HospitalInspections.org

Based on staff interviews, medical record review, and review of facility documents, it was determined the facility failed to ensure that patients are cared for in a safe setting.

Findings include:

1. The facility failed to ensure that a mechanism to identify the presence of weapons entering the facility is in place. (Cross refer to Tag A-144)

2. The facility failed to ensure that processes addressing visitor access to locked patient care units, are implemented. (Cross refer to Tag A-144)

Based on staff interviews, medical record review, and review of facility documents, it was determined the facility failed to ensure that: 1) a mechanism to identify the presence of weapons entering the facility is in place; 2) processes addressing visitor access to locked patient care units, are implemented.

Findings include:

1) Reference: Facility policy titled, "Weapons Detection Policy" (effective 9/10/23) states, " ... [Name of facility] is committed to providing a safe, secure environment for its employees, patients, physicians, visitors, vendors and volunteers. To that end, [name of facility] Security and Office of Emergency Management team works to maintain an environment that is free from weapons. This is consistent with the [name of facility] Nonviolence in the Workplace policy that specifically prohibits introduction into any company building, vehicle, or event firearms, bullets, explosives, or any knife or other device intended to be used as a weapon. ... In an effort to keep weapons including firearms and large knifes [sic] from being carried into our facilities, Weapons Detection Systems are authorized for deployment. ... ."

During the entrance conference on 12/11/23 at 10:00 AM, in the presence of Staff #1 (Standards Director), Staff #2 (Standards), Staff #3 (Chief Nursing Officer), and Staff #4 (Vice President, Quality & Safety), Staff #4 confirmed that on 12/8/23, a visitor entered the Pediatric Intensive Care Unit (PICU) and when told to leave, used a large knife to assault three staff members. The visitor was disarmed by a security officer and held until police arrived. Upon interview, Staff #4 stated, "The investigation is ongoing. We still don't have all the details."

Upon interview at 12:30 PM, Staff #4 confirmed that the facility does not have metal detectors to screen for weapons. Staff #4 stated, "We do not screen for weapons. We only screen behavioral health patients. We use a wand (handheld metal detector) for them."

An interview was conducted on 12/11/23 at 1:25 PM with Staff #10 (Director of Security). Staff #10 confirmed the facility does not have metal detectors. When asked if the facility identified a need for metal detectors Staff #10 stated, "We identified the need for metal detectors a while ago, but I'm sure there will be a push to get them now. I'm not sure why we haven't gotten them yet." Staff #10 was asked if security was seeing an increase in weapons being brought into the facility. He/she stated, "We are seeing an increase in knives, but not really any other weapons."

An interview was conducted with Staff #27 (Security Officer) on 12/11/23 at 2:06 PM. Staff #27 was asked how he/she screens for weapons. He/she stated, "We screen law enforcement or undercover officers for weapons visually. If they are armed, we ask them to remove their firearm and we secure it for them until they leave. To screen everyone else, we look for bulges. Otherwise, there is no way for us to know if anyone has a weapon." Staff #27 was asked if he/she was given additional instructions or training on weapons screening since the incident occurred. He/she stated, "We were told to be more vigilant and we have more awareness, but we don't do anything differently."

During a tour of the ED on 12/12/23 at 10:25 AM, an interview was conducted with Staff #12 (Armed Security Officer). When asked how he/she screens visitors or patients for weapons, Staff #12 stated he/she looks for weapons by "looking for bulges around the waist." When asked if his/her screening process for weapons changed after the incident that occurred on 12/8/23, Staff #12 stated, "No. I'm not doing anything differently."

At 10:44 AM, an interview was conducted with Staff #13 (Security Officer). When asked how he/she screens for weapons, Staff #13 stated, "You look for bulges. If we don't see anything, then there is no way for us to know that weapons are present." Staff #13 stated that he/she does not ask visitors or patients if they are carrying weapons. Staff #13 stated that his/her process for screening for weapons did not change after the incident that occurred on 12/8/23.

At 11:40 AM, an interview was conducted with Staff #10 (Director of Security). Staff #10 was asked if the facility's process for screening for weapons included asking persons entering the facility if they have weapons. Staff #10 stated, "No." Staff #10 was asked if the process for screening for weapons had changed after the incident that occurred on 12/8/23. Staff #10 stated, "No."

On 12/12/23, review of an incident report entered on 3/11/23 indicated the following:

On 3/10/23 at 11:45 PM, Patient #2 (P2) arrived to the ED via ambulance with reports of having "homicidal ideation towards teachers, classmates and dad." When changing into paper scrubs, the patient "took off [his/her] hoodie then proceeded to lift up [his/her] shirt ... and pulled out a kitchen knife that is 11.5 in (inches) long and initially tossed on the bed then picked it back up quickly and stated 'I am going to need this.'" Security was called for assistance and removed the knife from the patient. The incident report states, " ... 41. Post Incident Review Comments: There is an increase in need for support with security measures when it comes to weapons in the Emergency Department. ... 45. Recommendation Comments: Metal detectors."

