HospitalInspections.org

Based on the review of one of one medical record (Patient (P) 30), review of facility security video surveillance, review of facility documents, and staff interview, it was determined that the facility failed to ensure that all patients are free from abuse, and that incidents of alleged abuse are investigated.

Findings Include:

Facility policy titled, "Use of Force (reviewed 11/16/2021)" states, "... V. ESCALATION OF FORCE: ...C. Inspira staff are here to help people and even when force may be justified, the intent is only to take control of the dangerous person and to protect yourself and/or others. All employees must remember, "DO NO HARM" is always the goal through minimum impact with the dangerous person. ... VII. REVIEW OF USE OF FORCE INCIDENTS: ...C. A use of Force Review Committee shall be convened by the Director of Workplace Violence and will include representation from Employee Health and Safety, Human Resources, Risk Management, Security Manager, and affected employee's immediate supervisor, i.e, manager, director, VP. ... D. The representative from Risk Management will present all evidence referencing the event to the Review Committee. E. The Review Committee will make a determination if additional interviews are necessary, and if so, will proceed with panel interviews with involved staff. ... G. The Use of Force Review Committee will share their written findings with and make recommendations to the AVP of Safety and Security and the VP of Human Resources concerning the appropriateness of the level of force. ..."

On 7/21/23 at 10:00 AM, a review of P30's medical record was conducted. P30 was admitted to the facilities Child and Adolescent Mental Health Unit (CAMHU) on 3/26/23. The BH IP History and Physical from 3/27/23 at 9:10 AM stated, " ...Subjective: History of Present Illness ...Pt started to become emotionally/behaviorally dysregulated ~13:15P and pushing on exit doors attempting to elope, with enough force to knock bolts out of the door. Code gray was called. Once security entered the unit, pt escalated. Pt swung and punched security. There was non-therapeutic physical restraint intervention by security which appeared to contribute to further escalation. Pt continued to escalate and required 5 people to transport [him/her] to safety room for 4-point locked restraint. Pt remained combative, including punching another security guard in the face, spitting, and threatening to shoot and kill security. Pt also made multiple statements about wanting to die. Pt required IM [intramuscular] medication to regulate. "I hope you put something in there that kills me!." Pt with significant difficulty taking accountability for [his/her] actions and the consequences. ..."

On 7/21/23 at 1:54 PM, the security video of the incident that took place on 3/27/23 was viewed in the presence of S48 (Director of Security) and S60 (Director of Human Resources). In the video P30 is observed walking down a hallway and slamming against a door attempting to get out before pacing back and forth in the hallway. Multiple staff members are observed in the hallway with P30. S45 can be seen coming in the hallway through the doors with aggressive posturing and walks towards P30. P30 throws a punch at S45 and S45 grabs P30 by the collar and slams him/her up against a door 2 times. Multiple staff members were observed talking to S45 and gesturing for him/her to release P30. P30 then attempts to get out of S45's grip and S45 grabs P30 around the face and neck area to pushes him/her against the wall again. The other staff members in the hallway were attempting to place P30 in a therapeutic hold [the patient's arms were held by staff for safety] as P30 is visibly kicking and attempting to punch. S45 was seen pacing the hallway as P30 was taken down the hallway and then S45 abruptly exits the unit.

On 7/21/23 at 10:32 AM, an interview was conducted with S48 and S60. S48 explained that he/she was familiar with the incident and had been notified by security and risk management after the incident occurred. S45 explained that when an incident of staff on patient or patient on staff violence occurs an investigation is usually conducted to see what occurred. S45 indicated that statements would be taken from all parties involved and video tapes would be reviewed (if applicable) as part of the investigation. S60 explained that immediately after the incident occurred, the security officer involved, S45, left the facility and resigned. S48 explained that the case was discussed amongst administrative staff including the VP of Human Resources, the behavioral health administrative team and the security administrative team and since the security officer resigned and the police were notified the facility felt that a further investigation was not necessary. The facility failed to investigate an alleged and witnessed case of staff to patient abuse.

This CONDITION is not met as evidenced by:

Based on staff interview, medical record review, and facility document review, it was determined that the facility failed to ensure that there is an organized medical staff specific to each separately certified hospital as evidenced by: failure to ensure clearly defined medical staff oversight and accountability for each separately certified hospital (A0347); failure to ensure the medical staff of the hospital has voted to operate as a unified medical staff or as a separate and distinct medical staff (A0349); and failure to ensure that obstetricians/gynecologists are performing procedures within the scope of privileges granted (A0363).

