HospitalInspections.org

Based on observation, document review, policy review, record review, and interview, the Hospital failed to meet the Patient Rights Condition of Participation by failing to ensure all patients received care in a safe setting and failed to protect patients from all forms of abuse. The cumulative effect of these deficient practices places all patients, staff, and visitors at risk for physical and emotional abuse, harm and/or injury.


Findings Include:

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

2. The Hospital failed to ensure patients were free from all forms of abuse. (Refer to tag A-0145).

Based on observation, document review, policy review, record review, and interview, the Hospital failed to ensure all patients received care in a safe setting. Failure to provide care in a safe setting and failure to ensure the safety of all patients, staff, and visitors place all who are in the hospital at risk for harm and adverse outcomes.

Findings Include:

Review of a hospital document titled, "Patient's Rights and Responsibilities," undated showed, " ...4. Environment. You have the right to receive care in a safe setting ..."

Review of a hospital policy titled, "Administration Policy and Procedure" issued 01/01/23, showed, "To provide a mechanism for the Hospital staff to comply with the Hospital's zero tolerance policy on abuse, neglect and harassment, and requiring citizens and professionals to report suspected cases of child or dependent adult abuse neglect and/or harassment ...3. Identification: A proactive approach is maintained by the hospital to identify occasions of potential abuse or neglect. This includes patient rounds by the leadership team, review of patient surveys, and review of all significant patient complaints ...iv. Security will: a. Consult with Department Manager about additional security needs ...The hospital shall establish a post-incident response system that provides, at a minimum, an in-house crisis response team for employee victims and witnesses via individual and/or group crisis counseling. This may include support groups, family crisis intervention, and professional referrals ..."

Review of a hospital policy titled, "Visitation, Patients," revised 07/01/17 showed, " ...2. Visitation is encouraged between the hours of 8 AM and 8 PM, but allowances will be made for patients and visitors outside of these hours ..."


During a tour of the above-named hospital on 06/21/23 at 8:45 AM, showed the hospital had the following unsecured unlocked entrances that would allow anyone access to the hospital without detection:

1. Seven unlocked staircases entering the above-named hospital coming from Hospital B;
2. Three unlocked entrances off of the "C" elevator;
3. Two unlocked entrances off of "6" elevator (near mechanical room);
4. Two unlocked entrances off of "D" elevator;
5. And one unlocked entrance off of an "unmarked" elevator (near room 6088).

Review of a hospital document titled; "Census" dated 06/14/23 showed 35 patients were patients of the above-named Hospital.

Review of the hospital's document titled, "Incident Report Log," dated 01/01/23 through 06/21/23 showed the following:

06/15/23 at 1:45 AM, [Patient 1], Workplace Injury, Level 1- No Injury

During an interview on 06/22/23 at 12:52 PM Staff N, Certified Nurse Aide (CNA), stated, " ...I was doing hourly rounding her [Patient 1] door stays open on its own, there was a man in room he told me he was family member, the lights were off in room. I told him I was going to readjust her in bed, and he said I can help. I shut the door with a trash can, it was my first time having her as a patient and never had seen him before. He helped me help her up in the bed, then he walked and stood behind me. He felt really close and felt uncomfortable and [he] asked how to turn off the bed alarm. I told him I didn't know how to turn off the bed alarm. I made sure her gown was pulled down and that the blanket was up covering her body. I gave her the light I showed him how to turn off and on lights. She couldn't talk because she had a tracheostomy [tube placed in the neck to help a person breath] and when I asked her if she was ok she just looked at me. He asked me to shut door and I told him that her door wouldn't shut. I went to go look for the patient's nurse. It was one to three minutes later I started to hear the screaming ..."

Patient 1

Review of Patient 1's inpatient medical record showed Patient 1 was admitted on 06/12/23 with a diagnosis of Acute hypercapnic Respiratory Failure (AHRF - not enough oxygen in the blood) and Traumatic Brain Injury (TBI - injury of the brain).

Review of Patient 1's "Nurses Notes" dated 06/14/23 at 8:10 PM, showed Staff L, RN documented, "Assessment completed. VSS (Vital Signs Stable), afebrile. Trach (tracheostomy). Tracks, but doesn't follow commands. PIV (peripheral intravenous). Purewick (external female urinary catheter) in place. HOB (Head of Bed) elevated. Peg tube (Percutaneous endoscopic gastrostomy-tube place through the stomach for feeding) feeds per order. Oral care provided. Patient repositioned."

