HospitalInspections.org

Based on policy review, medical record review, video surveillance review, document review, and interview, the facility failed to protect and promote the rights of all patients related to care in a safe setting, for 6 of 30 medical records reviewed (Patient #1, Patient #16, Patient #17, Patient #18, Patient #19, and Patient #21).
1. Staff do not screen all patients for depression and/or suicidal ideation during the initiation of care to identify the need for safety interventions.
2. Facility protocols do not identify who the "supervisor" or "the person in charge," is during a lockdown. Staff were not properly notified of the lockdown, and the situation that caused the lockdown was not properly relayed to security.


Reference:
482.13(c)(2): The patient has the right to receive care in a safe setting.

Based on policy review, medical record review, video surveillance review, document review, and interview, the facility failed to protect and promote the rights of all patients related to care in a safe setting, for 6 of 30 medical records reviewed (Patient #1, Patient #16, Patient #17, Patient #18, Patient #19, and Patient #21).
1. Staff do not screen all patients for depression and/or suicidal ideation during the initiation of care to identify the need for safety interventions.
2. Facility protocols do not identify who the "supervisor" or "the person in charge," is during a lockdown. Staff were not properly notified of the lockdown, and the situation that caused the lockdown was not properly relayed to security.

Findings for #1 include:

Review of the policy "Emergency Department Standards of Care, " dated 04/03/24, revealed during triage assessment, patients are assessed for the following by the registered nurse and documented in the record: chief complaint and history of presenting complaint, pain assessment, vital signs including, initial vital signs are taken on all patients on admission including temperature, pulse, blood pressure, respiratory rate, stroke neuro checks as appropriate, skin integrity, presence of wounds , pressure ulcers, allergies, last menstrual period for all females between 10 and 60 years of age, height and weight, pertinent past medical history, physical assessment as appropriate for the complaint, status of advance directives, medication history, immunization history, risk of harm to self or others, fall risk assessment, and travel history.

Review of the policy "Depression Screening and Suicide Precautions," dated 07/17/24, revealed a policy to identify in-patients, observation patients, and Emergency Department patients using the PHQ9 tool at risk for depression and or suspected to be suicidal. The tool starts with "over the last two (2) weeks, how often have you been bothered by any of the following problems?" Questions include interests in doing things, feeling down, feeling tired/no energy, poor appetite/overeating, feeling bad about self/failure/let people down, trouble concentration, moving/speaking slow or feel restless, thoughts of hurting self/better off dead. Patients answer the questions with a numerical value and are totaled. Based on the assessment, the following interventions maybe implemented: a score below 5: No action required; a score of 5-9: Mild, notify the attending provider; a score of 10-14: Moderate, notify the attending provider, consider therapeutic treatment, refer to pharmacy for psychiatric pharmacy recommendations, and consider referral to social work; and a score of 15 and above: Severe, notify attending provider immediately, consider therapeutic treatment, refer to pharmacy for psychiatric pharmacy recommendations, refer to social work, and a psychiatry consult. If the patient scores one or greater on question number nine "thoughts that you would be better off dead, or of hurting yourself, " they will be considered at risk for suicide. Suicide precautions should be implemented for these patients. Patients scoring 5 or greater should receive information on available services.

Review of the staff education " Triage Training, " slides from the electronic education platform revealed triage documentation should include the chief complaint, pain assessment, vital signs, wounds, allergies, height weight, pertinent past medical history, advanced directives, medication history, risk of harm to self or others, fall risk assessment, offer HIV testing, last menstrual period for females aged 10 to sixty, visual acuity as needed, communication needs, travel history, and screening for systemic inflammatory response syndrome (SIRS). (The training does not include that a PHQ9/depression/suicide assessment is to be completed at triage.)

Review of Emergency Department medical record and video surveillance for Patient #1 revealed on 03/09/25 at 07:54 PM, Patient #1 presented to the Emergency Department for the complaint of rectal bleeding. At 08:03 PM, triage was initiated and vital signs, a medical history, and a neurological assessment were obtained. Patient #1 and spouse were sent back to the Emergency Department waiting room. At 10:41 PM, Patient #1 was moved to the main Emergency Department room #22 with their spouse. Vital signs were taken, an IV (intravenous line- a small, flexible tube inserted into a vein) was inserted, and blood/urine samples were collected for testing. According to Staff (Q), Registered Nurse, Patient #1 did not express any suicidal ideation. The spouse did not relay that Patient #1 had a gun or had thoughts of suicidal ideation. At approximately 11:38 PM, Patient #1's spouse came out of room #22 and appeared to be yelling. Multiple staff ran into the room and noted smoke coming from Patient #1's chest. Upon examination, Patient #1 was noted to have a gunshot wound to the right anterior chest. Staff (H) asked Patient #1 if they shot themself, Patient #1 nodded "yes." (No evidence was found to indicate the PHQ9 depression/suicide screening assessment was conducted prior to the shooting).

