Jefferson Abington Hospital

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 29817 Based on review of Governing Body Bylaws, medical records (MR), facility policy, and interview with staff (EMP) it was determined the facility’s Governing Body failed to provide oversight over the security department at Abington Hospital. Findings include: Review on July 11, 2024, of facility document “Amended and Restated Bylaws of the Abington Memorial Hospital d/b/a Jefferson Abington Hospital,” amended February 28, 2024, revealed “... 3.2.1 The Board shall have responsibility for overall policy and clinical direction of the Corporation with a focus on the following: performance improvement and patient safety; licensure and accreditation; professional credentialing; medical staff matters; compliance; disaster planning; supervision, control and use of the physical and financial resources of the Hospital within the annual operating and capital budgets; monitoring professional liability and clinical risk management programs; philanthropy; and community relations, subject in each case to the TJU [Thomas Jefferson University] Reserved Powers contained in Section 2.4 of these Bylaws, as applicable. The Board shall also have responsibility for any other matters required by applicable laws, licensure or accreditation standards to be exercised by a Hospital by applicable Governmental Authorities or Accrediting Agencies. The President and other senior management shall have responsibility for the day-to-day direction and management of the Hospital and the implementation of TJU-approved strategic policies and plans ...” Review on July 11, 2024, of facility policy “Use of Force” revised June 20024, revealed “... Security Officers at Jefferson may be required, from time to time, to use force to protect themselves, other persons or property. Security Officers may use force only in accordance with this Policy and State law ... Physical Force ... includes wrestling a person to the ground, using any form of wrist, arm, and leg locks, striking with hands or feet or other similar hand -to-hand confrontation ... Mechanical Force ... the utilization of some device or substance to overcome and individual’s resistance to a Security Officer’s authority. Examples includes the use of a baton, or chemical agent spray ... Deadly Force means force which, under the circumstances in which it is used, is readily capable of causing death or serious bodily injury. An example of deadly force would be a baton strike to a dangerous area on an individual ... Security Officer means any person who is employed by Jefferson Security Department or contracted by the Jefferson Security Department and is acting within official capacity ...” Review on July 11, 2024, of facility document “Security Officer - Job Description” approved January 2021, revealed. “... Required Experience, Education, Certification ... Valid ACT 235 Certification required within 90 days of hire ... Equipment Use ... Chemical Spray, handcuffs, police baton. Body and package scanners ... Officers must be able to present excellent appearance at all times and also be equipped with all required security instruments ...” Review on July 11, 2024, of the “Jefferson Health - North Region Public Safety Executive Briefing,” dated February 27, 2024, revealed The Enterprise Security Department presented a summary of actions to be implemented at Abington Hospital Campus. “... Public Safety and Non-Lethal Capabilities ... Non-Lethal equipment (OC Product [pepper spray], baton, handcuffs and Ballistic Vest)-target 10/2024 ... TASER and Body Camera - pilot program ...” Review on July 11, 2024, of the “Abington Health, Abington Memorial Hospital, Abington Health Foundation and [other CMS Certified Hospital name intentionally removed] Hospital Board of Trustees”, dated March 12, 2024, revealed no documentation the Governing Board approved the use of handcuffs, pepper spray and handcuffs at Abington Hospital. Interview on July 10, 2024, at 1:00 PM with EMP3 confirmed, “Handcuffs were used by (facility) security on May 10, 2024, on a patient that eloped from the Emergency department [ED]. Further interview confirmed, “[Facility] security are not police officers.” Interview on July 10, 2024, at 3:00 PM with EMP4 confirmed they were appointed by the governing body as the Chief Operating Officer (COO) of Abington Hospital and confirmed the use of handcuffs, batons, and pepper spray was approved by the Thomas Jefferson Enterprise Security Department and not the Governing Body of Abington Hospital.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 46816 Based on review of facility documents, medical records review (MR), and interview with staff (EMP), it was determined the facility failed to ensure the safety of patients in the Emergency department [ED]with the use of law enforcement weapons by the facility’s security personnel during a patient elopement for one of two medical records reviewed (MR2) Findings include: Review on July 10, 2024, of MR2 physician documentation “History and Physical,” revealed, the patient presented to the Emergency Department on May 6, 2024, “... 