In August, a Mercy hospital security guard bent a mental health patient's thumb towards her wrist during a scuffle. There was an audible pop and the patient screamed out in pain.

"You broke my (expletive) thumb," the patient reportedly said.

The patient, according to a report obtained Monday by the News-Leader, was strapped to a bed by her arms, legs and waist for hours while she repeatedly asked for, and did not receive medical attention for her injury.

That was one of a few incidents flagged by a complaint investigation in late August, which threw Mercy Hospital Springfield into upheaval. The hospital continues to be at risk of losing Medicare funding in November.

In quick succession this fall, the hospital fired a dozen employees, ushered in a new interim leadership team and promised to correct any deficiencies that led a federal agency to find there was "immediate jeopardy to the health and safety of patients."

A report, released Monday, sheds light on a series of incidents this year involving physical confrontations between Mercy staff and patients which caused the Centers for Medicare and Medicaid Services to threaten to end Medicare funding for the hospital.

While the "immediate jeopardy" status was lifted on Sep. 29, the hospital was not in compliance of two conditions that hospitals must meet to participate in Medicare, a CMS spokeswoman said.

In addition to staffing and leadership changes, Mercy is implementing enhanced hands-on training and close monitoring of performance in "tense situations," according to a statement from Mercy. According to the hospital's "plan of correction," it is also installing new non-locking restraints on some beds to replace old ones that lock.

According to CMS spokeswoman Julie Brookhart, a state agency will visit Mercy again in October to determine if everything is back in compliance. If not, the hospital risks termination of its Medicare funding on Nov. 5.

Mercy receives about $200 million in total revenue from Medicare each year, according to documents the hospital filed with the IRS for the years 2013 through 2016.

Brookhart has previously told the News-Leader most facilities take the necessary steps to correct deficiencies prior to termination.

CMS conducted an unannounced, on-site investigation in late August in response to a complaint and flagged four instances of "abuse and/or neglect" that occurred between April and August 2017.

That's in addition to several incidents documented in January by a CMS inspector, who went to the hospital as a result of a separate complaint regarding patient care. Those details were previously reported by the News-Leader.

The firing of the 12 hospital employees and the threat of loss of federal funding are a result of the newest August report, a Mercy spokeswoman confirmed.

Brookhart, with CMS, said it is not uncommon for a hospital to have more than one complaint investigation in a single year.

The new report talks specifically about the "abuse and/or neglect" of four patients and criticized the hospital's governing board of failing to ensure adequate oversight of patient care. It also criticized leadership's failure to ensure nursing staff adequately assessed and provided care to the needs of patients in three of those cases.

During the investigation, the governing board watched videos of some of the incidents involving patients for the first time and the recordings were different from what was previously reported to the board, the report said.

"The Governing Board had concerns with the management of the patients, felt the mismanagement of the patients were engrained in their culture, and that it was not the manner in which the hospital expected their patients to be treated," the report reads.

Through interviews and reviews of security camera footage, the document detailed the incidents which "had the potential to affect all patients in the hospital."

At the time of the investigation, there were 384 patients in the facility, 27 of which were in the psychiatric center, the report said.

Patient #1

In June, a man who was using anxiety, pain and anti-psychotic medications went to the emergency department for numbness in his left arm. He was accompanied by a friend.

The patient cursed while speaking to his friend in the waiting room. A security guard asked him not to use foul language. The security guard argued with the patient until the friend asked the security guard to leave the patient alone.

A few minutes later, the patient slid out of his chair and onto the floor, visibly shaking and in distress. His friend told staff the patient was having a seizure.

The report said video surveillance showed a nurse walk over and say "'You're alright,' in a sarcastic tone." The nurse asked the security guard to bring a gurney.

When the patient saw it was the same security guard as before, he became agitated, cursed at staff and refused help, saying he wanted to "go to another (expletive) hospital for help where they did not treat veterans like this."

The security guard followed the two people outside and continued to exchange words with them. Another security guard joined and "attempted to intimidate the patient and his friend," the report said, by pushing their backs repeatedly.

One of the guards grabbed the patient and the other tackled the patient to the ground. The patient's head hit the ground twice, scraping his forehead. The patient was handcuffed.

After police arrived, they took the handcuffs off the patient and allowed him and his friend to leave.

Patient #2

In April, a 28-year-old woman was voluntarily admitted to the psychiatric unit. A few days into her stay, she yelled at staff, apparently upset that her roommate was being touched by a male patient.

A nurse called security on the patient, who was loud and agitated. A security guard and a behavioral health technician guided the patient into the lunchroom, away from other patients.

The patient said she was thirsty and did not want to be by herself with any male staff, the report said.

The patient walked over to a sink to pour herself a cup of tea from a pitcher when the security guard grabbed her. Two staff members restrained her on the floor before others joined to carry her to a seclusion room.

On the way to a seclusion room, the report says, the patient grabbed a staff member's hair. She would not let go of the hair. Another security guard arrived and hit the patient's hand three or four times with a closed fist. The patient began crying and released the hair.

While being placed in restraints, the patient screamed, "You are hurting my arm" and "I just wanted to get a drink and he attacked me," the report said.

Patient #3

In April, an 18-year-old woman was admitted to Mercy's psychiatric center for a 96-hour hold with a "diagnosis of altered mental status," the report said.

Two staff members held her down as they placed an antipsychotic pill in her mouth.

In a phone interview, the nurse denied she forced medication into the patient's mouth.

The report said the nurse continued to work "after she forced the patient to take a medication that she had the right to refuse."

Patient #4

In August, a 22-year-old woman was voluntarily admitted to the facility's psychiatric center in August. She reportedly attempted to harm herself by wrapping a shoelace around her neck and picked at a wound on her arm, causing it to bleed.

Multiple staff members carried her to a bed to strap her down.

According to the report, a security guard bent the patient's thumb towards her wrist. The patient and at least one other person reported hearing an audible pop.

Video footage reportedly showed the following exchange between the guard and the patient after she was fully restrained.

"You brought this on," the guard said, according to the report.

"You don't have to hurt me though," the patient said before looking at her thumb. "My (expletive) thumb is swollen. My (expletive) neck."

The patient also had visible swelling to the right side of her face, the report said.

A nurse later wrote in a report that the patient was agitated and uncooperative. However, the report says video footage through the next two hours shows that the patient behaved calmly while complaining of pain. The nurse was also not in the room when he or she was supposedly performing an assessment of the patient's condition.

The patient remained restrained to a bed and secluded for hours after she calmed down, the report said.

She repeatedly requested Ibuprofen for her pain and x-rays, the report said.

According to Mercy's plan of correction, five security officers, three registered nurses, a behavioral health director, a director of security and the vice president of operations in security were fired.

A couple of the former staff members were also reported to the state board of nursing.

At least two others — an emergency department nursing manager and a behavioral health charge nurse — also left employment in September.

Mercy released a statement to the News-Leader Tuesday.

"At Mercy Hospital Springfield, we are deeply committed to caring for our community and our values of treating our patients with dignity and compassion in all situations. When we do not live up to those values, we have and will continue to take action," the statement said.

It said the plan of correction "has already shown significant success in reducing the number of situations in which our Public Safety Department is called for assistance."

"While we deeply regret that these incidents occurred, we have treated this as a learning opportunity as we reaffirm our commitment to our mission, values and charism," the statement said.

Read more:

Mercy Hospital Springfield fires 12 due to behavior in 'highly tense situations'

Mercy removed from 'immediate jeopardy' status

Mercy criticized for handling of violent, mentally ill patient, report shows