HospitalInspections.org

Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined the Governing Body failed to ensure Temple Hospital Inc. consistently operated in a manner that protected the health and safety of the patient population served.

This condition is not met as evidence by:

Based on observation, review of facility documents, reportable incidents and corrective actions implemented at the time of each incident, it was determined the facility's Governing Body failed to provide the necessary supervision and oversight to ensure safety in the provision of care and treatment based for the patient population served and failed to follow its own policies and procedures in order to promote and protect the patient's health and safety as evidenced by the hospital's patterns of serious events and infrastructure failures commencing May 2020 to January 2021.

Findings include:

Review of survey results from May 2020 through January 2021 revealed four reportable events:

1. Emergency Department (ED)-Episcopal Campus-a patient set fire in ED Room 8 on May 23, 2020. The facility identified a hand lighter on the patient requesting treatment during the ED safety search and returned the lighter to the patient upon entering the ED.

2. Emergency Department-Main Campus-a patient set fire in ED hallway bed on August 15, 2020, with a hand lighter that the facility failed to identify during the ED safety search process set fire in the ED. The facility failed to perform the safety search process according to facility policy for a patient entering the ED via stretcher by emergency medical services (EMS).

3. Behavioral Unit-Potter Morris Six (PM6)- inpatient behavioral health patient who was inadequately monitored was able to inflict self-harm resulting in death by hanging using a no-weight limitation shower rod in the patient's bathroom. The incident occurred on September 7, 2020.

4. Crisis Response Center (CRC)-Episcopal Campus: patient in the process of discharging from the Crisis Response Center with episodes of aggressive behavior prior to exiting the CRC. Clinical staff addressed the aggressive behavior by calling a Stat 13 emergency call for the assistance of additional staff to address the behavior. The attending physician for this patient was not notified of the episodes of aggressive behavior. The patient exited from the CRC with clinical staff assistance and jumped from a third-floor hallway window resulting in his death on December 10, 2020.

5. Behavioral Health Unit-Potter Morris Five (PM5)-inpatient behavioral health patient who was inadequately monitored was able to obtain materials to ignite a fire in the hallway of the PM5 unit which set off the fire alarm. The incident occurred on January 9, 2021.


Cross reference:
482.13 Patient Rights
482.13(c)(1): Privacy and Safety
482.13 (c)(2) Patient Rights: Care in Safe Setting
482.23(b)(3) RN Supervision of Nursing Care

Based on the systemic nature of the standard-level deficiencies related to Patient Rights, the facility failed to substantially comply with this condition.

The Condition is Not Met as Evidenced by:

Based on observation, a review of facility policies, documents, medical records (MR) and interview with staff (EMP), it was determined that Temple University Hospital Inc., failed to provide care in a safe setting as evidenced of the facility's failure to provide adequate licensed nursing staff monitoring for patients on the behavioral health unit (BHU) which enabled a patient the opportunity to start a fire in the hallway of the Potter Morris 5 (PM5) BHU unit; failed to ensure adequate licensed nursing staff to maintain oversight of the delivery of patient care and supervision of nursing support staff for monitoring of BHU common areas (hallways and group rooms) and failed to ensure the dignity of the patients in the behavioral health units.

The following standards were cited and show a systemic nature of non-compliance with regards to patient's rights as follows:

[482.13(c)(1)]: Privacy and Safety:
The observations conducted during the survey provided evidence that the facility failed to promote and protect the dignity of patients by failing to assist patients to promote a positive self-image and physical appearance with the provision of clothing as oppose to hospital gowns in the Potter Morris Five (PM5) behavioral health unit.

[482.13(c)(2) Tag 0144]: Patient Rights: Care in Safe Setting
The observations conducted during the survey provided evidence that the facility failed to promote and protect the rights of patients through supervised monitoring activity for patients and nursing support staff in the common areas of the unit and the provision of the patient's dignity.

[482.23(b)(3) Tag 0395]: RN Supervisor of Nursing Care
The information reviewed during the survey provided evidence of the lack of licensed nursing supervision in delivering care to patients in the behavioral health unit.

Based on observation, review of facility policies and interview with staff, it was determined that the facility failed to promote and protect the patient's right to privacy which includes the dignity of patients by failing to assist patients to promote a positive self-image and physical appearance with the provision of clothing as opposed to hospital gowns in the Potter Morris Five (PM5) behavioral health unit.

