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Based on facility Bylaws, documents, medical records (MR) and interview with staff (EMP), it was determined the Governing Body failed to provide effective oversight and operational accountability to ensure the delivery of safe patient care in the emergency department campuses of Temple University Hospital, Inc.

This condition is not met as evidenced by:

Based on facility Bylaws,documents, medical records (MR) and interview with staff (EMP), it was determined the Governing Body failed to ensure the hospital consistently operated in a manner that protected the health and safety of its patients admitted to the emergency departments at the Temple University Hospital-Main Campus and Temple University Hospital-Episcopal Campus resulting in fires initiated by patients for two of two medical records reviewed (MR1 and MR2).

Findings include:

Review of the facility's Bylaws "AMENDED AND RESTATED BYLAWS OF TEMPLE UNIVERSITY HOSPITAL, INC. dated December 13, 2019, revealed "Section 8.4, Professional Affairs Committee. The Professional Affairs Committee shall include the Chair, the Chief Executive Officer (CEO), ...the Professional Affairs Committee shall, on behalf of the Board, oversee the professional affairs of the Corporation as a health service facility, and shall be accountable to the Board, which has ultimate authority over and responsibility for the professional affairs of the Corporation. The Professional Affairs Committee shall establish a procedure for implementing, disseminating, and enforcing standards of patient treatment or medical care required for accreditation or licensing, including oversight of any risk management and performance improvement programs. "

Review of MR1 revealed "40-year-old male present to the ED on 05/23/2020 complaining of sharp chest pain. Patient is extremely paranoid and evasive with some questioning. Patient debating discharge vs voluntary rehab via the Crisis Response Center, when he barricaded himself in his room. An internal disaster occurred after he set a fire in his room."

Review of MR2 revealed "32-year-old male presented to ED (emergency department) on 08/15/20 for acute drug intoxication. Patient was not in a hospital gown and managed to get to his pocket, where he pulled out a lighter and lit the bed sheet on fire. Flames were witnessed by multiple employees and the fire was immediately extinguished with no harm to the patient, staff, or environment."

Review of facility document "Minutes of the Temple University, Inc. Professional Affairs Committee" date June 19, 2020, 9:00 AM via Conference Call revealed " "Discussion: Ms. [EMP1] summarized the details of the DOH survey conducted at TUH-Episcopal Campus and conditions cited in response to a recent ED incident. ...The Committee discussed the DOH action plan for TUH-Episcopal Campus ED. Action Taken: None. Follow-up: None."

An interview was conducted on August 31, 2020, at 9:15 AM with EMP4. EMP4 stated "I am in the process of developing new workflow patterns and opportunities for improvement within the leadership of both Temple Hospital-Main Campus and the Episcopal Campus. These are two unfortunate mistakes, but I continue to develop communication processes as to avoid anything like the fires in both of the emergency departments happening again. I know the origins of these two fires are similar and I am disappointed that the fires happened. We should have found both lighters." EMP4 further stated " We clearly missed the opportunity to prevent the fire at the Episcopal Campus. In addition, EMP14 stated "I have not watched the video of the security search for the 2nd fire here at Temple Main Campus, but we hope to learn from these unfortunate events."

An interview was conducted on August 31, 2020, at 10:30 AM with EMP2. EMP2 stated " I don't know the details of the action plan that had to be put into place for the fire that occurred in the Episcopal Campus Emergency Department. We are two different emergency department and have different requirements. We do not have to collaborate the activities of the Temple Main Campus with the security staff at the Episcopal Campus. I heard about the fire, but I was not directed to initiate any performance improvement actions for the Temple Main Campus security staff because of that fire"

An interview was conducted on September 2, 2020, at 10:40 PM with EMP7. EMP7 stated "While the CEO consistently sends the message that Temple-Main Campus and Temple-Episcopal Campus are one hospital, that message remains an initiative we pursue to bring to fruition as the leadership team. Operating as one hospital system remains a challenge for us as you can see based on staff perception of each of the campuses."

These following standards were cited and show a systemic nature of non-compliance:

482.13(c)(2) Tag-0144: Patient Rights-Care in Safe Setting
The information reviewed during the survey provided evidence that the facility failed to ensure dangerous objects/contraband were secured by the security staff during the safety search for patients entering the emergency department of Temple University Hospital-Main Campus and Temple University Hospital-Episcopal Campus resulting in the facility's failure to provide a safe environment based on video observation of two serious adverse events of fire in the emergency departments based on lighters retained by patients during the security screening search in the emergency departments.

482.41(a) Tag-0701: Maintenance of Physical Environment
The information reviewed during the survey and observation tour of the emergency department exam rooms provided evidence that the facility failed to ensure the provision of a safe setting for the delivery of care and services to meet the physical and mental health needs of patients seeking care in the hospital's emergency departments.

482.41(d)(2) Tag-0724: Physical Environment-Facilities, Supplies, Equipment Maintained
The information reviewed during the survey provided evidence that the facility failed to ensure security of the physical environment was maintained to prevent misappropriation of patient care equipment (oxygen tanks under stretchers).

482.55(b)(2) Tag-1112: Qualified Emergency Services Personnel
The information reviewed during the survey provided evidence that the facility failed to ensure the emergency department staff completed mandatory training for the high-risk patient population predominantly cared for in the Temple University Hospital-Main Campus and Temple University Hospital-Episcopal Campus emergency departments.

