HospitalInspections.org

Based on video observation, interview, and document review, the hospital failed to protect and promote each patients' rights when patient care was not provided in a safe environment for patients by the following:

Findings:

1. Failure to ensure a patient's right to be free from physical abuse was upheld in accordance with hospital policy, statutory and regulatory requirements. A security agent grabbed a patient and threw him on the ground. A-145 #1a

2. Failure to provide care in a safe setting when a security agent grabbed a patient and threw him on the ground. A-144 #1a

3. Failure to provide care in a safe setting when an Emergency Department (ED) Trauma Technician took away a patient's cane (an assistive device) when it was a windy night and the ground was wet. A-144 #1b

4. Failure to ensure that security agents generated an incident report for a witnessed patient fall and/or criminal activity (physical abuse/battery per hospital policy) in accordance with the hospital's policies. A-145 #1b

5. Failure to ensure that the hospital's Chain of Command policy was implemented when security agents and ED Trauma Technician witnessed a patient fall and/or criminal activity (physical abuse/battery per hospital policy). A-145 #1c

6. Failure to ensure that the hospital's Abuse Screening, Assessment, and Reporting policy was implemented when security agents and an ED Trauma Technician witnessed a physical abuse on hospital property, and did not report it, as mandated reporters. A-145 #1d

7. Failure to ensure that ED staff implemented the Bus Passes and Taxi Vouchers policy, when Patient 1, who had been discharged, returned to the Emergency Department requesting for a taxi voucher. A-1103


The cumulative effect of these systemic problems resulted in the hospital's failure to deliver care in compliance with the Condition of Participation for Patient's Rights and failure to provide patient care in a safe and secure environment.

Based on video observation, interview, record and document review, the hospital failed to provide care in a safe setting for 1 of 46 sampled patients (1). During an escort off hospital property on 12/13/15 at 11:13 P.M., a security agent (Security Agent 1) grabbed Patient 1 and threw him to the ground. Security Agent 1's failure to observe and ensure Patient 1's right to receive care in a safe setting was a violation of the hospital policy. In addition, an Emergency Department (ED) Trauma Technician (ED Tech 1) took away Patient 1's cane (an assistive device) when he was thrown onto the wet ground. ED Tech 1 walked Patient 1's cane to the bus stop and placed it into a cylindrical bin.

Findings:

1 a. A review of the hospital's Security Log, dated 12/13/15 at 11:11 P.M. was conducted. A Daily Activity Report (DAR) entry by Security Agent 1, dated 12/13/15 at 11:30 P.M., indicated that he was responding to a dispatch call regarding a discharged patient (Patient 1) who was refusing to leave the ED. A DAR entry by Security Agent 3, dated 12/13/15 at 11:48 P.M., indicated that Patient 1 was arguing with ED Tech 1 and was refusing to leave.

Patient 1 presented to Hospital A's ED on 12/13/15 with a chief complaint of flank pain per the Emergency Department Note by Physician 2, dated 12/13/15 at 3:10 P.M. Patient 1 was discharged on 12/13/15 at 10:40 P.M. per the ED Patient Care Timeline, date 12/13/15.

According to Physician 2's ED Note, dated 12/13/15, Patient 1's past medical history included the following: MI (myocardial infarction - heart attack), CVA (cerebrovascular accident - a sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain) with residual left sided weakness, nephrolithiasis (kidney stones) left flank pain and hematuria (blood in the urine). Per the same Note, Patient 1 had fallen several times in the last few weeks from left lower leg weakness status post CVA.

On 12/16/15 at 2:45 P.M., a security camera video footage dated 12/13/15 at 11:12 P.M. was reviewed at the hospital with the Chief Nursing Officer (CNO), the Director of Security, the Director of Regulatory Affairs (DRA), Quality Compliance Specialist (QCS 1) and the Nurse Director of Emergency Services (NDES). Per the video footage, the Director of Security confirmed that the following hospital staff were present during the incident: Security Agent 1, Security Agent 2, Security Agent 3 and ED Tech 1. Patient 1 was observed with a cane in his right hand. Patient 1 used the cane as he ambulated out of the ED. At approximately 11:13 P.M. on 12/13/15, Security Agent 1, Security Agent 2, Security Agent 3 were observed in close proximity to Patient 1. Security Agent 1 grabbed Patient 1 and threw him down to the wet ground (on the street).

A telephone interview was conducted with Patient 1 on 12/17/15 at 10:00 A.M. Patient 1 stated that he walked with a cane. He stated that on 12/13/15, he was discharged from the ED and walked out to the bus stop where he discovered that the bus system was closed. He stated that he returned to the ED to make a phone call to a community health group to coordinate a ride home. He stated that he made a second phone call to "medicare" and was unsuccessful. He stated that he walked up to the physican who treated him. He stated that the physician told him that they were not responsible for getting patients home and that no taxi vouchers would be given. Patient 1 alleged that he was "dragged out of the ED". He stated that out of the building, on public property, he was surrounded by 3 security agents and 1 "caucasian" ED employee. He stated that he was grabbed in the shoulder and thrown on the ground. He stated that his cane was thrown in a trash can. Patient 1 stated that he was bleeding on his left elbow, left wrist and left hand. He stated that he did not seek medical attention for his injuries.

A telephone interview was conducted with Physician 1 on 12/17/15 at 3:50 P.M. Physician 1 stated he was the attending physician for Patient 1 who presented to the ED on 12/13/15 at approximately 2:19 P.M., with a complaint of flank pain. Physician 1 stated he signed over care of Patient 1 at 9:00 P.M. to another attending physician and he was not aware that Patient 1 had any issues regarding transportation to home. Physician 1 stated he recalled that Patient 1 had a history of stroke, left sided weakness, a history of falls and that he ambulated with a cane. Physician 1 stated that since the buses were not running when Patient 1 was being discharged that it would be appropriate for Patient 1 to receive a taxi voucher taking into consideration Patient 1's history of falls, use of a cane and that Patient 1 had no other means of transportation home.

An interview and joint document review with Security Agent 2 was conducted on 12/18/15 at 8:03 A.M. Security Agent 2 stated that Patient 1 walked with a cane. He recalled that Patient 1 had clenched his fist, and then Security Agent 1 reached up and grabbed the patient from behind. He recalled that Security Agent 1 wrapped both his arms around the patient's back, there was commotion and Patient 1 fell to the ground. Security Agent 2 stated that Patient 1 was not a threat to anybody. He stated that the hospital's security protocol did not include touching the patient.

