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Based on a review of facility policy, documents, medical records (MR), and interview with staff (EMP), it was determined that the Hospital Of The University of Pennsylvania failed to provide patient care services in the emergency department timely and in a safe setting; failed to ensure patients received patient care services in the emergency department without abusive treatment by facility staff ; and failed to ensure the protection, promotion of the rights and dignity of patients seeking emergency services was maintained during the delivery of the patient care process.

Findings include:

The information reviewed during the survey provided evidence that the Hospital of the University of Pennsylvania, Cedar Avenue Campus Emergency Department failed to provide
a safe environment in the emergency department to receive emergency care services as evidence of the abusive treatment by staff to patient (MR21), failure to provide timely patient care services in the emergency department (MR21, MR22) and patient elopements (MR22).

Based on the seriousness of the non-compliance identified and the effect on patient outcome, the facility failed to substantially comply with this Condition (Patient Rights-482.13).

Cross reference:

482.13 (c)(2) Patient Rights: Care in Safe Setting.
482.13(c)(2) Patient Rights: Free From Abuse/Harrassment.

Based on a review of the facility's policy, documents (video coverage), medical record (MR) and interview with staff (EMP), it was determined that the facility failed to ensure a patient seeking emergency services at the Hospital Of The University of Pennsylvania (HUP), Cedar Avenue Campus Emergency Department received care in a safe setting by permitting the security guard staff to forcibly remove patients from the emergency department (MR21 and MR22).

Findings Include:

Review of facility policy, "Patients' Bill of Rights and Responsibilities" last reviewed August 16, 2017, revealed "All employees and staff of HUP/CPUP are responsible for fulfilling their duties in a respectful, competent manner. All employees and staff are expected to respect the patient's right to participate in his/her own care...,STATEMENT OF PATIENTS' RIGHTS...1. Respectful care given by competent personnel which reflects consideration of his/her personal value and belief systems and which optimizes his/her comfort and dignity...7. Good quality care and high professional standards that are continually maintained and reviewed...25. Receive care in a safe setting, and be free from all forms of abuse and harassment.

1) Review of the facility's video recording of an ED incident on March 3, 2022, video recording time stamped approximately 3:02 AM to 4:05 AM with EMP2, EMP4. EMP5, EMP6, EMP7, EMP8, EMP9 and EMP13 revealed MR21 was escorted by city police officers into the HUP-Cedar Avenue Campus Emergency Department. Further review of the video recording revealed MR21 completed the ED registration process and entered the ED waiting room area and was seated. MR21 then exited the ED waiting room area in what appeared to be a state of verbal distress, unescorted by staff and appeared to be walking toward the ED main hallway and was grabbed by EMP28 from the rear of the collar area of the upper clothing garment. Continued review of the video coverage revealed MR21 returned to the waiting room and sat in a waiting room chair. EMP27, EMP28 and EMP29 entered the waiting room and removed MR21 from a sitting position in the waiting room area and physically carried MR21 by the upper and lower extremities toward the ED sliding glass doors exiting the ED, passing through the ED alcove which contains a metal detector to the outside of the ED. Continued review of the video coverage revealed MR21 appeared to be emotionally and physically distressed and resistant to the physical handling and removal from the ED. Further review of the video recording revealed EMP27, EMP28 and EMP29 purposely made forcible contact with the head and body of MR21 with the metal detector located in the ED alcove during the removal of MR21 from the ED with the assistance of EMP27, EMP28 and EMP29. Further review of the video recording shows EMP27, EMP29, EMP30 and EMP33 walking outside of the ED toward the parking garage and MR21 exiting the parking garage away from the ED.

A telephone communication on March 14, 2022, at 1:10 PM with EMP8 and EMP9 revealed "We believe this was an unfortunate isolated incident that has occurred with this patient. The four individuals directly involved in this incident were placed on administrative leave pending the conclusion of this investigation. We became aware that this incident had occurred because EMP28 complained that EMP27 was not fully engaged in assisting EMP28 with addressing the patient (MR21) behavior in the HUP Cedar Avenue Emergency Department."

2) Review of MR22, progress note authored by CF1 dated October 29, 2021, at 8:53 AM revealed "The patient arrived via Emergency Medical Services. The patient was noncompliant with Emergency Department staff., verbally abusive and threatening. I was attempted to de-escalate with patient and the patient was unable to de-escalate. The patient was asked to leave the Emergency Department and return when able to comply in a safe manner. Patient then went outside the ED and laid down on the sidewalk. Security brought patient back into the ED. The patient had another family member at bedside, and we gave the patient another 10 minutes without stimulation. Patient started yelling at family member, myself, and staff again. The patient denied alcohol and cocaine use, the patient was oriented. Decided to give patient another 10 minutes. In that time, patient eloped."

Review of MR22, progress note authored by EMP34 dated October 29, 2021, at 9:10AM revealed "Delayed note due direct patient care. Patient was removed by security initially for irate behavior, per the request of ED provider [name redacted]. Patient ambulated out of ED with security escort then returned."

