Aspirus Stevens Point Hospital & Clinics, Inc.

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50644 Based on record review and interview, the facility staff failed to place appropriate restraint orders and assess and monitor patients in restraints per policy in 2 of 7 (Patient #1, #2) patients with restraints in a total universe of 23 medical records reviewed. Findings Include: Facility staff failed to place appropriate restraint orders and monitor patients in restraints per policy. See Tag A0168. Facility staff failed to complete a face-to-face assessment of patients in restraints per policy. See Tag A0178.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 50644 Based on record review and interview, the facility failed to place appropriate restraint orders and monitor patients according to type of restraints applied (violent) per policy in 2 of 7 patients (Patient #1 and #2) in restraints in a total of 23 medical records reviewed. Findings Include: A review of facility policy, “Restraint Policy” last revised on 09/2025 revealed, “Non Violent-Medical Management Restraints: Used to promote healing and improve the patient’s well-being, such as restraining to prevent self extubation, pulling critical lines, or patient safety concerns (Examples: removing dressings...Monitoring and documentation completed by RN...Every 4 hours...assessment minimally and as patient condition warrants...Violent/Self-Destructive Restraints: Used as an emergency measure for patients exhibiting violent and or/self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others...restraint monitoring...At initiation Every 2 hour assessments Visual observation at minimum every 30 minutes...The RN is responsible for initiation of a plan of care for all restraint types...The initiation of restraints requires the addition of a restraint plan of care within a calendar day...The plan of care is discontinued when restraints are no longer required...” Examples for Patient #1: A review of Patient #1’s medical record revealed that Patient #1 was admitted on 6/14/2025 to the facility’s ICU for hepatic encephalopathy (reversible brain dysfunction caused by liver damage that prevents the liver from filtering toxins from the blood). Non-Violent restraint orders were placed on 6/18/2025 at 12:16 AM. Four-point restraints for violence were started on 6/18/2025 at 12:00 AM due to Patient #1 being “Aggressive; Agitated; Verbally Abusive; Violent.” There was no evidence of a violent restraint order for Patient #1 per policy. Restraints were removed on 6/18/2025 at 5:22 PM. A review of the record revealed missing restraint assessments at 10:00 AM, 2:00 PM and 4:00 PM. There was no evidence of nursing assessments every 2 hours per policy for violent restraints. A review of Patient #1’s medical record revealed that restraints were applied for a 2nd time on 6/22/2025 at 1:15 AM. Non-Violent restraint orders were not placed until 6/22/2025 at 5:01 AM (4 hours after restraints applied). Restraint assessments were completed every 2 hours per violent restraint policy and restraints were removed on 6/22/2025 at 7:45 AM. “End of shift summary” written by ICU RN I on 6/22/2025 at 7:10 AM revealed, “...Patient started yelling at staff...was very inappropriate with staff. When asked if he could calm down he would scream...he grabbed RN’s arm and would not let go- RN could not break away from him...had his hand in a fist and was throwing it in the direction of the staff...an order for four-point restraints was given from overnight MD for the safety of the patient as well as the staff...” “Discharge Summary” written by ICU Hospitalist V on 7/1/2025 at 12:57 PM revealed, “...His episodes of agitation recurrently posed a safety risk to himself and people around him prompting...intermittently physical restraints...” There was no evidence that violent restraints were ordered per policy due to the patient’s behavior. No evidence that Patient #1 was monitored every 2 hours per the facility’s violent restraint policy. Example of Patient #2: Patient #2 was admitted to the facility’s ICU on 6/19/2025 at 2:36 PM for Encephalopathy. Non-violent/medical management restraints were ordered on 6/19/2025 at 6:10 PM by ICU Hospitalist Z and Patient #2 was placed in bilateral soft wrist restraints for “Pulling lines; Pulling tubes” on 6/19/2025 at 6:11 PM until 6/21/2025 at 7:30 AM. A review of the record revealed missing restraint assessments on 6/20/25 at 12:00 PM, 4:00 PM, and 8:00 PM and on 6/21/2025 at 6:00 AM per facility policy of every 4 hours. During an interview on 2/5/2026 at 8:55 AM, ICU RN J stated that they use soft wrist restraints the most to avoid patients from pulling out tubes/dressings/IVs (intravenous catheter). She stated that they also have ankle restraints and chemical restraints