HospitalInspections.org

The information reviewed during the unannounced complaint investigation survey on May 16, 2024, provided evidence the facility failed to substantially comply with this Condition of Participation by failing to provide a safe environment for a patient in the Emergency/Trauma Center. Video surveillance showed a security guard initiating physical contact, which resulted in a struggle until the patient was on the ground with the guard on top of the patient, holding patient by the neck/head until the patient was lifted onto a stretcher. A security staff member failed to deescalate a situation with a patient and instead was provacative and used excessive force.
A discussion took place with the survey team and the facility's administrative staff (EMP1), (EMP2), and (EMP5) regarding the survey team's concerns related to Patient's Rights on May 16, 2024, at 3:25 PM.
The Immediate Jeopardy was called at 4:20 PM on May 16, 2024.
The facility submitted an acceptable Immediate Jeopardy Removal Plan at 3:46 PM on May 17, 2024.
The Immediate Jeopardy was removed on-site on May 17, 2024. Condition of Participation non-compliance remains.
The surveyor validated the Immediate Jeopardy Removal Plan was substantially implemented by education logs, policy and procedure revisions, and interviews.
Cross reference
§482.13 (c)(2) Patient Rights: Care in a Safe Setting

Based on review of facility security video, policy and procedures, facility documents, personnel files (PF), medical record (MR) and interviews with staff (EMP) it was determined the facility failed to maintain a safe setting for a patient in the Emergency/Trauma Center.

Review on May 16, 2024, of security footage from the Emergency/Trauma Center, Camera AH-Toll Ground ETC515to421 and Toll Ground ETC500s, revealed on April 23, 2024, at 11:06 PM, PT1 is observed walking down the hallway, wrapped in a blanket. PT1 is being followed by EMP6 and EMP17. Behind them, nursing staff is seen following. EMP6 is observed stepping in front of PT1 to block from advancing further. EMP6 then bumps PT1 with their hip and a struggle ensues between PT1 and EMP6. PT1 attempts to fight off EMP6 and bites the forearm of EMP6. EMP6 continues to fight the effort of PT1 to get free. PT1 and EMP6 end up on floor. EMP6 is on top of PT1 and holds PT1 by the head/neck area. PT1 is lifted onto stretcher and 4-point restraints are placed.

Review on May 17, 2024, of facility policy, "Patient ' Rights and Responsibilities, 14.03 " , reviewed 11/2023, revealed, " Hospital patients have the right to safe, respectful, and dignified care at all times ... Receive care in a setting free from any form of abuse, harassment, and neglect. Receive kind, respectful, safe, quality care delivered by skilled staff."

Review on May 16, 2024, of facility policy, "Use of Force" reviewed 08/2020, revealed "A Security Officer may use Physical Force or Mechanical Force, when he/she reasonably believes it is immediately necessary at the time: ... To prevent a third party from committing suicide, inflicting serious bodily injury upon him/herself or committing a breach of the peace."

Review on May 16, 2024, of facility document "Investigation Findings of the Incident At Abington Hospital on April 23 - 28, 2024 Involving Jefferson Security Officers and Sergeants" revealed neither EMP6 nor EMP17 were told the patient was held on a 302 medical hold [an involuntary psychiatric situation in which the patient may need psychiatric hospitalization and admission to treat psychiatric medical conditions]. EMP15 heard EMP6 "gloating" over having "had to slam somebody" . EMP7 reported the incident to EMP18 who was a charge nurse. EMP18 notified EMP19 of the event. EMP7 stated in an email, which is part of the investigation, "My best information is that Nursing Administration is aware (besides being on the scene late the AOC this weekend is in Nursing so it -almost- goes without saying most or all of Nursing leadership is aware). "

Review on May 16, 2024, of EMP6's personnel file, revealed EMP6 completed the "Handle with Care" training and "CPI- Crisis Prevention Intervention" trainings on July 24, 2023. These trainings teach staff how to de-escalate patients in crisis situations and verify staff's competency in doing so.

Interview on May 16, 2024, at 2:32 PM with EMP9 confirmed "no" , after viewing video footage, when asked if patient physically or verbally aggressive. When asked about direction of patient ambulating EMP9 confirmed patient was "not going toward exit".

Interview on May 16, 2024, at approximately 5:20 PM with EMP6 confirmed being involved in altercation on April 23, 2024, at approximately 11:06 PM with PT1