HospitalInspections.org

Based on interview and record review, the hospital failed to protect and promote each patients rights.

Findings include:

The hospital failed to ensure all patients received care in a safe setting. (Refer to tag A-0144)

Based on observation, interview, and record review, it was determined the hospital did not provide a safe setting for 1 of 10 sampled patients. Specifically, a patient was not kept safe from injury during an incident with security. Additionally, the hospital did not conduct a thorough investigation of the incident. (Patient identifier: 5)

Findings include:

1. Patient 5 was readmitted to the hospital on 12/28/2023, after being discharged against medical advice (AMA) on 12/26/2023. Diagnoses upon re-admission included respiratory failure, heart failure, kidney disease, atrial fibrillation (irregular heart rhythm), and encephalopathy (disturbance in brain function that results in confusion and changes in behavior).

On 1/22/2024 at approximately 12:10 PM, patient 5 was interviewed related to an incident that occurred on 1/4/2024, which resulted in a right hip fracture. Patient 5 stated that he wanted to smoke a cigarette but that hospital staff were blocking the elevators. Patient 5 stated he took the stairs to exit the hospital and that a security guard "kicked me in the hip."

Patient 5 had multiple episodes of being combative, expressing a desire to discharge AMA and attempting to leave the hospital. The following was documented in patient 5's medical record:

On 12/28/2023 at 3:13 PM, an order was written that documented, "One to one Observation, Patient Safety Attendant (PSA)."

On 12/28/2023, a code green (meaning that a security officer was needed) was called due to "Pt. (patient) yelling, refusing to return to room, returned to room w (when)/security arrived."

On 12/29/2023 at 5:08 PM, it was documented that patient 5 was combative. A code green was called and a 1:1 (one to one) sitter was initiated.

On 12/29/2023 at 5:42 PM, a nurse documented, "notified provider that pt needs additional sedation medication because pt is not safe with how impulsive he is and how unstable he is."

On 12/30/2023, it was documented that "Pt remained confused and aggressive with a 1:1. Pt has had several code greens called ..." It was further documented that patient 5 was on a medical hold (a process by which a patient who is alert, but lacks capacity due to a medical condition, is prevented from leaving the hospital so that they can be treated).

On 12/30/2023 at 8:21 AM, it was documented, "Escape precautions ...fall precautions ...'Bed alarm,' unable to demonstrate successful use of call light."

On 12/30/2023, a code green was called due to patient 5 "being agitated and attempting to get out of bed." It was documented that a physical intervention/restraint was required until patient 5 got tired and went to sleep.

In an order dated 12/31/2023 at 12:58 AM, it was documented, "Patient frequently rising out of bed and swinging at staff members but not coordinated enough to hit them and very high risk for falls." Soft wrist restraints were ordered. It was further documented, "order valid per episode, no matter the timeframe (sic)."

On 12/31/2023, a code green was called related to patient 5 removing the oxygen tube. According to documentation, restraints were placed.

On 12/31/2023, it was documented that patient 5 had restraints placed at 6:02 AM, 8:05 AM, 10:00 AM, 12:15 PM, 2:10 PM, 4:18 PM, 6:00 PM, 8:56 PM and 11:07 PM.

On 1/1/2024, it was documented that patient 5 was placed in a restraint at 1:39 AM, 3:16 AM, 5:37 AM, 6:38 AM, 9:54 AM and 11:00 AM. A staff nurse documented, "4 points restraints are ok per MD. Haldol (a drug used to treat people with psychosis, which has calming effects) IV (intravenously) once ordered per MD." It was documented that the Haldol was administered at 10:50 AM for combative behaviors and attempting to leave the hospital.

On 1/1/2024, it was documented that a code green was called related to patient 5 being agitated. Patient 5 was placed in restraints for all four extremities.

On 1/1/2024 at 10:42 PM, it was documented "pt saying he wants to leave; put on pants and shirt to get ready to go home."

On 1/1/2024 at 11:03 PM, it was documented the patient was trying to leave.