This condition is not met as evidenced by:

Based on a systemic nature of standard-level deficiencies related to Patient Rights, it was determined the facility staff failed to substantially comply with this condition to ensure effective standards of operation for the provision of safe care for the patients receiving patient care services at Temple University Hospital Inc.(Temple University Hospital-Main Campus and Temple University Hospital-Episcopal Campus) emergency departments for substance abuse and mental health disorders.
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Findings:

Review of facility policy "Patient Rights and Responsibilities" last revised October 1, 2019, revealed "This policy shall apply to Temple University Hospital, Inc. (TUH), including TUH-Main Campus (TUH-MC), TUH-Episcopal Campus (TUH-EC). ...At Temple University Hospital, Inc. patients have the following rights: 1. To receive considerate, respectful, safe, quality care delivered by competency personnel. ...6. To receive quality care within the professional standards governing clinical practice."

These following standards were cited and show a systemic nature of non-compliance:

(482.13(c)(2) Tag-0144: Patient Rights-Care in Safe Setting
The information reviewed during the survey provided evidence that the facility failed to ensure dangerous objects were secured by the security staff during the screening search for patients entering the Temple University Hospital- Main Campus and Temple University Hospital-Episcopal Campus emergency departments resulting in the facility's failure to provide a safe environment and comply with facility policy.

482.41(a) Tag-0701: Maintenance of Physical Environment
The information reviewed during the survey and observation tour of the emergency department exam rooms provided evidence that the facility failed to ensure the provision of a safe setting for the delivery of care and services to meet the physical and mental health needs of patients seeking care in the emergency department.

482.41(d)(2) Tag-0724: Physical Environment-Facilities, Supplies, Equipment Maintained
The information reviewed during the survey provided evidence that the facility failed to ensure the security of the physical environment was maintained to prevent misappropriation of patient care equipment (oxygen tanks beneath stretchers in the emergency department).

482.55(b)(2) Tag-1112: Qualified Emergency Services Personnel
The information reviewed during the survey provided evidence that the facility failed to ensure emergency department staff completed mandatory training for in the Temple University Hospital-Episcopal Campus emergency department.
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A. Based on observation, review of facility policy, documents, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure objects classified as dangerous objects and contraband were secured by the security staff during the security screening process conducted for patients entering the emergency department (ED) of Temple University Hospital-Main Campus and Temple University Hospital-Episcopal Campus emergency departments for two of two medical records reviewed (MR1 and MR2).

Findings include:

Review of facility policy "Patient Rights and Responsibilities" last revised October 1, 2019, revealed "This policy shall apply to Temple University Hospital, Inc. (TUH), including TUH-Main Campus (TUH-MC), TUH-Episcopal Campus (TUH-EC). ...At Temple University Hospital, Inc. patients have the following rights: 1. To receive considerate, respectful, safe, quality care delivered by competent personnel. ...6. To receive quality care within the professional standards governing clinical practice."

1) Observation conducted on May 30, 2020, at 7:10 PM with EMP1 and EMP24 of TUH-EC emergency department video footage revealed MR1 (patient) surrendered a lighter to the security staff upon entering the emergency department during the security screening. Further observation of the video footage revealed the lighter was returned to MR1 during the security screening by the security staff.

Review of MR1 (patient), admitted on May 23, 2020, revealed chief complaint of "Chest pain and Hallucinations with a medical history of polysubstance use disorder. ...Patient uncooperative with history, appears paranoid and is intermittently aggressive." Further review revealed MR1 was admitted to ED exam room/treatment room eight.

Review of facility policy "Hospital Emergency Room-Screening for Dangerous Objects and Contraband" last reviewed December 2016 revealed "The purpose of this policy is to promote a safe, non-hostile, dignified environment for visitors, patients and staff inside the Temple University Emergency room (treatment area, waiting rooms, triage area and registration area). The words "Temple University Hospital" will represent Temple University Hospital and Temple University Hospital-Episcopal Campus. ...A. Dangerous Objects: For the purposes of this Policy, dangerous objects are defined as anything that can be used to inflict injury to a person, including objects that are typically utilized as weapons, such as ...5. Lighters ..."

Review of facility policy "Close Observation" last revised January 10, 2019, revealed "Level II Visual contact of patient: Visual observation of patient/patients at all times; May permit 2:1 supervision. 1. Patients appropriate for this level may include: a. Psychotic patients 2. Hallucination, delirium tremens with high level of agitation. 3. Dementia patients with high level of agitation. ...4. The registered nurse or designated member of the nursing staff removes all dangerous personal belongings from the patient's room such as matches, lighters, glass articles, etc."

An interview conducted on May 30, 2020, at 7:45 PM with EMP1 and EMP24 confirmed MR1 had a lighter during the security screening and it was returned to MR1 by the security staff. EMP1 and EMP24 also confirmed MR1 was admitted to TUH-EC with chest pain and hallucinations and escorted to exam room eight with the lighter. Further interview confirmed the lighter was not removed from MR1 by a registered nurse or designated member of the nursing staff. EMP24 stated "It would have been better for us if the security staff had of retained the lighter and followed the facility's policy for the removal of dangerous objects and contraband."
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Review of facility policy "Temple University Hospital-Main Campus Security Department Standard Operating Procedure- Hospital Emergency Room-Screening for Dangerous Objects and Contraband" last revised June 25, 2020, revealed "For the purpose of this policy, the following are defined as dangerous objects/contraband: ...10. Glass items 15. Lighters or matches 21. Perfume or aftershave 23. Cologne ..."

