HospitalInspections.org

Based on staff interviews and a review of the facility's Medical Staff Bylaws, the facility staff failed to ensure the medical staff bylaws addressed patients who came to the facility for emergency care and that the bylaws were appropriate for a facility that did not have a designated Emergency Department.

The Findings Include:

The Director of Regulatory Compliance provided a copy of the Medical Staff Bylaws which were approved by the Board of Directors on January 23, 2012. The above named bylaws section titled Organization Policy Riverside Rehabilitation Institute, Article II: General Medical Staff Rules and Regulations, Section E, Emergency Situations states, "If an emergency situation develops, action should be taken as follows: #2 Behavior health issues - assess the situation, initiate immediate action and contact the appropriate mental health agency. If it is identified that there may be harm to other individuals in the area, the local police should be contacted via 911."

The above named bylaws do not specify who should perform the assessment should no physician be available.

Based on staff interviews, review of the facility's policies and procedures and review of the facility's surveillance video, the facility staff failed to ensure there was a policy/procedure for assessing, treating and referring (when appropriate) a medical emergency. The facility did not have an emergency department but had the potential for random people to approach the facility for emergency care.

On March 2, 2012 an unknown male banged on the front entrance of the hospital which was answered by the on duty Protection Officer (security guard). The unknown male told the security guard he wanted to kill himself and needed help.

The Findings Include:

On March 2, 2012 at 0135 an unknown male banged on the front entrance of the hospital which was answered by the on duty Protection Officer (PO). The unknown male told the PO he (the unknown male) wanted to kill himself and needed help. The PO documented the following: "...he informed the unknown male the hospital "was not the facility". The unknown male sat on a bench outside the main entrance door and refused to leave the property unless the local authorities were called."

During an interview with the PO on 3/15/12 he stated, "I called the police. He (the unknown male) started flicking a lighter and I informed him he could not smoke on hospital property. Two (2) people came out of the building to smoke a cigarette and I walked away from the gentleman. When I returned which was seconds later the gentleman had set his jacket on fire. I stomped the fire out with my foot because there was no fire extinguisher nearby and I didn't have any gloves. The nearest fire extinguisher was inside the building and in the truck. I called the police a second time to tell them we needed an ambulance also. The police finally came and the gentleman was taken to the hospital. I notified the supervisor of the incident after the gentleman left."

The distance of the fire extinguishers was assessed by 3 environment/maintenance hospital employees who determined the fire extinguisher was approximately 52 feet from the door of the main entrance and approximately 60 feet from the bench which was outside the door of the main entrance. The Director of Safety and Protection estimated the truck was 60 feet from the entrance.

The nursing supervisor was interviewed on 3/15/12 and stated, "I didn't know there was a person at the front door until after the police had taken him away. I sent (name of Administrator) an email regarding what I knew of the incident."

A copy of the email sent from the nursing supervisor to the Administrator was provided by the Director of Regulatory Compliance. The email was reviewed and provided the following information:
"At approximately 2:00 this morning (3/2/12) (name of PO) reported he had intervened in a man attempting to commit suicide. Apparently the man approached (name of PO) outside, asking him (PO) to call someone to help him because he was going to kill himself. At that time 2 nurses came out the front door heading to the sidewalk for a smoke. (Name of PO) was distracted by making sure no one was in the area to cause a problem for the nurses the man sat on the bench beside the front entrance and sat (sig)himself on fire. (Name of PO) reported he was able to extinguish the fire before the man suffered any serious injury and called the police..."

The 2 nurses who walked out of the building were interviewed on 3/16/12 at 6:45 A.M.

Employee #6 stated, "(Name of PO) and a man sitting on the bench were outside when we exited the building. (Name of PO) walked up to us and said the gentleman appeared to be mentally unstable and the police have been called. (Name of PO) said he had not search the man and did not know if he had any type of weapon and to stay put. We were about 6 feet from the driveway by two trees and could not see anything."

Employee #7 stated, "As we came out the front entrance (name of PO) was standing and talking to someone on the bench. I asked if it was ok for us to come out and he said yes. (Name of PO) walked up to us where we were smoking and said the gentleman said he was going to kill himself and he had called 911. (Name of PO) walked back toward the man and we heard him say "Oh! No!" He (PO) then came back to us and told us the man had sat himself on fire but that he was ok. I could not see him (the unknown man); I guess he was still on the bench. (Name of PO) told us to not come in until the police arrived. We could not see the front of the building because a bush blocked our view."