Review of MR22, progress note authored by EMP34 dated October 29, 2021, at 9:20 AM revealed " Patient acting irate...Patient tried to throw a punch, and then was asked to leave by ED provider [name redacted] and security. Patient independently got up from bed and ambulated toward ED waiting area, while stating " I will walk back out there and pass back out again. Patient escorted to ED door by security."

A telephone conference call conducted on March 17, 2022, at 2PM with CF1, confirmed that MR22 was asked to leave the HUP Cedar Avenue Emergency Department due to behavior prior to the medical screening exam. CF1 stated "I remember this patient. The patient was very irate and disruptive. I was fearful for my myself and the staff. I did have the security staff escort the patient out of the emergency department because of behavior and informed the patient I could not wait (provide service) until the patient's behavior calmed down."

An interview conducted on March 28, 2022, at 3:15 PM with EMP9, confirmed that MR22 was escorted from the HUP Cedar Avenue Emergency Department twice by the hospital's security staff at the request of the ED provider due to behavior and prior to the completion of the medical screening examination. EMP9 confirmed that MR22 eloped from HUP Cedar Avenue Emergency Department after being escorted out of the ED by hospital security staff.

Based on a review of the facility's policy, documents (video coverage), medical record (MR) and interview with staff (EMP), it was determined that the facility failed to ensure a patient seeking psychiatric emergency services at the Hospital Of The University of Pennsylvania (HUP), Cedar Avenue Campus Emergency Department was free from abuse from the facility's security staff for one of one medical record reviewed (MR21).

Findings Include:

Review of the facility's video recording of an ED incident on March 3, 2022, video recording time stamped approximately 3:02 AM to 4:05 AM with EMP2, EMP4. EMP5, EMP6, EMP7, EMP8, EMP9 and EMP13 revealed MR21 was escorted by city police officers into the HUP- Cedar Avenue Campus Emergency Department. Further review of the video recording revealed MR21 completed the ED registration process and entered the ED waiting room area and was seated. MR21 then exited the ED waiting room area in what appeared to be a state of verbal distress, unescorted by staff and appeared to be walking toward the ED main hallway and was grabbed by EMP28 from the rear of the collar area of the upper clothing garment. Continued review of the video coverage revealed MR21 returned to the waiting room and sat in a waiting room chair. EMP27, EMP28 and EMP29 entered the waiting room and removed MR21 from a sitting position in the waiting room area and physically carried MR21 by the upper and lower extremities toward the ED sliding glass doors exiting the ED, passing through the ED alcove which contains a metal detector to the outside of the ED. Continued review of the video coverage revealed MR21 appeared to be emotionally and physically distressed and resistant to the physical handling and removal from the ED. Further review of the video recording revealed EMP27, EMP28 and EMP29 purposely made forcible contact with the head and body of MR21 with the metal detector located in the ED alcove during the removal of MR21 from the ED with the assistance of EMP27, EMP28 and EMP29. Further review of the video recording shows EMP27, EMP29, EMP30 and EMP33 walking outside of the ED toward the parking garage and MR21 exiting the parking garage away from the ED.

Review of facility policy "Assessment of Victims of Possible Abuse, Neglect or Exploitation" effective January 18, 2021, revealed "GENERAL PROCEDURE. 2. Assessment of a patient's alleged or suspected abuse, neglect, exploitation, or abandonment should be conducted in a non-threatening, non-accusation, confidential manner. 3. If abuse or neglect is suspected, the patient will be further assessed. Some indications of abuse are...b. Suspicion of neglect, exploitation or abandonment by care givers;...4. It is important to recognize that abuse or neglect may have occurred without any of these signs being present. ...Vulnerable Adult Abuse (18 to 59 years of age): 1. The employee or administrator having reasonable cause to believe on the basis of his/her medical, professional, or other training and experience that a Vulnerable Adult is a victim of abuse, neglect, exploitation or abandonment shall immediately make an oral report to the Pennsylvania Department of Human Services through the Protective Services Hotline 1 (800) 490-8505...This policy applies to all licensed health professionals, patient care and treatment providers, and those supervised or managed by such providers, clergy, students, employees, contracted workers, and volunteers who have direct contact with patients, children, and patients' families when carrying out their duties and thus should be aware of the indicators of abuse.... DEFINITIONS. Abuse: The occurrence of one or more of the following acts: (1) The infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. (2) The willful deprivation by a caregiver of goods or services which are necessary to maintain physical or mental health...Neglect: The failure to provide for oneself or the failure of a caregiver to provide goods, care or services essential to avoid a clerk and serious threat to the physical or mental health of an adult."

An interview conducted on March 17, 2022, at 2:45 PM with EMP2 and EMP9 confirmed that EMP27, EMP28 and EMP29 deliberately struck the head and body of MR21 on the metal detector in the ED alcove as was also confirmed during a review of the facility's video recording by the State Agency Survey Team.

A communication received by the State Agency Surveyor-Supervisor on March 5, 2022, from EMP4 revealed MR21 had voluntarily returned to the Hospital of the University of Pennsylvania, Cedar Avenue Campus Emergency Department to receive emergency services. The communication also detailed that MR21 was offered and accepted emergency services at the Cedar Avenue Campus Emergency Department and was offered the opportunity to press police charges for the assault on March 3, 2022.