; 1:1 observation with sitter to bedside; placed in a yellow gown; and was placed on Certificate of Need (CON-emergency psychiatric commitment) hold due to the potential of harm or danger to self and others. Review of the facility’s document titled, “eSAFE” incident report dated 7/5/2024, revealed “...ED [Emergency Department] bed 7 was brought in as a self-inflicted GSW [gunshot wound] to the head. Shortly after arrival, pt was placed on a CON d/t [due to] SI [suicidal ideation]and attempted suicide. [Registered Nurse-RN W] responded to [Patient #2] room after hearing screaming. Upon entry, [Patient #2] was removing bedside monitoring equipment, agitated, and asking to leave. [RN W] alerted [Medical Doctor-MD Y] of [Patient #2] behavior. [MD Y] gave a verbal order for IV [intravenous] Ativan [a sedating medication] and soft wrist restraints. [Patient #2] was placed in wrist restraints and medication was administered as prescribed. [Patient #2] was found again, out of bed, with restraints removed. [RN W] entered the room to find the [Patient #2] agitated with several...Security officers at bedside. [Patient #2] was visually upset and attempting to leave the ED. [RN W] alerted [MD Z] of [Patient #2] behavior and increased agitation. [MD Z] gave a verbal order for IM [intramuscular] medications and violent wrist restraints. [RN W] left the room to grab restraints, upon returning to the room, the [Patient #2] was found being placed in the bed by 4 security guards. Security was attempting to move the [Patient #2] in the bed when one of them verbalized being kicked. [SO X] then hit the [Patient #2] with a closed fist on his chest. [RN W] was unable to reach... [Patient #2] d/t the number of security officers at the bedside. [Patient #2] was thrashing during the attempt to restrain him. During the events...[Patient #2] became agitated and was grabbing at security. [SO X] stated “I’m going to punch you if you touch my officers again.” [SO X] then proceeded to hit the pt [Patient #2] several more times with a closed fist in the chest and abdomen...[SO X]...turned to [MD Z] and stated, ‘I had to punch him, he grabbed my guys.’...[Patient #2] was placed in violent restraints...intermittently sat up...was agitated. IM [intramuscular] medications were administered...[Patient #2] was hit with a closed fist several more times by [SO X] after med administration...” Medical record review of Patient #11’s medical record, dated 8/28/2024 at 11:15 PM, revealed “...CO [corrections officer] attempted to put mobility chains [immobilizes upper extremities] on Patient #11 due to patient being able to move hands freely. During this encounter, Patient #11 reached for off-duty officer’s gun. Security at bedside to subdue. Patient spitting blood onto security guards. Patient laughed and stated that ‘it’s funny because I have AIDS.’ Blood is on security guard’s skin and clothing. House supervisor made aware...CO requesting more officers to assist with patient...” Review of a facility incident report for Patient #11, dated 9/11/2024, revealed “...On 09/11/24, while reviewing the combative patient report, which I [Security Director] review daily, I [Security Director] saw [Security Officer O] antagonized and bully an almost incoherent patient. PT [Patient] I [Security Director] [Patient #11] was brought into the ER by the...County Sheriff’s Office, by Corrections Officer. The PT [Patient #11] had been violently beaten by other inmates while incarcerated and had open bleeding wounds on his face and in his mouth. [Security Officer O] reported a violent individual who was hitting and punching Police Officers, and at one point even trying to take officer firearm. In the footage I [Security Director] observed [Security Officer O] stalking the PT [Patient #11], who 99% of the time was sitting still and compliant. I watched the incident unfold with [Security Officer O] taking a hair net from the nurse’s station, placing it over the PT’s [Patient #11] head, and pulling it tight sneakily coming up behind the PT [Patient #11]. In the footage, [Security Officer O] is grinning. [Security Officer O] was not asked to assist and should have no dealings with a guarded...County Inmate. [Security Officer O] again grabbed the patient by the face, without being asked to assist, and violently shoved the patient’s head down into a bed with no regard for the open wounds on his face and in his mouth and not knowing if there was a neck injury or any kind of head injury. [Security Officer O] later takes a towel, which he was constantly fixated on for some reason on the PT [Patient #11] spitting, in which the video shows he never spit on anyone and told another officer to help him with this guy who is spitting and places the towel over the PT’s [Patient #11] face and holds his head immobile with heavy