An interview and joint document review with Security Agent 3 was conducted on 12/18/15 at 8:58 A.M. Security Agent 3 stated that he was the first to respond to the call for security assistance in the ED. He recalled that Patient 1, who had been discharged from ED, was refusing to leave and was disruptive. He stated that Patient 1 used a cane as he walked through and out of the ED. Per Security Agent 3, during the security escort off hospital property, he turned around to Security Agent 2 and asked him to take care of the incoming trauma. As he turned around, he saw that Patient 1 was on the ground. He did not see anybody put hands on Patient 1. Security Agent 3 stated that as Patient 1 was getting up from the ground, he alleged that Security Agent 1 pushed him. He stated that Security Agent 1 replied and said "push you... you fell." Security agent 3 stated that ED Tech 1 grabbed Patient 1's cane and walked it to the bus stop.

An interview with Physician 2 was conducted on 12/18/15 at 3:05 P.M. Physician 2 stated he was the physician who took care of Patient 1 on 12/13/15 in the afternoon who presented to the ED with a complaint of flank pain and walked with a cane. Physician 2 stated that after Patient 1 was discharged, Physician 2 heard Patient 1 being verbally threatening to an emergency room technician. Physician 2 stated Patient 1 was requesting several things and that security arrived and escorted Patient 1 out of the ED.

An interview and joint document review with Security Agent 1 was conducted on 12/18/15 at 3:28 P.M. He recalled responding to an ED call for security assistance. He stated that there were 3 security agents (Security Agent 1, Security Agent 2, and Security Agent 3) and an ED technician (ED Tech 1) that escorted Patient 1, who was discharged from the ED, off hospital property. Security Agent 1 stated that as the agents were trying to guide Patient 1 off hospital property, the patient fell to the ground.

An interview with the Security Manager was conducted on 12/22/15 at 1:28 P.M. The Security Manager stated that he reviewed the video footage, dated 12/13/15, more than 10 times and on a large screen. The Security Manager stated that he saw Security Agent 1 and Patient 1 on the street. He stated that in the video footage, it appeared that Security Agent 1 grabbed Patient 1's left arm with his left hand, and placed his right hand up onto the patient's shoulder back area, spun the patient and threw him down to the ground. Per the Security Manager, he considered this a "throw down" instead of a "take down". He stated that the "throw down" of Patient 1 was not justified, and not in accordance with the hospital's policy.

The hospital's Security Operations Policy titled "Escorts From Property", dated 9/4/13, was reviewed. The policy's purpose indicated that "To establish a standardized procedure for security agents escorting individuals off [hospital name] property in a manner that is safe and effective for everyone involved." The policy stipulated that "If the individual becomes uncooperative and/or refuses to leave the premises, Agents may use soft empty hand control techniques to assist/guide the individual off of the property." Per the policy, "The use of force to escort an individual off of the property should only be escalated when an individual becomes a physical threat to the security agent or others within the immediate vicinity." The policy also indicated that "Individuals escorted off [hospital name] properties will be escorted to the nearest public city street and/or bus stop. Once the individual is safely on public grounds, Agents will discontinue the escort and stand by until it can be reasonably expected that the individual will not return to [hospital name] property."

A review of the hospital's Security Operations Policy, titled "Daily Activity/Incident Reports", dated 10/1/13, was conducted. The policy indicated that "Security Agents shall document all routine activity and calls for service using the DAR (Daily Activity Report). An IR (Incident Report) shall be generated if the event is of a criminal nature, has a high potential for civil litigation, or is significant and outside the Agent's normal routine." The policy stipulated that "Security Agents shall generate an Incident Report for any of the following, but not limited to:

1. Criminal Activity such as theft, assault, battery, vehicle burglary, drug possession, etc.

2. Events that involve emergency response: Police, Fire, or Medical calls.

3. Events that have a high potential for liability: Falls, use of force, injury to staff, visitors, or patients, an accusation of workplace violence, or inappropriate conduct by staff.

According to the policy, "When a Security Agent is involved in, witnesses, or is called to any event that necessitates an incident report to be generated, that report shall be completed prior to the end of the Agent's shift unless otherwise authorized by a Supervisor or Manager." "The report shall provide a detailed account of the event and will include all relevant facts and information. The primary responding Agent to the event is responsible for the entirety of the report. Any Security Agent who assists, witnesses, or has pertinent information to the event is responsible for completing a supplemental report. Any battery resulting in injury, incident involving a firearm or dangerous weapon, along with any illegal action or incident the Security Director deems appropriate, is to be reported to jurisdictional law enforcement (hospital name Police, San Diego Police, or local law enforcement)." The policy also indicated that "Any Security Services Department employee who witnesses, has knowledge of, or has pertinent information of any injury caused to a patient, visitor, or staff member at the hands of a fellow employee, shall immediately report this information to their direct supervisor or manager. An incident report detailing the event will be completed prior to the end of shift."

An interview with the Director of Security was conducted on 12/22/15 at 2:02 P.M. The Director of Security stated that she viewed the video footage, dated 12/13/15, more than 20 times on a small screen and 7-8 times on a larger screen. The Director of Security stated that it appeared to her that during Patient 1's escort off of hospital property, a verbal altercation between Security Agent 1 and Patient 1 occurred on the street. Per the video, she stated that Security Agent 1 used a technique to throw the patient down to the ground. She defined battery as "unwanted touching with the intent to cause harm". She defined assault as "it can be a verbal threat or gestures with an intent or means to commit harm". She defined physical abuse as "ongoing physical assault on a person". The Director of Security stated that when Security Agent 1 grabbed and threw Patient 1 down to the ground, "it was battery." She also stated "yes, [Patient 1] was physically abused by [Security Agent 1's name]". She also agreed that multiple techniques, policies and procedures were not implemented by Security Agent 1, Security Agent 2, and Security Agent 3 during the escort off hospital property of Patient 1.

