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Based on documentation review and interviews it was determined the facility staff failed to protect and promote each patient's rights by not providing a safe environment for patients and staff. A review of the incident involving Patient #20 and how to protect the safety of patients and staff revealed the facility failed to put measures in place to make patients and staff safe. This resulted in an Immediate Jeopardy (IJ). The onsite Medical Facilities Inspectors investigated and communicated the finding to the State Agency (SA) at 11:25 a.m. on January 19, 2017. The facility Vice President of Patient Care Services, Director of Emergency and Ambulatory Services, Clinical Manager of Emergency Department and Director of Quality and Risk Management were informed of the IJ at 11:30 a.m. on January 19, 2017. The IJ was lifted after a Plan of Corrections was accepted at 2:20 p.m. on January 19, 2017 and the SA was notified at 2:30 p.m. on January 19, 2017.

See Citations #123, #144, and #147 for complete details.

Based on interview and documentation review it was determined that the facility failed to provide a patient with written notice of its resolution of a grievance within seven (7) calendar days of receipt per the facility's policy.

The findings include:

An interview with Staff Member #2 revealed that a letter was sent to Patient #20 regarding a complaint that was received on December 22, 2016. The letter was dated January 13, 2017, twenty two (22) calendar days after the complaint was received.

The facility's policy titled "Complaints and Grievances" reads in part "Most grievances should be responded to in writing (via Final Letter) within seven (7) calendar days of receipt. If the grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, the patient or the patient's representative shall be informed (via Acknowledgement letter) that the Division is still working to resolve the grievance."

On January 17, 2017 a medical record review for Patient #20 revealed that Patient #20 arrived at the facility on December 21, 2016 at 10:45 p.m. Triage was started at 10:50 p.m. and completed at 10:55 p.m. Patient #20 was triaged as a level three (3). Patient #20 complained of right upper arm injury after opening a window and needing a refill of a Xanax prescription.

Interviews on January 18, 2017 with Staff Member #10 and #12 revealed that Patient #20 was discussed after triage. The Physician determined there was no additional medical procedures required at that time. (For example, blood work or x-rays, etc.) Patient #20 was asked to wait in the waiting room.

According to the Department of Health and Human Services Triage Levels are Level 1 resuscitation required and Physician assess immediately, Level 2 emergent and Physician assess within 15 minutes, Level 3 urgent and Physician assess within 30 minutes, Level 4 Less Urgent and Physician assess within hour, and Level 5 Non-urgent and Physician assess within two (2) hours.

Interviews with Staff Members #10, #11 and #12 revealed that the Emergency Department was very busy on December 21, 2016; the night of the occurrence. There were no rooms available in the Emergency Department and at least nine or more patients were waiting in the waiting area to be seen by the Physician. All patients had been informed that they would be taken to a room in the Emergency Department as soon as a room was available.
At 11:27 p.m. Patient #20 laid self on floor and began spitting on the floor in the waiting room. Interview with Staff Member #14 revealed that this was witnessed by Staff Member #14. Staff Member #14 communicated that Patient #20 had been yelling, cursing and pacing inside and outside of facility since approximately 11:00 p.m. before laying self in floor. Staff Members #10 and #11 assisted Patient #20 onto stretcher and placed he/she in front of the nursing station in the emergency department so the patient could be observed until a room was available. Patient #20 was informed that a room would be available as soon as another patient was discharged.
At 11:37 p.m. Patient #20 was placed in a room.
At 11:55 p.m. Staff Member #10 stated that yelling of foul language and needing help was heard. Staff Member #10 went to room where Patient #20 was sitting up on stretcher screaming and cursing. The patient was informed that he/she was in a hospital and needed to keep it down and stop cursing due to other patients in the Emergency Department. Patient #20 then got louder and starting holding breath until turning red and blue. Staff Member #10 informed patient if he stopped breathing emergency procedures would be used to assist with breathing. Patient #20 then told Staff Member #10 "...to get out of the room before he/she got hurt." Staff Member #12 entered and heard this conversation and encouraged Staff Member #10 to leave the room. Staff Member #14 called 911 and informed a dispatcher that staff members had been threatened and the facility wanted the patient off the property. Staff Member #12 and #14 stated hearing the screaming and threats but did not enter the room.

At 12:10 a.m. Patient #20 was escorted out of the emergency department by an area police officer without handcuffs.

Patient #20 did not see a physician nor receive treatment during this time; one hour and 25 minutes.

An interview with Staff Members #1, #2, #3 and #4 revealed "...the Patient should have been seen by a physician and treated and before leaving the facility."