Review of a document in Patient 1's medical record, dated 06/14/23 titled, "24 Hour Patient Record and Plan of Care," showed, " ...Restraint Type bilateral soft wrist ..."

Further review of Patient 1's "Nurses Notes" failed to show documentation of the incident that occurred on 06/15/23 at 1:45 AM, when an intruder was found in her room.

Review of an "ED [emergency department] Note-Nursing" dated 06/15/23 at 12:23 PM, showed, "Forensic Nursing Services consulted with patient and her husband. Forensic exam completed" ...

Review of a "Progress Note-Generic" dated 06/15/23 at 2:23 PM by Staff AA, Advance Practice Registered Nurse (APRN), showed ..." Unfortunately, overnight she was found with a stranger in her room. There is concern of sexual assault. Perpetrator was removed from the room and attained by security SANE/SART exam and forensics was collected afterward."...

Review of a "Medical Director Note" in Patient 1's medical record, dated 06/15/23 at 8:41 PM, by Staff Z, Medical Director, showed, "Called by charge nurse and CEO regarding a possible sexual assault this AM. Came to the hospital immediately for assessment and coordination with SANE/SART nursing, security and administration. Discussed with patient's husband regarding our plan. He agrees with current assessment plans and evaluations. He states that he feels safe continuing care here since the perpetrator has been apprehended. Will continue to monitor and will be available anytime for continued support ..."

Patient 1's medical record failed to show a documented head to toe assessment by the provider following the incident on 06/15/23 at approximately 1:45 AM.

During an interview on 06/22/23 at 7:48 AM Staff H, RN, House Supervisor, stated that Patient 1 was nonverbal with a trach and it was her 2nd or 3rd day in the hospital. She could not do a thumbs up or wiggle toes. Staff H stated that Security was walking on unit and asked if I had seen a Hispanic male and that they did not let her know why security was looking for him, a nurse said that they had seen him in Patient 1's room. She stated that the door was shut when they entered Patient 1's room. She stated, "The suspect was sitting on the bed with patient by her knees, facing her when we opened door, he was doing hand shuffling and looked very surprised and was trying to pull up his gym shorts." She stated that Staff O, Security Guard stated, "I have been looking for you for 30 minutes stand up." Staff H stated that she has only seen security round 3 times in the 3 years she's been here and that they always tell her they are short staffed, and usually only have 2 security guards on at night. Staff H stated, "I wish there would have been notification of a suspicious person in the facility either overhead or via phone to alert staff ..."

During an interview on 06/22/23 at 12:36 PM, Staff Z, Medical Director stated that he was notified of the possible sexual assault incident and that he came in about 3:30 AM on 06/15/23 to performed an exam on the patient. Staff Z stated, "Per the records the patient seemed to be baseline..."

During an interview on 06/22/23 at 1:26 PM with Staff O, Security Guard stated," ...we split up and I went down the stairwell to the 6th floor. I saw an open patient room and didn't see anything and then stopped one of nurses and asked them if they had seen the picture of the guy on my phone. They told me he was in room 6107. The door was shut, me and the nurse walked in, and he was on the bed he fit the description perfectly. I knew it was him. He pulled the patients gown down and I told him to get away from the patient. I took him to the doorway to hand cuff him, when I tried to call on the radio and he started fighting me, throwing and punching by the bed of the female patient, I was trying to get away from patient he threw more punches he was strong and dragging me out the door"... Staff O stated that on 1st shift [Hospital B] has three to four security guards on staff with one in main lobby from 5:00 AM to 8:00 PM and one security guard in Emergency Department, and one guard does mobile patrol of [Hospital B] and buildings. He stated that it takes at least one hour to check to see if all the doors are locked, if one is open it, we have to search inside building. On 3rd shift the hospital has two to three guards depending on staff availability with one guard being posted in [Hospital B] emergency department and one guard on mobile patrol. Security gets calls from staff frequently about homeless begging or sleeping in garage, trying to open car doors, or yelling at visitors.