On 3/15/12 the Nurse Manager and the Director of Regulatory Compliance were asked for their policy pertaining to emergent care. The Nurse Manager stated, "We do not have a policy on emergent care only this. The Nurse Manager stated, "The nurses would refer the situation to the PO if someone like this gentleman came to the door asking for help. My gut would be to call 911."

The Nurse Manager presented the facility policy with the category: Criminal Activity and subject: Police Assistance # 800.005 with a Last Revision Date of 09/2007.

The policy was reviewed and the following is noted: "If the facts and situation warrants, the Protection Officer shall contact (911 if necessary) the local law enforcement when confronted with the following:
Threats to persons or property
Armed and unarmed assaults
Breaking and entering of any RHS facility
Breach of Peace, Fights, unruly crowd or individuals
Indecent exposure
Intoxicated persons, Mentally disturbed person or persons under the influence of drugs
Sexual Assaults (rape or molestation, etc.,)
Larceny to facility, patient, employee or visitor
Threatening, Harassing or Obscene phone calls
Robbery or homicide
Any strange, suspicious or unusual circumstance or person.

Protection Officers shall exhaust all means of providing assistance to maintain or restore the preservation of the peace and to prevent further destruction of property until the police arrive.

Once it has been established that any incident as outlined above has occurred, Officers shall notify:
1. Protection Supervisor
2. The Protection Supervisor shall contact the Protection Manager or Director, Safety & Protection Management...All detentions, inquires and contacts that result in a police response shall be documented in the log book and a QCCR written with complete details on the matter..."

The Director of Safety and Protection was asked to explain QCCR and stated, "That is our old way of documenting we have been using Midas for a while now."

The hospital surveillance video captured the above incident on video. The video was reviewed on 3/15/12 in the presence of the Director of Safety and Protection, Director of Regulatory Compliance and Nurse Manager. The video shows: the door opening, the unknown man entering the building as the PO approached the door, the man being escorted out of the building without any hands being placed upon him. The man eventually sat on the bench next to the front door entrance. (Video showed PO making a phone call and Director of Safety and Protection stated this is where the first call to the police occurred.) 2 people (identified as nurses by the nurse manager) exit the building, passing the unknown male sitting on the bench and PO, without stopping. The PO re-enters the building for approximately 10 to 15 seconds. The PO then walks out of view of the camera for approximately 10 to 15 seconds returns and finds the unknown man still sitting on the bench outside the front entrance, in flames from his lap to his head. The PO repeatedly kicked the unknown man in the chest to extinguish the flames, which were extinguished. The video shows the PO making a second call (identified by Director of Safety and Protection as a second call to the Police). Approximately 6 and 1/2 minutes pass before the police arrive. No one was observed assisting the PO with the unknown man throughout the video until the police arrived and assisted him.

There is no evidence the 2 staff who exited the building was asked by the PO to render assistance and there is no evidence the 2 staff offered assistance.

The Director of Safety and Protection (DPS) was interviewed on 3/15/12 regarding his investigation of the incident. The DPS stated, "He (unknown man) only threatened himself, he never threatened the PO or anyone or the building. He (the unknown man) never threatened the police or EMS. The only conversation PO reported with the 2 nurses was when they asked if it was safe to re-enter the building."

A copy of the SP's investigation of the incident was provided by the Nurse Manager and provided the following information:

"On 3/2/12 at approximately 1:30 A.M. an unidentified male knocked on the front door...The man asked for help and PO asked what kind of help. The man replied I'm going to kill myself. The man sat on the bench in front of the facility. PO began to question the man the man said two to three times "You better call CB because I want to kill myself." PO called 911. As PO was observing the man 2 nurses exited the facility and walked toward the street. PO was monitoring the nurses, the man began to cry which was heard by PO and began to flicker a lighter. The PO called to the man and announced that smoking was not allowed on campus. The PO noticed the man had sat himself on fire. PO came the man's aid and put the fire out using his (the PO's) foot. EMS (911) was called a second time. As PO waited on the EMS he yelled out for assistance but the 2 nurses had left the area. The police arrived and a short time thereafter the ambulance arrived..."