During an interview with Staff Member #11 it was revealed that Staff Member #11 was afraid. Staff Member #11 felt unable to protect the Patients and Staff during the situation. Staff Member #11 revealed that Security was not assisting during the situation and area Police took approximately fifteen (15) minutes to arrive. Staff Member #11 stated that this was not the first incident where the Patients and Staff felt unsafe. Staff Member #11 states the incidents were reported to Emergency Department Management via emails and phone calls. Staff Member #11 revealed that nothing has changed at the facility since this incident to make the Patients and Staff feel safe during future situations like this.

Staff Member #12 revealed during interview that he/she was afraid of Patient #20 and did not enter the Patient's room. Staff Member #12 stating that the yelling, cursing and threatening of Staff could be heard throughout the Emergency Department by Staff and other Patients. Staff Member #12 revealed that Patient #20 has called the Emergency Department since the incident to inquire about what staff are working. Staff Member #12 revealed that there have been no changes to protect the Patients and Staff from future incidents.

Staff Member #14 revealed during interview that he/she was at the desk in the waiting area when he/she was made aware of incident in the Emergency Department. Staff Member #14 revealed entering the Emergency Department and standing at the nursing station outside of the room of Patient #20. Staff Member #14 states, "...was kind of sort of afraid but did not enter the room". Staff Member #14 revealed the Emergency Department was very busy and the Patients as well as Staff heard what was going on. Staff Member #14 stated he/she called 911 due to threatening of the staff. Staff Member #14 stated that it is the policy of the security company to just call 911 in most cases. Staff Member #14 stated he/she never spoke with Patient #20 during the incident.

Staff Member #2 revealed during interview that the Emergency Department Staff have reported incidents in the past when they felt unable to protect the Patients and other Staff Members from harm. Staff Member #2 revealed that these incidents were reported to Administrative Staff each time they occurred. Staff Member #2 revealed that area police do not always respond immediately to their calls. Staff Member #2 stated that he/she has reached out to the area police department to try to have a better working relationship. Staff Member #2 revealed at least six (6) incidents in the past year where staff was threatened and area police were called. These incidents were reported to Administrative Staff. Staff Member #2 reveals that some Security Staff are better than others. The Security Staff on duty the night of the incident works four (4) to five (5) shifts per week.

Staff Member #15 revealed during interview that the he/she was aware of the incident that occurred. Staff Member #15 revealed that he/she would have intervened to calm the Patient and protect the Patients, Staff and the Patient from any harm. Staff Member #15 stated that the 911 call would be made after other attempts were unsuccessful to contain the situation.

The Standard Operating Procedure for security at the facility reads in part, "The (facility name) depends on you to enhance the safety and security of its employees, vendors and visitors and to protect its grounds, buildings, and other property from fire, theft, vandalism and the thoughtless acts of individuals...We must first and foremost maintain a security-oriented presence....You are expected to take whatever action is reasonably feasible and within your authority to alleviate the situation and protect personnel and property (in that order of importance) to the greatest extent possible."

Interviews with Staff Members #1, #3, and #4 reveal that they were aware of this incident and of previous incidents that threaten Patient and Staff safety at the facility and the lack of intervention by select security officers.

Based on observations and interviews it was determined the facility staff failed to ensure the Emergency Department Logs with patient names, reason being seen, date of birth and other personal information was protected from being seen by those who should not or do not need access to the information and from being destroyed.

The findings include:

On 1/17/17 during the initial tour of the off site Emergency Department (ED) the surveyor opened an unlockable closet door at the entrance to the ED. Inside the closet was at least 4 banker boxes (a card board box with a lid measuring 10" x 12" x 15" used to store files) dated 2014 to 2016. Each completely filled box contained information on patients who had been seen in the ED, why they were seen, their names, date of birth and other personal information. There was also pudding, drinks, office supplies and various other items in the closet.

Staff Member #4 stated, "We have been using those. They belong in the storage closet in the administration suite on the 3rd floor." The 3rd floor closet was visited. To get to the 3rd floor closet you entered the locked suite which had 3 other rooms including a conference room and an open area. The closet was in the conference room. The closet contained marketing supplies, food dishes, Audio/Visual equipment, wheel chairs and other items. Staff Member #4 was asked who had a key to the closet and stated, "Myself, [name of ED manager, name of imaging manger and name of operations manager] and the maintenance department."