During an interview on 06/22/23 at 2:01 PM Staff Q, RN stated, " ...I don't know if he came through double doors or up the stairs. He was walking like he knew where he was going I turned to go to the med room then I heard commotion in hallway and then saw the same guy then handcuffed ..."

During an interview on 06/22/23 at 2:05 PM with Staff P, Security Guard stated that on 06/15/23 at approximately 12:15 AM it was noted via camera footage an unidentified male was seen entering the [Hospital B] behind an employee. At approximately 1:20 AM dispatch received a call for a possible sexual assault from another floor in Hospital B, while taking the report another call came into dispatch at approximately 1:47 AM of a suspicious male subject in the above-named Hospital. Staff O, Security Guard went to another floor via stairs to look for suspicious male, upon entering the 6th floor of the above-named hospital which is co-located within the acute care Hospital B, Staff O was able to identify and attempt to apprehend the male subject while he was in Patient 1's Room. While Staff O was attempting to apprehend the subject, an altercation occurred between the subject and Staff O that went from Patient 1's room to the hallway and then into Patient 3's room within the above-named Hospital. Staff P helped Staff O detain the male subject. Staff P went on to state, " ...We didn't make an overhead page because we weren't for sure what we were dealing with at the time ..."

Patient 3
Review of Patient 3's inpatient medical record showed Patient 3 was admitted on 06/14/23 with acute pancreatitis (a condition where the pancreas becomes inflamed or swollen over a short period of time) with necrosis (death to most or all of the cells in an organ or tissue).

Review of Patient 3 medical record on 06/15/23 "Progress Note-Generic" showed " ...Slept okay last night, though had an incident in hallway limiting sleep ..."

During an interview on 06/22/23 at 10:35 AM Patient 3 stated, " ...Then there was huge commotion like punching and brawl that spilled out into the hallway. It landed in my room close to the foot of bed by the wheelchair the bad guy was holding his own he had like superhuman strength like he was on something, it took three grown men to subdue him. There was a nurse that was protecting me at foot of bed in case he tried to go near me because I could not move my legs only my arms .... Patient 3 went on to state, "At least three for sure maybe four times when my family has come to visit hospital, there have been crazy people outside the hospital [Hospital B] yelling and screaming at themselves and at my family, during the daytime at 10:00 AM. Once they walked the crazy guy off property what's that going to do, he can walk right back on property. I have not seen security walking around when I am up walking with therapy ..."

During an interview on 06/26/23 at 9:40 AM, Staff Y, Director of Security for Hospital B, stated " ...I had everything locked down the next morning ...I do I wish they would have called out a critical communication but there was delay and I got a call two hours later after incident ...with three security staff with this massive facility doesn't cut it ...I locked everything down the next morning, with only access through Emergency Department, 2nd floor garage, and main entrance during business hours ...We currently do not have a policy regarding suspicious persons within the hospital ..."

Based on observation, policy review, document review, record review and interview, the Hospital failed to ensure patients were free from all forms of abuse for 2 (Patient 1 and 3) of 35 patients in the hospital on 06/15/23. This deficient practice places all patients at risk for physical and emotional abuse, harm and injury.

Findings Include:

Review of a hospital document titled, "Patient's Rights and Responsibilities," undated showed, " ...4. Environment. You have the right to receive care in a safe setting ..."

Review of a hospital policy titled, "Administration Policy and Procedure" issued 01/01/23, showed, "To provide a mechanism for the Hospital staff to comply with the Hospital's zero tolerance policy on abuse, neglect and harassment, and requiring citizens and professionals to report suspected cases of child or dependent adult abuse neglect and/or harassment ...3. Identification: A proactive approach is maintained by the hospital to identify occasions of potential abuse or neglect. This includes patient rounds by the leadership team, review of patient surveys, and review of all significant patient complaints ...iv. Security will: a. Consult with Department Manager about additional security needs ...The hospital shall establish a post-incident response system that provides, at a minimum, an in-house crisis response team for employee victims and witnesses via individual and/or group crisis counseling. This may include support groups, family crisis intervention, and professional referrals ..."


Review of a hospital policy titled, "Visitation, Patients," revised 07/01/17 showed, " ...2. Visitation is encouraged between the hours of 8:00 AM and 8:00 PM, but allowances will be made for patients and visitors outside of these hours ..."