2) Observation conducted on August 31, 2020 at 2:40 PM with EMP5 and EMP 11 of TUH-MC video footage revealed MR2 entering the emergency department ambulance bay on August 15, 2020, at 9:10 PM on a stretcher. Further observation revealed MR2 handed EMP22 a lighter and a glass bottle of what appeared to be approximately three ounces in size filled with a clear liquid. EMP22 did not secure the three-ounce glass bottle filled with a clear liquid from MR2. In addition, further observation of the video footage revealed EMP11 and EMP22 did not complete a four-sided search of the body and arms of MR2 and did not perform the wanding technique with a hand-held detector for MR2 in the ED ambulance bay.

Review of MR2 revealed "Attending Note (EMP14)" dated August 15, 2020, at 9:10 PM revealed "Patient high on wet, initially calmed down so I unrestrained him but then he was running up and down the hallway celebrating being able to leave but it was apparent he was still too intoxicated to be discharged. I gave him 4 (four) IM (intramuscular) Versed (sedative) and he was restrained at which point he lit the sheet of his bed on fire ..."

Review of facility policy "Temple University Hospital-Main Campus Security Department Standard Operating Procedure- Hospital Emergency Room-Screening for Dangerous Objects and Contraband" last revised June 25, 2020, revealed "Emergency Department Ambulance Bay Procedures...B. Use of Hand-Held Metal Detectors...6. Wanding Technique for Hand-held detector...c. Pass the wand slowly over all four sides of the body and arms d. Stop at each activation and physically investigate the cause of the alarm (hand screen with touch where alarmed was activated) e. Do not allow anyone to pass without knowing why the alarm was activated."

An interview conducted on September 1, 2020, at 2:30 PM with EMP5 and EMP11 confirmed that EMP11 and EMP22 did not complete a thorough physical security screening search on all four sides of the body of MR2. EMP11 confirmed the glass bottle was cologne and it was returned to MR1 during the security search. EMP11 stated "The gloves that I had on are puncture resistance gloves. I probably missed feeling the lighters because of the thickness of the gloves. EMP5 stated "We are now wanding patients on stretchers coming through the ambulance bay which is what we should have completed for this patient (MR2). I will look into searching for different types of puncture resistance gloves for the security staff, so that the thickness of the gloves will not be an issue in the future during future security searches."
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B. Based on observation, facility policy, medical record (MR) and interview with staff (EMP), it was determined the facility failed to assess and provide appropriate clinical services for patients seeking emergency services for substance abuse disorders for two of two medical records reviewed (MR 1 and MR2)

Findings include:

1) Review of MR1, admitted on May 23, 2020, revealed chief complaint of "Chest pain and Hallucinations." Further review revealed past medical history of polysubstance use disorder. ...Patient uncooperative with history, appears paranoid and is intermittently aggressive."

Review of facility policy "Close Observation" last dated January 10, 2019, revealed "Level II Visual contact of patient: Visual observation of patient/patients at all times; May permit 2:1 supervision. 1. Patients appropriate for this level may include: a. Psychotic patients 2. Hallucination, delirium tremens with high level of agitation. 3. Dementia patients with high level of agitation. ...4. The registered nurse or designated member of the nursing staff removes all dangerous personal belongings front he patient's room such as matches, lighters, glass articles, etc."

Observation conducted on May 30, 2020, at 7:10 PM with EMP1 and EMP24 of TUH-EC emergency department video footage revealed MR1 (patient) entering into exam room/treatment room eight. Further observation revealed MR1 was placed in room eight alone and was not assigned a "Close Observation" status as per the facility's policy.

A telephone interview conducted on June 3, 2020, at 2:30 PM with EMP12 confirmed MR1 was admitted into exam room 8 and EMP12 was assigned as the primary nurse. EMP12 stated " I was told by the charge nurse that the patient was in room eight (8), however I was at the nurse's station trying to transfer my COVID-19 patient and I did not have time to see that patient. The patient was not assigned a one-one with a patient care technician (PCT). I was aware that the patient had been fighting with security upon his arrival to the ED and that a STAT 13 code was called. A Stat 13 code is initiated by staff for a patient displaying behavior problems such as uncontrolled agitation."

A request was made by the survey team on June 3, 2020 at 3:00 PM to EMP1 and EMP2 to speak with the charge nurse but the survey team was informed that the charge nurse was not available and was considered on a Leave of Absence (LOA) post the incident in the emergency department. EMP 29 stated "The charge nurse has been overwhelmed with the fire in the emergency department and is unable to speak with you."

A telephone interview conducted on June 3, 2020, at 3:30 PM with EMP10 confirmed visualization of MR1 in exam room 8 in the emergency department. In addition, EMP10 also confirmed MR1 had not been a patient previously in the Episcopal emergency department. EMP10 stated " I suspected substance abuse and recommended we address it. The patient was paranoid which was a result of his polysubstance abuse. Dr. [XXX] name redacted thought about 302 (involuntary commitment) the patient but I said there is nothing to 302 him on. The EMS report I reviewed stated the patient said "people were chasing him. He wanted his chest pain and substance abuse addressed. "EMP10 was unable to confirm whether MR1's state of hallucinations and of being paranoid was addressed during the ED visit and confirmed that the patient was not under a physician's order for a one to one with a patient care attendant for "Close Observation".

2) Review of MR2, admitted on August 15, 2020, revealed chief complaint of "Addiction Problem" Further review revealed past medical history of bipolar disorder (schizophrenia unspecified), attention deficit disorder, attention deficit hyperactivity, human immunodeficiency virus infection."