pressure. [Security Officer O] continues to get involved and gets into the face of the PT [Patient #11] cursing him and lunging at the PT [Patient #11], when the PT [Patient #11] leaned forward [Security Officer O] violently strikes the PT [Patient #11] again in his face, still not knowing if he could have further injured or killed the PT [Patient #11]. The...County deputy had to get between [Security Officer O] and the PT [Patient #11] and move him out of the way. [Security Officer O] stated he was spat on that was why he hit him, but video footage shows no blood coming from the PT’s [Patient #11] mouth or on [Security Officer O]. [Security Officer W] witnessed the incident and stated the blood came from [Security Officer O] slapping the Pt [Patient #11] with open wounds and made the blood splatter all over everyone. The report written by [Security Officer O] has him pressing charges on the PT [Patient #11] and charging him with Aggravated assault...” During an interview on 9/19/2024, at 12:55 PM, the Patient Safety Quality Manager, stated she was made aware on 9/19/2024 of the events that took place involving Security Officer O and Patient #11 on 8/28/2024. The Patient Safety Quality Manager could not explain why it took so long for her to be made aware of the patient abuse that occurred on 8/28/2024 until the morning of 9/19/2024, a period of 21 days. She stated that she and the abuse teams reviewed the video footage of Security officer O interacting with the Patient #11, and deemed Security Officer O’s interaction was abusive. The Patient Safety Quality Manager stated she contacted the Chief of Security and asked Security officer O to be removed from the hospital and not be allowed to return. During interview on 9/19/2024, at 1:10 PM, the Director of Security stated he was employed by the hospital’s contracted security company and has been the Director of Security since 4/1/ 2024. The Director of Security stated Security Officer O was the night shift supervisor, and he has noticed that most of the aggressive behavior documented had been on the night shift and by officers supervised by Security Officer O. Security officer O was terminated from the hospital’s contracted security company because of his abusive actions taken against the emergency room Patient #11. Refer to A-0115 and A-0144.”

“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: 32792 Based on facility policy review, medical record review, video footage review, review of facility documentation, observation and interviews, the facility failed to ensure patient rights were protected for 1 (Patient #25) of 18 patients reviewed for abuse by failing to protect Patient #25 from verbal and physical abuse. The findings include: Review of the facility policy “Abuse Reporting” dated 11/2023, revealed “...all patients have the right to be free from all acts of violence that could threaten their physical or mental well-being whether from staff, other patients, or visitors. The hospital will ensure that patients are free from all forms of abuse...if the allegation is against a current caregiver for the patient, the caregiver will be removed from caring for the patient and an alternative caregiver will be assigned...caregiver...will be placed on administrative leave during the investigation...” Review of the Emergency Department (ED) medical record, dated 10/26/2023 at 7:09 PM, revealed Patient #25 entered the ED with the chief complaint of Suicidal and Alcoholic Intoxication without complication. He was placed in room 36. Review of the “Systems and Physical Exam” revealed “...patient is clinically intoxicated, is answering most questions without difficulty...denies suicidal ideation...” Patient #25 had a blood alcohol [ETOH] level of 399 mg/dl [milligram/deciliter] (high) on 10/26/2023 at 7:51PM. The ED Course & [and] MDM [Medical Decision Making] dated 10/26/2023 at 8:23 PM, revealed “...awaiting sobriety and telepsychiatry evaluation...” Review of the “Safety Precautions” dated 10/26/2023 at 7:46 PM, for Patient #25, revealed an emergency (involuntary) hold had been placed with emergency detention due to potential danger of harm to self and/or others, suicide and elopement precautions, continuous 1:1 staffing, and placement in a yellow hospital gown. He denied suicidal thoughts, displayed no self-injurious behavior and displayed no harmful actions toward others. Review of the ED Progress Notes, dated 10/26/2023 at 9:00 PM, revealed Patient #25 was agitated and restless. He was medicated with Haldol (antipsychotic medication) 5 mg. Further review revealed an order for seclusion, dated 10/26/2023 at 9:34 PM, due to behaviors including pushing against staff, threatening harm to others and threatening stance. He was escorted to Room 14, the ED Seclusion Room. A review of the ED Progress