Cross Reference:
482.22(b)(1), (2), (3) Medical Staff Organization & Accountability
482.22(b)(4) Medical Staff Voting
482.22(c)(6) Criteria for Medical Staff Privileging

Based on staff interview and facility document review, it was determined that the facility failed to ensure clear organization and oversight of the medical staff.

Findings include:

Review of facility document "Medical Staff Bylaws Structure," dated September 19, 2019, indicated the presence of a "System Medical Executive Committee."

Review of facility document "Narrative Description of Inspira Medical Center Vineland and Inspira Medical Center [separately certified hospital] Medical Executive Committees [MEC] and Structure," undated, revealed "Inspira Medical Center Vineland has its own separate medical staff that is not combined or shared with any other acute care hospital." Further review of this document indicated the presence of two Medical Staff Campus Committees, which each include medical staff from Inspira Medical Center Vineland and medical staff from another separately certified hospital.

Interview on July 19, 2023, at 10:01 AM with S53 (Chief Legal Officer) indicated that each separately certified hospital has its own medical staff that report to a single Medical Executive Committee (MEC).

A request was made for MEC Meeting minutes for Inspira Medical Center Vineland for the past year. The document titled "Inspira Medical Center Vineland Medical Executive Committee (Provider Number 310032)" was provided for review. Review of the document indicated the presence of information for multiple separately certified hospitals under the Inspira Health Network. S39 (Chief Quality and Safety Officer) indicated that Inspira Medical Center Vineland does not have a specific medical executive committee and that all of the hospitals under the health network are incorporated into the one medical executive committee.

Interview on July 19, 2023, at 10:26 AM, with S53 indicated that Inspira Health Network maintains two separate CCNs for their campuses, but the MEC was the same for both CCNs.

Based on staff interview and facility document review, it was determined that the facility failed to ensure that the medical staff for each separately certified hospital within the healthcare network operates as either distinctly unified and integrated, or distinctly separate; and failed to provide evidence that a vote was held in accordance with the medical staff bylaws to establish a unified and integrated, or a separate medical staff.

Findings include:

A request was made for MEC Meeting minutes for Inspira Medical Center Vineland for the past year. The document titled "Inspira Medical Center Vineland Medical Executive Committee (Provider Number 310032)" was provided for review. Review of the document indicated the presence of information for multiple separately certified hospitals under the Inspira Health Network. S39 (Chief Quality and Safety Officer) indicated that the Inspira Medical Center Vineland does not have a specific medical executive committee and that all of the hospitals under the health network are incorporated into the one medical executive committee. The MEC meeting minutes provided identified a "VBE [Vineland, Bridgeton, Elmer] Campus Specific MEC Report" and a "WMH [Woodbury, Mullica Hill] Campus Specific Report." The Campus Specific reports each include campuses from separately certified hospitals.

Interview on July 19, 2023, at 10:01 AM with S53 (Chief Legal Officer) indicated that each separately certified hospital has its own medical staff that report to a single Medical Executive Committee (MEC), who then in turn reports to the Governing Body.

Upon request, the facility was unable to provide documentation that the medical staff members voted to accept a unified and integrated medical staff or structure, or voted to opt out of such a structure and to maintain separate and distinct medical staff for their respective hospital.

Based on staff interview, physician credential file review, and review of medical staff by-laws, it was determined that the facility failed to ensure that obstetricians/gynecologists are performing procedures within the scope of privleges granted.

Findings include:

Facility document titled, "Medical Staff Bylaws Credentialing Procedures" (approved 9/16/21) states, "... 4.A. Clinical Privleges 4.A.1. General: ...a. ...Only those clinical privleges granted by the board may be exercised, subject to the terms of these Bylaws. ..."

On 7/20/23 at 1:20 PM, during a review of physician personal files, privileges were reviewed for S41 (obstetrician/gynecologist) in the presence of S43 (Director of Medical Staff Services). The "Obstetrics Core Privileges" granted for S41 included "post-partum [after delivery] D&E [dilation and evacuation]" and did not include D&E procedures that were prior to delivery. This finding was confirmed by S43, who stated that he/she became aware of this yesterday.

