HospitalInspections.org

Based on observation, record review, and interview, the CAH failed to ensure the governing body assumed responsibility for policies to provide health care in a safe environment. This deficient practice was evidenced by failing to ensure hospital weapon detection system policies and security personnel competencies were updated after an incident of a patient (#1) bringing a weapon into the hospital.
Findings:

Review of Patient #1's medical record revealed, in part: "Psychiatry. Nursing Addendum. When skin assessment completed patient had a gun wrapped in towels, in his sock on his ankle."

In an interview on 08/04/2025 at 11:26 AM, S1Director of Quality confirmed Patient #1 was found with a gun in the hospital behavioral health unit. S1Director of Quality confirmed Patient #1 entered the hospital through the ED, passed through the ED EVOLV Weapon Detection System and the system did not alert that the patient had a weapon.

On 08/04/2025 at 1:51 PM, an observation of the ED EVOLV Weapon Detection System was conducted with S1Director of Quality and S2Security Manager. Observation revealed the EVOLV Weapon Detection System located near a walk-in/ambulatory entrance door and sliding entrance doors for ambulance personnel. In an interview at this time, S2Security Manager indicated for the EVOLV Weapon Detection System to function properly both the walk-in/ambulatory entrance door and sliding entrance doors had to be completely closed prior to individuals walking through the EVOLV Weapon Detection System. S2Security Manager indicated that if a door was not completely closed, the EVOLV Weapon Detection System may not alert security personnel of the presence of a weapon.

Review of the hospital "EVOLV Express Weapon Detection System" policy and procedure with an approval date 03/17/2025 revealed, in part: "I. Purpose. This operational standard provides guidelines on the effective operation of the Evolv Express Weapon Detection System and the identification and safe securing of any potential weapons threats entering an Ochsner facility. IV. Procedure. All individuals entering an Ochsner facility where Evolv Express Weapon Detection Systems are deployed are required to pass through and be scanned for weapons or dangerous instrumentalities except patients in active labor or patients with a medical emergency in route to the Emergency Department. Further review of the section "IV. Procedure" revealed no procedure stating that ED entrance doors had to be completely closed prior to individuals walking through the EVOLV Weapon Detection System.

Review of the hospital "EVOLV Weapon Detection System Checklist and Competency Acknowledgment" form for hospital security personnel assigned a security EVOLV post of duty or temporary assignment for EVOLV revealed the checklist and competency form did not address that ED entrance doors had to be completely closed prior to individuals walking through the EVOLV Weapon Detection System.

In an interview on 08/05/2025 at 9:17 AM, S1Director of Quality confirmed that ED entrance doors had to be completely closed prior to individuals walking through the EVOLV Weapon Detection System for the system to function properly.

In an interview on 08/05/2025 at 11:17 AM, S1Director of Quality confirmed hospital "EVOLV Express Weapon Detection System" policy and procedure and hospital "EVOLV Weapon Detection System Checklist and Competency Acknowledgment" form for hospital security personnel had not been updated to include ED entrance doors had to be completely closed prior to individuals walking through the EVOLV Weapon Detection System.

Based on observation, record review, and interview, the CAH failed to ensure the Quality Assessment Performance Improvement program addressed prevention of adverse events. This deficient practice was evidenced by failing to include monitoring of an identified issue with the weapon detection system after an incident of a patient (#1) bringing a weapon into the hospital.
Findings:

Review of Patient #1's medical record revealed, in part: "Psychiatry. Nursing Addendum. When skin assessment completed patient had a gun wrapped in towels, in his sock on his ankle."

In an interview on 08/04/2025 at 11:26 AM, S1Director of Quality confirmed Patient #1 was found with a gun in the hospital behavioral health unit. S1Director of Quality confirmed Patient #1 entered the hospital through the ED, passed through the ED EVOLV Weapon Detection System and the system did not alert that the patient had a weapon.

On 08/04/2025 at 1:51 PM, an observation of the ED EVOLV Weapon Detection System was conducted with S1Director of Quality and S2Security Manager. Observation revealed the EVOLV Weapon Detection System located near a walk-in/ambulatory entrance door and sliding entrance doors for ambulance personnel. In an interview at this time, S2Security Manager indicated for the EVOLV Weapon Detection System to function properly both the walk-in/ambulatory entrance door and sliding entrance doors had to be completely closed prior to individuals walking through the EVOLV Weapon Detection System. S2Security Manager indicated that if a door was not completely closed, the EVOLV Weapon Detection System may not alert security personnel of the presence of a weapon.

In an interview on 08/05/2025 at 9:17 AM, S1Director of Quality confirmed that ED entrance doors had to be completely closed prior to individuals walking through the EVOLV Weapon Detection System for the system to function properly.

Review of the hospital quality assurance and performance improvement records revealed no documented evidence the hospital monitored the ED EVOLV Weapon Detection System to ensure that ED entrance doors were completely closed prior to individuals walking through the EVOLV Weapon Detection System.

In an interview on 08/05/2025 at 12:51 PM, S1Director of Quality confirmed there was no documented evidence the hospital monitored that ED entrance doors were completely closed prior to individuals walking through the EVOLV Weapon Detection System in the quality program.