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Based on interview, document review, and review of hospital policy and procedures, the hospital failed to protect each patient's right to remain free from all forms of abuse or harassment.

Failure to protect from abuse or harassment places patients at risk for physical and psychological harm, serious injury, or death.

Findings included:

1. Failure to provide appropriate level of education and training to staff regarding the mitigation strategies for individuals at risk of harm to others.

Cross-reference: A0144

2. Failure to protect patients from physical assault while on hospital property.

Cross-reference: A0145

Due to the scope of the deficiencies cited under 42 CFR 482.13, the Condition of Participation for Patient's Rights was NOT MET.
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Based on interview, document review, and review of hospital policies and procedures, the hospital failed to develop an effective education and training system for all security staff that provide a safe and secure environment for all patients.

Failure to ensure that all security staff receive proper education and training places patients at risk for physical and psychological harm, serious injury, and death.

Findings included:

1. Document review of the hospital's policy titled, "Notice of Patients Rights and Responsibilities on Admission, 399," policy number 4899292, last revised 05/18, showed that every patient is offered a written copy of the hospital's document, "Patient's Rights and Responsibilities," and each patient or their legal representative is asked to sign the "Notice and Acknowledgement of Patient Rights/Responsibilities" form during the admission process. The document showed that all hospital patients have the right to be treated with dignity and respect, to be protected from verbal, mental, and physical abuse, and to receive an appropriate medical screening examination or treatment for an emergency medical condition within the capabilities of the hospital, regardless of the ability to pay for such services.

2. Document review of the hospital's policy titled, "Management of Disruptive Visitor Policy," policy number 6191257, last revised 03/19, showed that hospital security officers are to attempt to de-escalate disruptive visitors. If de-escalation is unsuccessful, security is to escort the disruptive visitor from the hospital and consider issuing a hospital trespass from the facility. Security may also consider calling the police and obtaining a criminal trespass, if needed. Document review showed that security staff are to complete an IRIS (an internal incident report) for any disruptive visitor, and the manager will activate the "Threat Assessment Team."

3. Document review of the hospital's policy titled, "Use of Force, 553.50," policy number 5412363, last revised 11/18, showed that if an individual is being physically assaulted and in danger of serious bodily harm or death, force that is reasonable and necessary may be utilized in order to keep individuals safe while escaping the situation. The document showed that reasonable and necessary force is used in self defense or in the defense of others, and only as a last resort. The hospital's policy showed that after all applications of force, staff will provide medical attention as needed for all individuals involved, notify the supervisor on duty, notify law enforcement on behalf of the victim if desired, report the incident to law enforcement when required by law or as deemed necessary, and complete an IRIS report.

4. Document review of the hospital's policy titled, "Standards of Conduct, 310," policy number 9136003, last revised 01/21, showed that all hospital employees are expected to conduct themselves in a manner deserving of public trust. Employees who engage in inappropriate or disruptive behavior including rude or abusive language, threatening (verbal or physical) behavior, harassment, and bullying may receive progressive corrective action, up to and including termination.

5. Review of hospital documents showed that:

a. On 08/15/20, hospital staff reported that during the shift on 08/14/20 at 11:49 PM, four hospital security staff were involved in a use of force incident in the hospital emergency department. The patient, (Patient #1201), a 60-year-old male and legally blind, had refused a COVID screen as part of his admission process and therefore was being discharged. Patient #1201 became angry, yelled at staff, and resisted discharge. Four hospital security officers (Staff #1201, #1202, #1203, and #1230) responded to the ED and thought that Patient #1201 was going to strike someone with his cane. Document review showed that Staff #1201 grabbed him, "similar to a headlock," while Staff #1202, Staff #1203, and Staff #1230 secured his other extremities. They held him on the ground, face down, with his head to the side for no more than five minutes. Document review showed that Patient #1201 did not resist while he was on the ground, and "when the police arrived and asked him if he was okay, he said, I am fine."

