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Based on interview and record review, the facility failed to ensure the safety of patients in the Birthing Center and Women's Resource Center, when Person 1 was able to walk behind the security kiosk, evade security, and use an elevator to enter the Birthing Center, a secure area without authorization.

This situation placed patients in the Birthting Center and Women's Resource Center at increased risk of privacy breech, exposure to disruptive behavior, and possible personal harm.

Findings:

During an interview on 8/16/17 at 1:03 PM, Patient Relations Manager (PRM) reported meeting with Person 1 on 6/26/17. The PRM said she informed Person 1 that the facility did not accept Cal-Fresh for meals, provided a food voucher for lunch, assisted with a request for medical records, and informed Person 1 that she would speak with her again regarding a request for an escort for appointments. PRM reported Person 1 accused PRM of discrimination, and began to speak to her in an "elevated tone." The PRM said after about 20 minutes of an escalated conversation, she ended the conversation as non-productive, and asked Person 1 to leave. Person 1 did not leave, and was informed by PRM that security would be contacted. The PRM said she referred the situation to her manager. Security was contacted to escort Person 1 from PRM's office, after she refused to leave.

During an interview on 8/16/17 at 1:38 PM, Security Director (SD) reported Person 1 had gotten to the Birthing Center floor and was asking questions, such as, "Where was the nursery," and, "What were the codes for the doors," SD reported reviewing security video footage and observing Person 1 walking behind the security kiosk near the elevators, evading security. Person 1 then used an elevator and entered the Birthing Center floor, a secured area. SD acknowledged this was a failure of their security procedures that afforded access by an unauthorized person to this secured area.

Record review of facility policy and procedure, "Management of Disruptive Behavior" (Last Approval: 12/2012), defined disruptive behavior as, "... behavior by patients, family members and/or visitors which is disruptive to the patient's own care, the care of other patients, the safety of staff, patients, visitors and institutional operations."; and included, "Entering clinical or restricted areas without permission of the staff", and, "Refusal to follow instructions by staff".

Review of the facility's policy and procedure, Policy 6.07.19, Security Services Departmental Procedure ( last approved December, 2012), indicated under "Background:" " ...It is the Security Departments role to assess the event and work with involved staff and available resources at the time to ensure adequate security and safety measures are put in place ..." Under "Procedures," the P&P indicated on page 21, " ...Once a disruptive ...situation has been de-escalated, the on-duty security supervisor or senior security officer shall have the responsibility to evaluate the possibility of repeated occurrences, the availability and possible need for added security resources ..."