Review of MR2 revealed "Attending Note (EMP14)" dated August 15, 2020, at 9:10 PM revealed "Patient high on wet (tainted form of a psychoactive drug), initially calmed down so I unrestrained him but then he was running up and down the hallway celebrating being able to leave but it was apparent he was still too intoxicated to be discharged. I gave him 4 (four) IM (intramuscular) Versed (sedative) and he was restrained at which point he lit the sheet of his bed on fire ..."

An interview conducted on August 31, 2020, at 9:30 AM with EMP23 confirmed MR2 was placed into two-point restraints (bilateral wrist restraints) upon removal from the EMS stretcher lap belt and placed into hallway bed (2) two, ED location red zone. EMP23 confirmed MR2 did not have an order for the two-point wrist restraints and a one-to-one patient care attendant for "Close Observation" as per the facility's policy.

Based on review of facility policy, medical record (MR) and interview with staff (EMP), it was determined the facility failed to obtain an order for the use of a restraint in one of one medical record reviewed (MR2).

Findings include:

Review on September 1, 2020, of facility policy "Use of Restraint" last revised October 1, 2019 revealed "...Types of restraints utilized may include, but are not limited to: 1. Soft limb restraints,...lap belt, if patient is unable to release...C. Initiation of restraint 1. A physician or other appropriately credentialed staff issues the order for restraint, prior to the application of the restraint. In a situation where restraints need to be applied emergently, alternatives/interventions may not be able to be attempted. The RN must obtain an order from the physician or other appropriately credentialed staff as soon as possible after restraint has been applied.... D. 1. Patient who are restrained for violent/self-destructive behaviors will have continuous one-to-one in-person observation for the duration of the restraint use."

Review of MR2 on September 1, 2020, revealed the application of two-point restraints for uncontrolled behavior for MR2 was applied on August 15, 2020, at 9:10 PM by EMP23 and removed and reapplied by EMP14. No evidence of documentation of a physician's order was found in MR2 for two-point restraints.

Review of MR2 on September 1, 2020, revealed "Attending Note (EMP1)" dated August 15, 2020, at 9:10 PM revealed "Patient high on wet, initially calmed down so I unrestrained him but then he was running up and down the hallway celebrating being able to leave but it was apparent he was still too intoxicated to be discharged."

An interview conducted on September 1, 2020, at 9:30 AM with EMP3 and EMP23 confirmed there was no physician's order for the application of the two-point wrist restraints for MR2 in the emergency department. EMP34 confirmed that MR2 was placed in two-point wrist restraints due to behavior and a physician's order was not obtained.

The condition is not met as evidenced by:

Based on the systemic nature of the standard-level deficiencies related to Quality Assessment and Performance Improvement Program, the facility failed to substantially comply with this condition.

Findings include:

The following standards were cited and show a systemic nature of non-compliance with regards to the Performance Improvement Program as follows:

482.21(b)(2)(ii), (c)(3): Tag-0283: Quality Improvement Activities
The information reviewed during the survey provided evidence the facility failed to ensure systemic tracking of serious adverse events, establish time frames to reassess compliance and performance of preventative measures for enhance operation performance standards within the emergency department campuses of Temple University Hospital Inc.

482.21(a), (c)(2), (e)(3): Tag-0286: Patient Safety
The information reviewed during the survey provided evidence the facility failed to ensure the adverse patient events were tracked and reported within the required time frame in compliance with Federal and State regulations.

Based on review of facility policy, documents and interview with staff (EMP), it was determined the facility failed to ensure systemic tracking of serious adverse events, establish time frames to reassess compliance and performance of preventative measures to enhance operation performance standards within the emergency department campuses of Temple University Hospital Inc for two serious adverse events reviewed.

Findings include:

Review of facility policy " TEMPLE UNIVERSITY HOSPITAL INC. PERFORMANCE IMPROVEMENT PLAN FY 2020" last revised January 8, 2020, revealed "This policy shall apply to Temple University Hospital, Inc. including TUH-Main Campus (TUH-MC), TUH-Episcopal Campus (TUH-EC)..The purpose of the Performance Improvement Program of Temple University Hospital Inc. is to provide systematic, organized methods to support improved data driven patient outcomes and operational performance to enhance safety. Board of Governors ensures that the performance improvement program reflects the complexity of the organization and its services; involves all Temple University Hospital Inc. departments and services from all campuses. Performance Improvement Methodology...1. Performance Improvement activities are driven by organizational priorities supporting patient safety and high quality of care. as well as regulatory compliance. ...General topics for ongoing measurement include the following: High volume, high risk, high cost and problem prone processes and associated hospital wide monitoring activities. ...Assessment...Adverse events or patterns of adverse events"

Review of facility document "Temple University Performance Improvement Committee Meeting Minutes" dated June 9, 2020, revealed "Episcopal Emergency Department/Incident Action Plan...the DOH (Department of Health) Action Plan for Episcopal Campus ED (Emergency Department), on May 23, 2020, there was a patient that entered the hospital and lit his room on fire. Further reviewed revealed no evidence of documentation of "

Review of facility documents "Temple University Performance Improvement Committee Meeting Minutes" dated July 14, 2020 and August 14, 2020 revealed no evidence of documentation of the serious adverse event for May 23, 2020, nor evidence of documentation of systematic tracking of the event within the committee in support of operational performance to enhance patient safety. Further review revealed no evidence of documentation to establish time frames to reassess compliance with initial implementation of preventative interventions of the emergency departments campuses performance.