On 08/27/20, hospital staff contacted Patient #1201 by telephone, and he filed a grievance with the hospital. Document review showed that the hospital conducted interviews with Staff #1202, security leadership (Staff #1206, Staff #1207), and Human Resources (Staff #1208) on 08/31/21. Document review showed that one staff member, Staff #1201, received a "verbal coaching" for inappropriate use of force from his supervisor (Staff #1206) on 10/02/20.

b. On 12/19/20, after escorting a patient (Patient #1202) out of the emergency department (ED), a hospital security officer (Staff #1201) allegedly told Patient #1202 to "shut the f--- u," slammed him to the floor causing injury to his back, and then told Patient #1202 the "ED was closed" when he attempted to get care for his back pain. Document review showed that on 12/29/20, Patient #1202 reported the allegation of abuse to the hospital and on 01/18/21, the Security Supervisor (Staff #1206), the interim Regional Director of Security (#1207), and the Human Resources Business Partner (Staff #1208) met with Staff #1202 to discuss the allegation. Document review showed on 02/04/21, Staff #1206 completed a "Coaching Record for Inappropriate Use of Force." On 02/12/21, Staff #1201 acknowledged receipt of his verbal warning.

c. Video documentation showed that on 02/19/21 at 10:00 PM, six security officers were standing on the sidewalk near the hospital's ambulance entrance. They were facing in the direction of a former emergency department (ED) patient (Patient #1401) near the bus stop. Two security officers (Staff #1202 and Staff #1203) began shining strobing flashlights into Patient #1401's face. Patient #1401 attempted to block the light with his arm, with the hood of his sweatshirt, and by turning away, but the two security officers persisted.

d. Video documentation showed that on 02/19/21 at 10:06 PM, Staff #1202 and Staff #1203 continued to follow Patient #1401 with their strobing flashlights as he walked north on South J Street. Staff #1201 was observed stepping in front of Patient #1401 and kicking him once in his right lower abdomen/groin region with his heel.

e. Video documentation showed that on 02/19/21 at 10:13 PM, Staff #1202 is observed kicking Patient #1401's belongings into the street in front of the hospital ambulance entrance.

f. Video documentation showed that on 02/19/21 at 10:26 PM, Staff #1202 was observed crossing the street off hospital property and using two hands to push Patient #1401 down to the ground.

g. Video documentation showed that on 02/19/21 at 10:47 PM, as Patient #1401 attempted to sit down on the corner of South 16th and South J Streets, Staff #1202 grabbed him beneath his arms, flipped him onto his stomach, and then pressed his head and face down toward the ground more than once. Staff #1202 was then observed on his knees, swinging his arms in a downward motion toward Patient #1401 while Staff #1203 stood by and observed. Only when cars approached did Staff #1202 stop swinging his arms and stand up.

6. On 04/20/21 between 10:45 AM and 11:30 AM, Investigator #12 and Investigator #14 interviewed four emergency department (ED) clinical staff. The interviews showed that four of four clinical staff reported that when addressing disruptive visitors, their first step is verbal de-escalation, followed by obtaining additional staff, including security, notifying the police when needed, notifying the hospital supervisor or chain of command, and completing an incident report. Four of four staff reported that if they witnessed a coworker physically or verbally abusing a patient or staff member, they would intervene if safe to do so, remove the coworker from the situation, and report the situation to the supervisor immediately.

7. On 04/20/21 between 2:00 PM and 2:30 PM, Investigator #12 and Investigator #14 interviewed two hospital security officers (Staff #1201 and Staff #1202). Staff #1201 and Staff #1202 stated that the "use of force" is used only as a last resort, and only in situations where it is self-defense, or while defending others. When asked if it is considered necessary to lay hands on an individual while escorting someone off the property, Staff #1201 and Staff #1202 stated that it was inappropriate to lay hands on a person while physically escorting them off property. Both staff stated that if visitors refuse to leave the property with a physical escort, they will call the police for assistance.

8. On 04/20/21 between 2:27 and 2:50 PM, Investigator #12 and Investigator #14 interviewed the interim Regional Director of Security (Staff #1207) and the Security Supervisor (Staff #1206). Staff #1206 and Staff #1207 confirmed that Staff #1202 violated the hospital's "Use of Force" policy. When asked if Staff #1201 violated the "Use of Force" policy on 02/19/21 at 10:06 PM, when he kicked Patient #1401, Staff #1206 and Staff #1207 stated that they "did not see the kick." The Risk Manager (Staff #1210), who was also present at the time of the interview, confirmed video observation of the kick.
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Based on observation, interview, document review, and review of hospital policies and procedures, the hospital failed to develop and implement an effective system to ensure a safe environment that prevented patient assault in 2 of 10 patients reviewed (Patient #1202, #1401).

Failure to protect patients from physical assault by implementing interventions to prevent physical assault risks violation of patient rights, care in an unsafe environment, and serious injury or death.

Findings included:

1. Document review of the hospital's policy titled, "Notice of Patients Rights and Responsibilities on Admission," policy number 4899292, last revised 05/18, showed the following:

a. All patients have the right to reasonable safety and security, and to be protected from neglect, verbal, mental, and physical abuse.

b. All patients have the right to be treated with dignity and respect.

