HospitalInspections.org

Based on policy and procedure review, medical record review, document review, and personnel interview, the facility failed to lock an entrance door after normal operating hours per facility policy/procedure which allowed an unauthorized individual to access the facility and cause harm to 1 patient (N1) and had the potential for unauthorized individuals to have access to all parts of the facility and access to all patients in order to cause harm for 1 facility.


Findings:

1. Review of the following policies & procedures on 7/14/14 at approximately 1114, 1116, and 1625 hours indicated the following:

A. Patient Rights, Policy No.: CORP_02, revised/reapproved 12/2/13 indicated on pg. 1 under Policy section, bulleted points, "Patients (or patient's representative as allowed under State law) have the right to...Receive care in a safe setting."

B. Locking/Unlocking Doors, Policy No.: SECUR_06, revised/reapproved 3/2014 indicated on pg. 1 under Action section, points 2, 3, 5, and 6, "Security will lock and secure all entrance and exit doors at the end of normal operating hours. All other exterior doors not specified here should remain locked at all times...Note and identify on the Daily Activity Report (DAR) doors found unlocked. Record in the DAR the room number, time and the name of the employee(s) for whom the door was unlocked."

C. Post Position - Southlake Campus, Policy No.: SECUR_02, revised/reapproved 3/2014 indicated on pg:
a. 1, under PP#1 (CCTV [Closed Circuit Television] Room) Security Officer/Security Guard (Responsible Person), points 2, 3, and 5, "Monitors all entrances into the hospital, protects persons and property...monitors all CCTV...Records all calls for assistance, incidents, accidents, thefts, and all other activity on the Daily Activity Log.
b. 2, under PP#2 (Outside Patrol) Security Officer/Security Guard (Responsible Person), point 7, "Locks and unlocks daily specified doors and entrances."
c. 3, under PP#4 Supervisor (Responsible Person), points 2 and 4, "Insures all positions are staffed and job duties of each position are being performed...Insures all reports are completed accurately at end of shift."

D. Security Department Scope of Service, revised/reapproved 2012, indicated on pg:
a. 1, under Scope of Patient Needs section, "Security is provided to maintain a safe and secure environment for all our guests and hospital property."
b. 2, under Services Provided section, point 16, "Secures all entrances to the hospital and lock and unlock areas within the hospital as needed."

E. Security Management Plan, revised/reapproved 6/2/13, indicated on pg:
a. 2, under Objectives section, point J, "Security department activity including investigations, routine patrol activities, special and routine requests for assistance, and other activities are appropriately documented."
b. 4, under Processes of the Security Management Plan, I.D. Program, "Access to the hospital is controlled by the hospital's Security Department during the nightly hours, whereby visitors are screened."

F. Patient Visitation, Policy No.: CORP_07, revised/reapproved 12/2/13 indicated on pg:
a. 1, under Policy section, "Patient welfare is our most important responsibility."
b. 2, under Procedure section, "Between the hours of 8:00 p.m. and 8:00 a.m. visitors are asked to acquire a visitor's pass at the Security desk near the entrance of the Emergency Department. Security will collaborate with nursing in accommodating visitors."

2. Review of closed patient medical records on 7/14/14 at approximately 1350 hours indicated:
A. patient N1 was an 80-year-old who presented to the Emergency Department (ED) on 7/4/14 for not being his/her usual self and was admitted to the facility for further medical management. On 7/8/11, was referred to the Rehabilitation Unit for inpatient Acute Rehabilitation Program.

a. Review of Nurse Notes dated 7/11/14 at 0028 hours indicated, "In another patient's room when I [P1, Staff Nurse] heard screaming. Ran to patient's room. Saw a man run out. Went in room. Patient was covered in blood. Code blue was called. Saw stab wound to the left chest and abdomen. Patient was alert. CPR (cardiopulmonary resuscitation) was started. Patient transferred to ICU (Intensive Care Unit). [Physicians] made aware."

b. Review of Code Documentation by Physician dated 7/11/14 at 0049 hours indicated the following: "Called for 'code blue'. Respond immediately. On arrival, patient is not following commands but respond to pain stimulation, spontaneous breathing, BP (blood pressure) 96/58, HR (heart rate) 96, oxygen saturation unknown...Continue resuscitation by primary team."

c. Review of Orders on 07/11/14 at 0448 hours indicated the following: "Provider Automatic Discharge (Patient Discharged/Expired)."

3. Review of Incident Reports for 7/1/14 through 7/14/14 on 7/14/14 at 1146 hours indicated one related to complaint.
A. An incident report was filed 7/11/14 at 0836 hours by P1 related to the fatal stabbing of patient N1 by C1, family, on 7/11/14 at approximately 0020 hours.
B. A code blue was called as well as security, physician notified, no family notified, patient lived with C1.
C. Patient was transferred to ICU (Intensive Care Unit) where they died due to their injuries.
D. A suggestion was "more safety measures need to be in place, no visitors should be allowed on the unit after visiting hours."
E. A facility investigation and root cause analysis are currently in process, as well as a police investigation.

