HospitalInspections.org

Based on document review and interviews, the Hospital failed to execute a corrective action plan as result of a significant hospital event involving Patient #1.

See A-283

Based on document review and interviews, the Hospital failed to implement a corrective action plan as a result of a significant hospital event regarding a physical altercation between Patient #1 and Public Safety (PS) staff. The Hospital's Quality Assessment and Performance Improvement (QAPI) team did not review the incident for the potential to identify opportunities of improvement to improve patient care.


Findings Include:

The Hospital Investigation Report, dated 04/28/20, indicated that on 03/28/2020, at about 12:20 A.M., an individual identified as Patient #1 was in the Emergency Department (ED) waiting area and that, according to PS Officer #1, (Officer #1, who was stationed at the ED front desk) Patient #1 walked up to Officer #1 and reported that he/she (Patient #1) was having suicidal thoughts. Officer #1 directed Patient #1 to check-in with ED staff at the registration window. Officer #1 indicated that Patient #1 appeared to leave the ED and then return a short time later and report again to Officer #1 that he/she felt suicidal.

A written statement by Officer #1, untitled, obtained by the Hospital's PS Department, dated 03/27/20, stated that Patient #1 came into the Hospital and approached the security window. Per the statement, Officer #1 said that Patient #1 wanted to commit suicide at which point, Officer #1 told him to go to the other registration window (a window where formal check-in of patients into the ED occurs). Officer #1 said that Patient #1 left the ED, and that 50 seconds later, Patient #1 entered again, and said that he/she wanted to commit suicide. Officer #1 said he directed Patient #1 to the patient greeter (the greeter is seated at the formal check-in area and initiates the check-in process).

The surveyors (Surveyor #1 and Surveyor #2) observed video footage on 07/20/20 at 11:15 A.M. from the event date, 03/28/2020, in a time frame between 12:25:15 A.M. and 12:27:56 A.M. Surveyors observed footage of an altercation that occurred between PS Officers and Patient #1. Officer #1, Officer #2, and Officer #3 appeared to be involved in the altercation with Patient #1. The footage ends with Patient #1 being escorted up the steps by PS Staff. The Operations/Training Supervisor of PS, indicated that no other footage was saved due to a camera blind spot. Observation of the video did not indicate any evaluation or screening by clinical staff.

Surveyor #1 interviewed Officer #2 and Officer #4 on 07/16/20 at approximately 4:30 P.M. Officer #2 said that as Patient #1 was being escorted out of the Hospital by Officer #1 and Officer #2, that as they were about to exit the doorway, Officer #1 took Patient #1's head, brought it back and then brought it forward and into the glass exit door. Patient #1 was pushed through the door and was now outside the Hospital and onto the street. At this time, other PS Officers arrived on scene to include Officer #4. Officer #4 said that Officer #1 was removed from the scene, and Officer #4 began speaking with Patient #1. Officer #4 stated that there was blood coming down Patient #1's face. Officer #4 said that Patient #1 requested to be seen by medical staff and requested Boston Police Dept (BPD) to be called. Officer #4 said that BPD arrived on scene and then left after Patient #1 decided not to file a report. Officer #4 brought Patient #1 back into the ED and Officer #4 launched an investigation.

Surveyor #1 interviewed Risk Manager (RM) #2 on 07/16/20 at 2:20 P.M. RM #2 said that the "assault" of Officer #1 on Patient #1 occurred at 12:27 A.M., when Officer #1 pushed Patient #1's head into the glass door.

Surveyor #1 interviewed the Director of Registration on 07/17/20 at 10:25 A.M. The Director said that Patient #1 electronically checked-in on 03/28/20 at 12:55 A.M. and that there was no history of prior check-in (registration).

The Department of Police and Public Safety (DPPS) policy titled Post Orders, ED Front, last updated 10/2018, states under 1h: "Immediately alert clinical staff of arriving patients in need of urgent medical care."

The DPPS policy titled Conduct and Ethical Behavior, last effective 11/12/2018, under section three (the procedure section) states "some examples of unethical behavior include but are not limited to:" with example number three stating "Failing to assist individuals needing or seeking medical care."

Interviews, document review and video observation review indicated that, during the incident involving Patient #1 and Officers #1, #2 and #3, PS staff (Officer #1, Officer #2, Officer #3) failed to follow the DPPS policy titled Conduct and Ethical Behavior and failed to alert clinical staff that Patient #1 was seeking medical care.

Surveyor #1 interviewed the PS Director on 07/16/20 at 11:30 A.M. The PS Director stated that other than the termination of Officer #1, no corrective actions were implemented by the Public Safety Department as a result of this incident.

Surveyor #1 interviewed RM #2 on 07/16/20 at 2:20 P.M. and on 07/17/20 at 2:45 P.M. RM #2 said that the Risk Department reviewed the incident via conference call on 04/21/20. This conference call included three senior risk managers, the Vice President of Risk, the PS Director and the Director of Registration. This team determined that Patient #1 was not a patient at the time of the incident involving Patient #1 and Officer #1. RM #2 said that this team viewed the incident as a public safety investigation, and the incident never went to the Quality Department of the Hospital for review.