Notes, dated 10/27/2023 at 9:00 AM, showed Patient #25’s behavior was charted as calm, cooperative and denied suicidal or homicidal thoughts. He was resting comfortably. Patient #25’s emergency hold and detention were discontinued on 10/27/2023 at 9:10 AM and the patient was discharged home on 10/27/2023 at 9:33 AM. An observation and tour of the ED on 3/4/2024 started at 4:00 PM, with the Director of ED Services and the Director of Risk Management and revealed the ED had a licensed bed capacity for 52 beds with a total bed capacity for 65 patients (including stretchers, vertical recliners, and chairs). Observation of the ED showed multiple staff and patients. Observation of the 1 of 1 Seclusion Room (#14), showed a small, windowless room with a padded, cushioned bed bolted to the floor. There was a small window to view in the door. A review of the ED video footage, dated 10/26/2023, no audio available, showed the following: -10:25 at 29 sec: observation of the Seclusion Room (Room 14). A staff member was standing opposite the seclusion room leaning against the wall. The seclusion room’s door was open. A security officer walked up to the door and walked out of frame. Patient #25 was observed standing in the door of the room, dressed in a yellow hospital gown with socks. He was observed talking to a sitter and looking up and down the hallway. -10:25 at 48 sec: Security Officer #1 appeared in the video. Patient Care Technician (PCT) #6 observed standing behind Security Officer #1. Security Officer #1 stepped up to Patient #25 and placed his left hand on the patient’s right shoulder. The Security Officer’s left hand was open with his palm was on the patient’s right shoulder. The patient and the security guard appeared to speak to each other. Patient #25 had his hands to his side. The fists were not clenched. Patient #25 raised his hand to block the security officer. Patient #25 attempted to walk further out of the room. Security Officer #1, with his left-hand, palm opened, pushed Patient #25 back into the room. Security Officer #2 arrived and both officers entered the room and placed the patient on the bed. -10:26. 8 sec. Security Officer #3 and a Metro Police Officer appeared and entered the Seclusion Room. It was not possible to observe the patient in the room with security and the police blocking the video footage. -10:26. 39 sec. Security Officer #1 exited the Seclusion Room. -10:27. Security Officer #2 exited the room. The Metro Police Officer and Security Officer #3 remained in the Seclusion Room. -10:28. 11 sec. Security Officer #1 re-entered the Seclusion Room. Security Officer #3 remained inside the Seclusion Room. The Metro Police stood in the Seclusion Room doorway. -10:29. 18 sec. Security exited the Seclusion Room and locked the door. -10:31. 39 sec. Security Officer #3 opened the Seclusion Door and looked in the room and shut the door. End of video footage. A review of the facility investigation, dated 10/27/2023, showed Patient #25 was in the Seclusion Room. He had been observed sleeping and the door had been opened. He woke up and walked out of the room. PCT#6 asked him to return to the seclusion room. The patient responded “no.” Security Officer #1 jumped in front of the patient and stated “get the f* back into the room” and then “...placed his hands on the patient chest and proceeded to shove him back into the room...” Further review revealed the “push/shove” used by Security Officer #1 was described by the Security Director as a 2-finger redirection, described as a redirectional nudge or push, with the use of 2 fingers to move a person away from you. The redirectional nudge was not a component of verbal de-escalation CIT (Crisis Intervention Training). During an interview on 2/27/2024 at 11:43 AM, Security Officer #3 stated he received a call for assistance to the Seclusion Room. He said he was unable to remember if he observed Security Officer #1 with his hands on Patient #25. He stated the patient tried to fight security and voiced he wanted to leave the facility. During an interview on 2/27/2024 at 12:00 PM, and on 2/28/2024 at 4:10 PM, with LSMW (licensed master prepared social worker), Director of the Behavioral Health team, she stated she assessed Patient #25 on 10/27/2023. She stated he did not meet criteria for an involuntary hold and was discharged home with follow-up with substance abuse services. She stated nursing did not have time to verbally de-escalate the situation before security intervened with the patient “...it’s all about leading with verbal skills and avoiding physical touch of the patient...” She stated she reviewed the video footage and Security Officer #1 did not use a 2 finger re-directional technique. She confirmed CIT training was based on verbal de-escalation techniques. During an interview on 2/27/2024 