2. Document review of the hospital's policy titled, "Reporting of Alleged Harassment, Abuse, or Neglect of Patients While in Our Care," policy number 8150174, last revised 06/20, showed the following:

a. Abuse allegations are reported to department leadership and investigated immediately.

b. When allegations involve staff members, department leadership will notify Human Resources and remove the staff person from the schedule until the investigation is complete.

3. Document review of the hospital's policy titled, "Management of Disruptive Visitor," policy number 6191257, revised 03/2019, showed the following:

a. Security officers are to attempt to de-escalate disruptive visitors. If de-escalation is unsuccessful, security is to escort the disruptive visitor from the hospital and consider a hospital trespass or calling the police to obtain a criminal trespass.

b. Managers or House Supervisors are to activate the Threat Assessment Team when de-escalation techniques are unsuccessful.

4. Document review of the hospital's policy titled, "Use of Force," policy number 5412363, revised 12/2015, showed the following:

a. Under no circumstances will an employee use unnecessary, unreasonable, excessive, or retaliatory force.

b. If force is used for self-defense, the employee is to notify the Supervisor, provide medical attention, report incident to law enforcement if indicated and file an incident report with the hospital.

5. Document review of the hospital's policy titled, "Standards of Conduct, 310," policy number 9136003, revised 01/2021, showed the following:

a. Disruptive and inappropriate behavior will result in progressive corrective action that is determined by the seriousness of the behavior.

b. Examples of defined inappropriate behaviors include threatening (verbal or physical) behavior, harassment, and bullying.

6. Document review of the hospital's policy titled, "Corrective Action," policy number 7112191, last revised 10/2019, showed the following:

a. Immediate corrective action is warranted when there is suspected abuse or failure to report observation of suspected abuse.

b. Immediate corrective action includes: Written Warning, Suspension (without pay), Suspension (indefinite), Final Warning (in lieu of suspension), Discharge from Employment, and Administrative Leave.

c. Administrative leave is non-disciplinary and indicated when there is a concern regarding patient safety.

7. Review of hospital quality documents showed that on 12/29/20, a patient (Patient #1201) filed a grievance alleging that he was assaulted by a staff member (Staff #1201) following his visit to the emergency department on 12/18/20. Document review showed that the hospital conducted an internal investigation, reviewed video documentation supporting Patient #1201's allegation of abuse, and interviewed Staff #1201 01/18/21. Document review showed that the security supervisor (Staff #1206) completed a "Checklist for Patients or Visitors Reporting Alleged Harassment, Abuse, or Neglect of Patients" form as part of the investigation process, and item 10a, "staff member is removed from the schedule," was marked "N/A."

8. Review of hospital video documents showed the following:

a. On 02/19/21 at 10:00 PM, six security officers were standing on the sidewalk near the hospital's ambulance entrance. The security officers stood near the ambulance entrance and appeared to be talking to a patient who had recently discharged from the emergency department (Patient #1401). Two security officers (Staff #1202 and Staff #1203) began shining flashing strobe lights into Patient #1401's face. Patient #1401 attempted to block the flashing lights with his arm, with the hood of his sweatshirt, and by walking in the opposite direction, but Staff #1202 and Staff #1203 would not relent.

b. On 02/19/21 at 10:06 PM, Staff #1202 and Staff #1203 continued to follow Patient #1401 with their flashing strobe lights as he walked north on J Street. Staff #1201 was observed stepping toward Patient #1401 and kicking him once in his right lower abdomen/groin region with his heel.

c. On 02/19/21 at 10:13 PM, Staff #1202 kicked Patient #1401's white belongings bag from the bus stop into the middle of J Street where they were run over by passing cars.

d. On 02/19/21 at 10:26 PM, Staff #1202 and Staff #1203 followed Patient #1401 across J Street, off hospital property. Staff #1202 used both hands to push Patient #1401 down to the ground.

e. On 02/19/21 at 10:47 PM, as Patient #1401 attempted to sit down on the corner of South 16th and J Streets, Staff #1202 grabbed him under his arms, flipped him onto his stomach, and pressed his head and face down into the ground repeatedly. Staff #1202 then knelt alongside Patient #1401 and began, swinging his arms in a downward motion toward Patient 1401's upper body. Staff #1203 stood by and observed the interaction, but he made no attempt to physically intervene. Only when cars approached did Staff #1202 stop swinging his arms and stand up. At 10:50 PM Patient #1401 stood up, swayed back and forth, and staggered as he followed Staff #1201, Staff #1202, and Staff #1203 south on J Street.

f. On 02/19/21 at 10:57 PM, Patient #1401 fell face forward on the sidewalk next to the mailbox near the hospital's main entrance. He did not move for 30 minutes. At 11:00 PM hospital security officer (Staff #1204) walked directly past Patient #1401, paused for five seconds, turned around, and passed him once more. He did not stop, nor did he send assistance.

g. On 02/20/21 at 4:33 AM, police, fire, and ambulance arrived to render assistance to Patient #1401 who lay unresponsive in the street directly in front of the hospital.