Findings include:

Review of facility policy "Right to Humane Physical and Psychological Environment: lasted revised August 20, 2019, revealed "SCOPE AND RESPONSIBILITIES: 3. Management staff of each Behavioral Health discipline are responsible for assuring compliance with the policy and procedure...a. Every patient has the right to be treated humanely and with consideration by all staff members. Any grossly negligent or intentional conduct of staff which causes or may cause emotional or physical harm to a patient is a violation of this right. b. Every patient has the right to assistance in developing a physical appearance which promotes a positive self-image. This includes the following: 1. The right to keep and wear his own clothing, unless there are reasonable grounds to believe such clothing or specific items constitute a substantial threat to the health or safety of the patient or others. 2. Clothing provided by the facility shall be neat, clean, appropriate to season and to the extent possible, consistent with the patient's personal preference. This clothing shall enable the patient to make a customary appearance within the community."

Review of facility policy "Maintaining A Safe and Therapeutic Environment" dated November 16, 2020, revealed " Policy: It is the policy of Temple University Hospital-Episcopal Campus to provide all patients served in The Behavioral Health Services a safe place for care that is welcoming, enhances their positive self-image and preserves their human dignity. To promote safety all patient will be required to wear slip on shoes or shoes without laces. Also, patient will be required to wear clothing without strings/belts."

An observation tour conducted on January 15, 2021, at 10:40AM through 11:10AM with EMP1 and EMP2 on PM5 revealed the following observations:
1. male patient wearing a hospital gown, with a sweater walking in the hallway.
2. female patient wearing a hospital gown with a blanket wrapped around her waist walking in the hallway.
3. male patient wearing a hospital gown, a shirt and jacket walking in the hallway.
4. female patient sitting in PM5-Room 546, wearing two gowns reading a book.
5. male patient wearing two hospital gowns with a blanket draped around his shoulders walking in the hallway.
6. Review of a group activity session revealed eight patients seated in a day room. Five of the patients in the group activity session were in hospital gowns.

An observation tour on January 15, 2021, at 11:15AM on PM5 with EMP1 and EMP2 revealed at the request of the survey team; EMP2 instructed a nurse from PM5 to approach a male patient wearing a hospital gown with a sweater about the his willingness to wear pants instead of the hospital gown. The patient responded to the nurse stating, "I am willing to wear pants if you give them to me. My pants were torn when I was admitted." The survey team requested the facility obtain the item requested by the patient from the hospital's clothing donations.

Cross Reference:
482.23(b)(3): RN Supervision of Nursing Care
482.13(c)(2): Patient Rights: Care in Safe Setting

Based on observation, a review of facility policies, documentation, medical records (MR) and interview with facility staff (EMP), it was determined that Temple University Hospital(TUH) Inc, failed to provide care in a safe setting as evidenced of inadequate patient monitoring resulting in a fire set by a patient in the hallway of Potter Morris Five (PM5), a behavioral health unit.

Findings Include:

Review of facility policy " Patient Rights and Responsiblities" dated October 1, 2019, revealed "PURPOSE: To define the rights and responsiblities of all patients treated at Temple University Hospital, Inc. for TUH Staff and Physicians as well as to outline the process to notify patients family members...At Temple University Hospital, Inc. patient have the following rights...6. To receive quality care within the professional standards governing clinical practice...28. To have access to an environment that preserves dignity and contributes to healing."


Facility document requested on January 10, 2021, and received on January 20, 2021, from EMP1 to the State Agency (SA) for an incident that occurred at Temple University Hospital-Episcopal Campus on a behavioral health unit (BHU)-Potter Morris 5 on January 9, 2021, at 7:09 PM revealed "On 1/9/2021, several staff members attempted to interact with him throughout the day to obtain his cooperation with the treatment team. The staff fulfilled his requests for pain medication, speaking with the physician when requested; patient was only partially cooperative. A video review on 1/9/2021, shows the patient picked something up from the hallway, possibly a paperclip, and ambulated in the hallway, sat down on the floor next to the electrical outlet. He gets up and down from the floor several times. It appears he has a paper in his hand. The video shows he is sticking something in the tamper resistant outlet. A spark is seen, he gets up from the floor and drops the paper which is on fire into the paper trash container and quickly walks up the hall. The paper trash container ignites and sets off the firm [sic] alarm system which alerts the staff."

