Clara Maass Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48965 Based on staff interviews, review of medical records, and review of facility documents, it was determined that the facility failed to ensure: 1). that a mechanism was in place to identify the presence of weapon(s) for civilians entering the facility, in accordance with facility policy and procedure, in one out of 10 Medical Records (Patient (P) 1) (Cross Reference - A0144); and 2). the Violence Assessment Tool (VAT screening) was appropriately documented for six out of six Medical Records (P1, P3, P4, P8, P9, and P10) whose diagnoses were alcohol intoxication or alcohol abuse related (Cross Reference - A0144). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patients. On January 4, 2024 at 2:33 PM, an IJ was identified for the facility’s failure to ensure that a mechanism was in place to identify the presence of weapon(s) for all civilians entering the facility, in accordance with facility policy and procedure. On January 4, 2024, at 3:50 PM, the IJ template was presented to administration and a removal plan was requested. On January 5, 2024, at 10:56 AM an acceptable plan of removal was received. The facility implemented the following: Initiated education to Emergency Department (ED) Registered Nurses (RNs) regarding the proper documentation and completion of the Violence Assessment Tool (VAT) in the Electronic Medical Record (EMR), provided education to all security officers/concierge and ED RNs regarding the new weapon detection security process for a security officer to be placed in the ambulance bay entrance at all times to screen all patients/visitors (as able) for weapons, a security officer will be stationed in the ambulance bay 24 hours a day/7 day a week, all visitors accompanying a patient arriving by ambulance will continue to be instructed to enter via the main ED entrance where they will be screened for weapons, a security officer/concierge will be assigned to screen patients/visitors at all entrances for the presence of weapons, security will be required to complete a Weapon Screening log in the ED ambulance bay. The IJ was resolved on January 5, 2024, at 1:30 PM, after the State Survey Agency verified full implementation of the removal plan through tours, staff interviews, document review and review of staff education. Cross Reference: A-0144 - 482.13(c)(2) Patient Rights: Care in Safe Setting”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48965 Based on medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to ensure: 1). that a mechanism was in place to identify the presence of weapon(s) for civilians entering the facility, in accordance with facility policy and procedure, in one out of 10 Medical Records(Patient (P) 1); and 2). that the Violence Assessment Tool (VAT screening) was appropriately documented for six out of six Medical Records (P1, P3, P4, P8, P9, and P10) whose diagnoses were alcohol intoxication or alcohol abuse related. Findings include: 1) On 1/4/24, P1’s medical record was reviewed. P1 presented to the Emergency Department (ED) on 1/1/24 at 8:27 PM via Emergency Medical Services (EMS), through the ambulance entrance, with a chief complaint of alcohol intoxication. P1 was triaged at 8:27 PM, and at 8:32 PM was placed in an ED Hallway bed. At 8:33 PM he/she screened negative on the Columbia Suicide Severity Rating Scale (C-SSRS). A VAT screening was completed by Staff (S) 23, a Registered Nurse (RN), on 1/1/24 at 9:30 PM that stated, “... Substance intoxification/withdrawal: not applicable.” A review of the facility’s documentation regarding an incident, dated 1/2/24, indicated that P1 became agitated and was attempting to get up from the stretcher. P1 stated multiple times “I want my gun” and was reaching for his/her bag. Patient was medicated and Security was immediately notified and responded to P1’s bedside. On 1/2/24 at 12:41 AM, Security and the RN searched P1’s belongings and located a firearm. The firearm was secured and the police were notified. Police responded and the firearm was turned over to law enforcement. Police Case # 24-000136 indicated that the Magazine was loaded, in the gun, and no round was in the chamber. An interview was conducted with S6, the AVP of the ED, on 1/4/24 at 10:43 AM. S6 confirmed the incident occurred, and explained that belongings are only searched if the patient is a Behavioral Health (BH) patient. Facility policy titled “Weapons Detection Policy” stated, “ ...1. Firearms specifically are not permitted even if the carrier has a valid federal or state license to possess a weapon or firearm, concealed or otherwise. ...Enforcement Mechanisms: Search Authorization: All individuals entering [name] property are subject to search, including WDS [weapons detection system] ...” Facility policy titled “Patient Search Policy” states, “ ...Policy: ...4. Illegal contraband and weapons are given to Security for disposition .... Procedure: 1. Upon presenting to triage, the following questions are assessed in order to identify patients with an increased risk for potential for harm to self or others: ...has the patient engaged in bizarre behavior or exhibited grossly impaired judgment?...2. An answer to any of the above questions of ‘yes’ is an indicator to initiate the Patient Watch Policy and perform a patient search ...” Facility policy titled “Suicide Risk Screening and Assessment” states, “ ...Definitions: Behavior health presentations: Patients may present with the following complaints: depression, anxiety, agitation, violent/combative behavior, paranoia, hallucinations, delusions, suicidal ideation, homicidal ideation, and acute psychosis. Also includes alcohol or substance abuse or disorders ...” An interview with S9, ED RN, took place on 1/4/24 at 10:48 AM. S9 explains that when a patient arrives via ambulance, they stop at the nurses’ station to be evaluated by the DIT (Discharge/Internal/Triage) Nurse. At this point, vital signs are taken. If the patient is a BH patient, the charge nurse assigns the bed, and a “Code Watch” is called. S9 explains that a “Code Watch” alerts security, the ED technician (tech), and ED provider (if needed), that they need to report to the patient’s room. S9 explains that patient belongings are searched and inventoried. At least 2 people must be present for the search of the patient’s belongings, it is typically security and the ED tech and/or ED RN. S9 reports that he/she would call a “Code Watch” on an intoxicated patient or one that is under the influence of drugs because these patients could have more drugs or alcohol in their bags. On 1/4/24 at 1:30 PM, S7, the Assistant Director of the ED, was asked where the nurse documents the questions assessed in the “Patient Search Policy.” S7 indicated that the questions are not asked of the patient or documented in the medical record. It’s a guide used to assist the nurse in determining if the Patient Search Policy should be implemented. On 1/4/24, at 1:32 PM, the above findings were reviewed with S6. S6 stated that the VAT assessment was not filled out correctly regarding the patients presenting complaint. Upon request, S6 provided an example of a VAT screening with the answer of “observed behavior” for the “Substance intoxification/Withdrawal” question. S6, indicated that if the question was answered as “observed behavior,” a violence risk score of “moderate risk” would have been generated and specific “Actions to take” would populate for the RN to select. S6 indicated that P1’s VAT assessment should have been answered as “observed behavior.” The VAT screening, when used appropriately, suggests measures to promote the safety of the patient and staff through therapeutic interventions. The VAT policy was requested. S6 stated that the facility does not have a specific VAT policy. The staff were educated on completing the VAT assessment through EPIC (an electronic health records system) training and it is the expectancy that the VAT assessment be completed correctly on all patients. S23, S24, and S25’s personnel file was reviewed and indicated all three staff completed the EPIC training. S23’s EPIC training was completed on 8/12/23, S24’s EPIC training was completed on 10/8/23, S25’s EPIC training was completed on 11/20/23. P1’s VAT assessment was not completed accurately, therefore he/she was not identifed as an increased risk for violence, or as a BH patient and was not searched. The patient was able to enter the facility with a concealed loaded weapon in their possession, which could have the potential to be used to cause harm to self or others. 49828 2) On 1/4/24, the medical records for (P1, P3, P4, P8, P9, and P10) were reviewed and revealed the following: P1 presented to the ED on 1/1/24 at 8:27 PM with a chief complaint of “Alcohol Intoxication.” A VAT screening was completed by S23, a Registered Nurse (RN), on 1/1/24 at 9:30 PM that stated, “... Substance intoxification/withdrawal: not applicable.” P3 presented to the ED on 1/1/24 at 1:45 AM with a chief complaint of “Alcohol Intoxication.” A VAT screening was completed by S24, an RN, on 1/1/24 at 2:31 AM that stated, “... Substance intoxification/withdrawal: not applicable.” The basic assessment documentation entered by S24 on 1/1/24 at 2:31 AM stated, “Psychosocial (WDL) [Within Defined Limits]: Exceptions to WDL: ETOH [alcohol].” P4 presented to the ED on 1/1/24 at 10:29 PM with a chief complaint of “Alcohol Intoxication.” A VAT screening was completed by S25, an RN, on 1/1/24 at 10:43 PM that stated, “... Substance intoxification/withdrawal: not applicable.” P8 presented to the ED on 1/1/24 at 2:26 AM with a chief complaint of “Alcohol Intoxication.” A VAT screening was completed by S24 on 1/1/24 at 2:38 AM that stated, “... Substance intoxification/withdrawal: not applicable.” The basic assessment documentation entered by S24 on 1/1/24 at 2:38 AM stated, “Psychosocial (WDL): Within Defined Limit (ETOH).” P9 presented to the ED on 1/2/24 at 10:49 PM with a chief complaint of “Alcohol Intoxication.” A VAT screening was completed by S24 on 1/2/24 at 11:18 PM that stated, “... Substance intoxification/withdrawal: not applicable.” The basic assessment documentation entered by S24 on 1/1/24 at 11:18 PM stated, “Psychosocial (WDL): Exceptions to WDL: ETOH.” P10 presented to the ED on 1/1/24 at 2:05 AM with a chief complaint of “Homeless, Alcohol Intoxication.” A VAT screening was completed by S24 on 1/1/24 at 2:34 AM that stated, “... Substance intoxification/withdrawal: not applicable.” On 1/4/24, at 1:32 PM, the above findings were reviewed with S6. S6 stated that the VAT assessments were not filled out correctly for the above patients regarding their presenting complaint. Upon request, S6 provided an example of a VAT screening with the answer of “observed behavior” for the “Substance intoxification/Withdrawal” question. S6, indicated that if the question was answered as “observed behavior,” a violence risk score would have been generated and specific “Actions to take” would populate for the RN to select. S6 indicated that VAT assessments should have been answered as “observed behavior.” The VAT screening, when used appropriately, suggests measures to promote the safety of the patient and staff through therapeutic interventions. The VAT policy was requested. S6 stated that the facility does not have a specific VAT policy. The staff were educated on completing the VAT assessment through EPIC (an electronic health records system) training and it is the expectancy that the VAT assessment be completed correctly on all patients. S23, S24, and S25’s personnel file was reviewed and indicated all three staff completed the EPIC training. S23’s EPIC training was completed on 8/12/23, S24’s EPIC training was completed on 10/8/23, S25’s EPIC training was completed on 11/20/23.”