A review of the hospital's policy titled "Patients' Rights and Responsibilities", dated 4/18/13, was reviewed. The policy's abstract indicated that "This policy informs all hospital employees about statutory and regulatory rights of patients and about the [hospital name] commitment to upholding these rights. Patients have a wide range of rights and responsibilities that are set forth in State and Federal requirements and in the [hospital name] standards. All employees are required to observe these rights, to assist patients in exercising their rights...." The policy stipulated that "Patients have the right to: ...12. Receive care in a safe setting...."

b. An untimed hand-written note, dated 12/15/15, by ED Tech 1 was reviewed. The note indicated that Patient 1 was verbally abusive to ED Tech 1 and security staff. Patient 1 walked to the street and refused to leave the hospital property. Security staff informed Patient 1 that he was trespassing and needed to wait at the bus stop. Per the note, Patient 1 became violent and attempted to punch a security agent when he missed and slipped on the road. Patient 1 landed on his buttocks and immediately got up threatening security. Patient 1 dropped his cane that he was not using to walk with, and instead was using it as a blunt object. ED Tech 1 proceeded to pick up the cane and walked it to the bus stop.

An interview and joint document review with ED Tech 1 was conducted on 12/17/15 at 2:00 P.M. ED Tech 1 stated that he worked on 12/13/15 and was assigned as a sitter to an ED patient from 7:00 P.M. to 7:00 A.M. He stated that because Patient 1 shoved him, he wanted to be an extra set of eyes and hands to ensure that no one else got hurt. Per ED Tech 1, Patient 1 swung his right arm with the cane in hand towards a security agent. The security agent blocked the patient's right arm, the patient slipped and fell on his bottom. He picked up Patient 1's cane because the patient did not use it in the ED and was using it as a weapon. He stated that he proceeded to walk to the bus stop with Patient 1's cane and hoped that the patient would follow. He stated that there was a trash can or an empty bin fixed to the bus stop and placed the cane in there for the patient to grab.

An interview with Physician 2 was conducted on 12/18/15 at 3:05 P.M. Physician 2 stated he was the physician who took care Patient 1 on 12/13/15 in the afternoon who presented to the ED with a complaint of flank pain and walked with a cane. Physician 2 stated that it is not best practice to remove assistive devices from patients.

An interview with the NDES was conducted on 12/18/15 at 4:00 P.M. The NDES stated that ED Tech 1 had a sitter assignment on 12/13/15, and had no business leaving the ED when Patient 1 required security escort off hospital property. The NDES stated that when ED Tech 1 took Patient 1's cane (an assistive device) from the patient and walked it to the bus stop. She stated that action was "awful". She confirmed that it was cold and raining on the night of 12/13/15. She acknowledged that a safe environment was not afforded to Patient 1 when his cane was taken from him by ED Tech 1.

An interview with the Chief Medical Officer (CMO) was conducted on 12/23/15 at 10:30 A.M. The CMO stated that the incident with Patient 1 was brought to the significant events committee meeting on 12/16/15 by the Chief Nursing Officer (CNO). The CMO stated that she watched the security camera (video) footage and stated she saw the security agent put his hands on Patient 1 and saw Patient 1 fall. The CMO stated she saw Patient 1's cane on the ground and did not see how it got there. The CMO stated what bothered her most was when she saw the ED Tech 1 pick up the cane and walk away with it since it was Patient 1's assistive device. The CMO stated that she reported the incident to the Governing Body of the hospital.

Based on video observation, interview, record and document review, Hospital A failed to ensure a patient's right to be free from physical abuse was upheld, for 1 of 46 sampled patients (1). On 12/13/15 at 11:13 P.M., during an escort off hospital property of a discharged patient from the Emergency Department (ED), Security Agent 1 took Patient 1's left hand, placed his right hand onto the patient's shoulder and threw the patient on the ground. Security Agent 1's failure to observe and ensure Patient 1's right to be free from abuse was a violation of the hospital policy, statutory and regulatory rights.

Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish.

Hospital A failed to ensure that security operations policies and hospital-wide policies were implemented during an escort of a discharged patient off hospital grounds, for 1 of 46 sampled patients (1). Three Security Agents (Security Agent 1, Security Agent 2, Security 3) did not generate an incident report for Patient 1's fall and/or a witnessed criminal activity (per hospital policy) in accordance with the hospital's Security Operations Policy. The hospital's Chain of Command and Abuse Screening, Assessment, and Reporting policy were not implemented when Security Agents and an ED Trauma Technician (ED Tech 1) did not follow and implement mandatory reporting requirements when they witnessed a fall and/or physical abuse/battery of a discharge patient (Patient 1).

These failures impeded the hospital from ensuring that Patient 1's rights were upheld and that a safe and abuse free environment was afforded to the patient.

Findings:

1a. A review of the hospital's Security Log, dated 12/13/15 at 11:11 P.M. was conducted. A Daily Activity Report (DAR) entry by Security Agent 1, dated 12/13/15 at 11:30 P.M., indicated that he was responding to a dispatch call regarding a discharged patient (Patient 1) who was refusing to leave the ED. Per the DAR, Patient 1 used his cane in a manner of aggression and in the process, pushed himself down. A DAR entry by Security Agent 3, dated 12/13/15 at 11:48 P.M., indicated that all agents responded to the ED for a former patient who was refusing to leave. Per the DAR, Patient 1 acted as though he was going to hit someone with his cane and in the process, he fell down and dropped his cane.

Patient 1 presented to Hospital A's ED on 12/13/15 with a chief complaint of flank pain per the Emergency Department Note by Physician 2, dated 12/13/15 at 3:10 P.M. According to Physician 2's ED Note, Patient 1's past medical history included the following: MI (myocardial infarction - heart attack), CVA (cerebrovascular accident - a sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain) with residual left sided weakness, nephrolithiasis (kidney stones) left flank pain and hematuria (blood in the urine). Per the same Note, Patient 1 had fallen several times in the last few weeks from left lower leg weakness status post CVA.

On 12/16/15 at 2:45 P.M., a security camera video footage dated 12/13/15 at 11:12 P.M. was reviewed at the hospital with the Chief Nursing Officer (CNO), the Director of Security, the Director of Regulatory Affairs (DRA), Quality Compliance Specialist (QCS 1) and the Nurse Director of Emergency Services (NDES). Per the video footage, the Director of Security confirmed that the following hospital staff were present during the incident: Security Agent 1, Security Agent 2, Security Agent 3 and ED Trauma Technician (ED Tech 1). Patient 1 was observed with a cane in his right hand. Patient 1 used the cane as he ambulated out of the ED. At approximately 11:13 P.M. on 12/13/15, Security Agent 1, Security Agent 2, Security Agent 3 were observed in close proximity to Patient 1. Security Agent 1 grabbed Patient 1 and threw him down to the wet ground (on the street).