During a tour of the above-named hospital on 06/21/23 at 8:45 AM, showed the hospital had the following unsecured unlocked entrances that would allow anyone access to the hospital without detection:

1. Seven unlocked staircases entering the above-named hospital coming from Hospital B;
2. Three unlocked entrances off of the "C" elevator;
3. Two unlocked entrances off of "6" elevator (near mechanical room);
4. Two unlocked entrances off of "D" elevator;
5. And one unlocked entrance off of an "unmarked" elevator (near room 6088).

Review of a hospital document titled; "Census" dated 06/14/23 showed 35 patients were patients of the above-named Hospital.

Review of the Hospital's document titled, "Incident Report Log," dated 01/01/23 through 06/21/23 showed the following logged information:

06/15/23 at 1:45 AM [Patient 1], Workplace Injury, Level 1- No Injury

Patient 1

Review of Patient 1's inpatient medical record showed Patient 1 was admitted on 06/12/23 with a diagnosis of Acute hypercapnic Respiratory Failure (AHRF - not enough oxygen in the blood) and Traumatic Brain Injury (TBI - injury of the brain).

Review of Patient 1's "Nurses Notes" dated 06/14/23 at 8:10 PM, showed Staff L, RN documented, "Assessment completed. VSS (Vital Signs Stable), afebrile. Trach (tracheostomy). Tracks, but doesn't follow commands. PIV (peripheral intravenous). Purewick (external female urinary catheter) in place. HOB (Head of Bed) elevated. Peg tube (Percutaneous endoscopic gastrostomy-tube place through the stomach for feeding) feeds per order. Oral care provided. Patient repositioned."

Review of a document in Patient 1's medical record, dated 06/14/23 titled, "24 Hour Patient Record and Plan of Care," showed, " ...Restraint Type bilateral soft wrist ..."

Further review of Patient 1's "Nurses Notes" failed to show documentation of the incident that occurred on 06/15/23 at 1:45 AM, when an intruder was found in her room.

Review of an "ED [emergency department] Note-Nursing" dated 06/15/23 at 12:23 PM, showed, "Forensic Nursing Services consulted with patient and her husband. Forensic exam completed" ...

Review of a "Progress Note-Generic" dated 06/15/23 at 2:23 PM by Staff AA, Advance Practice Registered Nurse (APRN), showed ..." Unfortunately, overnight she was found with a stranger in her room. There is concern of sexual assault. Perpetrator was removed from the room and attained by security SANE/SART exam and forensics was collected afterward."...

Review of a "Medical Director Note" in Patient 1's medical record, dated 06/15/23 at 8:41 PM, by Staff Z, Medical Director, showed, "Called by charge nurse and CEO regarding a possible sexual assault this AM. Came to the hospital immediately for assessment and coordination with SANE/SART nursing, security and administration. Discussed with patient's husband regarding our plan. He agrees with current assessment plans and evaluations. He states that he feels safe continuing care here since the perpetrator has been apprehended. Will continue to monitor and will be available anytime for continued support ..."

Patient 1's medical record failed to show a documented head to toe assessment by the provider following the incident on 06/15/23 at approximately 1:45 AM.

During an interview on 06/22/23 at 7:48 AM Staff H, RN, House Supervisor, stated that Patient 1 was nonverbal with a trach and it was her 2nd or 3rd day in the hospital. She could not do a thumbs up or wiggle toes. Staff H stated that Security was walking on unit and asked if I had seen a Hispanic male and that they did not let her know why security was looking for him, a nurse said that they had seen him in Patient 1's room. She stated that the door was shut when they entered Patient 1's room. She stated, "The suspect was sitting on the bed with patient by her knees, facing her when we opened door, he was doing hand shuffling and looked very surprised and was trying to pull up his gym shorts." She stated that Staff O, Security Guard stated, "I have been looking for you for 30 minutes stand up." Staff H stated that she has only seen security round 3 times in the 3 years she's been here and that they always tell her they are short staffed, and usually only have 2 security guards on at night. Staff H stated, "I wish there would have been notification of a suspicious person in the facility either overhead or via phone to alert staff ..."