On 1/2/2024 at 2:00 AM, it was documented the "pt was wanting to get on the elevator to leave."

On 1/2/2024 at 8:45 AM, it was documented that the patient "went on walk in hallway in wheelchair. Stood up from wheelchair while being pushed, went to staff elevators and pushed down button ..."

On 1/2/2024 at 11:30 AM, it was documented that the "pt was walking in hallway, would not sit in wheelchair or be redirected. Opened door to stairwell. Security was almost called, however other staff helped to redirect pt back to room."

On 1/2/2024 at 11:43 PM, it was documented that "pt got up and went to cough (sic), then put on his coat and went into hallway (sic)."

On 1/3/2024 at 7:18 AM, it was documented that patient 5 was physically violent and had been refusing all cares and medications. The staff member documented that patient 5 had tried to leave AMA on multiple occasions and was a flight risk.

On 1/3/2024 at 10:06 AM, it was documented that the "Pt is wanting to leave."

On 1/3/2024 at 11:23 AM, it was documented that the "Pt wanted to leave ... Then he wanted to walk the halls. He's attempted to leave AMA while doing this on 1/1 & 1/2."

On 1/3/2024 at 3:13 PM, it was documented that the "Pt has his coat and clothes on, ready to go home."

On 1/4/2024, orders were received to discontinue Ativan and Haldol. The patient safety attendant was discontinued. At 10:48 AM, the patient's blood pressure was 78/48 (normal blood pressure for an adult male aged 40-59 years is 124/77), he was drowsy and unable to express his thoughts clearly.

On 1/4/2024 at 11:56 AM, a nurse documented "I don't think dc'ing (discontinuing) the PSM (patient safety monitor) is a good idea, pt unstable, impulsive, refusing O2 (oxygen) and sats (saturations) in the 80's (normal is above 90%) without O2". The PSM was to be reordered.

On 1/4/2024 at 11:51 AM, an arterial blood gas was drawn. Pt 5's oxygen saturation was 89.8%. [Note an oxygen level lower than 90 has the potential for increased patient confusion.]

On 1/4/2024, it was documented that patient 5 was a flight risk at 12:14 PM and 1:06 PM.

On 1/4/2024 at 1:41 PM, a PSA documented, "Patient asked for a round. When we back (sic) to the room he ate a few bites from his tray and left the room trying leave (sic) the hospital by the stairs. Then they call (sic) green code."

On 1/4/2024 at 1:41 PM, the nurse assigned to care for patient 5 documented, "Code green called, security had to use force, may have injured his knees, prob (probably) needs x-ray."

On 1/4/2024, it was documented on the code green log that, "Patient on medical hold requiring security team intervention, resulting in broken hip."

On 1/4/2024 at 1:41 PM, the nurse documented "refusing to stay in bed, c/o (complains of) right hip pain and limping."

On 1/4/2024 at 1:46 PM, an order was received to restart the Ativan.

On 1/4/2024 at 1:53 PM, the nurse assigned to care for patient 5 documented, "pt standing up to pull pants up, help offered but pt refusing help and fellt (sic) bedside." [Note: patient 5 was allowed to stand without assistance after complaining of right hip pain and limping. Additionally, patient 5 was not restrained or kept from standing despite a security officer, nurse, and PSA being in the room.]

On 1/4/2024 at 2:43 PM, it was documented "MD (medical doctor) dx (diagnosis) of hip fracture ..."

On 1/4/2024 at 6:18 PM, it was documented that patient 5 was "up to use toilet (sic)." [Note: this occurred despite the hip fracture diagnosis.]

On 1/5/2024 at 11:59 AM, a physician consult documented that patient 5 was in his usual state of health until 1/4/2024, when he was involved in an altercation that resulted in immediate hip pain and inability to bear weight. [Note: after the altercation staff allowed the patient to stand unassisted and fall, stood patient 5 up and ambulated him to the stairs, allowed him to stand unassisted in his room resulting in a second fall, and allowed him up to use the toilet.]