Onsite observations, interviews with staff, and review of facility documents revealed that immediately following the 03/09/25 event, the facility had implemented the following corrective actions prior to the survey:
-On 03/09/25, the emergency department was placed in "lock down," which restricted all movement both inside and outside of the facility including the main lobby of the hospital.
-On 03/09/25 at 01:00 AM, the administrative team responded, met with staff to debrief, offered Employee Assistance Program (EAP) services, and Pastoral Care services. Staff met as a team to determine next steps, posted no weapons signage in the building, review access to building and Emergency Department, requested additional armed security for the Emergency Department, and review the current security guard post duties.
-On 03/10/25, the facility implemented one entry to the emergency department where are staff, patients, and visitors are stopped and all property checked for contraband including weapons. Signage was placed conspicuously throughout the Emergency Department, ambulance entry, and main lobby entry for notification weapons are not allowed in the hospital. All persons will be told that weapons of any kind are prohibited from entry. Any weapons declared or found on search will be either removed from the premises or secured in a safe location until the individual leaves the facility. Any patient or visitor brought in by ambulance will have belongings searched upon entry. All patients and visitors will be directed to the main entrance of the Emergency Department at the front of the facility. Family or visitors that accompanies Emergency Medical Services will be escorted to the front door for a bag search. Anyone exiting the emergency department will have to re-enter through the main door of the emergency department. All persons leaving and re-entering the facility will be searched each time they return.
-A communication system for staff to opt into receiving emergency communications was implemented by the hospital and instructions sent to staff to receive alerts via email, text message or pager.

Review of additional Emergency Department medical records revealed the PHQ9 depression/suicide screening assessment is not being conducted at the initiation of care for the following patients: Patient #16 (admission date of 03/10/25 for alcohol intoxication), Patient #17 (admission date of 03/05/25 for abdominal pain), Patient #18 (admission date of 03/09/25 for abdominal pain), Patient #19 (admission date of 03/10/25 for abdominal pain), and Patient #21(admission date of 03/05/25 for abdominal pain). The patients did not have a PHQ9 assessment completed at triage but instead the assessment was completed after being brought back to the main Emergency Department.

Interview on 03/17/25 at 11:34 AM with Staff (I), Registered Nurse, revealed the triage assessment in the electronic medical record includes chief complaint, initial vital signs, a triage note and acuity assignment. The PHQ9 assessment is used for depression/suicide screening and is typically completed at triage, however, is not part of the triage assessment. The assessment is auto populated in the electronic medical record to be completed while the patient is in the Emergency Department. Staff (I) triaged Patient #1. Staff (I) stated there were no indicators for self-harm. Patient #1 was irritable, but they did not seem suicidal or make any statements that they wanted to harm themselves. Patient #1's spouse was present during triage. Patient #1's vital signs were stable, they had an acuity of 3H (horizontal/urgent, a patient that is more likely to be admitted, may need imaging, has abdominal pain), and Patient #1 was placed back in the waiting room until a bed in back was open. While in the waiting room, Patient #1 appeared frustration, but did not have an outburst or caused any disruptions.

Interview on 03/18/25 at 11:00 AM with Staff (GG), Registered Nurse, and at 11:26 AM with Staff (BB), Registered Nurse, Staff (Z), Registered Nurse and Staff (AA), Registered Nurse, revealed during triage, the patient is asked the same questions which include asking the PHQ9 assessment.

Telephone interview on 03/18/25 at 04:27 PM with Staff (Q), Registered Nurse, revealed when a patient is triaged, all patients receive the same questions. Some questions are skipped due to time constraints, and the PHQ9 is completed during triage.

Telephone interview on 03/19/25 at 11:12 AM with Staff (R), Registered Nurse, revealed the PHQ9 assessment can be completed during triage or in the rear emergency department. Many times, the triage area is not private enough to complete these questions.

Interview on 03/19/25 at 05:00 PM and on 03/20/25 at 05:30 PM with Staff (C), Vice President of Operations, Staff (D), Director of Quality/Patient Safety, and Staff (E), Vice President of Patient Care Services, confirmed these findings.

