HospitalInspections.org

Based on review of Medical Records (MR), review of facility documents and interview with Staff (S) it was determined the facility failed to ensure freedom from pain and abuse of one patient as evidenced by: failing to implement their processes and policies on Workplace Violence and Abuse Reporting (A0145). This failure resulted in an Immediate Jeopardy, posing a serious risk of abuse and harassment to the patients, staff, and visitors.

During a review of the 3/29/24 video surveillance, an incident was noted between security officers and a discharged patient. It was observed that one officer forcefully placed his/her knee on the individual's head. On 4/23/24, upon interview with a security officer present during the event, the officer stated that one officer hit the individual in the face multiple times. Three officers involved were terminated. The facility was unable to provide the evidence of staff education after the 3/29/24 event.

On 4/24/24 at 2:18 PM, the facility submitted an acceptable removal plan. Verification of the removal plan was conducted to include interviews with staff, and review of the educational documents and sign in sheets from each unit in the hospital, noting who received the Workplace Violence and Abuse Reporting re-education. Upon interview with two registered nurses, five security guards, and one unit secretary, it was confirmed that the refresher education; regarding Workplace Violence and Abuse Reporting, and the updated documents. They were able to speak to the communication that needs to be made for any suspected abuse and where to find or who to ask for more explanation if needed. The staff reinforced the need to document any event, especially with suspected abuse, in the incident reporting system. Upon verification of the implementation of the removal, the IJ was lifted on 4/24/24 at 4:30 PM.

Cross Reference:
482.13(c)(3) Patient Rights: Free From All Forms of Abuse or Harassment.

Based on staff interview, review of facility documents, review of the security surveillance video, and review of one of one Medical Record, it was determined the facility failed to implement their policy and re-educate staff on Workplace Violence and Abuse Reporting; thus posing a serious risk of abuse or harassment to patients, staff and visitors.

Findings include:

On 4/22/24 at 10:20 AM, an entrance conference was conducted with Staff (S)1, the Director of Quality and Informatics. The facility policies, documents, medical record review, and a tour were requested. At 12:35 PM, the Incident Report Log was reviewed, and the following was revealed:

The Incident Report log entry dated "3/29/2024 4:52:52 PM" and titled, "Hospital, Behavior (Assault/Abuse/Neglect) Threat, Emergency Department" stated, "...The patient, [P1's name] had earlier resisted being discharged from the ER (Emergency Room). Security managed to convince the patient leave the ER. At the waiting [he/she] turned aggressive towards the security insisting to be let back into the ER .... The patient left the ED (Emergency Department) and came back armed with 3 rocks and shattered the ED entrance. [Name of Police Department] responded and took [him/her] into custody ...."

P1's Medical Record was reviewed in the presence of S1 and revealed the following:
On 3/29/24 at 2:32 PM, a Nurse Practitioner (NP) progress note indicated P1 arrived at the ED as a walk-in with complaints of being physically, emotionally, and mentally exhausted; not compliant with his/her medication. The NP note stated, " ...Patient selective with care, refused chest x-ray and blood to be drawn ... Patient made aware of all abnormal lab result and cleared for discharge by crisis and medically cleared. Patient instructed to follow-up with PMD [Primary Medical Doctor] after discharge. Patient agreed and verbalized understanding ...."
On 3/29/24 at 2:34 PM, S13's (ED Nurse) Nursing progress note stated, "Patient for discharge, written instructions given, advised to follow up with outpatient psych [psychiatric] as per crisis, patient refused to sign discharge instructions."
On 3/29/24 at 3:31 PM, S13's Nursing progress note stated, " ...Patient refusing to leave ED treatment area after being discharged, Security called, and patient escorted out of ED ...."
On 4/22/24 at 2:57 PM, the Security surveillance video [from 3/29/24] was reviewed in the presence of Staff (S)1, Director of Quality and Informatics, and S9. The following was revealed:

On 3/29/24 at 3:55 PM, Patient (P)1 walked away from the Emergency Department (ED) main entrance, towards Central Avenue. At 3:56:36 PM, P1 returns into view, approaches the ED main entrance, and throws three objects at the ED main entrance doors, shattering the glass. At 3:56:58 PM, S12, Interim Security Manager, S15, a Security Officer (SO), and S20, a SO, were viewed restraining P1 by securing his/her left and right arms, and waist. P1 falls to the ground and at 3:57 PM, S19, a SO, uses his/her knee to push P1's head to the ground, forcefully. At 3:58 PM, P1 was brought back inside to a chair at the end of the ramp, by the ED main entrance. The chair was not able to be viewed on the Security surveillance video. Upon interview, S9 stated this part of the ED main entrance is a "blind spot" and cannot be viewed on surveillance video.

The police report filed on 3/29/24 at 3:10 PM state, "... The officer spoke with the suspect[male/female] who was later identified as [P1] who stated [he/she] damaged the window to get the hospital staff attention because [he/she] still needs more help after being discharged ... [P1] stated that after [he/she] broke the glass the security guard jumped on [him/her] causing [him/her] to have a cut on [his/her] left ear and left eye. EMS [emergency medical services] responded to prisoner intake to treat [P1] for injuries."