Review of facility document "Event Action Plan Summary- Event-Patient Set His Sheets on Fire dated August 20, 2020, revealed "32-year-old male present to ED August 15, 2020...Unwitnessed, the patient pulled a lighter from his pocket and lit the bedsheet. Remove Oxygen Tanks from underneath stretchers...Patients who are unable to complete a primary security search, will have a second pat down and/or wanding at the bedside by Security. Further review revealed no evidence of documentation to establish time frames to reassess compliance with initial implementation of preventative interventions of the emergency departments campuses performance.

An interview conducted on September 1, 2020, at 11:00 AM with EMP17 confirmed the facility failed to ensure systemic operational tracking of performance improvement measures to enhance patient safety within the emergency department campuses of Temple University Hospital Inc. for the serious adverse events on May 23, 2020, and August 15, 2020. EMP17 confirmed that the Performance Improvement Committee and the Action Plan Summary did not reflect a systemic enhancement of preventative measures with implementation of established time frames to reassess compliance. EMP 17 further stated, "From an administrative staff standpoint inclusive of the hospital CEO we are working hard to create an environment of systemic performance improvement and a health system culture of inclusiveness for all campuses, however each campuses seem to function somewhat independently of the main campus. That is not the goal of Temple Hospital as a whole."

Cross Reference:
482.21(a), (c)(2), (e)(3): Tag-0286: Patient Safety

Based on a review of facility policy, documents, and interview with staff (EMP), it was determined the facility failed to ensure the adverse patient events were tracked and reported within the required time frame in compliance with Federal and State regulations.

Findings include:

Review of facility policy "Patient Safety Plan" dated June 19, 2020, revealed "TUH (Temple University Hospital Inc.) patient safety plan is based on the following principles: Communication about the importance of patient safety must be well conceived, repeated and consistent across the entire organization....Serious Event-an event, occurrence or situation involving the clinical care of a patient in a medical facility (hospital, surgery facility...) that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health services to the patient [Pennsylvania Act 13 of 2002, Medical Care Availability and Reduction of Error Act] Serious events are reportable to the Patient Safety Authority and Department of Health under Act 13... Infrastructure failure-An undesirable or unintended event, occurrence, or situation involving the infrastructure of a medical facility (hospital, ambulatory...) or the discontinuation or significant disruption of a service, which could seriously compromise patient safety. [Pennsylvania Act 13 of 2002, Medical Care Availability and Reduction of Error Act] Infrastructure Failure is reportable to the Patient Safety Authority and Department of Health under Act 13."

The Medical Care Availability and Reduction of Error Act, 40 P.S. § 1303.101 et seq. § 1303.313 Medical Facility reports and notifications (a) Serious event reports A medical facility shall report the occurrence of a serious event to the department and the authority within 24 hours of the medical facility's confirmation of the occurrence of the serious event. The report to the department and the authority shall be in the form and manner prescribed by the authority in consultation with the department and shall not include the name of any patient or any other identifiable individual information. (b) Incident reports A medical facility shall report the occurrence of an incident to the authority in a form and manner prescribed by the authority and shall not include the name of any patient or any other individual information. (c) Infrastructure failure reports. A medical facility shall report the occurrence of an infrastructure failure to the department within 24 hours of the medical facility's confirmation of the occurrence or discovery of the infrastructure failure. The report to the department shall be in the form and manner prescribed by the department.

Review on September 1, 2020, of facility documentation revealed "32-year-old male presented to ED (emergency department) on 08/15/20 for acute drug intoxication. Patient was not in a hospital gown and managed to get to his pocket, where he pulled out a lighter and lit the bed sheet on fire. Flames were witnessed by multiple employees and the fire was immediately extinguished with no harm to the patient, staff, or environment."

An interview conducted on September 1, 2020, at 10:00AM with EMP1 and EMP12 confirmed the fire occurred in the emergency department, hallway bed 2 on August 15, 2020. EMP12 confirmed the fire was not reported until August 20, 2020. EMP22 confirmed that the facility had failed to comply with the Pennsylvania (Pa.) State Law MCare ACT 13, 24-hour reporting requirement for infrastructure failure. EMP1 also confirmed that the Performance Improvement Committee and the Patient Safety Committee was one combined committee meeting. EMP1 stated "We will separate these two committees to ensure compliance with MCare ACT 13.

Cross Reference:

482.21(b)(2)(ii), (c)(3): Tag-0283: Quality Improvement Activities

Based on observation, review of facility Bylaws, documents, and interview with staff (EMP), it was determined the facility failed to ensure a safe physical environment was provided to patients seeking and receiving care in the Temple University Hospital-Episcopal Campus emergency department specific to the patient's needs.

This condition is not met as evidenced by:

Review of the facility's "BYLAWS OF THE PROFESSIONAL MEDICAL STAFF" last revised December 13, 2019, revealed "TEMPLE UNIVERSITY HOSPITAL, INC. (Temple University Hospital or the Hospital') is an affiliate of the Temple University Health System, Inc. ("TUHS"). The Board of Governors has delegated to the Professional Medical Staff the responsibility for the quality of medical care delivered in the Hospital by individual to who clinical privileges have been recommended by the Professional Medical Staff and granted by the PAC (Professional Affairs Committee of the Boards). It is recognized that the Professional Medical Staff must accept and discharge this responsibility, that the authority for administration of the Hospital is vested in the CEO."