The word hospital was on the sign identifying the building.

Based on staff interview, facility policy review and review of surveillance video the facility staff failed to ensure a patient was free from all forms of abuse; the staff neglected to appropriately assess an unknown male who presented to the facility requesting help for suicidal ideation's.

The Findings Include:

On March 2, 2012 at 0135 an unknown male banged on the front entrance of the hospital which was answered by the on duty Protection Officer (PO). The unknown male told the PO he (the unknown male) wanted to kill himself and needed help. The PO documented the following: he informed the unknown male the hospital "was not the facility". The unknown male sat on a bench outside the main entrance door and refused to leave the property unless the local authorities were called.

During an interview with the PO on 3/15/12 he stated, "I called the police. He (the unknown male) started flicking a lighter and I informed him he could not smoke on hospital property. Two (2) people came out of the building to smoke a cigarette and I walked away from the gentleman. When I returned which was seconds later the gentleman had set his jacket on fire. I stomped the fire out with my foot because there was no fire extinguisher nearby and I didn't have any gloves. The nearest fire extinguisher was inside the building and in the truck. I called the police a second time to tell them we needed an ambulance also. The police finally came and the gentleman was taken to the hospital. I notified the supervisor of the incident after the gentleman left."

The nursing supervisor was interviewed on 3/15/12 and stated, "I didn't know there was a person at the front door until after the police had taken him away. I sent (name of Administrator) an email regarding what I knew of the incident."

A copy of the email sent from the nursing supervisor to the Administrator was provided by the Director of Regulatory Compliance. The email was reviewed and provided the following information:
"At approximately 2:00 this morning (3/2/12) (name of PO) reported he had intervened in a man attempting to commit suicide. Apparently the man approached (name of PO) outside, asking him (PO) to call someone to help him because he was going to kill himself. At that time 2 nurses came out the front door heading to the sidewalk for a smoke. (Name of PO) was distracted by making sure no one was in the area to cause a problem for the nurses the man sat on the bench beside the front entrance and sat himself on fire. (Name of PO) reported he was able to extinguish the fire before the man suffered any serious injury and called the police...."

Employee #6 stated, "We (name of employee #7) went outside to smoke a cigarette. (Name of PO) and a man sitting on the bench were outside when we exited the building. (Name of PO) walked up to us and said the gentleman appeared to be mentally unstable and the police have been called. (Name of PO) said he had not search the man and did not know if he had any type of weapon and to stay put. We were about 6 feet from the driveway by two trees and could not see anything."

Employee #7 stated, "As we came out the front entrance (name of PO) was standing and talking to someone on the bench. I asked if it was ok for us to come out and he said yes. (Name of PO) walked up to us where we were smoking and said the gentleman said he was going to kill himself and he had called 911. (Name of PO) walked back toward the man and we heard him say "Oh! No!" He (PO) then came back to us and told us the man had sat himself on fire but that he was ok. I could not see him (the unknown man); I guess he was still on the bench. (Name of PO) told us to not come in until the police arrived. We could not see the front of the building because a bush blocked our view."

On 3/15/12 the Nurse Manager and the Director of Regulatory Compliance were asked for their policy pertaining to emergent care. The Nurse Manager stated, "We do not have a policy on emergent care only this. The Nurse Manager stated, "The nurses would refer the situation to the PO if someone like this gentleman came to the door asking for help. My gut would be to call 911."

The Nurse Manager presented the facility policy with the category: Criminal Activity and subject: Police Assistance # 800.005 with a Last Revision Date of 09/2007.

The policy was reviewed and the following is noted: "If the facts and situation warrants, the Protection Officer shall contact (911 if necessary) the local law enforcement when confronted with the following:
Threats to persons or property
Armed and unarmed assaults
Breaking and entering of any RHS facility
Breach of Peace, Fights, unruly crowd or individuals
Indecent exposure
Intoxicated persons, Mentally disturbed person or persons under the influence of drugs
Sexual Assaults (rape or molestation, etc.,)
Larceny to facility, patient, employee or visitor
Threatening, Harassing or Obscene phone calls
Robbery or homicide
Any strange, suspicious or unusual circumstance or person.

Protection Officers shall exhaust all means of providing assistance to maintain or restore the preservation of the peace and to prevent further destruction of property until the police arrive.

