HospitalInspections.org

A. Based on document review, observation and interview, it was determined that for 1 of 2 (Pt. #2) patients reviewed for abuse allegations, the Hospital failed to ensure the patient's right to remain free from all forms of abuse was protected, by failing to ensure a contracted Public Safety Officer did not intentionally harm a patient.

Findings included:

1. On 9/7/2021, the Hospital's policy titled, "Abuse; Patient Protection from Abuse" dated 2/5/2019, was reviewed. The policy included, "...Definitions: 'Abuse' means any physical or mental injury or sexual abuse intentionally inflicted by a hospital employee, agent, or medical staff member on a patient of the hospital does not include hospital, medical, health care, or other personal care services done in good faith in the interest of the patient according to established medical and clinical standards."

2. On 9/7/2021, the Hospital Public Safety Guidelines titled, "The Public Safety Department Post Assignment Instructions" dated 4/2020, was reviewed and included, "Location: Emergency Department Waiting Area/Temporary Ambulance Entrance ...6. Immediately notify [Hospital] Public Safety Dispatch of any situations requiring Public Safety assistance or intervention. Agency personnel should not take any enforcement action unless directed to do so by [Hospital] Public safety Officer."

3. The Hospital's incident report dated 8/10/2021 at 5:48 AM was reviewed. The incident report included, " ...Occurrence Type: Abuse/Assault. Occurrence subtype: Physical ...Did this event result in patient injury? Yes. Subject [Pt. #2] entered the ED waiting area when he was approached by contract security agent [E #10]. E #10 proceeded to push [Pt. #2] in the chest and then strike [Pt. #2] with a closed fist [Pt. #2] fell to the ground where [E #10] continued to strike and kick [E #10]. [Hospital] Safety Officers arrived and separated both [E #10 and Pt. #2 ...[Hospital] Public Safety reviewed the surveillance video which showed [E #10] was the aggressor and communicated this information to [local] police ..."

4. On 9/7/2021, Pt. #2's clinical record was reviewed. Pt. #2 was not admitted or registered in the ED on 8/10/2021 at 3:48 AM, during the time of the reported incident. Pt. #2 presented later to the ED [Emergency Department] on 08/10/2021 at 1:06 PM and was discharged on 8/10/2021 at 7:18 PM. Pt. #2 had a chief complaint of rib pain and a diagnosis of rib contusion (deep bruise on the rib).

-The ED Provider note written by a Family Nurse Practitioner (E #15), dated 8/10/2021 at 14:05 (2:05 PM), included, "Pt [Pt. #2] via EMS ambulatory to ED...for rib paint and hematuria since today. Pt. [Pt. #2] states he was assaulted by a security guard...Urinalysis - Urine blood: Trace."

5. On 9/7/2021 at 1:00 PM, with the Director of Public Safety (# 5), Associate Chief Nursing Officer (E #16), and Risk Managers (E #1 and E #17), videotape footage of the Emergency Department waiting room and entrance on 8/10/2021 was reviewed and included the following:

Camera #1 - Entrance to ED:
-On 8/10/2021 at 3:48:36 (3:48 AM and 36 seconds) Pt. #2 entered the ED.
-At 3:48:47 (3:48 AM and 47 seconds) Pt. #2 was on the floor in a self-protective position (lying on his side with his hands protectively covering his head). The contracted Public Safety Officer (E #10) was standing over Pt. #2 while punching and kicking Pt. #2. Pt. #2 was not fighting back.
-At 3:49:34 (3:49 AM and 34 seconds) the Hospital's Public Safety Officer (E #6) pushed and held E #10 away from Pt. #2.

Camera #2 - ED waiting room:
-On 8/10/2021 at 3:48:41 (3:48 AM and 41 seconds) Pt. #2 walked into the ED waiting room.
-At 3:48:42 (3:48 AM and 44 seconds) E #10 walked around the security desk, pushed Pt. #2 with an open hand and punched Pt. #2 with a closed fist, knocking Pt. #2 on the floor and out of camera view. Additional footage noted above from camera #1.