The survey team reviewed facility video tape of the PM5 hallway fire dated January 9, 2021, time stamped between the hours of 7:09 PM through 7:42 PM with EMP .
The Review on January 15, 2021, from 9:29 AM through 10:20 AM with EMP1, EMP3, EMP5, EMP6 and EMP8. Review of the video revealed : On January 9, 2021, at 7:10 PM on in-patient psychiatric unit Potter-Morris 5 (PM5), MR1 is noted to be sitting on the floor in the North end of the hallway wearing pants, gown and large blanket covering the top portion of his body. The camera view from the South end of the hall shows EMP12, mental health technician (MHT) engaged with the mobile computer across from the Nurses' Station. At 7:11:40 PM MR1 positions himself on the floor next to an electrical outlet. MR1 is observed lying on the floor for over two minutes next to the outlet without observation by PM5 staff. Video observation at 7:14 PM shows MR1 continues picking at the electrical outlet while obscuring his actions with the blanket draped over his head and arms. At 7:15:22 PM MR1 is observed to have ignited the paper, getting up while holding the burning paper beneath the blanket, walking over to the paper trash bag in the hallway and dropping the burning paper into the paper trach container. Video observation from the South end of the hallway shows EMP12 has been engaged with her computer as well as one of several patients that are seen in and around the nurses' station. As EMP12 gets up she continues to look at the computer and does not notice the flames at the North end of the hallway. A patient stationed mid-way between EMP12 and the flaming paper trash container alerts her to the flames. At 7:16 AM large flames are visible, MR1 is observed walking quickly to his room, passing EMP12 as she and other employees respond to the fire. MR1 enters his room, and reappears into the PM5 hallway again without a blanket over his clothing and enters the community room with other patients. Further observation of the video revealed MR1 was observed in the video sitting on the floor at the North end of the unit in the hallway without visual observation by staff members from 7:10 PM until after fire was started at 7:15 PM.

An interview conducted on January 15, 2021, at 9:43 AM with EMP1 who stated "As far as staffing on the unit, there was one mental health technician doing a a 1:1, the other mental health technician was with patients in the common areas, and the outgoing RNs for the shift and the incoming shift RN's were handing off change of shift report at the nurse's station. They (nurses) were not aware of what was going on in the hallway until the MHT yelled fire."

An interview conducted on January 15, 2021, at 10:15 AM with EMP1, EMP3 and EMP5 confirmed that MR1(patient) was observed in the video in the hallway of PM5 sitting/lying on the floor at the North end of the PM5 hallway without visual observation by EMP12 located in the same hallway as MR1 from 7:10 PM until after he started the fire at 7:15 PM. EMP1 and EMP3 confirmed EMP12 did not initiate a safety check to see if MR1 was impaired at the time the patient was sitting/lying on the floor.
___________

An observational tour conducted on January 15, 2021, at 10:15 AM with EMP3 of the security command station on the 1st floor revealed electronic monitors captioning views of the hospital's common areas of the various patient care areas including PM5.

An interview conducted on January 15, 2021, at 10:20 AM with EMP20 who stated "we view the monitor for urgent issues that demand our attention. We do not view the electronic monitors to look for specific details on the floors. Security does not have time look at the activity displayed on each of the units because the monitor views flip from place to place. We view major events such as Stat 13 which is an emergency code called for uncontrolled behavior by a patient and or visitor."

An interview on January 15, 2021, at 10:39 AM with EMP3 and EMP5 who stated "Security can see (the camera feed), but that's not their only job. The view is always flipping and they (security guard) have a lot going on."

An interview conducted on January 15. 2021, at 11:06 AM with EMP6 who stated " the location of the video monitors in the security command station are not in the optimal location for monitoring patient's activity in the common areas such as on PM5. Security does not have the time to do that nor are they required."

Cross Reference:
482.23(b)(3): RN Supervision of Nursing Care
482.13(c)(1): Privacy and Safety

Based on review of facility policy, documents. medical records (MR) and interview with staff, it was determined that Temple University Hospital Inc-Episcopal Campus failed to ensure the oversight of the mental health technician (MHT) by a licensed registered nurse (RN) resulting in inadequate monitoring of behavioral health patients on Potter Morris Five (PM5) resulting in an unmonitored patient igniting a fire in the paper trash container in the hallway of PM5.