Once it has been established that any incident as outlined above has occurred, Officers shall notify:
1. Protection Supervisor
2. The Protection Supervisor shall contact the Protection Manager or Director, Safety & Protection Management...All detentions, inquires and contacts that result in a police response shall be documented in the log book and a QCCR written with complete details on the matter..."

The Director of Safety and Protection was asked to explain QCCR and stated, "That is our old way of documenting we have been using Midas for a while now."

The hospital surveillance video captured the above incident on video. The video was reviewed on 3/15/12 in the presence of the Director of Safety and Protection, Director of Regulatory Compliance and Nurse Manager. The video shows the door opening, the unknown man entering the building as the PO approached the door, the man being escorted out of the building without any hands being placed upon him. The man eventually sat on the bench. Police are called. 2 people (nurses, 1 registered nurse and 1 licensed practical nurse) exit the building without stopping. The PO re-enters the building for approximately 10 to 15 seconds. The PO then walks out of view of the camera for approximately 10 to 15 seconds returns and finds the unknown man in flames from his lap to his head. The PO repeatedly kicked the unknown man in the chest to extinguish the flames. The police are called a second time. Approximately 6 and 1/2 minutes pass before the police arrive. The 2 people re-enter the building while police are present.

There is no evidence the 2 staff who exited the building were asked by the PO to render assistance and there is no evidence the 2 staff offered assistance.

The Director of Safety and Protection (DSP) was interviewed on 3/15/12 regarding his investigation of the incident. The DSP stated, "He (unknown man) only threatened himself, he never threatened the PO or anyone or the building. He (the unknown man) never threatened the police or EMS. The only conversation PO reported with the 2 nurses was when they asked if it was safe to re-enter the building."

Based on staff interviews and a review of the facility's Medical Staff Bylaws, the facility staff failed to ensure the medical staff was accountable to the governing body when patients who came to the facility for emergency care were appropriately assessed, treated and referred when appropriate.

The Findings Include:

The Director of Regulatory Compliance provided a copy of the Medical Staff Bylaws which were approved by the Board of Directors on January 23, 2012. The above named bylaws section titled Organization Policy (Name of Facility), Article II: General Medical Staff Rules and Regulations, Section E, Emergency Situations states, "If an emergency situation develops, action should be taken as follows: #2 Behavior health issues - assess the situation, initiate immediate action and contact the appropriate mental health agency. If it is identified that there may be harm to other individuals in the area, the local police should be contacted via 911."

The above named bylaws do not specify who should perform the assessment should no physician be available.


On March 2, 2012 at 0135 an unknown male banged on the front entrance of the hospital which was answered by the on duty Protection Officer (PO). The unknown male told the PO he (the unknown male) wanted to kill himself and needed help. The PO documented the following: he informed the unknown male the hospital "was not the facility". The unknown male sat on a bench outside the main entrance door and refused to leave the property unless the local authorities were called.

During an interview with the PO on 3/15/12 he stated, "I called the police. He (the unknown male) started flicking a lighter and I informed him he could not smoke on hospital property. Two (2) people came out of the building to smoke a cigarette and I walked away from the gentleman. When I returned which was seconds later the gentleman had set his jacket on fire. I stomped the fire out with my foot because there was no fire extinguisher nearby and I didn't have any gloves. The nearest fire extinguisher was inside the building and in the truck. I called the police a second time to tell them we needed an ambulance also. The police finally came and the gentleman was taken to the hospital. I notified the supervisor of the incident after the gentleman left."

The nursing supervisor was interviewed on 3/15/12 and stated, "I didn't know there was a person at the front door until after the police had taken him away. I sent (name of Administrator) an email regarding what I knew of the incident."

A copy of the email sent from the nursing supervisor to the Administrator was provided by the Director of Regulatory Compliance. The email was reviewed and provided the following information:
"At approximately 2:00 this morning (3/2/12) (name of PO) reported he had intervened in a man attempting to commit suicide. Apparently the man approached (name of PO) outside, asking him (PO) to call someone to help him because he was going to kill himself. At that time 2 nurses came out the front door heading to the sidewalk for a smoke. (Name of PO) was distracted by making sure no one was in the area to cause a problem for the nurses the man sat on the bench beside the front entrance and sat himself on fire. (Name of PO) reported he was able to extinguish the fire before the man suffered any serious injury and called the police...."