that are used more for patients who are aggressive and they “have exhausted everything else as options.” She stated that before using restraints they initiate increased rounding, video monitors, and/or sitters before using restraints. ICU RN J stated that for restraints a doctor order is needed and if being aggressive then the provider will “usually come to assess” the patient. During an interview on 2/5/2026 at 12:50 PM, Hospitalist Medical Director P stated that restraints are used for 2 reasons, 1 being to prevent a patient from pulling out IVs or tubes which would be nonviolent and then the other being that they are a “threat to self or staff.” He stated that if restraints were needed they would call a hospitalist to assess the situation and see the patient face to face to determine if restraints were needed. During an interview on 2/5/2026 at 2:35PM, Quality Director B stated that for violent restraints patient assessments should be documented every 2 hours and for nonviolent every 4 hours. She stated there “seems to be some confusion with providers about violent versus non-violent restraint use.” During an interview on 03/03/2026 at 9:00 AM with RN EE, when asked if four-point restraints would be considered violent or non-violent, RN EE stated that it would depend on the situation. If it was because the patient was pulling on tubes and lines, she would consider the restraints to be non-violent, but if ordered for a behavioral reason the restraints may be either violent or non-violent. RN EE stated she would have to refer to the policy to determine. RN EE stated that she is tasked with restraint documentation for both violent and non-violent restraints. RN EE did not feel like she saw very many violent restraint orders in the ICU, even if patients were utilizing 4-point restraints. When asked if the 4-point restraints were placed due to behavior RN EE stated that even then patients are typically pulling on lines so the restraints would be considered non-violent. During an interview on 3/3/2026 at 8:12 AM, when asked if Patient #1’s four-point restraints would be deemed violent or non-violent, Quality Director B stated, “I would have deemed [Patient #1’s restraints] violent.” Quality Director B stated that she reviews all restraint documentation and follows up with providers and staff if documentation is missing. Yearly computer-based restraint training is required for RNs and CNAs. Quality Director B also stated, “We know we have a lot of work to do with restraints and the restraint topic is a work in progress.” During interviews with ICU RNs, ICU Hospitalists and Quality, there was no evidence that staff were able to delineate the difference between violent and non-violent restraints and the monitoring requirements for the different restraint types.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 50644 Based on record review and interview, the facility failed to complete a face-to-face assessment per policy in 1 of 7 patients (Patient #1) needing restraints in a total sample of 23 medical records reviewed. Findings Include: A review of facility policy, “Restraint Policy” last revised on 09/2025 revealed, “...The Physician or Advanced Practice Clinician responsible for the patient’s care must see and assess the patient...Upon initiation, a face-to face assessment by the Physician or Advanced Practice Clinician must occur within one hour and minimally every 24 hours with continued restraint use...The face-to face assessment and the subsequent documentation includes: The patient’s immediate situation Reaction to the intervention Medical and behavioral condition Need to continue restraint...” A review of Patient #1’s medical record revealed that Patient #1 was admitted on 6/14/2025 to the facility’s ICU for hepatic encephalopathy (reversible brain dysfunction caused by liver damage that prevents the liver from filtering toxins from the blood). Four-point restraints for violence were started on 6/18/2025 at 12:00 AM due to Patient #1 being “Aggressive; Agitated; Verbally Abusive; Violent.” Restraints were removed on 6/18/2025 at 5:22 PM. The restraint order placed for Patient #1 was “Non-Violent/Medical Management.” There was no evidence of a documented face-to-face assessment completed per policy. On 6/22/2025 at 5:01 AM restraints were re-ordered by ICU Hospitalist Z for aggressive and violent behavior. Four-point restraints started on 6/22/2025 at 1:15 AM and removed at 7:45 AM. There was no evidence of a documented face-to-face assessment completed per policy. During an interview on 2/5/2026 at 9:29 AM, ICU RN K stated that they use wrist and 4-point restraints. She stated that they would initiate a restraint when they can’t control the patient’s safety. ICU RN K stated they would call the physician to come assess the patient and place an order for a restraint. During an interview on 2/5/2026 at 12:50 PM Hospitalist Medical Director P stated that face to face would be documented in the chart as a “Dot Phrase” (Epic charting flowsheet for restraint charting) from the hospitalist and an order would be placed. Hospitalist Medical Director P stated that if a violent restraint is needed for aggressive behaviors then interventions done need to be documented.