Findings for #2 include:

Review of the policy "Lockdown Policy," dated 08/17/23, revealed an Emergency Department lockdown is used to regulate entry to/exit from the emergency room only. Any individual observing or becoming aware of a threat to safety or security are authorized to initiate a lockdown. Call 911 and provide as much detail as possible. Call the switchboard and report, if applicable to your location. The switchboard will notify security and the nursing supervisor. The determination to authorize the continuation of a lockdown will be at the discretion of the person in charge. A change in the type of lockdown (higher level or reduced level) may be authorized by the person in charge or at the direction of law enforcement, based on the changing needs of the situation. At the direction of the person in charge, the switchboard will initiate mass notification with the type and location of the threat. At all control points during a lockdown, individuals may be screened, depending on the circumstances of the situation. For the duration of the lockdown, security will facilitate the movement of ambulatory and Emergency Medical Services (EMS) patients that present during lockdown. The person in charge will make the decision to terminate or discontinue a lockdown. If law enforcement assistance is on site, the person in charge will make the decision to terminate or discontinue the lockdown when recommended to do so by the law enforcement agency. At applicable locations, the person in charge will communicate the "All Clear" notification to the switchboard who will announce via overhead paging that the lockdown is "All Clear" three times. Switchboard will initiate mass notification that the lockdown is "All Clear".

Review of the policy "Weapons Control Policy, " dated 08/17/23, revealed local law enforcement will be contacted immediately if any individual outwardly displays or otherwise exhibits a weapon in a threatening or hostile manner. Associates identifying an individual possessing a weapon in a nonthreatening or hostile manner will contact security or the person in charge, depending on location. Security or the person in charge will respond to the department/location and determine are they verified law enforcement, if no, contact local law enforcement. If the individual refuses to cooperate and/or is unable to cooperate due to a medical or other condition, local law enforcement will be called. Documentation of the incident will be entered in the Security Daily Activity Log.

Review of policy "Active Shooter Response," dated 10/31/24, revealed the facility will send a mass communication notification to activate the System Healthcare Command Center (HCC) and initiate the facility CEMP (comprehensive emergency management plan). The HCC team will direct and coordinate communication and response activities within the campus and in conjunction with external agencies and organizations. Upon recognizing an active shooter situation at the facility, immediately call 911 in an area that is safe to do so and communicate your location and any additional details related to the incident. If applicable, notify the switchboard and/or by direct overhead page. For an active shooter in the immediate work area: Run, if you see a weapon or hear shots fired in your area. Alerts will be sent to mass communication users when an active shooter has been identified at any facility campus. Notification messages will also be delivered via overhead announcement in applicable locations. Mass communication messages will be sent for the duration of the event to provide continued information and instructions to associates, as directed by the Hospital Command Center (HCC) in coordination with the guidance and instructions of law enforcement. When law enforcement arrives to the area, they will direct and coordinate all actions. Law enforcement will communicate campus actions with the facility.

Review of the "Lockdown," training video revealed a total lockdown includes that all perimeter access is secured, and no entrance or exit is permitted. A partial lockdown includes restriction to select exits, entrances, or specific departments and parts of the building. A lockdown can be initiated by "anyone" to begin the investigation, to continue the lockdown, escalate it or clear it. May times this is initiated by calling the switchboard.

Review of the document "Catholic Health Security Incident Report," dated 03/10/25 at 12:00 AM, revealed a self-inflicted shooting with injuries incident occurred in room #22. Staff (PP), Security Officer, documented they were notified of a gunshot victim. Staff (PP) radioed to lockdown the hospital. Another security associate locked down all doors and placed a security guard at each door. Staff (PP) proceeded to the ambulance bay to wait for the victim. A few minutes later a call came over the radio for a security officer to go to room #22 in the Emergency Department. Staff (PP) was called to room #22. Upon arrival to room 22, it was relayed to Staff (PP) that Patient #1 shot themselves. The local police department arrived around the time that Staff (PP) did. Security was in room #22. The local police department took control of the scene and secured the weapon. No call was made over the switchboard intercom. The call was made after the fact. No one notified security that the shooting took place in the room until after the fact. Patient #1 was transported to another faciality for care. Staff (QQ), Security Officer, documented that at 12:00 AM, a call came over the radio to lockdown the Emergency Department, there was a gunshot victim in room #22. After about 40 minutes, Patient #1 was taken via ambulance to another facility and the lockdown was over.

Interview on 03/17/25 at 11:34 AM with Staff (I), Registered Nurse, revealed they were in the triage area when the incident happened. Staff (I) verbally heard about the incident from Staff (O), Immediate Treatment Assistant, who told them the Emergency Department was on lockdown. There was confusion among staff whether the sound heard was a gun or not.

