HospitalInspections.org

Based on interview and a review of facility documentation, the facility failed to ensure the provision of care to patients in a safe setting which was free of gunfire assault by an unauthorized entrant affecting 1 of 11 sampled patients (#1), and 1 staff member (B).

Findings:

An interview of Emergency Room (ER) Paramedic A was performed at 1:32 PM on 7/20/16. She stated she saw person #11 (a non-patient), enter the ER lobby area in the early morning hours of 7/17/16. She said that he did not say anything to her. He went directly to an adjoining bathroom and eventually exited and walked down the hallway in the direction of the Atrium area of the hospital. Observation of the Atrium area at approximately 12 PM on 7/19/16 revealed it to be the core of the hospital's overall structure, around which various units on different floors radiated. At this time in the hallway area which was before actual entrance into the the reception area and then the Atrium, person #11 had not yet crossed the threshold of the reception area, and was therefore not yet subject to presentation before reception personnel.

A review of hospital security video was performed on 7/20/16 at approximately 11:49 AM with the Risk Manager. The video consisted of camera shots from different locations in the facility which covered the early morning hours of 7/17/16. A view from outside of the hospital revealed that person #11 arrived on his bicycle, headed towards the ER entrance at 1:59 AM on 7/17/16. A view towards the ER entrance revealed person #11 walking up to the entrance at 2:02 AM on 7/17/16. A view of the ER lobby, with panning, revealed person #11 entered the lobby and headed in the direction of the restrooms and hallway to the right, which were out of view. The ER lobby is the area where ER Paramedic A was located.

The next video involved a camera with a view of the main reception area of the hospital, which was adjacent to the Atrium. The video revealed the presence of Switchboard Operator C at the desk until 2:04 AM on 7/17/16. At that time, she departed from the station. At 2:05 AM on 7/17/16, the camera revealed person #11 walking past the reception desk, towards the left side of the screen. His presence was not challenged by anyone. Since person #11 was seen walking through the reception area, this video confirmed that he had exited directly from the previously described pathway which was connected to the ER. Thus, the video revealed that person #11 gained entry into the hospital proper without being challenged.

During an interview of the Security Manager on 7/20/16 at 2:10 PM, she stated that Switchboard Operator C had been assigned to the front desk in the early morning hours of 7/17/16. She confirmed that she was not present at the desk when person #11 walked by. She stated that Switchboard Operator C left to go to the restroom just prior to person #11 walking by. She stated that prior to her departure, Switchboard Operator C had requested other staff to relieve her but they were involved with other matters and could not comply. She stated that Switchboard Operator C could not wait any longer to use the restroom and left her station.

A review of the Job Description for Switchboard Operator C revealed the following: "Knows ....safety procedures and regulations as pertains to work area."

A review of hospital policy "Guide to Front Desk Shift Duties" read, "The Front Desk Officer or designated staff member will be guided in their duties by this document....The front desk officer or designated staff member is posted at the main lobby entrance to the Hospital from 9 PM to 6 AM. Visitor access to the hospital is controlled by the Front Desk Officer of designated staff member from 9 PM to 6 AM. The front desk officer or designated staff member will address persons that are not staff members to determine their destination in the hospital. The officer or designated staff member will then have the visitor sign in and obtain the name of the patient or employee the visitor wants to see all information will be recorded on the Visitor Log Sheet. The officer or designated staff member will verify with a picture ID (identification). If the visitor is requesting to visit the Women's Center or ICU (intensive care unit) you must identify with a picture ID. All other areas you may just verify identification. The officer or designated staff member will then issue the appropriate Visitor's pass....The front desk officer or designated staff member is to remain in the immediate vicinity of their post at all times. When taking a break, a front desk officer or designated staff member must coordinate with other Security Officers in order to be relieved. At no time is front desk to be left unattended."

During an interview of the Security Manager on 7/21/16 at 12:29 PM, she confirmed that the policy "Guide to Front Desk Shift Duties" would have applied to Switchboard Operator C as a "designated staff member." She confirmed that Switchboard Operator C had not followed this policy with respect to her being absent from her station when person #11 entered the hospital proper at approximately 2:05 AM on 7/17/16.

In the examination of video, the next camera showed the Atrium. The video showed person #11 walking past to the left at 2:05 AM on 7/17/16.

The next camera view showed the hallway for rooms 320 through 325. The two double doors at the beginning of the hall were shown. The unauthorized entrant, person #11, came into view at 2:06 AM on 7/17/16. He went directly into the first room on the left, room 320 at 2:06 AM on 7/17/16. No staff were visible. He had not looked into any other rooms. A staff member was seen running into the room at 2:07 AM on 7/17/16 and quickly running out. Next, other staff are seen running at 2:07 AM on 7/17/16. At 2:08 AM on 7/17/16, person #11 was seen coming out of the room.

The next camera view from panning camera #47 showed staff running in the vicinity of the nurses' station at 2:07 AM on 7/17/16. This immediately precedes the above mentioned exit of the room by person #11 at 2:08 AM on 7/17/16. This camera, camera #47, also showed person #11 beginning at 2:08 AM on 7/17/16. A panoramic view at 2:10 AM on 7/17/16 showed two security staff members taking person #11 to the floor.

During an interview of the Risk Manager on 7/21/16 at 12:50 PM, he stated that while person #11 was in room 320 after 2 AM on 7/17/16, he had shot the room occupants, patient #1 and staff B with a handgun. He stated that they were declared dead in room 320 by the Titusville Police Department.

Person #11 had gained access to a patient care area without being challenged by staff, as required by policy, and killed a patient and a staff member.

During an interview of the Risk Manager on 7/21/16 at approximately 2:45 PM, he confirmed the findings.