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50644 Based on record review and interview, the facility failed to respond to oxygen saturation falling below lower-limit parameter in the physician orders in 1 (Patient #1) of 23 patient medical records reviewed. Findings Include: A review of facility policy titled “Clinical Alarms Management Policy & Procedure” last revised 10/2022 revealed, “ ...Clinical alarm systems are intended to alert patient care staff of potential patient problems, but if they are not properly managed, they can compromise patient safety ...3. User Responsibilities: ...B. It is the responsibility of the user to ensure that alarms are used appropriately and safely, and the sound levels are sufficient to notify staff in the event of an alarm ...C. All alarms will be responded to by the appropriate clinical personnel. Alarms will not be silenced or suspended without the appropriate clinical assessment ...” A review of Patient #1’s “Admission/Discharge/Transfer” events revealed that Patient #1 was admitted to the Intensive Care Unit (ICU) as an Intermediate Care Patient (IMC) on 06/14/25 at 12:19 PM. Patient #1 was changed to overflow status on 06/19/25 at 6:21 PM and remained as overflow status until his death on 07/01/2025 at 11:40 AM. A review of Patient #1’s “Orders” revealed that vital signs were to be taken “per routine” and to notify the physician based on policy. “Oxygen therapy” was ordered as, “Keep O2 Sat above 92%.” A review of Patient #1’s medical record “Vitals” and “Oxygen Therapy” flowsheets revealed on 07/01/2025 at 10:00 AM, Patient #1’s pulse was documented as 72 beats per minute (bpm) and oxygen saturation was documented as 89%. There was no evidence of an assessment, initiation of oxygen therapy or other respiratory intervention, or notification to the physician as a result of the oxygen saturation lower then 92%. At 11:00 AM, Patient #1’s pulse was documented as 58 bpm and oxygen saturation was documented as 82%. There was no evidence of an assessment, initiation of oxygen therapy or other respiratory intervention, or notification to the physician as a result of the oxygen saturation lower then 92%. Patient #1 was found deceased at 11:35 AM. During an interview on 03/3/2026 at 9:00 AM, RN EE stated if a patient is not on telemetry and the monitor is used to take the vital signs the monitor would still alarm at the nurse’s station if the vitals including oxygen saturation were out of normal range. During a phone interview on 3/3/2026 at 10:21 AM, RN U verified she was the nurse caring for Patient #1 at the time of his death on 7/1/2025. RN U stated she went to Patient #1’s room on 7/1/2025 around 11:35 AM because she heard his IV pump beeping. RN U stated she remembers looking at Patient #1 and exclaiming, “Oh my gosh, he’s dead!” ... RN U stated she then called ICU Hospitalist V to report that Patient #1 had expired. “We were all surprised.” When asked if she could recall the last time she was in Patient #1’s room prior to his death, RN U could not remember the exact time. Explained to RN U that Patient #1’s chart revealed several low oxygen saturation readings on 7/1/2025 which were flagged by the electronic medical record as critical values and asked if someone sitting in Patient #1’s room should have been able to hear the corresponding alarms. RN Ustated,”... we should have heard it at the desk (nurse’s station).” When asked if [CNA FF] reached out to RN U at any time on 7/1/2025 with any updates or condition changes regarding Patient #1’s condition, RN U responded, “No.” During a phone interview on 3/3/2026 at 2:01 PM, when asked to describe her shift with Patient #1 on 7/1/2025, CNA FF stated, “It was a normal day. [Patient #1] had his same breathing rhythm that went between loud and quiet. The nurses were in and out doing IV care and other things. I did vitals and cares. I couldn’t get much out of [Patient #1] for conversation.” When asked to describe what she remembered about Patient #1’s death, CNA FF stated, “[ICU RN U] came in because [Patient #1’s] IV was beeping. [ICU RN U] noticed [Patient #1] wasn’t breathing. It was a surprise to me that [Patient #1] had passed.” When asked if she remembered seeing or hearing an alert related to Patient #1’s low oxygen saturation readings, CNA FF stated, “I’m not sure. It’s hard to remember.””

