HospitalInspections.org

Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined the Governing Body failed to ensure Temple Hospital Inc., consistently operated in a manner that protected the health and safety of the patient population served.

This condition is not met as evidence by:

Based on a review of facility documents, reportable incidents and corrective actions implemented at the time of each incident, it was determined the facility's Governing Body failed to provide the necessary supervision and oversight to ensure safety in the provision of care and treatment based on the patient population served and failed to follows its own policies and procedures in order to promote and protect the patient's health and safety as evidenced by the hospital's patterns of serious events and infrastructure failures over the past eight month commencing May 2020 to December 2020.

Findings include:

Review of survey results from May 2020 through December 2020 revealed four reportable events:

1. Emergency Department (ED)-Episcopal Campus-a patient set fire in ED Room 8 on May 23, 2020. The facility identified a hand lighter on the patient requesting treatment during the ED safety search and returned the lighter to the patient upon entering the ED.

2. Emergency Department-Main Campus-a patient set fire in ED hallway bed on August 15, 2020, with a hand lighter that the facility failed to identify during the ED safety search process set fire in the ED. The facility failed to perform the safety search process according to facility policy for a patient entering the ED via stretcher by emergency medical services (EMS).

3. Behavioral Unit-Potter Morris Six (PM6)- inpatient behavioral health patient who was inadequately monitored was able to inflict self-harm resulting in death by hanging using a no-weight limitation shower rod in the patient's bathroom. The incident occurred on September 7, 2020.

4. Crisis Response Center (CRC)-Episcopal Campus: patient in the process of discharging from the Crisis Response Center with episodes of aggressive behavior prior to exiting the CRC. Clinical staff addressed the aggressive behavior by calling a Stat 13 emergency call for the assistance of additional staff to address the behavior. The attending physician for this patient was not notified of the episodes of aggressive behavior. The patient exited from the CRC with clinical staff assistance and jumped from a third-floor hallway window resulting in his death on December 10, 2020.


Cross reference
482.13 (c)(2) Patient Rights: Care in Safe Setting.
482.13 Patient Rights

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to comply with this condition.

This condition is not met as evidence by:

Based on a review of facility policies and procedures, documents and interview with staff (EMP), it was determined the facility failed to ensure the provision of safe and considerate patient care by competent staff based on professional standards governing clinical practice for the safety of the patient population served in the Crisis Response Center (CRC).

Findings include:

Review of facility policy on December 15, 2020, "PATIENT RIGHTS AND RESPONSIBLITIES' effective August 2000 revealed "...Patient at TUH (Temple University Hospital) have the right to safe, considerate, respectful and dignified care at all times. ...1. To receive considerate, respectful, safe, quality, care delivered by competent personnel....To receive quality care within the professional standards governing clinical practice."

Review of facility document on December 15, 2020, "Incident Report" dated December 10, 2020, authored by EMP11 revealed " The patient being escorted by two techs (crisis response technicians) from CRC treatment area, as the patient approached the security zone I asked out loud was a Stat 13 needed and no one responded and I wasn't told to call a Stat until the patient reached the door. I called for Stat 13 after the panic button was pressed, one tech gave access for the door [to be opened] and both techs escorted the patient in the hallway where one tech did not exit (the CRC)."

A telephone interview conducted on December 15, 2020, at 11:01 AM with EMP16 who stated "I observed part of the interview with the patient (MR1) that the intern (EMP8) conducted. EMP8 presented the case of the patient (MR1) to me and I gave approval for discharge and outpatient care. When Stat 13 happened, I responded to that call, but the patient had already jumped out of the third-floor hallway window. I did not have direct interaction with the patient prior to his discharge. The attendings always go over any discharges with the interns to make sure they make sense. We have a certain number of direct interviews we observe but do not have direct contact with every patient in the crisis center. [Name Redacted-EMP8] said he let the patient know that he was to receive outpatient referral, which was what we're doing with the majority of our drug and alcohol patients. Right now, during the second wave of high prevalence of coronavirus in attempt to keep the CRC census down, despite screening, we are referring patients coming in for drug and alcohol treatment, unlikely to have life threatening withdrawal, we are referring them to outpatient care." EMP16 confirmed that he had not received notification of the patient's episodes of aggressive behavior from the CRC clinical staff prior to the patient exiting the CRC.

