HospitalInspections.org

Based on review of Governing Body Bylaws, medical records (MR), facility policy, and interview with staff (EMP) it was determined the facility's Governing Body failed to provide oversight over the security department at Abington Hospital.

Findings include:

Review on July 11, 2024, of facility document "Amended and Restated Bylaws of the Abington Memorial Hospital d/b/a Jefferson Abington Hospital," amended February 28, 2024, revealed "... 3.2.1 The Board shall have responsibility for overall policy and clinical direction of the Corporation with a focus on the following: performance improvement and patient safety; licensure and accreditation; professional credentialing; medical staff matters; compliance; disaster planning; supervision, control and use of the physical and financial resources of the Hospital within the annual operating and capital budgets; monitoring professional liability and clinical risk management programs; philanthropy; and community relations, subject in each case to the TJU [Thomas Jefferson University] Reserved Powers contained in Section 2.4 of these Bylaws, as applicable. The Board shall also have responsibility for any other matters required by applicable laws, licensure or accreditation standards to be exercised by a Hospital by applicable Governmental Authorities or Accrediting Agencies. The President and other senior management shall have responsibility for the day-to-day direction and management of the Hospital and the implementation of TJU-approved strategic policies and plans ..."

Review on July 11, 2024, of facility policy "Use of Force" revised June 20024, revealed "... Security Officers at Jefferson may be required, from time to time, to use force to protect themselves, other persons or property. Security Officers may use force only in accordance with this Policy and State law ... Physical Force ... includes wrestling a person to the ground, using any form of wrist, arm, and leg locks, striking with hands or feet or other similar hand -to-hand confrontation ... Mechanical Force ... the utilization of some device or substance to overcome and individual's resistance to a Security Officer's authority. Examples includes the use of a baton, or chemical agent spray ... Deadly Force means force which, under the circumstances in which it is used, is readily capable of causing death or serious bodily injury. An example of deadly force would be a baton strike to a dangerous area on an individual ... Security Officer means any person who is employed by Jefferson Security Department or contracted by the Jefferson Security Department and is acting within official capacity ..."

Review on July 11, 2024, of facility document "Security Officer - Job Description" approved January 2021, revealed. "... Required Experience, Education, Certification ... Valid ACT 235 Certification required within 90 days of hire ... Equipment Use ... Chemical Spray, handcuffs, police baton. Body and package scanners ... Officers must be able to present excellent appearance at all times and also be equipped with all required security instruments ..."

Review on July 11, 2024, of the "Jefferson Health - North Region Public Safety Executive Briefing," dated February 27, 2024, revealed The Enterprise Security Department presented a summary of actions to be implemented at Abington Hospital Campus. "... Public Safety and Non-Lethal Capabilities ... Non-Lethal equipment (OC Product [pepper spray], baton, handcuffs and Ballistic Vest)-target 10/2024 ... TASER and Body Camera - pilot program ..."

Review on July 11, 2024, of the "Abington Health, Abington Memorial Hospital, Abington Health Foundation and [other CMS Certified Hospital name intentionally removed] Hospital Board of Trustees", dated March 12, 2024, revealed no documentation the Governing Board approved the use of handcuffs, pepper spray and handcuffs at Abington Hospital.

Interview on July 10, 2024, at 1:00 PM with EMP3 confirmed, "Handcuffs were used by (facility) security on May 10, 2024, on a patient that eloped from the Emergency department [ED]. Further interview confirmed, "[Facility] security are not police officers."

Interview on July 10, 2024, at 3:00 PM with EMP4 confirmed they were appointed by the governing body as the Chief Operating Officer (COO) of Abington Hospital and confirmed the use of handcuffs, batons, and pepper spray was approved by the Thomas Jefferson Enterprise Security Department and not the Governing Body of Abington Hospital.

Based on review of facility documents, medical records review (MR), and interview with staff (EMP), it was determined the facility failed to ensure the safety of patients in the Emergency department [ED]with the use of law enforcement weapons by the facility's security personnel during a patient elopement for one of two medical records reviewed (MR2)

Findings include:

Review on July 10, 2024, of MR2 physician documentation "History and Physical," revealed, the patient presented to the Emergency Department on May 6, 2024, "... 31-year-old male, death,[sic] presents today with concerns for suicidal and homicidal ideations. He presents from his group home with a 302 in place. The 302 was reviewed with concerns for suicidal and homicidal behavior ..."

Review on May 10, 2024, of nursing documentation for MR2 "ED Notes", dated May 10, 2024, revealed, "... Approximally [sic] one hour later pt refused to stay in room and exited the ER [Emergency Room] and went down old york road [sic] near zipley garage [sic]. Pt was gesturing that he was going to jump in front of cars. Pt was restrained w/ handcuffs by campus security ..."


Interview on July 10, 2024, at 1:00 PM with EMP3 confirmed, "Handcuffs were used by (facility) security on May 10, 2024, on a patient that eloped from the ED. It was outside the buildings that the handcuffs were used. The patient eloped from the ED, may have been a 302, nurse was physically engaged with patient, patient was resisting efforts to go back to the ED. Security placed the patient in handcuffs, Abington Police Department was notified." Further interview confirmed, "[Facility] security are not police officers."

Interview on July 10, 2024, at 3:00 PM with EMP3 confirmed security personnel that completed ACT 235 training carry handcuffs, batons, and pepper spray. Further interviewed confirmed "security staff continues to carry weapons today."