“RESPIRATORY CARE SERVICES POLICIES CFR(s): 482.57(b) Services must be delivered in accordance with medical staff directives. This Standard is not met as evidenced by: 50644 Based on record review and interview, the facility failed to provide respiratory assessments as ordered for 1 of 11 patients (Patient #1) requiring respiratory therapy in a total universe of 23 medical records reviewed. Findings Include: A review of facility policy, “Noninvasive Positive Pressure Ventilation (NPPV) Procedure-Respiratory Therapy (System)” last revised 09/2025 revealed, “...I. Indications for use ...C. Patients with medically unacceptable hypoxemia as evidenced by pulse oximetry ...D. Patients with obstructive sleep apnea who may benefit from augmented ventilation preventing upper airway obstruction during sleep ...Respiratory Care Services will provide NPPV. A. Per physician order, which may include mode, respiratory rate...amount of oxygen as needed, along with frequency and duration of use...If approved by Department Management: patients may bring in their own NPPV unit from home, complete “Inspection Of Patient-owned Equipment CPAP (Continuous Positive Airway Pressure)/NPPV Machine” form, if available and have the patient sign a release and waiver form. The therapist will be sure all the patient’s questions are answered and equipment needed. The patient should be checked and CPAP/NPPV flowsheet filled out at a minimum of once a shift while the patient is using the unit...” A review of Patient #1’s medical record revealed: A review of “Order History” revealed that on 6/14/2025 at 1:45 PM, ICU Hospitalist R placed the order, “CPAP Patient May Use Home Unit.” On 6/14/2025 at 9:03 PM, ICU Hospitalist R placed another order for “CPAP/BIPAP nights RT.” Both orders remained active until 7/1/2025 at 8:18 PM, when they were discontinued from Patient #1’s chart following his death. On 6/14/2025 (no time), “Home Noninvasive Ventilation Release Form” was signed by Patient #1’s wife/activated POA and witnessed by RT HH, allowing Patient #1 to use his home CPAP machine during his hospital stay. A review of “Noninvasive Vent” flowsheet entries from 6/14/2025 revealed that at 8:07 PM, Patient #1’s home unit had not yet been delivered and respiratory therapy (RT) was at Patient #1’s bedside to begin the initial NPPV setup of “Vent type: ResMed.” At 8:32 PM, the ResMed unit was turned on. At 8:35 PM, a flowsheet comment revealed, “Poor fitting with our XL mask. Not tolerating. Placed on nasal cannula.” A review of “Noninvasive Vent” flowsheet entries from 6/15/2025 to 7/1/2025 revealed the following: -From 6/15/2025 to 6/20/2025, each entry revealed “Vent type: ResMed” and “mode: standby.” -From 6/21/2025 to 6/22/2025, flowsheet revealed no evidence of RT documentation at any time. -On 6/23/2025 at 3:29 AM, flowsheet entry revealed “Vent type: home machine” and “mode: Continuous positive airway pressure.” -From 6/23/2025 at 8:01 AM to 6/26/25 at 12:26 PM, all flowsheet entries revealed either “Vent type: home machine” or “Vent type: ResMed,” all of which were documented in “standby” mode. -From 6/26/2025 at 12:26 PM until 7/1/2025, flowsheet revealed no evidence of RT documentation at any time. During an interview on 3/3/2026 at 8:38 AM, Respiratory Manager L stated that RT is expected to round nightly on each patient who has an active CPAP or BiPAP order on his/her chart, even if the patient brings the machine from home. When asked if RT still rounds nightly on patients who have been previously noncompliant with NPPV therapy, Respiratory Manager L stated, “Yes. If a patient’s order is still active, RT should still round and document on that patient every night.” When asked what other strategies could have been tried for Patient #1 on 6/14/2025 when RT documented “poor fitting XL mask-not tolerating,” Respiratory Manager L stated, “[RT] could have tried a different therapy ...I would have liked to see a comment in the chart if [Patient #1] was refusing [the CPAP] or if a physician was notified.” When asked if oxygen by nasal cannula was an appropriate substitution for Patient #1’s CPAP therapy at that time, Respiratory Manager L replied, “No. I would like to see documentation regarding communication with the doctor.” When asked if she would expect to see documentation of Patient #1’s CPAP being on him each night, Respiratory Manager L stated, “I would expect to see [the CPAP] on at night since it was ordered, or if not there should be a reason why.” When asked if Patient #1 was wearing his CPAP at the time of his death, Respiratory Manger L stated, “I see no documentation of it. It looks like the last filed entry [on the “Noninvasive Vent” flowsheet] was on the 26th (6/26/2025).””