Interview on 03/17/25 with Staff (O), Immediate Treatment Assistant, revealed they were assigned to the Emergency Department waiting room on 03/09/25. Staff (O) was made aware of the incident when another aide came from the back and told Staff (O) that there was a shooting victim, and the hospital needed to go on lockdown. They were never told the shooting happened in the Emergency Department

Interview on 03/18/25 at 11:00 AM with Staff (GG), Registered Nurse, and at 11:26 AM with Staff (BB), Registered Nurse, Staff (Z), Registered Nurse and Staff (AA), Registered Nurse, revealed in the emergency department when the lockdown occurs, the notification is word of mouth from other staff members, and there is no overhead announcement made. They have heard common codes announced overhead such as a cardiac arrest, code pink, and rapid response, but never a "lockdown" code.

Interview on 03/18/25 at 11:52 AM with Staff (DD), Switchboard Operator, Staff (EE), Switchboard Operator, and Staff (FF) Switchboard Operator, revealed in the event of an active shooter, they would call the Police Department, and they may receive a call from staff or security who called the switchboard for emergencies only. In the event of a lockdown, the emergency room staff will typically tell them if there's a lockdown. They would send out a mass communication alert, call the supervisor, and call security if needed.

Telephone interview on 03/19/25 at 01:28 PM with Staff (P), Registered Nurse, revealed they were the Emergency Department Charge Nurse on 03/09/25. When Staff (P) got to room #22, there were three other registered nurses in the room attending to Patient #1. Patient #1's spouse was screaming. Staff were unsure exactly what happened. At 11:51 PM, Staff (P) left the room and called local law enforcement and instructed another nurse to call security to lock down the hospital. Local law enforcement showed up prior to security showing up. Staff (P) does not recall discussing the lockdown reason with security or security asking why they were locked down. Staff (HH), Registered Nurse Supervisor, was on the unit when the incident occurred and was on the scene immediately. Patient #1 was stabilized and transported to another facility. Local law enforcement left with the gun and spouse. The lockdown was cleared by a security officer before discussing with the supervision. Staff (P) stated it was their understanding that the house supervisor clears any lockdowns.

Telephone interview on 03/18/25 at 02:30 PM with Staff (W), Physician, revealed the incident occurred at the end of their shift on 03/09/25. Staff (W) was unaware if the facility was in a lockdown and is unsure how it is announced. In the past a lockdown is verbal communication among staff and not announced overhead.

Interview on 03/19/25 at 10:25 AM with Staff (HH), Registered Nurse Supervisor, revealed they passed Patient #1's room and heard a "firecracker" sound. Staff (HH) turned around, look back into Patient #1' s room, saw smoke coming from Patient #1' s right chest, and their right arm in a downward position, while the spouse was screaming. A lot of staff responded to attend to Patient #1. Staff (HH) stayed out of the room. Staff (HH) spoke with Staff (P), Registered Nurse, who was in charge, and they collaboratively agreed a lockdown would be called in the Emergency Department and local law enforcement would be called. Staff (P), Registered Nurse, called local law enforcement and security. Staff (P), Registered Nurse, told security that they " need to lockdown the hospital, that there was a gunshot victim. " There was confusion from security, that they thought a gunshot victim was coming to the Emergency Department and went to lock the ambulance entrance. Once security was informed the shooting happened in the Emergency Department, the lead security guard reported to room #22 and stayed there until local law enforcement arrived. Law enforcement arrived quickly and took custody of the gun. Staff (HH) called administration to advise them on the situation. There was no text notification about the lockdown and there was not an overhead announcement about the lockdown. Security guards were walking around letting staff know the hospital was on lockdown. Patient #1 was stabilized and transferred to another facility. The lockdown was cleared by the lead security guard when local law enforcement told security that the scene was "all clear," and Patient #1 left the facility. Staff (HH) and Staff (P), Registered Nurse, were surprised that security cleared the lockdown. Staff (HH) stated it was their understanding that the one in charge is the one to clear the lockdown.

Interview on 03/I9/25 at 12:14 PM with Staff (II), Security Guard Supervisor, revealed when a lockdown is in place in the Emergency Department, one guard is in the hallway of the main lobby of the Emergency Department, two guards at the Emergency Department entrance, and one at the ambulance entrance. The ambulance entrance access code is automatically disabled, and ambulance drivers are required to call security to be buzzed in during a lockdown. Security guards cannot end a lockdown, only initiate it. Law enforcement can end a lockdown with an "all clear.

Interview on 03/19/25 at 05:00 PM and on 03/20/25 at 05:30 PM with Staff (C), Vice President of Operations, Staff (D), Director of Quality/Patient Safety, and Staff (E), Vice President of Patient Care Services, confirmed these findings.