9. Investigator #12 interviewed the Human Resources Marketing Director while reviewing the personnel files of 5 hospital security staff (Staff #1201, #1202, #1203, #1204, #1214). Document review showed that on 10/06/20, Staff #1201 received "verbal coaching" for a use of force incident on 08/14/20. Document review showed that on 02/04/21, Staff #1201 received a "verbal warning" for a use of force incident on 12/19/20. During the investigation, Staff #1208 confirmed the investigator's finding that improper use of force is a form of abuse, and according to hospital policy, would result in immediate corrective action. Staff #1208 confirmed the investigator's findings that verbal coaching and verbal warnings were not considered forms of immediate corrective action.

10. On 04/21/21 at 2:15 PM, Investigators #12 and Investigator #14 interviewed the Security Supervisor (Staff #1206) and the interim Regional Security Director (Staff #1207). During the interview, Staff #1206 and Staff #1207 stated that staff should only use force for self-defense and to protect others. If force is used, it must be reasonable and necessary, and it is to be used only as last resort. Staff #1206 and Staff #1207 stated that when conducting investigations for potential use of force violations that occurred on 08/14/20 (Patient #1201), 12/18/20 (Patient #1202), and 02/19/21 (Patient #1401), they did not remove any staff members from their scheduled shifts during the initial investigation Staff #1207 stated that "they would have removed Staff #1202 from the schedule" immediately, but he did not return to work after his shift on 02/19/21. When the investigators asked why Staff #1201 had not been removed from the schedule per hospital policy for the event that occurred on 02/19/21, Staff #1206 and Staff #1207 stated that they "did not see the kick," but they would go back and review the video. Staff #1206 and Staff #1207 confirmed the investigators' findings that Staff #1203 should have reported the use of force by Staff #1202 to his supervisor, and Staff #1203 should have offered Patient #1401 medical attention following the application of use of force.
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Based on interview, document review, and review of hospital policies and procedures, the hospital failed to ensure that patient safety and security incidents were reported into the SCORS system according to hospital procedure for 3 of 13 events reviewed.

Failure to ensure timely reporting of patient safety and security events limits the hospital's ability to implement measures that prevent or mitigate future patient harm.

Findings included:

1. Document review of the hospital's policy titled, "Incident Reporting Information System (IRIS) Guidelines and Management," policy number 7647729, revised 06/2020, showed the following:

a. Incident reports are to be entered whenever there's an injury of any kind to a patient, visitor, or employee.

b. Supervisors are to be immediately notified of serious events.

c. Incident reports are to be submitted within 24 hours of an incident occurring.

2. On 04/21/21, Investigator #12 and Investigator #14 interviewed the interim Regional Director of Security (Staff #1207) and the Security Supervisor (Staff #1206). Staff #1206 stated that the security officers use a department specific SCORS system to routinely monitor and record their daily activities. Staff #1206 stated that he reads the SCORS reports each day, and if he sees a potential use of force violation, he will escalate it to his director, Staff #1207. Staff #1206 stated that in addition to the SCORS report, security staff are also expected to complete a security IRIS if they are involved in use of force incidents.

3. On 04/26/21, Investigator #12 reviewed security SCORS report documents with Staff #1206 and Staff #1207. Document review showed that:

a. On 02/19/21, Staff #1214 responded to an incident in the emergency department (ED) at 7:00 PM, but he did not complete a SCORS report until 02/25/21 at 9:44 PM.

b. On 02/20/21, Staff #1201 responded to an incident in the ED at 5:00 AM, but he did not complete a SCORS report until 02/22/21 at 5:58 AM.

c. On 02/20/21, Staff #1201 responded to an incident in the ED at 5:30 AM, but he did not complete a SCORS report until 02/22/21 at 5:30 PM.

During the document review, Staff #1206 and Staff #1207 confirmed that it is the expectation that security officers enter SCORS reports within 24 hours of the event.
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