HospitalInspections.org

A. Based on observation, interview with staff, and review of facility policy and procedure, it was determined that the facility failed to ensure that patients receive care in a safe environment.

Findings include:

Reference: The POLICY section of facility policy titled "University Hospital Patients In Law Enforcement Custody" stated: ".....
1) Patients in Law Enforcement Custody:
1.1) A patient in law enforcement custody is defined as any patient who is in the custody of a law enforcement agency (i.e., corrections agency, police, etc.) and is being medically treated at UH (University Hospital). The patient will receive the same level of care and treatment as any other patient at UH.
1.2) The law enforcement agency that has custody of the patient must provide necessary and appropriate law enforcement supervision while patient is receiving care in all areas of the facility.
.....
4) Care and Treatment of Patients in Law Enforcement Custody:
4.1) An assigned law enforcement officer must accompany the patient in law enforcement agency custody whenever the patient leaves the nursing unit for ancillary treatment or testing. The escorting officer will remain with the patient at all times and will be responsible for the return of the patient to the nursing unit and his assigned room.
4.2) It is the responsibility of assigned officers to protect the patient in law enforcement custody around hospital staff, other patients and visitors. Assigned officers are not to interfere with medical care but must be aware of all persons entering the room and that have contact with the patient.
....."

1. Review of the Emergency Department (ED) Record of Patient #1 dated 8/26/15 indicated that he/she arrived in the ED at 3:25am. The medical record stated:
".....
HPI (History of Present Illness)
HPI Comments: Pt. (Patient) under ____ Police Custody, handcuffed to the left hand/wrist to the bed rail.
....
Physical Exam
.....
Patient is verbally abusive to the staff, yelling & cursing @ this provider.
.....
Impression and Plan
.....
540 AM Walked out during MSE (Medical Screening Exam), without notifying the staff. I was notified by RN _____ __________, that the pt escaped while in the radiology dept (department) (while under ___ police custody).
.....
ED Notes - ED Provider Notes
.....
4:30AM Pt received AOx3 (alert and oriented times three) in police custody, cuff noted on patient, patient C/O pain to knee, assessment noted.
.....
5:04AM Pt medicated as ordered, will transport to radiology.
.....
5:10AM Pt transported to radiology by ED technician via wheelchair, Police custody with patient. Pending xrays and results.
.....
5:35AM Notified by nurse Manager ______ that patient unable to be located by police custody or staff. Name and description of patient given to security officers.
....."

2. Review of surveillance camera images indicated that Patient #1, a patient who came to the ED in police custody, was walking quickly through a hallway to the main lobby of the hospital unaccompanied where he/she exited the hospital. Administrators #1 and #4 agreed.

3. The two police officers assigned to maintain custody of the patient failed to remain with the patient at all times while he/she was away from the ED in the Radiology Department.


B. Based on a review of facility policy and procedure and a General Order used by the local police department officers assigned to maintain custody of patients treated at the hospital and interview with administrative staff, it was determined that the two documents are contradictory.

Findings include:

Reference #1: Facility policy titled "University Hospital Patients In Law Enforcement Custody" stated:
".....
8) Conduct of Officers Visiting or Assigned to University Hospital
.....
8.3) All officers assigned to patients will be required to station themselves directly outside the patient's room and must maintain direct visual contact of the patient, with the door remaining open at all times, except in cases of airborne isolation or so instructed by clinical staff.
....."

Reference #2: ___ POLICE DEPARTMENT GENERAL ORDER titled PROCEDURE FOR TRANSPORTING AND SAFEGUARDING SICK AND INJURED PRISONERS stated: ".....
VII. Duties and responsibilities of the Police Officer Guarding Prisoners
Police officers assigned to guard a prisoner/patient shall adhere to the following policy guidelines:
G. When guarding prisoners that have been assigned to a hospital room for continued treatment and observation, guarding officer(s) shall station themselves inside the prisoners room to guard the prisoner.
1. Only medical reasons that would expose the guarding officer to a potential hazard will allow the
officer(s) to remain outside the prisoner's hospital room.
2. Once the medical hazard to the guarding officer(s) is over, the officer(s) shall station themselves inside the prisoner's room.
....."

1. On August 27, 2015, both policies were presented to the surveyor as being applicable to patients in custody of the ___ Police Department by Staff #1. The facility policy states that the police shall station themselves outside of the room of a patient who is in custody and the police department policy stated that, unless there is a medical hazard, that the police shall station themselves inside of the patient's room.


C. Based on a review of one medical record, a tour of two patient care areas, and interviews with administrative staff, it was determined that the facility did not have a policy to maintain the safety of patients in custody, or other patients in the hospital, while the patient in custody is using the toilet.

Findings include:

1. Facility policy titled "University Hospital Patients In Law Enforcement Custody" does not address the monitoring of patient's in police custody while the patient is using the toilet in a testing area. Administrator #1 stated that there were no other hospital policies for the monitoring of patient's in custody who need to use the toilet.

2. Review of the medical record of Patient #1 indicated an entry made by a practitioner: "540 AM Walked out during MSE, without notifying the staff. I was notified by RN _____ __________, that the pt escaped while in the radiology dept (department) (while under ____ police custody)."

3. Administrator #7 stated that Patient #1 asked to use the bathroom while in the Radiology Room 4 to have x-rays done. He/she stated that the radiology technician asked one of the assigned police officers to stay with him/her inside of the room and the other officer to go in the hallway where there was another door to the bathroom which was located inside of Radiology Room 4. The patient was permitted to go into the bathroom alone with the door closed. After some time, it was determined that the patient had exited the door into the hallway and walked out of the hospital through the main lobby doors unobserved by the police officer in the hallway. A surveillance camera confirmed the patient's exit from the hospital.

4. A tour of the bathroom in Radiology Room 4 indicated the presence of an over sink light. The cover over the fluorescent bulb contained two metal end caps attached with hexagonal screws. The screws were easily removed from the caps and the caps were removed from the light. Each end cap had two sharp edges and could potentially be used as a weapon.

5. A tour of the bathroom in Patient Room F317, which was occupied by a patient in the custody of two law enforcement officers, indicated the presence of the same type of over sink light as referenced above.

6. Administrator #4, at 11:50am on August 27, 2015, stated that there was no facility policy addressing the monitoring of patients in police custody while using the toilet.