During an interview on 06/22/23 at 12:36 PM, Staff Z, Medical Director stated that he was notified of the possible sexual assault incident and that he came in about 3:30 AM on 06/15/23 to performed an exam on the patient. Staff Z stated, "Per the records the patient seemed to be baseline..."

During an interview on 06/22/23 at 1:26 PM with Staff O, Security Guard stated," ...we split up and I went down the stairwell to the 6th floor. I saw an open patient room and didn't see anything and then stopped one of nurses and asked them if they had seen the picture of the guy on my phone. They told me he was in room 6107. The door was shut, me and the nurse walked in, and he was on the bed he fit the description perfectly. I knew it was him. He pulled the patients gown down and I told him to get away from the patient. I took him to the doorway to hand cuff him, when I tried to call on the radio and he started fighting me, throwing and punching by the bed of the female patient, I was trying to get away from patient he threw more punches he was strong and dragging me out the door"... Staff O stated that on 1st shift [Hospital B] has three to four security guards on staff with one in main lobby from 5:00 AM to 8:00 PM and one security guard in Emergency Department, and one guard does mobile patrol of [Hospital B] and buildings. He stated that it takes at least one hour to check to see if all the doors are locked, if one is open it, we have to search inside building. On 3rd shift the hospital has two to three guards depending on staff availability with one guard being posted in [Hospital B] emergency department and one guard on mobile patrol. Security gets calls from staff frequently about homeless begging or sleeping in garage, trying to open car doors, or yelling at visitors.

During an interview on 06/22/23 at 2:01 PM Staff Q, RN stated, " ...I don't know if he came through double doors or up the stairs. He was walking like he knew where he was going, I turned to go to the med room then I heard commotion in hallway and then saw the same guy then handcuffed ..."

During an interview on 06/22/23 at 2:05 PM with Staff P, Security Guard stated that on 06/15/23 at approximately 12:15 AM it was noted via camera footage an unidentified male was seen entering the [Hospital B] behind an employee. At approximately 1:20 AM dispatch received a call for a possible sexual assault from another floor in Hospital B, while taking the report another call came into dispatch at approximately 1:47 AM of a suspicious male subject in the above-named Hospital. Staff O, Security Guard went to another floor via stairs to look for suspicious male, upon entering the 6th floor of the above-named hospital which is co-located within the acute care Hospital B, Staff O was able to identify and attempt to apprehend the male subject while he was in Patient 1's Room. While Staff O was attempting to apprehend the subject, an altercation occurred between the subject and Staff O that went from Patient 1's room to the hallway and then into Patient 3's room within the above-named Hospital. Staff P helped Staff O detain the male subject. Staff P went on to state, " ...We didn't make an overhead page because we weren't for sure what we were dealing with at the time ..."

Patient 3

Review of Patient 3's inpatient medical record showed Patient 3 was admitted on 06/14/23 with acute pancreatitis (a condition where the pancreas becomes inflamed or swollen over a short period of time) with necrosis (death to most or all of the cells in an organ or tissue).

Review of Patient 3 medical record on 06/15/23 "Progress Note-Generic" showed " ...Slept okay last night, though had an incident in hallway limiting sleep ..."

During an interview on 06/22/23 at 10:35 AM Patient 3 stated, " ...Then there was huge commotion like punching and brawl that spilled out into the hallway. It landed in my room close to the foot of bed by the wheelchair the bad guy was holding his own he had like superhuman strength like he was on something, it took three grown men to subdue him. There was a nurse that was protecting me at foot of bed in case he tried to go near me because I could not move my legs only my arms .... Patient 3 went on to state, "At least three for sure maybe four times when my family has come to visit hospital, there have been crazy people outside the hospital [Hospital B] yelling and screaming at themselves and at my family, during the daytime at 10:00 AM. Once they walked the crazy guy off property what's that going to do, he can walk right back on property. I have not seen security walking around when I am up walking with therapy ..."

During an interview on 06/26/23 at 9:40 AM, Staff Y, Director of Security for Hospital B, stated " ...I had everything locked down the next morning ...I do I wish they would have called out a critical communication but there was delay and I got a call two hours later after incident ...with three security staff with this massive facility doesn't cut it ...I locked everything down the next morning, with only access through Emergency Department, 2nd floor garage, and main entrance during business hours ...We currently do not have a policy regarding suspicious persons within the hospital ..."