6. On 9/7/2021 at 11:02 AM, an interview was conducted with Director of Public Safety (E #5). E #5 stated that upon review of the videotape footage on 8/10/2021, E #10 who was a contracted Public Safety Officer initiated physical contact with Pt. #2 by hitting Pt. #2 first and without cause. E #5 stated that the contracted public Safety Officers are placed at a desk in the waiting room and act more as a receptionist to observe and report. E #5 stated that the contracted Public Safety Officers are supposed to use the radio to contact the Hospital Public Safety Officers if a patient or visitor is showing signs of aggression. E #5 stated E #10 did not follow the guidelines. E #5 stated that E #10 was removed from the Hospital premises immediately following the incident and is not allowed to work for the Hospital again.

7. On 9/8/2021 at approximately 2:00 PM, an interview was conducted with a Risk Manager (E #1). E #1 stated that Risk Management and Public Safety leadership have discussed possible changes with the duties and responsibilities of contracted Public Safety Officers, but no changes have been implemented. E #1 stated that there is not any formal documentation of the changes that were discussed. E #1 stated that this was an isolated incident


B. Based on document review and interview, it was determined that for 1 of 2 (Pt. #2) patients reviewed for abuse, the Hospital failed to ensure that patients remain free from abuse by ensuring incidents of abuse are investigated, analyzed, and appropriate corrective actions occur following an incident of contracted staff to patient abuse.

Findings Include:

1. The Hospital's incident report dated 8/10/2021 at 5:48 AM was reviewed. The incident report included, " ...Occurrence Type: Abuse/Assault. Occurrence subtype: Physical ...Did this event result in patient injury? Yes. Subject [Pt. #2] entered the ED waiting area when he was approached by contract security agent [E #10]. E #10 proceeded to push [Pt. #2] in the chest and then strike [Pt. #2] with a closed fist [Pt. #2] fell to the ground where [E #10] continued to strike and kick [E #10]. [Hospital] Safety Officers arrived and separated both [E #10 and Pt. #2 ...[Hospital] Public Safety reviewed the surveillance video which showed [E #10] was the aggressor and communicated this information to [local] police ..."

2. The local police report dated 8/10/2021 at 5:13 AM, included documentation that Pt. #2 was assaulted by E #10, a contracted Hospital Public Safety Officer.

3. On 9/7/2021, Pt. #2's clinical record was reviewed. Pt. #2 was not admitted or registered in the ED on 8/10/2021 at 3:48 AM, during the time of the reported incident. Pt. #2 presented later to the ED [Emergency Department] on 08/10/2021 at 1:06 PM and was discharged on 8/10/2021 at 7:18 PM. Pt. #2 had a chief complaint of rib pain and a diagnosis of rib contusion (deep bruise on the rib).

-The ED Provider note written by a Family Nurse Practitioner (E #15), dated 8/10/2021 at 14:05 (2:05 PM), included, "Pt [Pt. #2] via EMS ambulatory to ED...for rib paint and hematuria since today. Pt. [Pt. #2] states he was assaulted by a security guard...Urinalysis - Urine blood: Trace."

4. On 9/7/2021 at 11:02 AM, an interview was conducted with Director of Public Safety (E #5). E #5 stated that upon review of the videotape footage on 8/10/2021, E #10 who was a contracted Public Safety Officer initiated physical contact with Pt. #2 by hitting Pt. #2 first and without cause. E #5 stated that the contracted public Safety Officers are placed at a desk in the waiting room and act more as a receptionist to observe and report. E #5 stated that the contracted Public Safety Officers are supposed to use the radio to contact the Hospital Public Safety Officers if a patient or visitor is showing signs of aggression. E #5 stated E #10 did not follow the guidelines. E #5 stated that E #10 was removed from the Hospital premises immediately following the incident and is not allowed to work for the Hospital again.

5. On 9/8/2021 at approximately 2:00 PM, an interview was conducted with a Risk Manager (E #1). E #1 stated that Risk Management and Public Safety leadership have discussed possible changes with the duties and responsibilities of contracted Public Safety Officers, but no changes have been implemented. E #1 stated that the Hospital is in the process of evaluating and analyzing what changes should be implemented. E #1 stated that there is not any formal documentation of the changes that were discussed. E #1 stated that this was an isolated incident. The Hospital failed to provide evidence of the changes to prevent future contracted staff of patient abuse.