The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ST FRANCIS HOSPITAL & MEDICAL CENTER 114 WOODLAND STREET HARTFORD, CT 06105 Dec. 19, 2018
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on clinical record review and interview for 1 (P#5) of 11 patients who underwent interactions with hospital security staff while in the Emergency Department (ED) the facility failed to ensure that the patient was provided care in a safe setting that was free from abuse. The findings include:

P#5 had diagnoses that included a history of alcohol abuse and chronic foot and shoulder pain and was evaluated in the Emergency Department (ED) on 11/1/18 for a chief complaint of blood in his/her stool for 3 weeks. P#5 was well known to the ED staff, was assessed, cleared medically and discharged .

According to a hospital security report dated 11/1/18 and substantiated by video monitoring, an altercation had occurred between P#5 and Security Officer SO#1 in the ED waiting area while P#5 was being escorted out of the ED after discharge.

According to a written statement dated 11/1/18 at 6:11 AM by Registered Nurse (RN) #4 and a subsequent interview on 12/7/18 at 8:55 AM, RN#4 indicated P#5 had been discharged and was escorted out of the ED by Security Officer (SO) #1 and SO #2 (ED Shift Supervisor) to the waiting area. P#5 proceeded to walk to the triage desk agitated, spitting food and demanding a medical cab. SO#1 approached P#5 and P#5 became more agitated. SO#1 was asked to back away by SO#2 multiple times. P#5 became more agitated and swung at SO#1 and SO#1 grabbed P#5. SO#2 joined by another security officer (SO#3) attempted to get between SO#1 and P#5 to deescalate the situation. SO#1 did not back off as instructed and the situation escalated again. SO#1 then pushed P#5 against the desk and had his/her hands on P#5's neck. A silent alarm and Code "Grey" was called to triage, the situation deescalated and SO#1 was removed from the area. P#5 was asked if he/she was injured and wanted to be evaluated however P#5 declined. P#5 calmed and was escorted out of the ED without further incident.

During interviews with SO#2 and SO#3 on 12/10/18 they indicated P#5 had been discharged and was in the waiting area requesting a medical cab. He/she was hostile and yelling at the staff as per his/her usual behaviors and it was explained that P#5 was not eligible for a cab because he/she could not provide an address of residence. SO#3 indicated he/she did not understand why SO#1 reacted the way he/she did as SO#1 had escorted P#5 out of the ED many times before without incident and was familiar with P#5's behaviors.

Hospital Patients' Rights Policy indicated the patient has the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation during the hospital stay. The policy further directs that staff must report allegations or actual assault or abuse of a patient to their supervisor following chain of command, including Leadership of the area that the incident occurred. Risk Management will be notified who will discuss with the administrative Supervisor to determine next steps including reporting to local law enforcement as appropriate and/or at the patients request.

Note: Review of the hospital Patient Rights policy identified staff guidance in the event of an allegation of abuse. The hospital does not have a separate Abuse policy.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on clinical record review and interview for 1 (P#5) of 11 patients who underwent interactions with hospital security staff while in the Emergency Department (ED) the facility failed to ensure that the patient was free from abuse and failed to ensure the hospital's Patient Rights policy was followed when an incident of possible abuse was identified. The findings include:

P#5 had diagnoses that included a history of alcohol abuse and chronic foot and shoulder pain and was evaluated in the Emergency Department (ED) on 11/1/18 for a chief complaint of blood in his/her stool for 3 weeks. P#5 was well known to the ED staff, was assessed, cleared medically and discharged .

A. According to a hospital security report dated 11/1/18 and substantiated by video monitoring, an altercation had occurred between P#5 and Security Officer SO#1 in the ED waiting area while P#5 was being escorted out of the ED after discharge.

According to a written statement dated 11/1/18 at 6:11 AM by Registered Nurse (RN) #4 and a subsequent interview on 12/7/18 at 8:55 AM, RN#4 indicated P#5 had been discharged and was escorted out of the ED by Security Officer (SO) #1 and SO #2 (ED Shift Supervisor) to the waiting area. P#5 proceeded to walk to the triage desk agitated, spitting food and demanding a medical cab. SO#1 approached P#5 and P#5 became more agitated. SO#1 was asked to back away by SO#2 multiple times. P#5 became more agitated and swung at SO#1 and SO#1 grabbed P#5. SO#2 joined by another security officer (SO#3) attempted to get between SO#1 and P#5 to deescalate the situation. SO#1 did not back off as instructed and the situation escalated again. SO#1 then pushed P#5 against the desk and had his/her hands on P#5's neck. A silent alarm and Code "Grey" was called to triage, the situation deescalated and SO#1 was removed from the area. P#5 was asked if he/she was injured and wanted to be evaluated however P#5 declined. P#5 calmed and was escorted out of the ED without further incident.