A telephone interview was conducted with Patient 1 on 12/17/15 at 10:00 A.M. Patient 1 stated that he walked with a cane. He stated that on 12/13/15, he was discharged from the ED and walked out to the bus stop where he discovered that the bus system was closed. He stated that he returned to the ED to make a phone call to a community health group to coordinate a ride home. He stated that he made a second phone call to "medicare" and was unsuccessful. He stated that he walked up to the physician who treated him. He stated that the physician told him that they were not responsible for getting patients home and that no taxi vouchers would be given. Patient 1 alleged that he was "dragged out of the ED". He stated that out of the building, on public property, he was surrounded by 3 security agents and 1 "Caucasian" ED employee. He stated that he was grabbed in the shoulder and thrown on the ground. He stated that his cane was thrown in a trash can. Patient 1 stated that he was bleeding on his left elbow, left wrist and left hand. He stated that he did not seek medical attention for his injuries.

An interview and joint document review with Security Agent 2 was conducted on 12/18/15 at 8:03 A.M. Security Agent 2 stated that he worked the graveyard shift on 12/13/15, from 10:00 P.M. to 6:00 A.M. He recalled responding to a call for security assistance with a patient that was refusing to leave the ED. Security Agent 2 stated that Patient 1 walked with a cane. He recalled that Patient 1 had clenched his fist, and then Security Agent 1 reached up and grabbed the patient from behind. He recalled that Security Agent 1 wrapped both his arms around the patient's back, there was commotion and Patient 1 fell to the ground. Security Agent 2 stated that Patient 1 was not a threat to anybody. He stated that the hospital's security protocol did not include touching the patient. Security Agent 2's Supplemental report, dated 12/16/15 at 2:50 P.M., indicated that during an escort of a patient off hospital property, Security Agent 1 grabbed Patient 1 from behind, up by the neck and shoulder. Per the report, there was a little commotion between Security Agent 1 and Patient 1, and the patient was lying on the ground. Security Agent 2 wrote that he remembered Patient 1 getting up and saying "You should not have put your hands on me." He stated that "anytime a security agent puts hands on anybody, you have to write a report." He acknowledged that hospital security protocols and policies were not implemented or followed during the escort of Patient 1 off hospital property.

An interview and joint document review with Security Agent 3 was conducted on 12/18/15 at 8:58 A.M. Security Agent 3 stated that he was the first to respond to the call for security assistance in the ED. He recalled that Patient 1, who had been discharged from ED, was refusing to leave and was disruptive. He stated that Patient 1 used a cane as he walked through and out of the ED. Per Security Agent 3, during the security escort off hospital property, he turned around to Security Agent 2 and asked him to take care of the incoming trauma. As he turned around, he saw that Patient 1 was on the ground. He did not see anybody put hands on Patient 1. Security Agent 3 stated that as Patient 1 was getting up from the ground, he alleged that Security Agent 1 pushed him. He stated that Security Agent 1 replied and said "push you... you fell." Security agent 3 stated that ED Tech 1 grabbed Patient 1's cane and walked it to the bus stop.

An interview and joint document review with Security Agent 1 was conducted on 12/18/15 at 3:28 P.M. Security Agent 1 confirmed that he was an agent on duty on 12/13/15 from 10:00 P.M. to 6:00 A.M. He recalled responding to an ED call for security assistance. He stated that there were 3 security agents (Security Agent 1, Security Agent 2, and Security Agent 3) and an ED technician (ED Tech 1) that escorted Patient 1, who was discharged from the ED, off hospital property. Security Agent 1 stated that as the agents were trying to guide Patient 1 off hospital property, the patient fell to the ground. He stated that Patient 1 stood back up and "got in his face." He stated that Patient 1 was told that he needed to leave repeatedly. Security Agent 1 could not recall if Patient 1 swung his cane at anyone. He stated that Patient 1 did not physically touch the agents or the ED technician. He recalled that Patient 1 was verbally abusive and was cursing at them.

A review of the hospital's security Daily Activity Report (DAR), dated 12/13/15 at 11:30 P.M. was conducted with Security Agent 1 (the writer) during the interview. According to the DAR, Security Agent 1 wrote in his event note that an individual (Patient 1) was refusing to leave hospital property. He wrote that "... At the time of us stopping him from going back towards the hospital he tried to use his cane in a manner of aggression and in the process of that he pushed himself down and the ER (Emergency Room) tech (ED tech 1) took the cane and took it to the bus stop." There were discrepancies identified between events recalled by Security Agent 1 and what he wrote in his DAR, dated 12/13/15 at 11:30 P.M. Security Agent 1 stated "its a catch 22, there are policies that should be followed and there are policies don't work with patients".

A review of the hospital's security Healthcare Defensive Tactics System (HDTS), effective date of 12/15/15, was conducted. All security agents were trained on HDTS. Per HDTS, the following were escort strategies and technique:

1. Maintain 45 degree angle and distance (4-6 feet away)
2. Direct individual where you want them to go
3. Use verbal and non-verbal skills
4. Do not point
5. Maintain awareness.

In addition, HDTS indicated that post incident response and documentation was a required task.

An interview with the Security Manager was conducted on 12/22/15 at 1:28 P.M. The Security Manager stated that he reviewed the security camera video footage, dated 12/13/15, more than 10 times and on a large screen. The Security Manager stated that he saw Security Agent 1 and Patient 1 on the street. He stated that in the video footage, it appeared that Security Agent 1 grabbed Patient 1's left arm with his left hand, and placed his right hand up onto the patient's shoulder back area, spun the patient and threw him down to the ground. Per the Security Manager, he considered this a "throw down" instead of a "take down". He stated that the "throw down" of Patient 1 was not justified, and not in accordance with the hospital's policy. The Security Manager also stated that the steps observed during this escort off hospital property on 12/13/15 at 11:12 P.M. were not in accordance with the Security Agents' Crisis Prevention Institute (CPI - a training organization that specializes in the safe management of disruptive and assaultive behavior) training. He explained that CPI and HDTS training were required training that all security agents completed. He explained that Patient 1 should not have been surrounded by the security agents. He stated that surrounding a patient equals a detention, one must always leave the patient a way out. He stated that Patient 1 should have been taken to a safe area, not the street. He stated that when Security Agent 1, Security Agent 2, and Security Agent 3 were interviewed regarding this incident, they all acknowledged that their CPI training/techniques were not implemented.

