HospitalInspections.org

Based on staff interview, review of the facility's surveillance video, and review of facility policy and procedure, it was determined that the facility failed to protect and promote each patients rights by ensuring that everyone who presents to the facility is properly identified and screened.

Findings include:

The facility failed to ensure that anyone who presents to the facility is properly identified and screened prior to gaining entrance during hours when the main lobby is closed. (Refer to Tag 0144)

Based on staff interview, review of the facility's video surveillance footage, and review of facility policy and procedure, it was determined that the facility failed to ensure that all visitors are properly identified upon arrival.

Findings include:

Facility policy titled, "(SR.2) Identification & Access Control Policy (undated) states, " ...POLICY: Goals: To provide a visible device (ID Badge, wristband, or pass) to patients, staff, and visitors to indicate official hospital business. To control access to and egress from sensitive areas (i.e, ground floor, Newborn Nursery, ED, Special Care Units, Pharmacy). To reduce the risk of potential security incidents of unauthorized persons. Plan: Patients, Visitors, and Personnel should have appropriate identification. ...Visitors will obtain a pass from the Patient Information Desk/Security. ..."

On 10/11/23 at 1:27 PM, an interview was conducted with S32 (Director of Security) who stated that anyone who comes into the facility needs to be "qualified" prior to being allowed in. S32 explained that qualifying included verifying the person's identity, finding out why they are at the facility (as a patient, as a visitor, as a vendor) and determining what assistance is needed. S32 explained that all security staff is educated to this process during their onboarding.

On 10/11/12 at 1:56 PM, a review of the facility's security surveillance video from the incident on 8/12/23 was reviewed. Review of the surveillance video from the ED entrance revealed that on 8/12/23 at 3:20 AM, the following occurred:

In the ED lobby, S39 (Security Guard) was observed standing, S41 (Patient Access Representative/Registrar) was sitting at the front desk, and S42 (Pivot Nurse) was sitting at a computer around the corner at the nursing station.

At 3:20:24 AM, a taxi pulls up to the ED entrance and the Taxi Driver (TD) gets out, walks around car, and opens door. At the same time inside the ED, S39 was observed sitting down in a chair at his/her station pulling out his/her cell phone and looking at the cell phone.

At 3:21:25 AM, the TD walked into the ED entrance and past the security officer (the first point of contact into the ED), who was on his/her phone and did not look up, greet, or interact with the TD. The TD walks up to the registration desk, interacts with S41 and gestures "pregnant belly" and "wheelchair".

At 3:21:57 AM, the TD walks over to S39, who was still on his/her cell phone. The TD was seen talking to security guard and security guard points in a direction (towards the main lobby). The TD exited the ED, got into the taxi and drove away.

Review of the Security Surveillance Footage from the Front Main Lobby Entrance, revealed the following:

At 3:24:04 AM, the TD pulled up to main entrance, got out, walked around the car, and opened the door. Another female (companion- not P1) was seen exiting the car.

At 3:24:24 AM, the TD walked up to main entrance doors looks around and then rings doorbell. After the TD rang the bell, he/she started to walk away from the door as if he/she was looking around for someone, then came back to the door.

At 3:24:54 AM, at the main entrance (consisted of 2 set of doors). The first set of doors opens, the TD stood inside the first door while looking into the lobby for someone but did not go through the 2nd set of doors.

At 3:25:16 AM, the TD entered the main lobby thru the 2nd door and walked down the lobby walkway towards the back of the main lobby. TD saw S40 (security officer) and started talking and gesturing.

On 10/12/23 at 10:23 AM, a telephone interview was conducted with S39. S39 explained that he/she saw the man (taxi driver) come in and speak to the registrar, but he/she was unaware of what was said. S39 explained that the man then came to him/her and asked where the main lobby was located, to which S39 gave directions and the man left. When asked if he/she "qualified" the man or asked any additional questions, S39 explained that he did not.

At 10:56 AM, an interview was conducted with S40 (Security Officer). S40 explained that if someone comes to the front lobby off hours and rings the bell, the dispatcher (also a security guard) will talk with the person over the intercom to qualify (find out who they are and what they need) them and then buzz them into the building. S40 explained that the dispatcher will alert the security officer in the main lobby via phone or radio, that someone is at the lobby door and being let in. S40 indicated that this should be done prior to letting anyone in the main lobby. S40 explained that on 8/12/23 when this incident occurred, he/she was at the back security station answering the phone. S40 stated that he/she was not notified that someone had entered the lobby until he saw the taxi driver walking through the lobby asking for help.

At 1:28 PM, an interview was conducted with S35 (Lead Security Officer) who work primarily in dispatch. S35 explained that when the main lobby is closed, an officer is always stationed in the main lobby. S35 explained that when anyone comes to the main lobby after hours they have to ring the buzzer in order to gain entrance. S35 explained that there is a video intercom that the dispatcher has access to, and that the dispatcher can see the person and is to qualify them prior to letting them in the main lobby. S35 indicated that the dispatcher will notify the officer in the main lobby prior to giving anyone access to the main lobby.

The facility failed to ensure a safe environment by allowing a person access into the main lobby without alerting the security guard first.

Based on review of one of one medical record (MR #8) of a patient who left the emergency department (ED) without being seen by a medical provider, and review of facility policy and procedure, it was determined that the facility failed to ensure that attempts to locate a patient in the ED waiting area is documented in the medical record.

Findings include:

Review of Facility policy titled, " Left Against Medical Advice (AMA), Left Before Triage, Left After Triage, and Left Without Treatment" (last reviewed 3/21/22) states, " ...POLICY: ...IV. Left without treatment- Patient who left the ED prior to treatment and intervention by the provider. Attempts are made to locate the patient. Documentation of "called, no answer" one time should be reflected in the EMR ..."

Review of Patient #8 (P8)'s medical record revealed that P8 presented to the ED on 5/1/23 at 9:12 PM. Documentation under "ED Triage part 1" stated, "Pt wants to figure out if [he/she] is having a miscarriage. Pt reports heavy bleeding during period with 'pieces' that began yesterday ... Vital signs performed. ..." At 12:51 AM, the "Disposition Documentation" stated, " ...Patient left after triage ..." P8's medical record lacked documentation that any attempts were made to locate the patient.