4. Video Surveillance was reviewed, accompanied by P15 (Security Manager), on 7/14/14 at approximately 1815 to 1835 hours for 7/11/14 and indicated the following:
A. At 0010 hours, a motorcycle rider arrives and parks between two trucks then walks up to dock doors.
B. At 0012 hours, disappears from view.
C. At 0033-0034 hours, arrives at motorcycle and gets on, turns on lights, sat for about a minute, backs out, and turns.
D. At 0036 hours, driver out of frame.

5. Daily Activity Report dated 7/10/14 and 7/11/14 was reviewed on 7/15/14 at approximately 1410 hours and confirmed:
A. This is the security log for these dates.
B. The Daily Activity Report lacked documentation on 7/10/14 at 2003 hours and 2318 hours and 7/11/14 at 0655, 2046, and 2338 hours of what doors were unlocked and whether or not they were relocked.

6. Personnel P15 (Security Manager) was interviewed on 7/14/14 at approximately 1517 and 1759 hours and confirmed:
A. Suspect gained entry through alternate means, he/she entered through double doors in the dock area. It is unclear whether they were propped open or closed. Those doors are meant to be locked. There is a procedure titled, "Post Position-Southlake Campus", SECUR_02 related to this that specifies on page 2 under PPP#2 point 7, "Locks and unlocks daily specified doors and entrances". There is no list of daily specified doors, but it is an expectation of security staff that the dock doors are part of the specified doors. Hospital staff was not aware that the suspect was in the facility until a security officer, [P24], was notified by a nurse's aide (NA) that this suspect was acting strange. They both approached the patient's room and the NA asked the patient if everything was okay and he/she said yes (C1 is family).

7. Personnel P17 (Security Guard) was interviewed via phone on 7/15/14 at approximately 1116 and 1402 hours and confirmed:
A. Yes the dock door area cameras were monitored the night of the incident by myself (the Unit 1 dispatcher) from the CCTV camera room, but that night I received a call that a gunshot wound (GSW) victim was being brought in. I had to leave the CCTV room to assist Unit 3 [P24] (a new employee) with locking down the Emergency Room, which is protocol when a GSW comes in. No one is available to monitor these cameras if the person watching them is called out. Around the same time of the GSW victim coming in, the suspect pulled up in the dock area. I called in Unit 2 [P18] who was patrolling the outside perimeter at the time, but the cameras were not being monitored by security when the suspect arrived. A few minutes later, I got a call about the stabbing incident on 3W1 and responded.
B. There were only 3 security guards on a shift, which was not enough for what happened that night. The dock doors have no badge swipe entrance and employees are often seen entering through these doors. During the time I have been working here, those dock doors have never been locked. I work interior patrol and checking those doors is not part of my responsibilities. It is the responsibility of Unit 2. All security guards switch working the 3 different Units and when I work Unit 2 I make sure they are locked, but then they sometimes get unlocked and propped open. Not sure who unlocks them, all the security guards have keys.
C. The Unit 1 Security Guard/Security Officer is to log entries in the Daily Activity Report (DAR) when other Security Guard/Security Officer Units report the information to them. I was the Unit 1 Security Guard on the midnight shift from 11 pm on 7-10-14 to 7:30 am on 7-11-14. The DAR for this time period should have documented what door is locked or unlocked and what patient unit or room was involved for each entry.

8. Personnel P15 (Security Manager) was interviewed via phone on 7/15/14 at approximately 1318 hoursand confirmed, it is the responsibility of the Unit 1 Security Guard/Security Officer to log entries in the Daily Activity Report (DAR) when other Security Guard/Security Officer Units report the information to the Unit 1 Security Guard/Security Officer. All fields are to be complete, for example what door is locked or unlocked and what patient unit or room the activity took place in, as well as any other information given. The DAR for 7-10-14 and 7-11-14 is incomplete.

9. Personnel P18 (Security Officer/Police Officer) was interviewed via phone on 7/15/14 at approximately 1321 hours and confirmed:
A. The dock door area cameras are monitored by the Unit 1 Security Guard/Security Officer/Dispatcher from the CCTV room. They are not usually called away from their station, but may be in an emergency and then no one is there monitoring the security cameras. I was working on the midnight shift from 11 pm on 7-10-14 to 7:30 am on 7-11-14. I check the exterior perimeter of the facility 2 times during my shift usually 2 hours after my shift begins and 2 hours prior to the end of my shift. I did not get to the dock door area prior to the stabbing incident that occurred on 7-11-14, so I am unsure whether or not the dock doors were locked. The dock door is considered an exterior door. There were back to back gunshot wound (GSW) victim security calls that night and those are considered emergencies, so all security personnel were called to respond to secure the Emergency Room.