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 47413 Based on record review and interview the facility failed to follow the timelines outlined in the grievance policy to acknowledge and investigate 1 grievance (Patient #13) in a total of 2 grievances reviewed. Findings Include: A review of the facility’s policy titled, “Patient Complaints and Grievances Policy” last revised 02/2025 revealed, “... Grievances will be forwarded to the leader of the department/clinical manager involved... for ALL hospitals, if unable to investigate and resolve the grievance within approximately 7 business days from receipt, a written or verbal notice of acknowledgement will be communicated to the patient...” A review of the grievance “PC78550” filed by Patient #13 to the facility on 03/17/2025 revealed that Patient #13 stated that his linens had not been changed throughout his hospitalization and that the CNAs (certified nursing assistants) had not rounded on him throughout his hospitalization. Further review of the grievance revealed that there was no acknowledgement letter sent to Patient #13 and there was no investigation started as of 04/08/2025 (date of survey). During an interview on 04/08/2025 at 10:30 AM with Director of Quality E, when asked about the grievance, Director of Quality E stated, “It has not been addressed yet.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 29972 Based on record review and interview, the facility failed to protect patients from further abuse while an investigation was ongoing, failed to thoroughly investigate allegations of abuse, and failed to educate staff on the need for immediate reporting of abuse, in response to 2 of 2 Caregiver Misconduct Incident Reports reviewed (Patient (Pt) #1, Pt #2), in a total sample of 3 incident reports reviewed. Findings include: The facility failed to protect patients from further abuse when 1 of 1 employees accused of abuse (Paramedic A) worked providing direct patient care while the investigation was still ongoing. SEE TAG A-0145. The facility did not fully investigate alleged incidents of abuse by interviewing all staff and patients who might have provided insight into the allegation per facility policy. SEE TAG A-0145 In response to allegations of abuse, the facility created draft policy/workflow that did not require immediate reporting of abuse by staff or managers. SEE TAG A-0145”

“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: 29972 Based on record review and interview, the facility failed to protect patients from further abuse while an investigation was ongoing, failed to thoroughly investigate allegations of abuse, and failed to educate staff on the need for immediate reporting of abuse, in response to 2 of 2 Caregiver Misconduct Incident Reports reviewed (Patient (Pt) #1, Pt #2), in a total sample of 3 incident reports reviewed. Findings Include: Review of policy and procedure #14653861 titled, “Reporting and Investigating Caregiver Misconduct” last reviewed 11/2023 revealed the following: -“Immediately upon learning of any allegations of potential caregiver misconduct, staff must take the necessary steps to protect all patients from possible subsequent incidents of mistreatment or injury by taking the following steps: 1. Take steps necessary to ensure the safety of patients. Notify your immediate leader using the chain of command. Leader is to immediately reach out to HR (Human Resources) to consult regarding investigative leave for the accused employee from patient contact or responsibility. This may include removing the individual from patient care contact or responsibilities, additional supervision or monitoring of the patient and/or the accused, an alternative work assignment, review of the care plan with appropriate interventions as necessary, and suspension of the accused if deemed appropriate...Any employee witnessing alleged or actual misconduct is required to report this occurrence immediately to leader or supervising authority. (Failure to report abuse subjects the employee to disciplinary action.) ...All alleged violations involving caregiver misconduct must be thoroughly investigated and documented. A thorough investigation is conducted by the operational leader, Risk, and/or Compliance and may include ...2. Interviewing individual(s) (includes staff, visitors, patients, patient’s relatives, etc.) who may be able to provide insight into the allegation .... It is recommended that interviews should be conducted with two individuals and that a signed statement is completed by any employee who is part of the investigation...” Review of the “Misconduct Incident Report” submitted to the Department of Health Services on 04/11/2024 at 8:42 AM by Risk Manager E, revealed that on Friday 04/05/2024 (no time) Pt #1 notified hospital staff about an incident that occurred on Wednesday 03/27/2024 at 4:00 PM while Pt #1 was in the Emergency Department (ED). Per the Incident Summary, “(Pt #1) presented to the Emergency Department with head and chest pain, so they were giving (Pt #1) medications to lessen the pain which she said made her weak and tired. Patient reported that the staff member (Paramedic A) came in the room at one point and closed the door and pulled the curtains. (Paramedic A) then started to remove the EKG (electrocardiogram) pads and (Pt #1) felt (Paramedic A) fondled her left breast...