Review of facility document "Environment of Care Management Program-Annual Review Fiscal Year 2018-2019 last reviewed at Governing Board Meeting in October 2019" revealed "...Temple University Hospital-Episcopal Campus...The purpose of the annual report is to assess the effectiveness of all components of ...Temple University Hospital-Episcopal Campus... The scope of the report includes the evaluation of how well the sites manage the environment of care: a summarization the effectiveness in improving safety performance over the past year; and a list of goals and objectives for improving safety at all Temple Health sites in the coming year. ...Opportunities for improvement identified during ongoing hazard surveillance, risk assessment, and other EOC activities drive the selection of special EOC projects and initiatives. ...Episcopal-Conducting behavioral health risk assessments...Facilities is modifying patient rooms to reduce ligatures ... Weekly document reviews with supervisors to make sure Temple University Hospital (TUH) facilities is compliant with all regulatory requirements...Continuing with anti-ligature in the Emergency Department (ED)."

Review of facility documents "Environment Care of Committee Meeting Minutes" dated April 23, 2020, and May 28, 2020 (post internal disaster), revealed No updates for Anti-Ligature Efforts in the Temple Episcopal Emergency Department. Further review revealed evidence of documentation for each of the committee meeting minutes with evidence of the following documentation "Temple Hospital-Episcopal Campus Administration-"No Updates"

Review of facility documents "Emergency Department (ED) Monthly Environment of Care (EOC) Dashboard and ED EOC Monthly Meeting Minutes revealed for the month of January, February, March, April and May 2020 the following: areas of compliance for the Temple University Hospital-Episcopal Campus: General Safety-97%, Risk Management-100%, Security Management-98% and Behavioral Health-100%."

An interview conducted on May 30, 2020, at approximately 7:40 PM with EMP1 and EMP24 confirmed the facility's leadership had previously identified the ligature risks in the emergency department. EMP2 confirmed the identified ligature risk issues were not documented in the monthly ED EOC dashboard nor was the ligature risk issues documented in the ED EOC Monthly Meetings Minutes for the months of January, February, March, April and May 2020. EMP2 confirmed the ligature risk issues were not documented nor addressed in the EOC Committee meeting minutes for April and May 2020. EMP2 was unable to confirmed as to whether the facility had established a current action plan to address the identified ligature risk issues in the ED to improve safety measures for ED patients.

An interview conducted on May 30, 2020, at 7:45 PM with EMP1 and EMP24 confirmed that the last risk assessment completed for Temple University Hospital- Episcopal Campus emergency department was completed on January 31, 2019. The facility was unable to produce a risk assessment recently completed for the emergency department that addressed the ligature risks.

Cross reference:
482.13(c)(2): Tag-0701: Patient Rights: Care In Safe Setting
482.41(d)(2): Tag-0724: Facilities, Supplies, Equipment Maintenance
482.41(a): Tag-0701: Maintenance of Physical Plant

Based on an observation, facility policies and interview with staff (EMP), it was determined that the facility failed to maintain a safe physical environment in the emergency department to meet the safety needs of the patient population served.

Findings include:

Review of facility policy "Patient Rights and Responsibilities" last revised October 1, 2019, revealed "This policy shall apply to Temple University Hospital, Inc. (TUH), including TUH-Main Campus (TUH-MC), TUH-Episcopal Campus (TUH-EC). ...At Temple University Hospital, Inc. patients have the following rights: 1. To receive considerate, respectful, safe, quality care delivered by competency personnel. ...

An observation tour conducted on May 30, 2020, at 6:50 PM with EMP1 and EMP24 of emergency department exam rooms four and ten revealed the existence of the following ligature risks: a goose neck sink faucet with weight bearing hot and cold water mounted handles in each ED exam room, unsecured loose wiring greater than 12 inches in length in each room hanging from wall and ceiling fixtures, overhead adjustable ceiling mounted exam lights, unsecured wall med gases, uncased wall hung protruding televisions and exam room doors that do not swing outward but inward with protruding door hinges.

An interview conducted on May 30,2020, at approximately 7:40 PM with EMP1 and EMP24 confirmed the above ligature findings observed during the tour in emergency department exam rooms four and ten. EMP24 stated " We have a large number of patients with psychiatric disorders however we are not predominately a psychiatric hospital. Although the ligature risks identified throughout the unit have not been removed from the exam rooms in the ED, we have staff remove as many of the ligature risks as possible for psychiatric patient.

Cross Reference:
482.13(c)(2): Tag-0144: Patient Rights: Care in Safe Setting
48241(d)(2): Tag-0724: Facilities, Supplies, Equipment Maintenance

Based on observation, review of facility policy, documents, documentation and interview with staff (EMP), it was determined the facility failed to prevent misappropriation of an oxygen tank stored beneath a stretcher in room eight (8) for a patient with special needs seeking and receiving care in Temple University Hospital-Episcopal Campus emergency department.

Findings include:

Review of facility policy "Patient Rights and Responsibilities" last revised October 1, 2019, revealed "This policy shall apply to Temple University Hospital, Inc. (TUH), including TUH-Main Campus (TUH-MC), TUH-Episcopal Campus (TUH-EC). ...At Temple University Hospital, Inc. patients have the following rights: 1. To receive considerate, respectful, safe, quality care delivered by competency personnel. ...6. To receive quality care within the professional standards governing clinical practice....(6) ART (Appropriate Response Training) principles are to be utilized whenever possible to de-escalate the situation and maintain safety, (7) If the threat is imminent-the caregiver(s) should initiate for a Stat 13 or a Code Grey to assist in the containment of the patient in a safe manner.