In an operative report dated 1/5/2024 at 11:59 AM, a physician documented that patient 5 had a displaced fracture of the hip that required surgical repair.

2. A review of the hospital's code green log, dated from 12/28/2023 through 1/4/2024, revealed four code green calls related to patient 5's agitation, yelling, leaving his room, and attempting to leave the hospital AMA. Two of the four events resulted in patient 5 being restrained. On one occasion patient 5 was placed in soft wrist restraints and on another occasion, patient 5 was placed in 4-point restraints. On 1/4/2024 patient 5 was physically restrained and was taken down to the ground by security officer (SO) 1. After the incident patient 5 was diagnosed with a hip fracture.

3. The event report was requested by the survey staff. The event's description documented, "Patient on medical hold requiring security team intervention, resulting in broken hip for patient." The incident note by SO 1 documented, "On January 4, 2024, at approximately 1332 (1:32 PM) I (SO 1) responded to a code green that was called in the Southwest Stairwell for (patient 5) who is on a medical hold and was trying to leave the hospital. (Patient 5) got to level 3 in the Southwest Stairwell right by the Maintenance penthouse. I came up the other side of the stairs and exited the doors to find the nurses telling (patient 5) to come back to his room. The Nurse (sic) stated that he is on a medical hold and cannot leave. I asked (patient 5) to turn around and head back to his room (room number redacted), he refused and kept walking towards me, I stood in front of the door that leads to the stairwell and told him he needs to turn around and go back to his room, he continued to get closer and I put my hand up to stop him from pushing me back and told him he can go back to his room or we will escort him to his room by force. (Patient 5) started to push past me and I grabbed his arm and turned him around and tried to escort him back to the elevator. (Patient 5) started telling me to (explicit language redacted) and then grabbed my right Shoulder. I pulled (patient 5) towards the wall and tried to hold him there while I waited for backup Officer to arrive. (Patient 5) pushed back off the wall and I used my Avade tactics (a training provided to security guards on how to restrain a patient) to gain control of his arm and assisted him to the ground where I held him until Security Officer (SO 2) and Security Officer (SO 3) arrived.

(SO 3) and myself assisted (patient 5) with standing up and walking to the stairs to sit down until the wheelchair arrived. (SO 4) arrived with the wheelchair and I assisted (patient 5) with sitting down on it and wheeled him to the service elevator and back to (room number redacted). (Patient 5) told me that he hates Security bothering him, I told (patient 5) to please stay in his room and be respectful to staff and he won't have to see Security again and not to leave until his medical hold is cleared by the Dr ..."

4. The surveyors requested witness statements from all staff members involved in the event on 1/4/2024. The witness statements did not occur until after the survey team arrived onsite, 19 days after the incident occurred. According to some of the witnesses, they could not recall everything that happened because so much time had passed.

On 1/23/2024 at 2:48 PM, PCT 1 documented in an incident note that "...When the patient finished going down the stairs he turned to the right following the exit and there security intercepted him. Just at that moment the patient lost my sight, because his nurse was also going down the stairs in front of me and when I also went down the stairs I heard his body fall to the ground and I saw that the patient was on the floor. The patient tried to get up and he couldn't, he got on his knees and tried to stand up but he couldn't ... During the transfer from the wheelchair to the bed, we realized that the patient was injured, he was flexing his right knee and we thought that he had injured his right knee. And while the patient was sitting on the edge of the bed, he tried to stand up without saying anything and fell on his knees. ...The patient was in a lot of pain ..."

On 1/23/2024 at 5:54 PM, RN 1 sent her witness statement in an email to the nurse manager (NM). RN 1 documented, "... Force was used to physically stop the patient from leaving. The pt was forced to the ground and then other security guards arrived on the scene. The pt then complained of leg/hip pain, the pt was escorted to the stairs to sit while another security guard got a wheelchair and then we took the pt via wheelchair by elevator back to his room ..."