On 7/21/23, a review of medical records for patient (P) 7 and P15 revealed the following:

On 3/16/23, S41 performed a D & E procedure on P7, a same day surgery patient, prior to delivery. S41 documented in the History and Physical Report that P7 was 16.5 weeks pregnant, "unable to find [fetal] heart rate with Doppler or with ultrasound in office. Sent for stat ultrasound and confirmed no fetal cardiac activity. ...Fetal demise before 20 weeks with retention of dead fetus." On 3/16/23, S41 also performed a D&E procedure on P15, a same day surgery patient, prior to delivery. S58 (OB/GYN resident) documented in the History and Physical, signed by S41, that P15 was 24.5 weeks, presenting with intrauterine fetal demise, "with fetus measuring 16.2 weeks." The facility failed to ensure that all obstetricians are performing procedures within the scope of their granted privleges.

Based on medical record review (Patient (P)2), review of facility documents and staff interview it was determined that the facility failed to ensure that that there is coordination and communication between the Emergency Department (ED) and the Case Management/Social Worker/Behavioral Health teams.

Findings include:

Facility Policy titled, "CC 2 Discharge Planning Policy (unknown date)" states, " ...CC 2j: Homeless: Patient is identified as homeless during IA or via consult and wants assistance with housing. ... Is the patient in the ER? Yes- ED Physician can contact Administration to confirm next steps. ..."

Facility document titled "BART/CRISIS PROCESS (unknown date)" states, " ... Arrived to ED with SI/HI or other behavioral concerns. - BART- RN Complete BART referral form- Wait for BART team assessment and dispo. ..."

Facility document titled, "BH Case Management Referral Workflow (BART) (unknown date)" states, "Physician to place BH Case Management Referral Order for all patients with any level of mental health or substance use issues. Nurse to Complete BH Case Management Referral Form. Behavioral Health & Addiction Resource Team (BART) Assesses Patient- Referral to Crisis/PESS - Referral to Voluntary Inpatient - Referral to OORP team - Referral to Outpatient Treatment. ..."


On 7/19/23 at 9:30 AM, P2's medical record from 12/27/22 was reviewed. P2 presented to the facilities Emergency Department (ED) on 12/27/22 at 6:21 AM complaining of chest pain. The patient was triaged as an ESI (Emergency Severity Index) of 5. P2 had vital signs taken and an EKG (electrocardiogram) performed at 6:24 AM. The patient was taken to the ED waiting room while waiting for a room to open in the ED. The ED Nursing Note from 12/27/22 at 7:01 AM states, " .. Pt [Patient] escorted out of ED for inappropriate sexual behavior to wait to be seen. PD [Police Department] was called for patient due to the nature of the sexual behavior. While waiting for PD and to be seen, pt was escorted to the benches outside of the ED, and the patient was told [he/she] would have to wait here to be seen by a doctor. When pt got outside to wait with security, pt continued walking with security following. Security tried getting pt to come back into ED to be seen. Pt told security "I don't want to be seen." The patients ED disposition was listed as left without being seen.

On 7/19/23, a request was made to see the number of visits P2 had made to the facility's ED since December of 2022. Review of P2's ED visits indicated that P2 had made 16 visits to the facility's ED from December 2022 until July 2023. A review of P2's medical records revealed that P2 has a history that includes the following: Chest Pain, Homelessness, Recurrent Depressive Disorders, Suicidal Thoughts, Tobacco Use, Mood Disorder and Schizoaffective Disorder. In January of 2023, P2 made 11 visits to the facility's Emergency Department for complaints of chest pain, body pain and aches and an episode of ETOH [alcohol abuse]. On 9 out of 11 of these visits, P2's disposition was listed as discharged home.

Review of P2's medical records lacked evidence that P2 was seen by case management, social work or behavioral health. On 7/19/23 at 11:35 AM, during an interview with Staff (S)14 (Director of Care Coordination), he/she explained that social work/case management is available in the ED 8AM to 8PM, 7 days a week. S14 explained that the CM/SW team will assist patients who are homeless to connect with resources such as shelters. S14 indicated that the ED staff would have to consult the CM/SW team for them to see the patient. S14 reviewed P2's medical records and the last care management assessment was from October 6, 2021. When questioned if P2 should have been seen due to the history of mental illness, homelessness and the frequent visits to the ED, S4(AVP of Emergency Services), S7 (Clinical Director of Emergency Services) and S14 all confirmed that the ED staff should have consulted CM/SW to see P2.