The information reviewed during the survey provided evidence that the facility failed to ensure effective communication with the medical staff as to the patient's (MR1) episodes of aggressive behavior and Stat 13 call within the CRC in a timely manner prior to the patient's discharge from the CRC.

A discussion took place with the survey team and the facility's administrative staff (EMP1, EMP3 and EMP5) regarding the survey team's concerns related to Patient's Rights for a safe environment on December 15, 2020, at approximately 3:50 PM.

Cross reference
482.13 (c)(2) Patient Rights: Care in Safe Setting.

Based on observation of facility video, review of facility policies, documents, medical records (MR), and interview with staff (EMP), it was determined the facility failed to provide the necessary care to ensure a safe discharge from the Crisis Response Center for one of one medical record reviewed (MR1).

Findings include:

Observation of facility video footage on December 15, 2020, with EMP1, EMP3 and EMP7 of the incident that occurred in the Crisis Response Unit on December 10, 2020, revealed the patient (MR1) displayed two episodes of aggressive behavior prior to discharge from the Crisis Response Center (CRC). A review of the patient on the video footage on December 10, 2020, revealed an episode of aggressive behavior in the main waiting area that included EMP10, EMP12, EMP19 and EMP20. The second episode of aggressive behavior was viewed via the facility's video footage in the CRC security area that included EMP10, EMP12 and EMP20. Further observation of the video revealed the CRC security guard witness the patient's aggressive behavior and initated the Stat 13 emergency assistance call based on the directive of EMP12 prior to the patient exiting the CRC.

Review of facility policy on December 21, 2020, "Management Of Aggression" effective February 28, 2013, revealed " SCOPE AND RESPONSIBILITIES: 1. This policy and procedure is distributed to all units and departments of the TUH-Episcopal Campus. 2. It is the responsibility of all staff to adhere to the policy and carry out the procedures as outlined in the procedure. 3. Staff are to notify the physicians in their departments or units when there are issues with aggressive patients or visitors. ... Patients and visitors should be assessed for their risk of dangerousness, when they appear to be upset or agitated in an effort to anticipate and prevent violence. Staff are to utilize the principles taught in customer service training and in ART to de-escalate the situation. 2. To assist in problem solving and conflict resolution, staff should notify the charge nurse, immediate supervisor and unit or department physician as to the nature of the conflict or the threat, and seek assistance in managing the situation.
3. The Manager or supervisor will review the clinical situation and attempt to facilitate a resolution. They may also involve the patient's physician and treatment team so that an appropriate treatment plan can be implemented and safety of the unit or department can be maintained."

An interview conducted on December 15, 2020, at 1:09 PM with EMP 12 who stated, "I said to the security guard to hit the Stat 13 button. EMP 20 (crisis response technician) was trying to get him to calm down, because he wouldn't calm down. As a safety precaution, I instructed the security guard to hit the Stat 13 Button."

An interview conducted on December 15, 2020, at 1:59 PM with EMP10 who stated, "It's not uncommon that patients go the wrong way when exiting the CRC and when you tell them to come back they come back. I have heart and knee health problems. My days of running after patients are over. He [patient] did not acknowledge my directions when I called him to come back. I was behind the hallway doors, heard glass breaking which made me speed up. The Stat 13 alarm had gone off, so I was the first person that followed him out of the CRC door. I couldn't tell you who was going to walk him out. So when he went out of the CRC door I followed him."

An interview conducted on December 15, 2020, at 2:09 PM with EMP13 who stated "A Stat 13 requires a group of staff to escort an aggressive patient. Pre-cert, print papers, grab personal belongings and escort patient out during the discharge process. EMP10 [name redacted] would have been doing the pre-cert that day. It's a team effort. Who ever is available escorts the patient out. So it's not an assignment."

An interview conducted on December 21, 2020, at 4:15 PM with EMP19 who stated, " I was the triage nurse for him (MR1) when he arrived to the CRC. Patients are not assigned to a primary nurse in the CRC. We all do what is necessary to take care of these patients. I was involved with the patient when he had his first aggressive episode in the CRC main waiting area. It would have been the CRC charge nurse responsibility to call the physician to report the patient's aggressive behavior. That would not have been my responsibility to make that call. I was not involved in the second episode of his aggressive behavior prior to leaving the CRC in the area where the security guards sits. I was told by the staff what occurred prior to the patient leaving the CRC. When the second incident occurred, I was trying to get his (patient) clothing from the belongings closet."

Cross Reference:
482.12 Governing Body
482.13 Patient Rights