On 4/8/2023 at 1:00 PM, an interview was conducted with RN 1. RN 1 was asked to describe patient 5's behavior on 1/4/2024. She stated that he was noncompliant, grumpy, aggressive and just rude. RN 1 was asked why the orders for as needed Ativan and Haldol were discontinued. RN 1 stated that she did not know. RN one was asked why patient 5 was not restrained prior to going down the stairs. RN 1 stated that she did not know and was able to provide potential interventions to prevent patient 5 from leaving his room/floor. RN 1 was asked if she had heard SO 1 state the patient 5 that he was not going to this again today. RN 1 stated, "It rings a bell" but was unable to recall the specific wording. When asked to provide details about how the patient was forced to the ground, RN 1 stated that SO 1, "put his leg out to keep him [patient 5] from leaving" and that patient 5 ended up on the ground. RN 1 stated that she did not witness patient 5 having a second fall while on the 3rd floor, but that she was told later.

On 1/23/2024 at 5:27 PM, RN 2 documented in an incident note that "...Security came through the door at the end of the hall and restrained the patient up against the wall. The patient fought to get off of them and looked as if they went to try hit (sic) security. The security officer said he had (sic) was not doing this again today with this patient and used force to get him to the ground. When the patient hit the ground it (sic) was a loud crack. After a short time of holding the patient there security attempted to help him up ... He got to almost standing and fell again. Security got him to the stairs ... He was placed in a wheelchair and taken up back to (room number redacted) in his room. In his room myself and the sitter offered to help him with his pants and he declined and tried standing. We both instructed him to stay sitting unless he was willing to let us help due to increased pain and instability ... he kept yelling at us and told us not to help when he then stood up and fell in the room ..." [Note: A loud crack was heard by staff when Patient 5 was taken to the ground by security. Immediately following this, Patient 5 was allowed to fall in the presence of the same staff and was then ambulated to a stairwell.]

On 4/8/2024 at 2 PM, RN 2 was re-interviewed. RN 2 was asked to explain how SO 1 used force to get patient 5 on the floor. RN 2 asked, "It happened so fast, I couldn't even tell you." RN 2 further stated that one minute patient 5 was up against the wall then was on his stomach on the floor. RN 2 was asked about her statement that SO 1 stated, "I'm not going to do this with you again today" and whether it was said in a demeaning way. RN 2 stated that it was like a parent telling a child that they were not going to do this again today. RN 2 was asked if she witnessed SO 1 putting his foot out to stop patient 5 from exiting the 3rd floor. RN 2 stated that she recalled SO 1's right leg getting tangled up with patient 5's legs. RN 2 was asked about the 2nd fall that occurred on the 3rd floor and stated that patient 5 attempted to stand up unassisted and fell to his knees. She further stated that patient 5 pushed SO 1 "off" and continued to be aggressive. RN 2 stated that patient 5 did not get to a full standing position when he "stumbled back down."

5. Patient 5 had previously left the hospital "AMA," and was continually expressing flight risk, and repeatedly attempting to leave. The patient had an unstable gait, was a high fall risk, confused and impulsive, and the hospital continued to allow the patient to enter into a hallway after he had verbally or physically threatened to elope for three days preceding the event. During the event, the patient's nurse documented that security used force during the code green, and a written statement and a second staff interview corroborated the same. After the code green was called, the patient fell to his knees after the patient care staff had documented that they knew he was injured [Note: patient 5 should have not been allowed to stand or walk after it was known that he may be injured, and there should have been an assessment of patient 5's injuries before moving him]. After the patient was diagnosed with a fractured hip, six hours later he was allowed to get up to use the toilet prior to having surgery.

6. Additionally, on 1/4/2024 at 7:44 PM, patient advocate (PA) 1 documented, "CHRM (Clinical High-Reliability Manager) to be consulted on high harm issue. Possible reportable event... Patient advocate to seek witness statements from all individuals involved in this incident. ..." [Note: There was no documentation from PA 1 that witness statements from all individuals involved, were conducted.]