A review of employee files were conducted on 12/22/15. Security Agent 1, Security Agent 2, and Security Agent 3 were current with their CPI and HDTS training.

The hospital's Security Operations Policy titled "Escorts From Property", dated 9/4/13, was reviewed. The policy's purpose indicated that "To establish a standardized procedure for security agents escorting individuals off [hospital name] property in a manner that is safe and effective for everyone involved." The policy stipulated that "If the individual becomes uncooperative and/or refuses to leave the premises, Agents may use soft empty hand control techniques to assist/guide the individual off of the property." Per the policy, "The use of force to escort an individual off of the property should only be escalated when an individual becomes a physical threat to the security agent or others within the immediate vicinity." The policy also indicated that "Individuals escorted off [hospital name] properties will be escorted to the nearest public city street and/or bus stop. Once the individual is safely on public grounds, Agents will discontinue the escort and stand by until it can be reasonably expected that the individual will not return to [hospital name] property."

A review of the hospital's Security Operations Policy, titled "Daily Activity/Incident Reports", dated 10/1/13, was conducted. The policy indicated that "Security Agents shall document all routine activity and calls for service using the DAR (Daily Activity Report). An IR (Incident Report) shall be generated if the event is of a criminal nature, has a high potential for civil litigation, or is significant and outside the Agent's normal routine." The policy stipulated that "Security Agents shall generate an Incident Report for any of the following, but not limited to:

1. Criminal Activity such as theft, assault, battery, vehicle burglary, drug possession, etc.

2. Events that involve emergency response: Police, Fire, or Medical calls.

3. Events that have a high potential for liability: Falls, use of force, injury to staff, visitors, or patients, an accusation of workplace violence, or inappropriate conduct by staff.

According to the policy, "When a Security Agent is involved in, witnesses, or is called to any event that necessitates an incident report to be generated, that report shall be completed prior to the end of the Agent's shift unless otherwise authorized by a Supervisor or Manager." "The report shall provide a detailed account of the event and will include all relevant facts and information. The primary responding Agent to the event is responsible for the entirety of the report. Any Security Agent who assists, witnesses, or has pertinent information to the event is responsible for completing a supplemental report. Any battery resulting in injury, incident involving a firearm or dangerous weapon, along with any illegal action or incident the Security Director deems appropriate, is to be reported to jurisdictional law enforcement (hospital name Police, San Diego Police, or local law enforcement)." The policy also indicated that "Any Security Services Department employee who witnesses, has knowledge of, or has pertinent information of any injury caused to a patient, visitor, or staff member at the hands of a fellow employee, shall immediately report this information to their direct supervisor or manager. An incident report detailing the event will be completed prior to the end of shift."

A review of the hospital's policy titled "Patients' Rights and Responsibilities", dated 4/18/13, was reviewed. The policy's abstract indicated that "This policy informs all hospital employees about statutory and regulatory rights of patients and about the [hospital name] commitment to upholding these rights. Patients have a wide range of rights and responsibilities that are set forth in State and Federal requirements and in the [hospital name] standards. All employees are required to observe these rights, to assist patients in exercising their rights...." The policy stipulated that "Patients have the right to: ...12. Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment. Patients have the right to access protective and advocacy services including notifying government agencies of neglect or abuse."

An interview with the Director of Security was conducted on 12/22/15 at 2:02 P.M. The Director of Security stated that she viewed the video footage, dated 12/13/15, more than 20 times on a small screen and 7-8 times on a larger screen. The Director of Security stated that it appeared to her that during Patient 1's escort off of hospital property, a verbal altercation between Security Agent 1 and Patient 1 occurred on the street. Per the video, she stated that Security Agent 1 used a technique to throw the patient down to the ground. She defined battery as "unwanted touching with the intent to cause harm". She defined assault as "it can be a verbal threat or gestures with an intent or means to commit harm". She defined physical abuse as "ongoing physical assault on a person". The Director of Security stated that when Security Agent 1 grabbed and threw Patient 1 down to the ground, "it was battery." She also stated "yes, [Patient 1] was physically abused by [Security Agent 1's name]". She also agreed that multiple techniques, policies and procedures were not implemented by Security Agent 1, Security Agent 2, and Security Agent 3 during the escort off hospital property of Patient 1.

b. An interview and joint document review with the Security Manager was conducted on 12/22/15 at 1:28 P.M. The Security Manager stated the Security Agent 1, Security Agent 2 and Security Agent 3 did not generate an incident report for a patient fall during a security escort of hospital property process in accordance with the hospital's Security Operations Policy. In addition, the Security Manager stated that based on his viewing of the security camera video footage, dated 12/13/15, Patient 1 did not have a fall as indicated in the security agents' DARs. He stated that Security Agent 1 threw Patient 1 to the ground without justification. He stated Security Agent 1's actions were not in accordance with the hospital's Security Operations policy.

An interview with the Director of Security was conducted on 12/22/15 at 2:02 P.M. She defined battery as "unwanted touching with the intent to cause harm". She defined assault as "it can be a verbal threat or gestures with an intent or means to commit harm". She defined physical abuse as "ongoing physical assault on a person". The Director of Security stated that when Security Agent 1 grabbed and threw Patient 1 down to the ground, "it was battery." She also stated "yes, [Patient 1] was physically abused by [Security Agent 1's name]". She acknowledged that Security Agent 1, Security Agent 2, and Security Agent 3 did not generate an incident report for witnessing a fall and/or criminal activity as specified in their Security Operations Policy.

c. The hospital's policy titled "Chain of Command", dated 10/17/13, was reviewed. The policy defined Chain of Command as "... an authoritative structure established to resolve administrative, clinical, or other patient safety issue by allowing healthcare staff and physicians to present an issue(s) of concern through the lines of authority until resolution is reached." Per the policy, examples include but not limited to conflicts or refusal to adhere to policies and procedures, would require staff to notify their chain of command.