On 4/22/24, a tour of the ED was conducted with S1 and S2, the ED Nurse Manager. During the tour, the following was revealed:

At 11:04 AM, upon interview with S6, a Security Officer (SO), S6 explained that the nurse manager, security supervisor, or any witness to a violent act can call the police, and the manager of security documents all calls to the police in the Security Shift Report. S6 indicated he/she was not debriefed, nor did he/she receive any re-education regarding Abuse Reporting, Handle With Care (HWC: de-escalation and restraint training) and/or the policy regarding Workplace Violence (after the incident of 3/29/24).

On 4/23/24, the Workplace Violence (WPV) Committee meeting minutes from November 2023 to April 2024, were reviewed and the following was revealed:
The WPV Committee's meetings for January and February 2024 were "canceled."
The discussion regarding Handle With Care (HWC) was "tabled" (not discussed), due to a lack of time.

On 4/23/24 the following staff members were interviewed, and the following was revealed:
At 10:34 AM, S7, Security Supervisor, stated he/she "contacted the EOPD, many times due to the aggressive behavior of [P1]." S7 indicated that P1 was considered trespassing, because he/she was discharged from the ED at that time. S7 stated that S12 filed an incident report with the police report number, and informed him/her to go home, it was the end of the shift. S7 informed surveyors that he/she did not receive any re-education regarding Abuse Reporting, HWC, and/or regarding Workplace Violence (after the incident of 3/29/24).

At 11:13 AM, S13, a Registered Nurse (RN) stated that on 3/29/24, "[P1] refused to leave ED Bay 13, after being discharged." S13 indicated that P1 did not meet the criteria for drug detoxification, which he/she requested. S13 stated that he/she "was unable to verbally redirect [P1] and he/she informed the SO in the ED that assistance was needed." S13 explained that following an incident all witnesses were supposed to fill out a witness statement to go along with the incident report. S13 did not receive any re-education regarding Abuse Reporting, HWC, and/or regarding Workplace Violence (after the incident of 3/29/24).

At 12:02 PM, S15, a SO, indicated that towards the end of his/her shift on 3/29/24, he/she was alerted (via overhead page) that assistance was needed with an aggressive patient in ED Bay 13. S15 explained that when he/she arrived at ED Bay 13, ED staff were surrounding P1, and [S15] instructed staff to step away and provide P1 with space. S15 stated that he/she and ED staff were able to verbally re-direct P1 into a wheelchair, and then P1 was escorted out of the ED waiting room. P1 sat in a chair at the end of the wheelchair ramp, and S15 returned to his/her post.

S15 stated he/she returned to the ramp, where he/she observed S12, S18 and S20 with P1. S15 indicated that S12 had moved the chair in which P1 was sitting, out of the camera view, and S18 struck P1 in the head and face, with closed fists and S12's elbow. P1's nose began to bleed, and this was right when the EOPD came in. S15 stated that he/she "wrote, not typed, a witness statement, when I returned to work the next day," regarding the incident with P1 on 3/29/24. S15 indicated he/she did not receive any re-education regarding Abuse Reporting, HWC, and/or the policy regarding Workplace Violence (after the incident of 3/29/24).

At 2:08 PM, S16, a SO, indicated he/she was watching the security cameras and observed the SOs standing outside of the ED main entrance, and went to help. S16 indicated he/she did not assist in physical de-escalation/restraint, because P1 was already on the ground and "it didn't feel right to do that to someone that was already on the ground." S15 indicated he/she did not receive any re-education regarding Abuse Reporting, HWC, and/or the policy regarding Workplace Violence (after the incident of 3/29/24).

At 2:22 PM, an interview with S9, Director of Operations, confirmed that the DOH was not notified of the alleged excessive force used on P1. S9 further stated that no one was debriefed regarding the incident with P1 on 3/29/24, and re-education of HWC and workplace violence "would probably begin within the next two weeks." S9 indicated he/she attended a Workplace Violence Committee meeting on 4/19/24, and "the discussion of re-educating staff [Abuse Reporting, HWC and Workplace Violence] was initiated." S9 stated, "I don't know which department specifically would receive the education." S9 also explained that witness statements were not necessary when incident reports are filed. S9 explained that S7 and/or S12 did not make him/her aware that there was a physical incident between P1 and S12, S18, and S19 on 3/29/24. S9 stated that the investigation of the incident was initiated "after I heard rumors of the incident from facility staff." The investigation began on 4/4/24 and was concluded on 4/8/24. S9 confirmed the alleged excessive force used on P1 was not reported to the local police department.

Review of the facility policy titled, "Responding to Adverse Events," dated 2017 stated, " ... 7. All individuals who witnessed or participated in the occurrence will be part of the debrief. It is required that all the individuals involved participate in the debrief if at all possible. ... 8. The RCA meeting is the next step. ... 9. ... The purpose of this meeting is to finalize the root causes and establish a corrective action plan as appropriate. 10. The Quality Team will partner with the Operations Team to implement, document, and measure the corrective actions." It was determined that the facility practice was not in accordance with the facility policy.