HospitalInspections.org

Based on interview and document review the hospital failed to ensure care in a safe setting when a man with a gun entered the hospital but not all staff members were aware of emergency response plans. This had the potential to affect all patients at the hospital.

Findings include:

P1's medical record was reviewed. P1's admission to the hospital occurred on September 11, 2017. During the admission process, P1's initial nursing assessment, dated September 12, 2017 included an assessment of P1's home safety and violence risk. P1 denied any concerns.

During an interview on September 14, 2017 at 12:35 p.m., P1 stated her boyfriend visited her on September 13, 2017 at about 12:15 p.m. At the same time, another visitor was in the room as well. The two visitors became angry at one another and P1's boyfriend pulled a gun from his pants. P1's boyfriend hit her in the face and abdomen. He then ran out of the room and into the hall.

During an interview on September 14, 2017 at 9:40 a.m. Security Director (SD)-E stated the incident occurred on the P1/medical surgical unit. A visitor to room 130 brandished a weapon/gun. The visitor struck P1 on the head and abdomen and then ran out of the room. Staff called 911 and pushed the duress button on the unit immediately. Local law-enforcement as well as hospital security staff responded and security initiated an overhead page alerting all staff and visitors to the threat. Security staff initiated a sweep of the building, ensuring staff and patient safety. Security and law-enforcement staff investigated and viewed hospital video and determined that the gunman left the hospital grounds. At 12:45 p.m. law-enforcement and security staff determined, the situation was resolved at the hospital and called the all clear. SD-E stated staff initiated the Active Threat protocol per policy as far as hospital staff could tell, but not all after-action reviews of the incident were complete yet.

During an interview on September 14 2017 at 10:25 a.m. Registered Nurse (RN)-J stated at about 12:30 p.m. on September 13, 2017 a tall man entered the hall from room 130 and stated a man had a gun. RN-J stated she ran to the desk and initiated the active threat protocol. RN-J stated the man with the gun ran down the hall and off the unit towards the front door while trying to put the gun back in the front of his pants. RN-J stated she and other staff in the area ran to shelter in a safe place. RN-J stated security and law enforcement were there very quickly. RN-J stated P1 told her that the man with the gun hit her, and P1's physician assessed her for injury and her physician noted no permanent injury related to the incident. RN-J stated she was aware of the procedure for an active threat, had participated in drills related to the procedure, and followed that procedure.

During an interview on September 14, 2017 at 11:15 a.m., Physician (MD)-D stated hospital staff has drills on these types of situations on a regular basis. He was in the professional building next door and heard the overhead page. MD-D stated that, as far as he knew, all staff responded to the situation appropriately and according to the established protocol. MD-D stated he assessed P1 after the incident and stated that although the gunman struck P1, she required no medical treatment for any injuries related to the incident.

During an interview on September 14, 2017 at 12:55 p.m. Registered Nurse (RN)-I stated she was at lunch in the conference room when she heard an active threat/code silver page for her unit. She got up, shut the door and pulled a table in front of it. Within a couple of minutes, some other staff came into the room as well. RN-I stated she previously had training on the active threat procedure, knew what to do related to the overhead page, and was familiar with the procedures involved.

During an interview on September 14, 2017 at 12:25 p.m., Nursing Assistant (NA)-M stated she was present on unit P1 on September 13, 2017 when the overhead page "Active Threat" occurred. NA-M stated she was not familiar with what the term "Active Threat" meant, so she did not shelter in place initially. NA-M stated her hospital training included that "Silver Code" meant an active shooter and that she would have known run or hide if that term had been paged, but was not aware of the change in terminology, and therefore she did not respond appropriately. NA-M stated when she left the break room to see what was happening security instructed her to hide, so she did so.

During an interview on September 14, 2017 at 12:15 p.m. Health Unit Coordinator (HUC)-N stated she could not recall any training related to what the term "Active shooter" meant. HUC-N stated she did not know what to do when the overhead page included that term. HUC-N stated she was in the break room when the page occurred and she left the break room with some other staff. She then went into an office with other staff who knew what to do and were barricading the door and removing batteries from their paging devices, so she did the same.

During an interview on September 14, 2017 at 1:10 p.m., Clinical Manager (CM)-V stated the hospital changed the term "Code Sliver" to "Active Threat" at the beginning of the summer, 2017. All staff was educated related to the change and the protocols involved including licensed and unlicensed staff. Additionally the emergency procedures are in a binder located in the medication room on the unit.

The policy/procedure titled Workplace Violence-Active shooter, dated June 2017 indicated it was to be used to alert staff of an active threat (person with any type of weapon) or other form of workplace violence. Call 911 and give the location, number of suspects, type of weapon, any casualties, Direction the suspect is travelling, and physical description of the suspect. Call 21111 to activate the Active Threat procedure. Under Consider: 1. Evacuation, 2. Shelter in place, 3. Take action as a last resort.