Findings include:

Review of facility policy "Maintaining a Safe and Therapeutic Environment" last revised November 16, 2020, revealed "GENERAL GUIDELINES: A. The RN (registered nurse) is responsible for the oversight and supervision of the Tech (mental health technician)...STAFF SAFETY MEASURES... i. Strictly adhere to keeping all tools, chemicals, equipment, machinery, plastic bags and sharp objects under the direct control of the employee who is using them....a. Staff members are expected to be vigilant on the clinical units and are expected to monitor the behavior of patients throughout the day. The patient's assigned contact persons should make himself known to the patient at the beginning of each shift and should be aware of their participation in activities and routine unit functions...15. No items should be left in the hallway than can be used as a weapon or pose a fall risk.

The survey team reviewed facility video tape of the PM5 hallway incident dated January 9, 2021, time stamped between the hours of 7:09 PM through 7:42 PM with EMP .
The Review on January 15, 2021, from 9:29 AM through 10:20 AM with EMP1, EMP3, EMP5, EMP6 and EMP8. Review of the video revealed : On January 9, 2021, at 7:10 PM on in-patient psychiatric unit Potter-Morris 5 (PM5), MR1 is noted to be sitting on the floor in the North end of the hallway wearing pants, gown and large blanket covering the top portion of his body. The camera view from the South end of the hall shows EMP12, mental health technician (MHT) engaged with the mobile computer across from the Nurses' Station. At 7:11:40 PM MR1 positions himself on the floor next to an electrical outlet. MR1 is observed lying on the floor for over two minutes next to the outlet without observation by PM5 staff. Video observation at 7:14 PM shows MR1 continues picking at the electrical outlet while obscuring his actions with the blanket draped over his head and arms. At 7:15:22 PM MR1 is observed to have ignited the paper, getting up while holding the burning paper beneath the blanket, walking over to the paper trash bag in the hallway and dropping the burning paper into the paper trach container. Video observation from the South end of the hallway shows EMP12 has been engaged with her computer as well as one of several patients that are seen in and around the nurses' station. As EMP12 gets up she continues to look at the computer and does not notice the flames at the North end of the hallway. A patient stationed mid-way between EMP12 and the flaming paper trash container alerts her to the flames. At 7:16 AM large flames are visible, MR1 is observed walking quickly to his room, passing EMP12 as she and other employees respond to the fire. MR1 enters his room, and reappears into the PM5 hallway again without a blanket over his clothing and enters the community room with other patients. Further observation of the video revealed MR1 was observed in the video sitting on the floor at the North end of the unit in the hallway without visual observation by staff members from 7:10 PM until after fire was started at 7:15 PM.

An interview conducted on January 15, 2021, at 9:43 AM with EMP1 who stated "As far as staffing on the unit, there was one mental health technician doing a a 1:1, the other mental health technician was with patients in the common areas, and the outgoing RNs for the shift and the incoming shift RN's were exchanging shift report at the nurse's station. They (nurses) were not aware of what was going on in the hallway until the MHT yelled fire."

An interview conducted on January 15, 2021, at 10:15 AM with EMP1, EMP3 and EMP5 confirmed that MR1(patient) was observed in the video in the hallway of PM5 sitting on the floor at the North end of the PM5 hallway without visual observation by EMP12 located in the same hallway as MR1 from 7:10 PM until after he started the fire at 7:15 PM. EMP1 and EMP3 confirmed EMP12 did not initiate a safety check to see if MR1 was impaired at the time the patient was sitting/lying on the floor.

An interview conducted on January 19, 2021, at 2:24 PM with EMP13 confirmed that prior to the incident the licensed nurses were in the nurses station or in the conference room across from the medication room completing the nurse to nurse handoff for change of shift. EMP13 stated " We were not aware of the incident until we heard the mental heath technician (MHT) yelled "there is a fire". As to how patients are assigned on the unit, the nurses make up the patient assignments not the mental health technicians. We work out together with the MHT's to cover the needs of the unit. Nurses do the necessary documentation at the nurse's station because we do not have a mobile computer device to document on. We rely on the MHT's to be out on the floor."

Cross Reference:
482.13(c)(2): Patient Rights: Care in Safe Setting
482.13(c)(1): Privacy and Safety