Employee #6 stated, "We (name of employee #7) went outside to smoke a cigarette. (Name of PO) and a man sitting on the bench were outside when we exited the building. (Name of PO) walked up to us and said the gentleman appeared to be mentally unstable and the police have been called. (Name of PO) said he had not search the man and did not know if he had any type of weapon and to stay put. We were about 6 feet from the driveway by two trees and could not see anything."

Employee #7 stated, "As we came out the front entrance (name of PO) was standing and talking to someone on the bench. I asked if it was ok for us to come out and he said yes. (Name of PO) walked up to us where we were smoking and said the gentleman said he was going to kill himself and he had called 911. (Name of PO) walked back toward the man and we heard him say "Oh! No!" He (PO) then came back to us and told us the man had sat himself on fire but that he was ok. I could not see him (the unknown man); I guess he was still on the bench. (Name of PO) told us to not come in until the police arrived. We could not see the front of the building because a bush blocked our view."

On 3/15/12 the Nurse Manager and the Director of Regulatory Compliance were asked for their policy pertaining to emergent care. The Nurse Manager stated, "We do not have a policy on emergent care only this. The Nurse Manager stated, "The nurses would refer the situation to the PO if someone like this gentleman came to the door asking for help. My gut would be to call 911."

The Nurse Manager presented the facility policy with the category: Criminal Activity and subject: Police Assistance # 800.005 with a Last Revision Date of 09/2007.

The policy was reviewed and the following is noted: "If the facts and situation warrants, the Protection Officer shall contact (911 if necessary) the local law enforcement when confronted with the following:
Threats to persons or property
Armed and unarmed assaults
Breaking and entering of any RHS facility
Breach of Peace, Fights, unruly crowd or individuals
Indecent exposure
Intoxicated persons, Mentally disturbed person or persons under the influence of drugs
Sexual Assaults (rape or molestation, etc.,)
Larceny to facility, patient, employee or visitor
Threatening, Harassing or Obscene phone calls
Robbery or homicide
Any strange, suspicious or unusual circumstance or person.

Protection Officers shall exhaust all means of providing assistance to maintain or restore the preservation of the peace and to prevent further destruction of property until the police arrive.

Once it has been established that any incident as outlined above has occurred, Officers shall notify:
1. Protection Supervisor
2. The Protection Supervisor shall contact the Protection Manager or Director, Safety & Protection Management...All detentions, inquires and contacts that result in a police response shall be documented in the log book and a QCCR written with complete details on the matter..."

The hospital surveillance video captured the above incident on video. The video was reviewed on 3/15/12 in the presence of the Director of Safety and Protection, Director of Regulatory Compliance and Nurse Manager. The video shows the door opening, the unknown man entering the building as the PO approached the door, the man being escorted out of the building without any hands being placed upon him. The man eventually sat on the bench. Police are called. 2 people (nurses, 1 registered nurse and 1 licensed practical nurse) exit the building without stopping. The PO re-enters the building for approximately 10 to 15 seconds. The PO then walks out of view of the camera for approximately 10 to 15 seconds returns and finds the unknown man in flames from his lap to his head. The PO repeatedly kicked the unknown man in the chest to extinguish the flames. The police are called a second time. Approximately 6 and 1/2 minutes pass before the police arrive. The 2 people re-enter the building while police are present.

There is no evidence the 2 staff who exited the building were asked by the PO to render assistance and there is no evidence the 2 staff offered assistance.

The Director of Safety and Protection (DSP) was interviewed on 3/15/12 regarding his investigation of the incident. The DSP stated, "He (unknown man) only threatened himself, he never threatened the PO or anyone or the building. He (the unknown man) never threatened the police or EMS. The only conversation PO reported with the 2 nurses was when they asked if it was safe to re-enter the building."

A review of the PO's personnel file was conducted during a previous survey on 3/14/12. The PO's personnel file did not indicate he had ever received training in assessing a person who is potentially suicidal. A copy of the facility's Behavioral Intervention Program was provided by the Nurse Manager on 3/15/12. The program was reviewed and there is no evidence in the training a PO received training to assess a potentially suicidal person.