An interview and joint document review with the Security Manager was conducted on 12/22/15 at 1:28 P.M. The Security Manager stated the Security Agent 1, Security Agent 2 and Security Agent 3 did not notify their immediate supervisor when a patient fall occurred during a security escort off hospital property in accordance with the hospital's Security Operations Policy. In addition, the Security Manager stated that based on his viewing of the security camera video footage, dated 12/13/15, Patient 1 did not have a fall as indicated in the security agents' DARs. He stated that Security Agent 1 threw Patient 1 to the ground without justification. He acknowledged that Security Agent 1, Security Agent 2, and Security Agent 3 did not notify their immediate supervisor when a witnessed fall and/or criminal activity occurred.

An interview with the Director of Security was conducted on 12/22/15 at 2:02 P.M. She defined battery as "unwanted touching with the intent to cause harm". She defined assault as "it can be a verbal threat or gestures with an intent or means to commit harm". She defined physical abuse as "ongoing physical assault on a person". The Director of Security stated that when Security Agent 1 grabbed and threw Patient 1 down to the ground, "it was battery." She also stated "yes, [Patient 1] was physically abused by [Security Agent 1's name]". She acknowledged that Security Agent 1, Security Agent 2, and Security Agent 3 did not notify their immediate supervisor for witnessing a fall and/or criminal activity as specified in their Security Operations and hospital Chain of Command Policy.

d. A review of the hospital's Abuse Screening, Assessment, and Reporting policy, dated 12/19/13, was conducted. The policy's scope indicated that it applied to all [hospital name] employees, volunteers, trainees, and students. The policy's abstract indicated that it "... provides appropriate guidelines for recognizing cases of suspected abuse and (ii) outlines statutory reporting requirements for mandated reporters. Per the policy, mandatory reporter was defined as an "... employee, official, or volunteer who is required by law, to report the abuse or neglect, or reasonable suspicion of abuse or neglect, of children, elders, or dependent adults to specified authorities." The policy defined physical abuse as "Any act that results in a non-accidental physical injury; willful infliction of any cruel or inhuman corporeal punishment or injury." The policy also defined reasonable suspicion as "Objectively reasonable for a person to entertain a suspicion based upon facts that could cause a reasonable person in a like position, drawing, when appropriate, on his or her training and experience." The policy indicated that "Mandated Reporters must comply with the reporting obligations imposed by federal and state law." Per the policy, "Initial external reports must be made as soon as reasonably feasible by telephone or via Internet reporting tool. If the initial report is made by telephone, it must be followed by a written report as soon as reasonably practicable, but in any event, within... 2 working days of the initial telephone report for dependent adult and elder abuse." The policy instructed that if the Mandated Reporter observes an incident that reasonably appears to be physical abuse, the following procedure will be implemented:

1) Notify the attending physician or responsible provider
2) Contact the Elder and Dependent Adult Abuse Reporting Line
3) Complete form SOC 341, Report of Suspected Dependent Adult/Elder Abuse
a. Mail to the Department of Social Services within 2 working days.

A review of employee files were conducted on 12/22/15. The hospital's forms titled "Elder/Dependent Adult Abuse Reporting Requirement Employee Notification and Acknowledgement" and "Dependent Adult Abuse Reporting Compliance Statement", were signed by employees to certify that they have read, understood, and will comply with the abuse reporting requirements. Security Agent 1, Security Agent 2, and Security Agent 3 had signed copies of these forms in their files. A signed copy of this form was not found for ED Tech 1.

A group interview with the Emergency Department Nurse Manager (EDNM), the NDES and QCS 2 was conducted on 12/22/15 at 10:00 A.M. They all agreed that ED Tech 1 was a mandated reporter. They acknowledged that ED Tech 1 did not notify his chain of command, nor did he report this incident to Adult Protective Services, as mandated reporter.

An interview and joint document review with the Security Manager was conducted on 12/22/15 at 1:28 P.M. The Security Manager stated "we're all mandated reporters." The Security Manager acknowledged that the security agents did not report and fulfill their responsibilities as mandated reporters.

An interview with the Director of Security was conducted on 12/22/15 at 2:02 P.M. She defined battery as "unwanted touching with the intent to cause harm". She defined physical abuse as "ongoing physical assault on a person". The Director of Security stated that when Security Agent 1 grabbed and threw Patient 1 down to the ground, "it was battery." She also stated "yes, [Patient 1] was physically abused by [Security Agent 1's name]". She acknowledged that the security agents did not follow and implement the hospital's Abuse Screening, Assessment, and Reporting policy, as mandated reporters.

Based on interview and record review, Hospital A failed to ensure that an inventory of patient belongings and a discharge disposition screen had been performed and completed in accordance with the Emergency Department (ED) Standards of Patient Care and Patient Belongings in the ED policy, for 1 of 46 sampled patients. There was no documented evidence found in Patient 1's medical record to demonstrate that an inventory of his patient belongings had been performed, and that the discharge process was completed. Patient 1's completed discharge disposition screen and a signed/written discharge instruction (after visit summary signature page) should have been found in his medical record.

The lack of documented patient belongings, a discharge disposition screen and a signed after visit summary made it difficult to determine if the hospital's discharge process in the ED was implemented in accordance with their ED Standards of Patient Care and hospital policies.

Findings:

1 a. Patient 1 presented to Hospital A's ED on 12/13/15 with a chief complaint of flank pain per the Emergency Department Note by Physician 2, dated 12/13/15 at 3:10 P.M. According to Physician 2's ED Note, Patient 1's past medical history included the following: MI (myocardial infarction - heart attack), CVA (cerebrovascular accident - a sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain) with residual left sided weakness, splenic laceration (cut in the spleen) status post major trauma, nephrolithiasis (kidney stones) left flank pain and hematuria (blood in the urine). Per the same Note, Patient 1 had fallen several times in the last few weeks from left lower leg weakness status post CVA.