(Paramedic A) then started to put his hand down (Pt #1’s) panties.” Review of the “Misconduct Incident Report” submitted to the Department of Health Services on 04/11/2024 at 8:44 AM by Risk Manager E, revealed that on Saturday 04/06/2024 (1 day after 1st alleged incident) Pt #2 notified hospital staff about an incident that occurred on Friday 04/05/2024 at 3:00 PM while Pt #2 was in the ED. Per the Incident Summary, “(Pt #2) stated staff member (Paramedic A) administered (Pt #2) Dilaudid for her pain and she became ‘loopy’. (Pt #2) stated that (Paramedic A) pulled down her gown and asked (Pt #2) if she had her leopard print bra on and then fondled (Pt #2’s) breast.” Per Incident Report, “Patient self reported this incident to the entity, as she felt it was very wrong. (Pt #2) also subsequently filed a report with law enforcement.” Review of Event SBARC (Situation, Background, Assessment, Recommendation, Communication) email sent to leadership staff from Risk Manager E on 04/08/2024 at 10:29 AM, with a subject line “...Alleged Caregiver Misconduct Emergency Department” revealed the following: - “4/5/24: Patient 1 called Patient Experience and reported concerns. Patient Experience immediately notified Compliance and Risk to initiate further fact-finding.” - “4/5/24: Nursing leaders and Human Resources collaborated to discuss steps to be undertaken to ensure patient safety throughout investigation. - “4/6/24: Patient 2 called and spoke to ED Manager and reported concerns.” - “4/8/24: Multidisciplinary team convened to discuss plan for investigation, including placing the staff member on administrative leave pending investigation.” Review of Paramedic A’s Timecard revealed that Paramedic A worked in the ED/Urgent Care on 04/05/2024 (day staff was notified of incident) beginning at 3:58 PM and punched out at 8:31 PM (worked 4 hours 33 minutes). Review of “Corrective Action Form” dated 04/09/2024 (no time) revealed, “On 04/09/2024 a multidisciplinary team met to discuss the complaints and determine if these complaints fall under the definition of Caregiver Misconduct. The caregiver misconduct review meeting resulted in substantiated caregiver misconduct. A Misconduct Incident Report will be submitted to DQA (Division of Quality Assurance) as well as a report submitted to the licensing body...we have decided to terminate (Paramedic A’s) employment with (hospital) effective immediately.” Per interview with ED Manager D on 04/24/2024 beginning at 11:03 AM, Patient Experience was notified of Pt #1’s sexual assault allegations on Friday 04/05/2024 at 2:00 PM. ED Manager D stated that she/he confirmed that Paramedic A was not scheduled to work on 04/05/2024 and consequently, scheduled a meeting with HR and leadership to discuss the plan for investigation for Monday 04/08/2024. ED Manager D stated that there was a staff call-in the evening of 04/05/2025 and Paramedic A picked up unscheduled hours in the ED. ED Manager D stated that the charge nurse was not aware of the alleged incident and allowed Paramedic A to work. ED Manager D stated that Paramedic A worked in the ED after hospital staff was made aware of the allegations against Paramedic A; ED Manager D stated that Paramedic A should not have worked. Per ED Manager D, HR and Manager D met with Paramedic A on Monday 04/08/2024 and placed Paramedic A on leave pending an investigation; Paramedic A was subsequently terminated on 04/09/2024. Review of facility investigation reports revealed that the facility did not interview other staff and patients present in the ED on the dates of the alleged incidents per facility policy. Staff who worked with Patients 1 and 2 on the dates in question were not interviewed to determine if they witnessed anything out of the ordinary or if they noticed any change in the patients’ condition or demeanor after the alleged incidents and prior to discharge from the ED. Per interview with ED Manager D on 04/24/2024 beginning at 11:03 AM, based on the investigation there were no witnesses during the alleged incidents to interview so staff interviewed the two complainants (Pt #1 and Pt #2) and Paramedic A, who denied the allegations. Per ED Manager D, there were no complaints about Paramedic A from the ED staff on the dates in question. The incidents were not reported by patient #1 or patient #2 until after they left the ED. ED Manager D stated that there were no other staff or patient interviews conducted. Per interview with Chief Nursing Officer (CNO) B on 04/24/2024 beginning at 11:30 AM, CNO B stated that the leadership team did identify a “gap” in reporting and have made revisions to the workflow for reporting of Caregiver Misconduct to ensure “tighter timeline” for staff removal from work in regards to 24 hour departments. Per CNO B, the Caregiver Misconduct reporting workflow revision is still in “draft form” and has not yet been rolled out to staff. Review of “Caregiver Misconduct Process Steps,” Draft Workflow (undated) revealed, “Staff member/provider observes or is made aware of alleged caregiver misconduct (abuse, neglect or misappropriation of property)...Staff member/provider follows chain of command for notifying one-up as soon as possible after the perceived misconduct...Department/unit leader notified as soon as possible...” The draft policy does not call for immediate reporting by staff of perceived/observed caregiver misconduct but indicates reports to be made “as soon as possible.” This could result in a delay in reporting and in the protection of patients from further abuse.”