On 1/19/17 at approximately 10:30 A.M. Staff Member #8 was interviewed and was asked who has keys to the closet in the administrative suite that is used to store ED logs containing personal medical information. Staff Member #8 stated, "I do, security (which was later determined to be passed from one security guard to the next), the supply delivery person, property manager, clinical manager of the ED, advanced imaging manager, operations coordinator and director of ambulatory services. I just started about 3 months ago so I am not sure of who had the keys before I got here."

Two copies of policies related to the storage of medical records were provided. One was currently in force and the other was in the process of being reviewed to be put into place.
The current policy titled Record Retention under the subtitle Storage states, "Within [Name of Healthcare System], our records are stored in the applicable departments."
The Revised policy titled Records Retention Policy under Policy section #4 states, "Records containing confidential and proprietary information will be securely maintained, controlled and protected to prevent unauthorized access."

Based on document review and interview it was determined the facility staff failed to ensure the Quality Assessment and Performance Improvement (QAPI) program incorporated patient and staff safety issues from the off site Emergency Department (ED) into the ongoing QAPI program and collected data related to patient and staff safety issues from the off site Emergency Department (ED) and reported the data into the ongoing QAPI program, patient and staff safety issues from the off site Emergency Department (ED) were reviewed in the ongoing QAPI (Quality Assessment and Performance Improvement) program to ensure all patients who came to the ED were able to be seen by the physician, even when acting aggressively and threatening and that the Quality Assessment and Performance Improvement (QAPI) program included the off site Emergency Department (ED) by reporting the data into the ongoing QAPI program related to safety and security.

Please see Tags 273, 283, 286 and 308 for more detailed information related to this condition.

Based on document review and interview it was determined the facility staff failed to ensure the Quality Assessment and Performance Improvement (QAPI) program incorporated patient and staff safety issues from the off site Emergency Department (ED) into the ongoing QAPI program.

The findings include:

On 1/19/17 at approximately 1:30 P.M. Staff Member #2 provided the following information. "I have been reporting safety issues to my director for four to five years in our ED staff meetings. Since about 2010 we have had issues with the [Name of Local Police Department] and the security staff. We have at least 2 security officers that aren't much help in an aggressive or hostile situation. The ED staff are afraid. The ED staff send me emails about incidents that occur, which are mostly in the evening and night. We have about 3-4 incidents a month where the police need to be called.
The ED staff have also voiced their concerns in the employee satisfaction surveys that are done yearly.

Staff Member #3 was interviewed on 1/19/17 at approximately 9:30 A.M. and provided the following information. "It took over a year to decide which program the staff would be taught in handling aggressive situations. We (the QAPI Program) have focused on the main hospital and have not addressed the safety or security issues at [Name of off site ED]. We have not reported any issues to the Med Executive Committee.

A review to the training for the ED staff at the off site facility revealed 28 of the 48 people not including physicians have been trained in the new program "Handle With Care." Physicians are not required to receive the training.

Based on document review and interview it was determined the facility staff failed to ensure the Quality Assessment and Performance Improvement (QAPI) program collected data related to patient and staff safety issues from the off site Emergency Department (ED) and reported the data into the ongoing QAPI program.

The findings include:

On 1/19/17 at approximately 1:30 P.M. Staff Member #2 provided the following information. "I have been reporting safety issues to my director for four to five years in our ED staff meetings. Since about 2010 we have had issues with the [Name of Local Police Department] and the security staff. We have at least 2 security officers that aren't much help in an aggressive or hostile situation. The ED staff are afraid. The ED staff send me emails about incidents that occur, which are mostly in the evening and night. We have about 3-4 incidents a month where the police need to be called.
The ED staff have also voiced their concerns in the employee satisfaction surveys that are done yearly.

Staff Member #3 was interviewed on 1/19/17 at approximately 9:30 A.M. and provided the following information. We (the QAPI Program) have focused on the main hospital and have not addressed the safety or security issues at [Name of off site ED]. We have not reported any issues to the Med Executive Committee. The reporting process is for the issues to be discussed in the ED Department meetings, which are held about 8 times a year. The ED manager of the Director of Ambulatory Services will bring the issues to the QMS (Quality Measures) meeting which is held quarterly. From there the issue are sent to the Med Exec (Medical Executive) Committee.

A review to the training for the ED staff at the off site facility revealed 28 of the 48 people not including physicians have been trained in the new program "Handle With Care." Physicians are not required to receive the training.

Based on document review and interview it was determined the facility staff failed to ensure patient and staff safety issues from the off site Emergency Department (ED) were reviewed in the ongoing QAPI (Quality Assessment and Performance Improvement) program to ensure all patients who came to the ED were able to be seen by the physician, even when acting aggressively and threatening.