An interview and joint record review with the Registered Nurse (RN 1) was conducted on 12/17/15 at 2:52 P.M. RN 1 recalled caring for Patient 1, as his primary nurse, on 12/13/15 (night shift 7:00 P.M. to 7:00 A.M.) RN 1 stated that when she received the discharge orders from the physician, she generated the discharge paperwork, reviewed it with the patient and answered his questions. She stated that she performed Patient 1's discharge and followed the hospital's discharge process. She recalled completing the discharge disposition screen and obtaining the signed after visit summary signature page from the patient. During a review of a general discharge disposition screen, it contained the following elements: departure condition, mobility at departure, level of consciousness, orientation level, cognition, language/speech, patient teaching, departed with, patient's ability to verbalize when and where to obtain follow-up (yes or no), patient's ability to verbalize sign and symptoms to report, eye opening, best verbal response, best motor response, and Glasgow Coma Scale score (a scoring system to describe a person's level of consciousness). A completed discharge disposition screen was not found in Patient 1's medical record.

A review of the hospital's ED Standards of Patient Care, fiscal year 2014/2015, was conducted. The ED Standards of Patient Care indicated that "Person responsible for patient disposition (admission, transfer or discharge) from the Emergency Department will be responsible for checking that all department forms have been completed." The ED Standards of Patient Care also stipulated that "Patient disposition will be entered in the disposition screen of the electronic medical record. Required charting elements include time of discharge, mode of departure, type of aftercare instructions given to the patient, condition of patient upon discharge, accompanying person and any other pertinent information."

An interview with the Nurse Director of Emergency Services (NDES) was conducted on 12/17/15 at 3:29 P.M. The NDES confirmed that RN 1 had clicked on "awake" of discharge disposition screen and did not complete the rest of Patient 1's discharge disposition screen. The NDES stated that the discharge disposition screen should have been completed and found in Patient 1's medical record in accordance with the ED Standard of Patient Care.

b. An interview and joint record review with the Registered Nurse (RN 1) was conducted on 12/17/15 at 2:52 P.M. RN 1 recalled caring for Patient 1, as his primary nurse, on 12/13/15 (night shift 7:00 P.M. to 7:00 A.M.) RN 1 stated that when she received the discharge orders from the physician, she generated the discharge paperwork, reviewed it with the patient and answered his questions. She stated that she performed Patient 1's discharge and followed the hospital's discharge process. She recalled completing the discharge disposition screen and obtaining the signed after visit summary signature page from the patient. However, during the record review, Patient 1's after visit summary signature page could not be found in the medical record.

A review of the hospital's ED Standards of Patient Care, fiscal year 2014/2015, was conducted. The ED Standards of Patient Care indicated that "Upon discharge, patients will receive written information about the nature of illness/injury." It stipulated that "The patient will acknowledge understanding of appropriate treatment, follow up care, available resources and referrals as indicated by patient's condition. After verification of understanding by the patient and/or significant other, the RN will witness the appropriate signature on the written discharge instructions. The signed/written discharge instructions will then become a permanent part of the medical record."

On 12/22/15 at 9:40 A.M., the Quality Compliance Specialist (QCS 2) confirmed that the medical records department could not find Patient 1's after visit summary signature page.

A follow-up interview with the Nurse Director of Emergency Services (NDES) was conducted on 12/22/15 at 9:41 A.M. The NDES stated that the after visit summary signature page should have been in Patient 1's medical record in accordance with the ED Standard of Patient Care.

c. An interview with RN 3 was conducted on 12/22/15 at 9:06 A.M. RN 3 recalled Patient 1 and being his primary nurse on 12/13/15 (dayshift 7:00 A.M. to 7:00 P.M.) He stated that for most of his shift the patient was either in ultrasound (medical imaging) or CT (computerized tomography - is an imaging procedure that uses special x-ray equipment to create detailed pictures, or scans, of areas inside the body). He stated that he recalled Patient 1 having a metal cane that was hooked onto the patient's gurney while in the ED.

Patient 1's medical record was reviewed. There was no documented evidence that ED Registered Nurses (RNs) had documented Patient 1's belongings in the medical record. Within a general Patient Belongings section of the medical record, the following information would be documented: patient location, items from home necessary for daily activity or medical treatment such as dentures, glasses, hearing aid, home medications, mobility devices, medical equipment, valuables, valuable disposition, and other belongings.

A review of the hospital's policy and procedure titled "Patient Belongings in the Emergency Department", dated 10/14/14, was conducted. The policy indicated to "Ask the patient to identify anything of value in the bags/cases and verify (including but not limited to: money, jewelry, cell phone, checkbook, dentures, hearing aide) - document each individual item of value in Epic (hospital's electronic medical record system)".

An interview with the Quality Compliance Specialist (QCS 2) was conducted on 12/23/15 at 9:15 A.M. in the presence of the Nurse Director of Emergency Services (NDES). The QCS 2 stated that the patient belongings documentation could not be found in Patient 1's medical record. The NDES stated that an inventory of Patient 1's belongings should have been documented and found in the medical record per the hospital policy.

Based on video observation, interview, record, and document review, Hospital A failed to ensure that Emergency Department (ED) staff implemented the Bus Passes and Taxi Vouchers policy, for 1 of 46 sampled patients (1) when Patient 1, who had been discharged, returned to the Emergency Department requesting for a taxi voucher. Failure to implement this policy impeded the hospital from meeting the transportation needs of a discharged patient from the ED.

Findings:

Patient 1 presented to Hospital A's ED on 12/13/15 with a chief complaint of flank pain per the Emergency Department Note by Physician 2, dated 12/13/15 at 3:10 P.M. Patient 1 was discharged on 12/13/15 at 10:40 P.M. per the ED Patient Care Timeline, date 12/13/15.

According to Physician 2's ED Note, dated 12/13/15, Patient 1's past medical history included the following: MI (myocardial infarction - heart attack), CVA (cerebrovascular accident - a sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain) with residual left sided weakness, nephrolithiasis (kidney stones) left flank pain and hematuria (blood in the urine). Per the same Note, Patient 1 had fallen several times in the last few weeks from left lower leg weakness status post CVA.

On 12/16/15 at 2:45 P.M., a security camera video footage dated 12/13/15 at 11:12 P.M. was reviewed at the hospital with the Chief Nursing Officer (CNO), the Director of Security, the Director of Regulatory Affairs (DRA), Quality Compliance Specialist (QCS 1) and the Nurse Director of Emergency Services (NDES). Per the video footage, the Director of Security confirmed that the following hospital staff were present during the incident: Security Agent 1, Security Agent 2, Security Agent 3 and ED Trauma Technician (ED Tech 1). Patient 1 was observed with a cane in his right hand. Patient 1 used the cane as he ambulated out of the ED.