During interviews with SO#2 and SO#3 on 12/10/18 they indicated P#5 had been discharged and was in the waiting area requesting a medical cab. He/she was hostile and yelling at the staff as per his/her usual behaviors and it was explained that P#5 was not eligible for a cab because he/she could not provide an address of residence. SO#3 indicated he/she did not understand why SO#1 reacted the way he/she did as SO#1 had escorted P#5 out of the ED many times before without incident and was familiar with P#5's behaviors.

A written report by the Security Supervisor dated 11/1/18 at 8:00 AM indicated after the incident SO#1 was removed from the ED and assigned to another area of the hospital until he/she could be relieved and finish his/her report. The report indicated SO#1 denied any wrong doing and denied he/she put his/her hands on P#5.

The Security Supervisor assigned on 11/1/18 was not available for interview during the investigation.



B. Review of the hospital security report failed to indicate if local law enforcement were called immediately following the altercation on 11/1/18. A local law enforcement report dated 11/5/18 indicated the Director of Security had contacted the local law enforcement about the altercation. The incident including the video recording was reviewed by local law enforcement however because P#5 had not called police to file a complaint and/or returned to the hospital claiming injuries the report was filed for documentation purposes only.

During a review of the incident with the Director of Security on 12/6/18 at10:15 AM he/she indicated SO#1 should have been escorted out of the building immediately pending an investigation, the Director of Security and Leadership should have been notified and the local law enforcement should have been called. The Director of Security indicated he/she was not notified of the incident immediately and he/she called local law enforcement to report the incident when he/she became aware. Local law enforcement viewed the video and did not view the incident as an assault. The Director of Security indicated SO#1's employment was terminated as a result of the incident.



C. During a review of the incident with the Clinical Risk Manager on 12/6/18 at 9:10 AM he/she identified escalation via the chain of command used in the event of witnessed abuse or an allegation of abuse had not been implemented. Based on the hospital Patients' Rights policy the expectation was that notification of the incident would have been reported up the chain of command for further direction. The Clinical Risk Manager indicated he/she was on call and did not receive a call about the incident and Risk Management was not notified until the next day.

During an interview with Director of Nurses (DON) on 12/6/18 at 10:45 AM he/she indicated after the incident occurred neither the DON and/or Nurse Manager in the ED were notified of the incident.

Hospital Patients' Rights Policy indicated the patient has the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation during the hospital stay. The policy further directs that staff must report allegations or actual assault or abuse of a patient to their supervisor following chain of command, including Leadership of the area that the incident occurred. Risk Management will be notified who will discuss with the administrative Supervisor to determine next steps including reporting to local law enforcement as appropriate and/or at the patients request.

Note: Review of the hospital Patient Rights policy identified staff guidance in the event of an allegation of abuse. The hospital does not have a separate Abuse policy.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on clinical record review and interview for 1 (P#11) of 4 patients reviewed for use of restraints the hospital failed to ensure medical record restraint documentation was complete according to hospital policy. The findings include:

P#11 was evaluated in the ED for treatment of substance abuse. According to medical record documentation P#11 was confused, uncooperative, impulsive and physically aggressive. P#11 was placed in 4 point locked restraints on 12/3/18 at 1:00 PM.

During a review of the medical record with the ED Quality Data Analyst on 12/7/18 it was identified the medical record lacked documentation of a written physician's order for the 4 point locked restraints.

The hospital Restraint Policy indicated each mechanical restraint or seclusion must be ordered and the order must be in accordance with the identified limits for up to a total of 24 hours.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
Based on clinical record review and interview for 1 (P#11) of 4 patients reviewed for use of restraints the hospital failed to ensure medical record restraint documentation was complete according to hospital policy. The findings include:

P#11 was evaluated in the ED for treatment of substance abuse. According to medical record documentation P#11 was confused, uncooperative, impulsive and physically aggressive. P#11 was placed in 4 point locked restraints on 12/3/18 at 1:00 PM.

During a review of the medical record with the ED Quality Data Analyst on 12/7/18 it was identified the medical record lacked documentation of a physician face to face evaluation within 1 hour of restraint application.

According to the hospital Restraint Policy a physician or licensed independent practitioner (LIP) must evaluate the patient face to face within 1 hour after the initiation of the restraint.
VIOLATION: PATIENT RIGHTS Tag No: A0115
The Condition of Patient Rights has not been met.

Based on clinical record review and interview for 1 (P#5) of 11 patients who underwent interactions with hospital security staff while in the Emergency Department (ED) the facility failed to ensure that the patient was provided care in a safe setting that was free from abuse. In addition, the facility failed to ensure the restraint policy was followed during a restraint episode.



Please see A144, A145, A168 and A178.