Based on staff interviews, facility policy review and surveillance video review the facility staff failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care for a patient who presented to the hospital for emergent care.

On March 2, 2012 an unknown male banged on the front entrance of the hospital which was answered by the on duty Protection Officer (security guard). The unknown male told the security guard he wanted to kill himself and needed help. At no time during the incident was the nursing supervisor called to assess the situation.

The Findings Include:

On March 2, 2012 at 0135 an unknown male banged on the front entrance of the hospital which was answered by the on duty Protection Officer (PO). The unknown male told the PO he (the unknown male) wanted to kill himself and needed help. The PO documented the following: he informed the unknown male the hospital "was not the facility". The unknown male sat on a bench outside the main entrance door and refused to leave the property unless the local authorities were called.

During an interview with the PO on 3/15/12 he stated, "I called the police. He (the unknown male) started flicking a lighter and I informed him he could not smoke on hospital property. Two (2) people came out of the building to smoke a cigarette and I walked away from the gentleman. When I returned which was seconds later the gentleman had set his jacket on fire. I stomped the fire out with my foot because there was no fire extinguisher nearby and I didn't have any gloves. The nearest fire extinguisher was inside the building and in the truck. I called the police a second time to tell them we needed an ambulance also. The police finally came and the gentleman was taken to the hospital. I notified the supervisor of the incident after the gentleman left."

The nursing supervisor was interviewed on 3/15/12 and stated, "I didn't know there was a person at the front door until after the police had taken him away. I sent (name of Administrator) an email regarding what I knew of the incident."

A copy of the email sent from the nursing supervisor to the Administrator was provided by the Director of Regulatory Compliance. The email was reviewed and provided the following information:
"At approximately 2:00 this morning (3/2/12) (name of PO) reported he had intervened in a man attempting to commit suicide. Apparently the man approached (name of PO) outside, asking him (PO) to call someone to help him because he was going to kill himself. At that time 2 nurses came out the front door heading to the sidewalk for a smoke. (Name of PO) was distracted by making sure no one was in the area to cause a problem for the nurses the man sat on the bench beside the front entrance and sat himself on fire. (Name of PO) reported he was able to extinguish the fire before the man suffered any serious injury and called the police...."

The 2 nurses who walked out of the building were interviewed on 3/16/12 at 6:45 A.M.

Employee #6 stated, "(Name of PO) and a man sitting on the bench were outside when we exited the building. (Name of PO) walked up to us and said the gentleman appeared to be mentally unstable and the police have been called. (Name of PO) said he had not search the man and did not know if he had any type of weapon and to stay put. We were about 6 feet from the driveway by two trees and could not see anything."

Employee #7 stated, "As we came out the front entrance (name of PO) was standing and talking to someone on the bench. I asked if it was ok for us to come out and he said yes. (Name of PO) walked up to us where we were smoking and said the gentleman said he was going to kill himself and he had called 911. (Name of PO) walked back toward the man and we heard him say "Oh! No!" He (PO) then came back to us and told us the man had sat himself on fire but that he was ok. I could not see him (the unknown man); I guess he was still on the bench. (Name of PO) told us to not come in until the police arrived. We could not see the front of the building because a bush blocked our view."

On 3/15/12 the Nurse Manager and the Director of Regulatory Compliance were asked for their policy pertaining to emergent care. The Nurse Manager stated, "We do not have a policy on emergent care only this. The Nurse Manager stated, "The nurses would refer the situation to the PO if someone like this gentleman came to the door asking for help. My gut would be to call 911."

The Nurse Manager presented the facility policy with the category: Criminal Activity and subject: Police Assistance # 800.005 with a Last Revision Date of 09/2007.

The policy was reviewed and the following is noted: "If the facts and situation warrants, the Protection Officer shall contact (911 if necessary) the local law enforcement when confronted with the following:
Threats to persons or property
Armed and unarmed assaults
Breaking and entering of any RHS facility
Breach of Peace, Fights, unruly crowd or individuals
Indecent exposure
Intoxicated persons, Mentally disturbed person or persons under the influence of drugs
Sexual Assaults (rape or molestation, etc.,)
Larceny to facility, patient, employee or visitor
Threatening, Harassing or Obscene phone calls
Robbery or homicide
Any strange, suspicious or unusual circumstance or person.