Upon interview on 12/12/23 at 11:45 AM, Staff #10 was asked if he/she was aware of the incident indicated on the incident report. Staff #10, "I am involved with incidents and follow-up that involve security concerns or violence in the workplace. Incidents involving violence in the workplace are discussed in the Violence in the Workplace Committee. Our Assistant Director of Security tracks and trends the incidents and reports them to HR (Human Resources)." Upon interview at 11:49 AM, Staff #4 stated, "Verge reports (incident reports) go to [Staff #10] if they are related to security or workplace violence."

2) Reference #1: Facility policy titled, "Visitor Management Policy" (effective 6/30/23) states, "All people presenting to a [name of hospital system] hospital or business office without an authorized [name of hospital system] identification badge will receive a visitor badge upon entering the building. Visitors will be instructed to visibly display the badge on their person at all times. Each affiliate will use FAST-PASS as the designated Visitor Management system to record all persons entering the building with the exception of clinical vendors. FAST-PASS will be installed at the affiliate Main Entrance and additional points of entry as assessed by local security/leadership to ensure compliance with the policy. ... Visitation is restricted for those in custody (forensic patients) and the forensic patients name and information shall not be published or shared on the daily in-patient directory."

Reference #2: Facility policy titled, "Visitor Management Procedure" (effective 9/3/23) states, " ... 3. Procedure ... Performed By: Reception Desk (desk employee, security personnel and/or volunteer) ... Required Action Steps: Patient/visitor welcomed to facility and asked to provide appropriate ID ... Visitor is asked to provide reason for visit: visiting inpatient, has appointment, unannounced visit, etc. ... Confirm validity of visit reason per local affiliate level visitation policy via one of the following: ... Inpatient: access EMR (electronic medical record) to confirm patient room location/visitation permitted."

Reference #3: Facility policy titled, "Patient Visitation" (effective 2/3/23) states, " ... Behavioral Health, Labor and Delivery, NICU (Neonatal Intensive Care Unit), PICU (Pediatric Intensive Care Unit), and Pediatrics have visitor guidelines that address specific patient safety issues."

During the entrance conference on 12/11/23 at 10:00 AM, in the presence of Staff #1, Staff #2, Staff #3, and Staff #4, Staff #4 confirmed that on 12/8/23, a visitor entered the Pediatric Intensive Care Unit (PICU) and when told to leave, used a large knife to assault three staff members. Staff #4 stated that the PICU is a locked unit, with a security officer assigned to a post outside the unit at all times. When asked about the visitation process, Staff #4 stated that when visitors present to the main lobby desk requesting to visit a patient in PICU, the receptionist must first call the unit and receive approval for the visitor to come to the unit, prior to giving the visitor a pass.

A tour of the PICU was conducted on 12/8/23 at 10:30 AM, in the presence of Staff #2 and Staff #5 (AVP Nursing). The unit was closed and there were no patients or staff observed on the unit. Staff #5 stated, "Peds and PICU are all locked units. For safety, there is also only one set of elevators that have access to the 5th floor where those units are located. There is a camera outside the door of the PICU and there is a security officer assigned to the floor. No one has access unless you have business there."

An interview was conducted with Staff #7 (Security Officer) on 12/11/23 at 10:54 AM. Staff #7 was the security officer currently assigned to the 5th floor, which includes PICU, General Pediatrics, and the Mother/Baby Unit. All of the units are locked units. When asked what his/her role was, Staff #7 stated, "I'm assigned here my whole shift. I don't leave unless I'm relieved for break. When visitors come off the elevator, I call them over to me and ask to see their pass. They are supposed to have a pass from downstairs in order for them to come up here. If they don't have a pass, I send them back downstairs. Once I check their pass, I have them sign in the visitor's log. Everyone has to sign in. Then I tell them how to get to their unit. A lot of times, the visitors get confused because we have three different units on this floor."

A request was made to Staff #7 to view the visitors' sign-in log for 12/7/23 and 12/8/23. Review of the visitors' sign-in log lacked evidence that the visitor involved in the incident occurring on 12/8/23, signed the visitors' log.

Upon interview on 12/11/23 at 1:25 PM, Staff #10 (Director of Security) was asked about the visitation process for the locked units on the 5th floor, specifically the PICU. He/she stated, "Visitors present to the registration desk in the Main Lobby. Someone from the desk calls the unit first to make sure its ok for them to come upstairs. The visitor gets a pass. When they get to the unit, they are buzzed in." When asked about visitor restrictions, Staff #10 stated, "Security officers do not have access to the system, so there is a log book kept at the desk with visitor restrictions. Security and registration staff are supposed to check the log book or look in the system to make sure there are no visitor restrictions in place before they issue a pass." Staff #10 was asked if all visitors to the locked units on the 5th floor are required to sign in with the security officer on the 5th floor. Staff #10 stated, "Yes and I can tell you that regarding the incident, that was not done. There were two instances that the security officers did not do what they were supposed to do. First, the security officer downstairs (main lobby desk) did not call the unit to verify that the visitor was allowed to come up. I spoke with the officer, who said he/she gave a pass to the visitor without calling the unit first because the officer saw the visitor before. This is not our protocol. Then, when the visitor got upstairs, the security officer did not make [him/her] sign in. Again, this was against our protocol." Staff #10 was asked if he/she knew how the visitor gained access to the PICU, as the unit is locked. Staff #10 stated, "My understanding is that the visitor followed a tech inside the unit as the tech was walking in."