The findings include:

On 1/19/17 at approximately 1:30 P.M. Staff Member #2 provided the following information. "I have been reporting safety issues to my director for four to five years in our ED staff meetings. Since about 2010 we have had issues with the [Name of Local Police Department] and the security staff. We have at least 2 security officers that aren't much help in an aggressive or hostile situation. The ED staff are afraid. The ED staff send me emails about incidents that occur, which are mostly in the evening and night. We have about 3-4 incidents a month where the police need to be called.
The ED staff have also voiced their concerns in the employee satisfaction surveys that are done yearly.

Staff Member #3 was interviewed on 1/19/17 at approximately 9:30 A.M. and provided the following information. "It took over a year to decide which program the staff would be taught in handling aggressive situations. We (the QAPI Program) have focused on the main hospital and have not addressed the safety or security issues at [Name of off site ED]. We have not reported any issues to the Med Executive Committee.

A review to the training for the ED staff at the off site facility revealed 28 of the 48 people not including physicians have been trained in the new program "Handle With Care." Physicians are not required to receive the training.

Interviews with Staff Members #10, #11 and #12 revealed that the Emergency Department was very busy on December 21, 2016; the night of the occurrence. There were no rooms available in the Emergency Department and at least nine or more patients were waiting in the waiting area to be seen by the Physician. All patients had been informed that they would be taken to a room in the Emergency Department as soon as a room was available.

At 11:27 p.m. Patient #20 laid self on floor and began spitting on floor in the waiting room. Interview with Staff Member #14 revealed that this was witnessed by Staff Member #14. Staff Member #14 communicated that Patient #20 had been yelling, cursing and pacing inside and outside of facility since approximately 11:00 p.m. before laying on the floor. Staff Members #10 and #11 assisted Patient #20 onto a stretcher and placed he/she in front of the nursing station in the emergency department so the patient could be observed until a room was available. Patient #20 was informed that a room would be available as soon as another patient was discharged.

At 11:37 p.m. Patient #20 was placed in a room.

At 11:55 p.m. Staff Member #10 stated that yelling of foul language and needing help was heard. Staff Member #10 went to room where Patient #20 was sitting up on stretcher screaming and cursing. The patient was informed he/she was in a hospital and needed to keep it down and stop cursing due to other patients in the Emergency Department. Patient #20 then got louder and starting holding breath until turning red and blue. Staff Member #10 informed patient if he stopped breathing emergency procedures would be used to assist with breathing.

Patient #20 then told Staff Member #10 "...to get out of the room before he/she got hurt." Staff Member #12 entered and heard this conversation and encouraged Staff Member #20 to leave the room. Staff Member #14 called 911 and informed dispatcher that staff members had been threatened and facility wanted the patient off the property. Staff Member #12 and #14 stated they heard the screaming and threats but did not enter the room.

At 12:10 a.m. Patient #20 was escorted out of the emergency department by an area police officer without handcuffs.

Patient #20 did not see a physician nor receive treatment during this time; one hour and 25 minutes.

An interview with Staff Members #1, #2, #3 and #4 revealed "...the Patient should have been seen by a physician and treated and before leaving the facility."

Based on document review and interview it was determined the facility staff failed to ensure the Quality Assessment and Performance Improvement (QAPI) program included the off site Emergency Department (ED) by reporting the data into the ongoing QAPI program related to safety and security.

The findings include:

On 1/19/17 at approximately 1:30 P.M. Staff Member #2 provided the following information. "I have been reporting safety issues to my director for four to five years in our ED staff meetings. Since about 2010 we have had issues with the [Name of Local Police Department] and the security staff. We have at least 2 security officers that aren't much help in an aggressive or hostile situation. The ED staff are afraid. The ED staff send me emails about incidents that occur, which are mostly in the evening and night. We have about 3-4 incidents a month where the police need to be called.
The ED staff have also voiced their concerns in the employee satisfaction surveys that are done yearly.

Staff Member #3 was interviewed on 1/19/17 at approximately 9:30 A.M. and provided the following information. We (the QAPI Program) have focused on the main hospital and have not addressed the safety or security issues at [Name of off site ED]. We have not reported any issues to the Med Executive Committee. The reporting process is for the issues to be discussed in the ED Department meetings, which are held about 8 times a year. The ED manager of the Director of Ambulatory Services will bring the issues to the QMS (Quality Measures) meeting which is held quarterly. From there the issue are sent to the Med Exec (Medical Executive) Committee.

A review to the training for the ED staff at the off site facility revealed 28 of the 48 people not including physicians have been trained in the new program "Handle With Care." Physicians are not required to receive the training.