Protection Officers shall exhaust all means of providing assistance to maintain or restore the preservation of the peace and to prevent further destruction of property until the police arrive.

Once it has been established that any incident as outlined above has occurred, Officers shall notify:
1. Protection Supervisor
2. The Protection Supervisor shall contact the Protection Manager or Director, Safety & Protection Management...All detentions, inquires and contacts that result in a police response shall be documented in the log book and a QCCR written with complete details on the matter..."

The hospital surveillance video captured the above incident on video. The video was reviewed on 3/15/12 in the presence of the Director of Safety and Protection, Director of Regulatory Compliance and Nurse Manager. The video shows the door opening, the unknown man entering the building as the PO approached the door, the man being escorted out of the building without any hands being placed upon him. The man eventually sat on the bench. Police are called. 2 people (nurses, 1 registered nurse and 1 licensed practical nurse) exit the building without stopping. The PO re-enters the building for approximately 10 to 15 seconds. The PO then walks out of view of the camera for approximately 10 to 15 seconds returns and finds the unknown man in flames from his lap to his head. The PO repeatedly kicked the unknown man in the chest to extinguish the flames. The police are called a second time. Approximately 6 and 1/2 minutes pass before the police arrive. The 2 people re-enter the building while police are present.

There is no evidence the 2 staff who exited the building was asked by the PO to render assistance and there is no evidence the 2 staff offered assistance.

The Director of Safety and Protection (DSP) was interviewed on 3/15/12 regarding his investigation of the incident. The DSP stated, "He (unknown man) only threatened himself, he never threatened the PO or anyone or the building. He (the unknown man) never threatened the police or EMS. The only conversation PO reported with the 2 nurses was when they asked if it was safe to re-enter the building."

A copy of the DSP's investigation of the incident was provided by the Nurse Manager and provided the following information:

On 3/2/12 at approximately 1:30 A.M. an unidentified male knocked on the front door...The man asked for help and PO asked what kind of help. The man replied I'm going to kill myself. The man sat on the bench in front of the facility. PO began to question the man the man said two to three times "You better call CSB because I want to kill myself." PO called 911. As PO was observing the man 2 nurses exited the facility and walked toward the street. PO was monitoring the nurses, the man began to cry which was heard by PO and began to flicker a lighter. The PO called to the man and announced that smoking was not allowed on campus. The PO noticed the man had sat himself on fire. PO came the man's aid and put the fire out using his (the PO's) foot. EMS (911) was called a second time. As PO waited on the EMS he yelled out for assistance but the 2 nurses had left the area. The police arrived and a short time thereafter the ambulance arrived...

Based on staff interviews, facility policy review and surveillance video review the facility staff failed to ensure there were clear expectations for safety for patient(s) as well as staff and visitors in the event of an emergent situation on the hospital campus.

The Findings Include:

On March 2, 2012 at 0135 an unknown male banged on the front entrance of the hospital which was answered by the on duty Protection Officer (PO). The unknown male told the PO he (the unknown male) wanted to kill himself and needed help. The PO documented the following: he informed the unknown male the hospital "was not the facility." The unknown male sat on a bench outside the main entrance door and refused to leave the property unless the local authorities were called.

During an interview with the PO on 3/15/12 he stated, "I called the police. He (the unknown male) started flicking a lighter and I informed him he could not smoke on hospital property. Two (2) people came out of the building to smoke a cigarette and I walked away from the gentleman. When I returned which was seconds later the gentleman had set his jacket on fire. I stomped the fire out with my foot because there was no fire extinguisher nearby and I didn't have any gloves. The nearest fire extinguisher was inside the building and in the truck. I called the police a second time to tell them we needed an ambulance also. The police finally came and the gentleman was taken to the hospital. I notified the supervisor of the incident after the gentleman left."

The nursing supervisor was interviewed on 3/15/12 and stated, "I didn't know there was a person at the front door until after the police had taken him away. I sent (name of Administrator) an email regarding what I knew of the incident."