A review of the "Visitor Management Policy" and the "Visitor Management Procedure" was conducted on 12/12/23. There was no indication in either policy that main lobby desk staff or security personnel were required to call the locked units to request approval for visitors to visit those units prior to issuing a visitor's pass. Upon interview on 12/12/23 at 9:50 AM, Staff #4 stated, "When a visitor arrives to the main lobby desk, they let the staff member know who they are here to visit. The staff member will look in the system and check the log book to see if there are any visitor restrictions for that patient. If the visitor wants to go to one of the locked units, the staff member calls the unit first to get approval from unit that the patient can come up. Usually, it's the patient's nurse that gives approval. Then once the unit says its ok for the visitor to come to the unit, the staff member will give the visitor a visitor's pass. After a certain time, registration staff leave for the day and security will sit at the main lobby desk. Security follows the same procedure. I don't know if we have a policy, but that is our process."

On 12/12/23, review of an incident report entered on 5/29/23 revealed the following:

Patient #7 (P7) was an inmate from the county jail who was admitted to the facility on 5/15/23 and was currently a patient on unit B4. The incident report states, "[P7] was supposed to be on visitor restriction, but a person claiming to be [his/her] uncle came up to the unit at 11:50 AM, was stopped by the officers and was sent away. [The uncle] claimed that the patient's mom told him the location and she was told by someone from the hospital."

On 12/12/23, review of an incident report entered on 8/21/23 revealed the following:

Patient #3 (P3) was admitted to the facility on 8/20/23 and was currently a patient in the ICU (Unit C8). The incident report states, "At about 8:30 PM, the Unit Clerk received a call from the Pass Desk (main lobby desk) regarding a visitor who was claiming to be the [spouse] of the patient in C811. The patient's chart contained an approved/restricted visitor's list created a few hours earlier by the patient's mother and verified next of kin. ... the Unit Clerk confirmed with the Pass Desk that the visitor was not approved to visit the patient. The Unit Clerk then advised that the visitor in question could personally contact the mother of the patient if they wanted to be added to the existing approved list. Shortly after the call ended, the visitor found their way to the unit. ... When the individual finally responded to the Unit Clerk's inquiry and identified [him/herself] as the unapproved visitor, the Unit Clerk told [him/her] that she was not approved to visit the patient. ... the Unit Clerk alerted security about the hostile visitor, the panic button was pressed and a security officer came up and escorted the visitor off the unit... .

On 12/12/23, review of an incident report entered on 10/20/23 revealed the following:

Patient #8 (P8) arrived to the ED on 10/17/23. The incident report states, "Patient has a visitor restriction from October 17th 2023. Visitor restricted form handed to security and staffing on 17th. Patient complained that yesterday around 7:30 PM [he/she] had a visitor irrespective of the visitor restricted list. Security was notified and Nurse Manager [name of nurse manager] made aware."

A second incident report entered on 10/21/23 indicated that P8 again complained that visitors were allowed to come into his/her room despite signing a visitor restriction form. The incident report states, "Patient reported that visitors were allowed to come up to [his/her] room despite signing a visitor restriction. The patient's friend visited [him/her] at 3 pm and found [him/her] sleeping, took [his/her] picture, and sent it out without [his/her] consent. This invasion of privacy greatly upset the patient, as [he/she] had explicitly signed off on visitor restrictions."

Review of P8's medical record revealed the patient was pregnant and had a history of domestic violence at home. On the physician's progress note dated 10/19/23 at 6:50 AM, the physician documented, " ... 6. Suspected domestic violence ... no visitors."

On 12/12/23 at 1:30 PM, an Immediate Jeopardy (IJ) was identified for the the facility's failure to ensure that a mechanism is in place to identify the presence of weapon(s) for all civilians entering the facility and failure to implement processes for visitor access to locked units. A copy of the IJ template was provided to the facility on 12/12/23 at 3:03 PM. An acceptable IJ removal plan was received on 12/13/23 at 10:55 AM. An on-site visit to verify implementation of the IJ removal plan was conducted on 12/13/23. Verification of the implementation of the IJ removal plan included the following: Observation of the "Fast Pass" visitor check-in process in the main lobby and the Emergency Department (ED), staff interviews, review of staff re-education, and review of the revised Weapons Detection Policy. The IJ was removed on 12/13/23 at 2:20 PM.