at 4:05 PM, Security Officer #2 stated Patient #25 was yelling and attempted to leave the Seclusion Room. He stated he [Patient #25] balled his fists, grinded his teeth, and was verbally aggressive toward the sitters. He said he was going to the bathroom and leaving the facility. The Officer said the sitters were not allowed to walk to the bathroom with secluded patients...only the medical staff or security walked those patients to the bathroom. He stated he did not see Security Officer #1 place his hand on the patient’s shoulder or push him back into the room. He stated he became involved when he heard the patient yelling at security and had to be held in place “...so he wouldn’t kick us...” He stated security stayed in the seclusion room and talked to the patient after the incident and explained to him if he cooperated, he would be discharged sooner. During an interview on 2/28/2024 at 10:50 AM and on 3/4/2024 at 12:55 PM, the Director of Security stated Security Officer #1 was no longer employed at the facility. The Director stated he had observed the video footage. He stated Patient #25 refused to return to the Seclusion Room and the officer ’’...turned him by placing a hand on his shoulder...” He stated Security Officer #1 received verbal counseling “...he should have attempted more verbal de-escalation prior to placing his hands on the patient...” He stated facility policy instructed staff to use minimum amount of force necessary on patients. He said Security Officer #1 used a ’’...redirectional touch...” When asked to describe the 2-finger technique, the Director of Security stated it was a technique to get a patient to turn in a certain direction “...a nudge...” He confirmed he observed the video footage “...it was more than a 2-finger...it was a palm...palm nudge...”. He stated Security Officer #1 received verbal counseling on physical contact with patients “...hands on too quick...” and “...he should have taken more time to de-escalate.” He stated Security Officer #1 also received a corrective action plan that included not using profanity, to take time to verbally de-escalate instead of physical re-direction, and to take the CIT (verbal re-directional training for behavioral health patients). He confirmed Security Officer #1 was not suspended or removed from the ED on 10/26/2023. He stated he thought it could be handled with verbal counseling. He confirmed it was the expectation of the facility to provide a safe and secure environment “...cussing at a patient is not in the policy...open palm was not part of our training...” During a telephone interview on 2/29/2024 at 12:51 PM, ED Physician #1 stated Patient #25 was very intoxicated, violent, and agitated when he entered the ED. He denied suicidal ideation, but was placed on an involuntary hold, with telepsychiatry ordered after he had a chance to sober up overnight. During a telephone interview on 2/29/2024 at 1:00 PM, PCT #6 stated he was standing across from the Seclusion Room on 10/26/2023 when Patient #25 was in seclusion. Patient #25 stood ’’...barely...” outside the opened seclusion door. PCT #6 stated someone asked Security Officer #1 why the patient was outside the seclusion room. PCT #6 said he instructed the patient to return inside the room “...[Security Officer #1] jumped straight in...I didn’t ask for assistance...” He said Security Officer told him the patient showed signs of physical aggression because he was clenching his fists. He stated he didn’t observe the patient clenching his fists “...I know he shoved him...[Patient #25] was drunk and unsteady on his feet...it could have gone a different way...”. During a telephone interview on 3/4/2024 at 2:10 PM, Registered Nurse (RN) #9 stated at the time of the incident she was caring for a critical patient in another room. She stated, when she observed him in the Seclusion Room, Patient #25 was cooperative and nonviolent. She stated he had no injuries from the incident and he voiced no complaints to her. During an interview on 3/4/2024 at 3:20 PM, PCT #7 stated the Seclusion Door had been opened because he had been compliant with care, but was very drunk, and required continued observation. She observed Patient #25 in the seclusion doorway. Security Officer #1 approached him and used inappropriate language to the patient. She said the patient made a sudden move and walked out of the room. Security Officer #1 “...put his hand on his chest and pushed him in the room...” She stated Security Officer #1 “...cussed him...” During an interview on 3/4/2024 at 4:00 PM, the Director of Risk Management stated there was no time to use intervention techniques with Patient #25 because Security Officer #1 intervened too quickly “...it was inappropriate but did not cause physical or mental harm to the patient...” Refer to TN00065911”