Review of facility policy "Identifying Potential for Aggressive Patient Behavior" last reviewed April 28, 2020, revealed "Identifying patients at risk for aggressive behavior-Potentially aggressive patients usually give signs or cues of aggressive behavior. Some can be identified through observation and other signs may be assessed through a risk assessment. ...ii Assess for the patient's predisposing facts to violence. Some of these indicators of violence may include but are not limited to 1) Presence of psychotic psychopathology (hallucinations, delusions, anxiety, panic mania...) 444. Presence of alcohol or drug use.... ii) Assessment of the environment-Prevention and early assessment of the threat of violence includes ensuring general safety in the environment. Caregivers should always be aware of ... (2) Any objects in the area that can be used as a weapon..."

During the on-site investigation, the survey team completed an observation tour of emergency department (ED) exam room four and ED exam room ten. The survey team observed oxygen tanks secured underneath each stretcher in exam rooms four and ten.

Review of facility documentation "Incident Report" dated May 23, 2020, revealed "On Saturday, May 23, 2020, at 2:32 PM. I (EMP7) responded to a Stat 13 in the E.D. treatment room 8 for a male patient. The patient barricaded himself in the room using the bed to block the door. I told the nurse to call 911 for a barricaded person. The patient was tampering with the oxygen tank, he was turning it on and off. The patient started lighting the bed on fire. At 3:13 PM the facility engineer on duty broke the window. I then call a CODE RED for the E.D. The E.D. staff and I started to evacuate the patients from the E.D. The patient was in Room 8, where he climbed out of the window. He then threw a chair into the Nurse's Station, he then ran to the front of the E.D....The patient's backpack and his jacket was searched manually..., during his [security guard] search he [security guard] discovered several hypodermic needles."

Review of facility document "Action to Reduce Safety Security Risk" dated January 31, 2019, completed by EMP9 revealed "Department Surveyed: Emergency Department-Risk Elements: Lifting more than 10 lbs. (pounds); Pushing; pulling, reach above head; Lifting, moving, turning patients, slips and falls; ergonomic risks; Others; Falls-Equipment in the hallways; Objects in walking path, Falls from bed; Falls while ambulating; Furniture Set-up; Furniture Setup; Furniture condition; Height for access; Handrails available; Wheelchair available; Workplace Violence; Security Assault; Theft Potential; Infant/Child Abduction; Combative Patient; Medication Access"

A telephone interview conducted on June 3, 2020, at 7:30 AM with EMP26 confirmed that MR1 was treated for Chest Pain while in the emergency department. EMP26 stated "I wanted to rule out other complaints and then send to CRC (Crisis Response Center) for polysubstance abuse. I wanted to offer him information about the CRC but there was no educational information in the ED about the CRC. EMP26 was unable to confirm as to whether MRI received the information about the CRC. EMP 26 was unable to confirm whether MR1's state of hallucinations and of being paranoid was addressed during the ED visit.

A telephone interview conducted on June 3, 2020, at 8:30 AM with EMP25 confirmed MR1 (patient) was agitated and that the patient had barricaded himself into room eight. Further interview confirmed that a Stat 13 was called and there was a loud noise in Triage 1. EMP5 further stated that the patient had been playing with the oxygen tank turning it off and on. EMP5 stated " I heard people saying he set the oxygen tank was on fire. EMP25 further stated that the patient was not on a one-one with a patient care technician. There is a list of equipment that must be removed before the patient goes into an ED exam room assigned to have a one-one with a patient care technician. All gurneys (exam room stretchers) are maintained with oxygen tanks underneath."

A telephone interview conducted on June 3, 2020, at 9:30 AM with EMP27 confirmed that a Stat 13 was called MR1 (patient) due to an emotional escalation in the security check area. EMP3 further stated "There is no specific policy on how to handle patients with hallucinations.... Oxygen tanks are left in the room on the gurney (stretcher). Rooms (doors) don't lock."

A telephone interview conducted on June 3, 2020, at 2:30 PM with EMP28 confirmed that MR1 was admitted into exam room 8 and EMP28 was assigned as the primary nurse. EMP28 stated " I was told by the charge nurse that the patient was in room eight (8), however I was at the nurse's station trying to transfer my COVID-19 patient and I did not have time to see this patient. The patient was not assigned a one-one with a patient care technician (PCT). I was aware that the patient had been fighting with security upon his arrival to the ED and that a STAT 13 code was called. A Stat 13 code is initiated by staff for a patient displaying behavior problems."

A telephone interview conducted on June 3, 2020, at 12:30 PM with EMP29 confirmed that all emergency department (ED) stretchers in Temple Episcopal emergency department exam rooms have an oxygen tank located beneath the stretcher and that it is the responsibility of the ED nurse to check daily that the oxygen tank is present beneath each ED exam room stretcher and ready for use. EMP29 was asked to confirm if the oxygen tank underneath the exam room stretcher was removed for Crisis Response patients receiving medical clearance in the ED. EMP29 was unable to confirm that removal of the oxygen tank beneath the stretcher is a practice of the emergency department. EMP29 stated: Nursing is responsible to ensure oxygen tanks are in place underneath each of the stretchers located in each ED exam room. Therefore, oxygen tanks were not included on the "Action to Reduce Safety Security Risk" assessment report dated January 31, 2019,

A telephone interview conducted on June 4, 2020, at 8:30 AM EMP30 confirmed that MR1 (patient) wanted treatment in the Crisis Response Center after leaving the ED. There were a number of Stat 13 calls because the patient refused to be searched. Patient had oxygen cylinder in his hand. We were all concerned about what he would do with the oxygen cylinder. It was notice that smoke was at the bottom of the stretcher in ED exam room eight which was the room in which the patient was in. Now we all knew the patient was in danger to self because of the oxygen tank. It was decided we would break the window to ED exam room eight. All of a sudden there was a loud sound. Not sure what it was. The patient may have dropped the oxygen tank. All stretchers are equipped with oxygen tanks"

A telephone interview conducted on May 30, 2020, at 5:50 PM with EMP24 confirmed that the emergency department exam rooms have wall piped in oxygen. Further interview confirmed that the facility's practice in storing oxygen tanks underneath each ED exam room stretcher was not a necessity in the emergency department because of the wall piped oxygen. In addition, EMP24 stated "In this incident, having the oxygen tank underneath the stretcher in exam room eight with this patient did create a potential hazard to the patient and to all in the emergency department."