On 1/8/2024 at 6:44 PM, the security manager (SM) documented that a "Use of Force Review" would be conducted related to the incident.

A post-incident "Use of Force Review" was conducted on 1/16/2024, two weeks after the incident occurred, for the incident on 1/4/2024. The committee members involved in the review included the security manager, compliance, administration, security supervisor, and the office of clinical excellent. It was documented that the evidence review included a video review of patient 5 when out of his room, "reports" (there was no documentation of what reports were reviewed), and an in-person statement from [SO 1]. The outcome from the review committee determined that no malintent or abuse by SO 1 was identified. [Note: The "Use of Force Review" committee did not obtain witness statements from the additional personnel that observed, or was involved, in the incident prior to determining if malintent or abuse had occurred.] The incident report did not contain pertinent information to determine if malintent or abuse had occurred.

The survey team requested witness statements from the registered nurses and personal care technician involved in the incident. The hospital staff did not obtain written witness statements until 1/23/2024, nineteen days after the incident occurred and after the survey had started. According to some of the witnesses' involved in the incident, via written statements and interviews, staff were not able to recall finer details of the event (i.e. observation of the patient being placed against the wall, when the patient was taken down by SO 1 or how the patient was observed on the floor, etc) since time had passed. By interview with the office of clinical experience, the hospital had not interviewed the personal care technician and registered nurses involved in the incident, which may have elicited additional information into the incident.

It was determined the hospital did not conduct a thorough investigation into the incident that occurred on 1/4/2024, when the initial investigation was conducted (1/22/2024). Additionally, at a later date, the hospital conducted an additional investigation into the incident, which was reviewed by surveyors on 4/2/2024. There was no documented evidence the hospital conducted further interviews with the employees involved in the incident; this would have elicited additional information related to the incident on 1/4/2024, as was identified during further investigation by surveyors when they re-interviewed witnesses on 4/10/2024.

7. During the initial survey conducted from 1/22/2024 through 1/30/2024, the following policy and procedures were reviewed:

a. Physical Security Use of Force and Post-Incident Review Guideline

"Purpose

Because of the wide variety of situations that can occur within a healthcare facility that may involve the use of force by security officers, a variety of force options are necessary to bring a successful conclusion to those situations. This guideline sets for the reporting and applicable review level of incidents involving use of force...

Definitions

Excessive Use of Force - Any use of force that is unreasonable, unnecessary, or disproportional in relation to the force required to effectively and safely resolve a conflict.

Intermediate Level Force - Any use of force involving physical interactions that results in: (1) evidence of injury to the individual or security officer; (2) complaints of persistent pain or injury by the individual or the security officer...

Local Team - Team generally consisting of unit manager where incident occurred, local Office of Patient Experience (Patient Advocacy and CRM) local Security, and if needed, local Human Resources Business Partner and local Compliance...

Post-Incident Review Team - Team generally consisting of system-level representatives from Legal, Compliance, Office of Patient Experience (Patent Advocate and CRM), Human Resource Employee Relations, and Security.

Guideline...

4. Reporting and Review of Intermediate Level Force Incidents...

4.2 The involved security officer submits a written report by the end of the shift. The report includes:

4.2.7. Any injury sustained or complained of by the individual;

4.2.8. Information regarding a medical assessment or evaluation; including whether the individual refused...

4.3. The Security Director/Manager reviews the report in a timely manner and notifies the Local Team. The Local Team convenes as soon as practicable following the incident to assist in the investigation and determine appropriate action.

4.4. The Local Team makes a determination on whether the security officer used appropriate force.

4.5. While most reviews can be conducted by the Local Team, it may escalate the incident to the Post-Incident Review Team for direction and guidance as needed.

4.6. The incident should be escalated to the Post-Incident Review Team when media may be involved, if there is any evidence or concerns of excessive use of force..."

The Post-Incident Review Team did not review the incident until 1/16/2024. The review did not include interviews with all hospital staff that were involved in the incident.