A copy of the email sent from the nursing supervisor to the Administrator was provided by the Director of Regulatory Compliance. The email was reviewed and provided the following information:
"At approximately 2:00 this morning (3/2/12) (name of PO) reported he had intervened in a man attempting to commit suicide. Apparently the man approached (name of PO) outside, asking him (PO) to call someone to help him because he was going to kill himself. At that time 2 nurses came out the front door heading to the sidewalk for a smoke. (Name of PO) was distracted by making sure no one was in the area to cause a problem for the nurses the man sat on the bench beside the front entrance and sat himself on fire. (Name of PO) reported he was able to extinguish the fire before the man suffered any serious injury and called the police...."

Employee #6 stated, "We (name of employee #7) went outside to smoke a cigarette. (Name of PO) and a man sitting on the bench were outside when we exited the building. (Name of PO) walked up to us and said the gentleman appeared to be mentally unstable and the police have been called. (Name of PO) said he had not search the man and did not know if he had any type of weapon and to stay put. We were about 6 feet from the driveway by two trees and could not see anything."

Employee #7 stated, "As we came out the front entrance (name of PO) was standing and talking to someone on the bench. I asked if it was ok for us to come out and he said yes. (Name of PO) walked up to us where we were smoking and said the gentleman said he was going to kill himself and he had called 911. (Name of PO) walked back toward the man and we heard him say "Oh! No!" He (PO) then came back to us and told us the man had sat himself on fire but that he was ok. I could not see him (the unknown man); I guess he was still on the bench. (Name of PO) told us to not come in until the police arrived. We could not see the front of the building because a bush blocked our view."

On 3/15/12 the Nurse Manager and the Director of Regulatory Compliance were asked for their policy pertaining to emergent care. The Nurse Manager stated, "We do not have a policy on emergent care only this. The Nurse Manager stated, "The nurses would refer the situation to the PO if someone like this gentleman came to the door asking for help. My gut would be to call 911."

The Nurse Manager presented the facility policy with the category: Criminal Activity and subject: Police Assistance # 800.005 with a Last Revision Date of 09/2007.

The policy was reviewed and the following is noted: "If the facts and situation warrants, the Protection Officer shall contact (911 if necessary) the local law enforcement when confronted with the following:
Threats to persons or property
Armed and unarmed assaults
Breaking and entering of any RHS facility
Breach of Peace, Fights, unruly crowd or individuals
Indecent exposure
Intoxicated persons, Mentally disturbed person or persons under the influence of drugs
Sexual Assaults (rape or molestation, etc.,)
Larceny to facility, patient, employee or visitor
Threatening, Harassing or Obscene phone calls
Robbery or homicide
Any strange, suspicious or unusual circumstance or person.

Protection Officers shall exhaust all means of providing assistance to maintain or restore the preservation of the peace and to prevent further destruction of property until the police arrive.

Once it has been established that any incident as outlined above has occurred, Officers shall notify:
1. Protection Supervisor
2. The Protection Supervisor shall contact the Protection Manager or Director, Safety & Protection Management...All detentions, inquires and contacts that result in a police response shall be documented in the log book and a QCCR written with complete details on the matter..."

The Director of Safety and Protection was asked to explain QCCR and stated, "That is our old way of documenting we have been using Midas for a while now."

The hospital surveillance video captured the above incident on video. The video was reviewed on 3/15/12 in the presence of the Director of Safety and Protection, Director of Regulatory Compliance and Nurse Manager. The video shows the door opening, the unknown man entering the building as the PO approached the door, the man being escorted out of the building without any hands being placed upon him. The man eventually sat on the bench. Police are called. 2 people (nurses, 1 registered nurse and 1 licensed practical nurse) exit the building without stopping. The PO re-enters the building for approximately 10 to 15 seconds. The PO then walks out of view of the camera for approximately 10 to 15 seconds returns and finds the unknown man in flames from his lap to his head. The PO repeatedly kicked the unknown man in the chest to extinguish the flames. The police are called a second time. Approximately 6 and 1/2 minutes pass before the police arrive. The 2 people re-enter the building while police are present.

There is no evidence the 2 staff who exited the building were asked by the PO to render assistance and there is no evidence the 2 staff offered assistance.

The Director of Safety and Protection (DSP) was interviewed on 3/15/12 regarding his investigation of the incident. The DSP stated, "He (unknown man) only threatened himself, he never threatened the PO or anyone or the building. He (the unknown man) never threatened the police or EMS. The only conversation PO reported with the 2 nurses was when they asked if it was safe to re-enter the building."