Cross Reference:
482.13(c)(2): Tag-0144: Patient Rights: Care in Safe Setting
482.41(a): Tag-0701: Maintenance of Physical Plant

Based on review of facility policy, documents, documentation and interview with staff (EMP), it was determined the facility failed to ensure the emergency department (ED) staff completed educational training to enhanced staff competency to provide care to patients displaying combative behavior in the ED.

Findings include:

Review of facility policy "Patient Rights and Responsibilities" last reviewed October 1, 2019, revealed "Scope: TUH-Episcopal Campus...Policy: To receive considerate, respectful, safe, quality care delivered by competent personnel."

Review of facility policy "Identifying Potential for Aggressive Patient Behavior" last revised April 28, 2020, revealed "Stat 13- (Episcopal Only)-Emergency situation whereby a patient is becoming or has been assaultive, all available clinical and security staff responds."

Review of facility document "ACTION TO REDUCE SAFETY SECURITY RISK FY 2019" DATE-Episcopal Emergency Department" dated January 31, 2019, completed by EMP9 revealed : Scoring Legend Criteria "0=Virtually No Risk, 1=Minimal Risk, 2=Moderate Risk, 3=High Risk, 4=Severe Risk w/history. Further review revealed evaluation of Risk Assessment Scoring for the Episcopal Emergency Department as follows: Risk Score Total for the Episcopal Emergency Department=4-Workplace Violence and Combative Patient. Further review revealed the facility's corrective action plan was to provide "Civility training for all ED staff/CIA/CARE, ART (Appropriate Response Training) Training."

Review of facility document "ACTION TO REDUCE SAFETY SECURITY RISK-Temple University Hospital Episcopal Campus 2017 dated December 15, 2017, revealed: Scoring Legend Criteria "0=Virtually No Risk, 1=Minimal Risk, 2=Moderate Risk, 3=High Risk, 4=Severe Risk w/history. Further review revealed evaluation of Risk Assessment Scoring for the Episcopal Emergency Department as follows: Risk Score Total for the Episcopal Emergency Depart =4-Combative Patient. Further review revealed the facility's corrective action plan was to "Maintain stat 13, Install additional panic button in minor care."

Review of facility documentation "Incident Report" dated May 23, 2020, revealed "On Saturday, May 23, 2020, at 2:32 PM. I (EMP31) responded to a Stat 13 in the E.D. treatment room 8 for a male patient. The patient barricaded himself in the room using the bed to block the door. I told the nurse to call 911 for a barricaded person. The patient was tampering with the oxygen tank, he was turning it on and off. The patient started lighting the bed on fire. At 3:13 PM the facility engineer on duty broke the window. I then call a CODE RED for the E.D. The E.D. staff and I started to evacuate the patients from the E.D. The patient was in Room 8, where he climbed out of the window. He then threw a chair into the Nurse's Station, he then ran to the front of the E.D....The patient's backpack and his jacket was searched manually..., during his [security guard] search he [security guard] discovered several hypodermic needles."

Review of facility documentation "Environment of Care Meeting Packet" date May 28, 2020 revealed the following Stat Calls/Panic Buttons within Temple University Hospital-Episcopal Campus:
"1. Fiscal Year 2019-2020: July-April=1753, 2. Fiscal Year 2018-2019: July-June=1791, 3. Fiscal Year 2017-2018: July-June=1674. Further review revealed the following stat calls/panic button calls: July 2019= 166, August 2019=152, Sept 2019=189, Oct 2019=219, Nov. 2019=167, Dec 2019=159, Jan 2019= 215, Feb=165, Mar=161, Apr=160."

An interview conducted on May 30, 2020, at 7:45 PM with EMP1 and EMP24 confirmed that the current Safety Security Risk Assessment was completed on January 31, 2019, for Temple University Hospital-Episcopal Campus. Further interview confirmed that the Safety Security Risk Assessment score was "4"=Severe Risk with/history for Combative Patient and Workplace Violence. In addition, EMP1 and EMP24 confirmed the Civility and CIA/CARE and ART Training was to be utilized as the corrective action for the assessment score of "4". EMP1 also confirmed that thirty-six ED staff members attended the training in 2019. EMP1 and EMP24 confirmed that the facility had not mandated the ED staff to attend the ED training which was the reason why only thirty-six ED staff members attended.

An interview conducted on May 30, 2020, at 7:55 PM with EMP24 confirmed the necessity of having staff complete the training for combative patients/ workplace violence to ensure the competency of the emergency department staff. EMP24 stated " We have a large population of patients received through the emergency department that display combative behavior. At times this behavior can be overwhelming for our clinical staff and our security guards."


Cross Reference:
482.12(c)(2): Tag-0144: Patient Rights: Care in Safe Setting
482.41(d)(2): Tag-0724: Facilities, Supplies, Equipment Maintenance