A telephone interview was conducted with Patient 1 on 12/17/15 at 10:00 A.M. Patient 1 stated that he walked with a cane. He stated that on 12/13/15, he was discharged from the ED and walked out to the bus stop where he discovered that the bus system was closed. He stated that he returned to the ED to make a phone call to a community health group to coordinate a ride home. He stated that he made a second phone call to "medicare" and was unsuccessful. He stated that he walked up to the physician who treated him. He stated that the physician told him that they were not responsible for getting patients home and that no taxi vouchers would be given. Patient 1 alleged that he was "dragged out of the ED". He stated that out of the building, on public property, he was surrounded by 3 security agents and 1 "Caucasian" ED employee. He stated that he was grabbed in the shoulder and thrown on the ground. He stated that his cane was thrown in a trash can. Patient 1 stated that he was bleeding on his left elbow, left wrist and left hand. He stated that he did not seek medical attention for his injuries.

An untimed hand-written note, dated 12/15/15, by ED Tech 1 was reviewed. The note indicated that Patient 1, who had been discharged from the ED, was allowed to use the phone in the waiting room to call for a cab. Patient 1 walked back into the ED towards the physician's area asking for a taxi home. Patient 1 was informed that "we do not provide vouchers" to patients unless criteria was met. Patient 1 was informed to leave the ED by staff. Patient 1 became verbally abusive and pushed ED Tech 1. Security assistance was activated. Per the note, a physician informed Patient 1 that vouchers were not provided and that he was discharged. Patient 1 was escorted out of the ED by security and ED Tech 1.

An interview and joint document review with ED Tech 1 was conducted on 12/17/15 at 2:00 P.M. ED Tech 1 stated that he picked up a shift on 12/13/15 and was assigned as a sitter to an ED patient from 7:00 P.M. to 7:00 A.M. He confirmed that the untimed, hand-written note was his recollection of the events on 12/13/15. He recalled that Patient 1 was demanding a taxi voucher. He stated that the physician (name unknown) was not able to provide Patient 1 with a taxi voucher.

An interview and joint record review with Registered Nurse (RN 1) was conducted on 12/17/15 at 2:52 P.M. RN 1 recalled caring for Patient 1, as his primary nurse, on 12/13/15 (night shift 7:00 P.M. to 7:00 A.M.) RN 1 stated that when she received the discharge orders from the physician, she generated the discharge paperwork, reviewed it with the patient and answered his questions. She stated that she performed Patient 1's discharge and followed the hospital's discharge process. She stated that she had a discussion with Patient 1 about transportation. She remembered Patient 1 telling her that he had taken the bus to the ED. She had checked the online bus schedule which indicated that no buses were running. She stated that she asked Patient 1 if he needed a taxi or if he had a friend to call. She stated that Patient 1 replied and said he could call a friend. Per RN 1, she discharged Patient 1 and assumed that his transportation needs were met. RN 1 was not aware that Patient 1 had returned to the ED requesting for a taxi voucher.

A phone interview with RN 3 was conducted on 12/18/15 at 7:35 A.M. RN 3 stated that she was the charge nurse on 12/13/15, night shift (7:00 P.M. to 7:00 A.M.) RN 3 stated that if a patient required assistance getting home and was asking for a taxi voucher or a bus pass, ED staff were instructed to see the charge nurse. She explained that the ED's social worker assisted patients with transportation needs but on a weekend and after hours, the charge nurse was that resource person. She stated that if the charge nurse was unavailable then the staff were instructed to follow their chain of command.

A review of the hospital's policy titled "Bus Passes and Taxi Vouchers", specific to the ED, dated 11/12/15, was conducted. The policy indicated that "The ED is able to provide transportation assistance in the form of a bus pass or taxi voucher, when warranted. Please confer with ED SW (social worker) when questions of transportation assistance occur. If an ED SW is not on duty, please confer with a the Charge RN. All transportation assistance provisions should be documented in the patient's chart."

The hospital's policy titled "Chain of Command", dated 10/17/13, was reviewed. The policy defined Chain of Command as "... an authoritative structure established to resolve administrative, clinical, or other patient safety issue by allowing healthcare staff and physicians to present an issue(s) of concern through the lines of authority until resolution is reached." Per the policy, examples include but not limited to conflicts or refusal to adhere to policies and procedures, would require staff to notify their chain of command.

A telephone interview was conducted with Physician 1 on 12/17/15 at 3:50 P.M. Physician 1 stated he was the attending physician for Patient 1 who presented to the Emergency Department on 12/13/15 at approximately 2:19 P.M., with a complaint of flank pain. Physician 1 stated he signed over care of Patient 1 at 9:00 P.M. to another attending physician and he was not aware that Patient 1 had any issues regarding transportation to home. Physician 1 stated he recalled that Patient 1 had a history of stroke, left sided weakness, a history of falls, and that he ambulated with a cane. Physician 1 stated that since the buses were not running when Patient 1 was being discharged that it would be appropriate for Patient 1 to receive a taxi voucher taking into consideration Patient 1's history of falls, use of a cane and that Patient 1 had no other means of transportation home.

An interview with Physician 2 was conducted on 12/18/15 at 3:05 P.M. Physician 2 stated he was the physician who took care Patient 1 on 12/13/15 in the afternoon who presented to the ED with a complaint of flank pain and walked with a cane. Physician 2 stated that after Patient 1 was discharged, Physician 2 heard Patient 1 being verbally threatening to an emergency room technician. Physician 2 stated Patient 1 was requesting several things and that security arrived and escorted Patient 1 out of the ED. Physician 2 stated in regards to patient transportation needs that is usually arranged by the social workers or nursing staff in the emergency department and not a routine practice of the Medical Staff.

An interview with the NDES was conducted on 12/18/15 at 4:00 P.M. The NDES stated that ED Tech 1 had a sitter assignment on 12/13/15, and had no business leaving the ED when Patient 1 required security escort off hospital property. The NDES stated ED Tech 1 should have notified the primary or charge nurse (his chain of command) when Patient 1 returned to the ED requesting for a taxi voucher. She stated that it was cold and raining on the night of 12/13/15, Patient 1 should have been placed in a cab. She acknowledged that hospital's policies related to chain of command and taxi vouchers were not implemented.