31-year-old male, death,[sic] presents today with concerns for suicidal and homicidal ideations. He presents from his group home with a 302 in place. The 302 was reviewed with concerns for suicidal and homicidal behavior ...” Review on May 10, 2024, of nursing documentation for MR2 “ED Notes”, dated May 10, 2024, revealed, “... Approximally [sic] one hour later pt refused to stay in room and exited the ER [Emergency Room] and went down old york road [sic] near zipley garage [sic]. Pt was gesturing that he was going to jump in front of cars. Pt was restrained w/ handcuffs by campus security ...” Interview on July 10, 2024, at 1:00 PM with EMP3 confirmed, “Handcuffs were used by (facility) security on May 10, 2024, on a patient that eloped from the ED. It was outside the buildings that the handcuffs were used. The patient eloped from the ED, may have been a 302, nurse was physically engaged with patient, patient was resisting efforts to go back to the ED. Security placed the patient in handcuffs, Abington Police Department was notified.” Further interview confirmed, “[Facility] security are not police officers.” Interview on July 10, 2024, at 3:00 PM with EMP3 confirmed security personnel that completed ACT 235 training carry handcuffs, batons, and pepper spray. Further interviewed confirmed “security staff continues to carry weapons today.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49501 The information reviewed during the unannounced complaint investigation survey on May 16, 2024, provided evidence the facility failed to substantially comply with this Condition of Participation by failing to provide a safe environment for a patient in the Emergency/Trauma Center. Video surveillance showed a security guard initiating physical contact, which resulted in a struggle until the patient was on the ground with the guard on top of the patient, holding patient by the neck/head until the patient was lifted onto a stretcher. A security staff member failed to deescalate a situation with a patient and instead was provacative and used excessive force. A discussion took place with the survey team and the facility’s administrative staff (EMP1), (EMP2), and (EMP5) regarding the survey team’s concerns related to Patient’s Rights on May 16, 2024, at 3:25 PM. The Immediate Jeopardy was called at 4:20 PM on May 16, 2024. The facility submitted an acceptable Immediate Jeopardy Removal Plan at 3:46 PM on May 17, 2024. The Immediate Jeopardy was removed on-site on May 17, 2024. Condition of Participation non-compliance remains. The surveyor validated the Immediate Jeopardy Removal Plan was substantially implemented by education logs, policy and procedure revisions, and interviews. Cross reference §482.13 (c)(2) Patient Rights: Care in a 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: 49501 Based on review of facility security video, policy and procedures, facility documents, personnel files (PF), medical record (MR) and interviews with staff (EMP) it was determined the facility failed to maintain a safe setting for a patient in the Emergency/Trauma Center. Review on May 16, 2024, of security footage from the Emergency/Trauma Center, Camera AH-Toll Ground ETC515to421 and Toll Ground ETC500s, revealed on April 23, 2024, at 11:06 PM, PT1 is observed walking down the hallway, wrapped in a blanket. PT1 is being followed by EMP6 and EMP17. Behind them, nursing staff is seen following. EMP6 is observed stepping in front of PT1 to block from advancing further. EMP6 then bumps PT1 with their hip and a struggle ensues between PT1 and EMP6. PT1 attempts to fight off EMP6 and bites the forearm of EMP6. EMP6 continues to fight the effort of PT1 to get free. PT1 and EMP6 end up on floor. EMP6 is on top of PT1 and holds PT1 by the head/neck area. PT1 is lifted onto stretcher and 4-point restraints are placed. Review on May 17, 2024, of facility policy, “Patient ’ Rights and Responsibilities, 14.03 “ , reviewed 11/2023, revealed, “ Hospital patients have the right to safe, respectful, and dignified care at all times ... Receive care in a setting free from any form of abuse, harassment, and neglect. Receive kind, respectful, safe, quality care delivered by skilled staff.” Review on May 16, 2024, of facility policy, “Use of Force” reviewed 08/2020, revealed “A Security Officer may use Physical Force or Mechanical Force, when he/she reasonably believes it is immediately necessary at the time: ... To prevent a third party from committing suicide, inflicting serious bodily injury upon him/herself or committing a breach of the peace.” Review on May 16, 2024, of facility document “Investigation Findings of the Incident At Abington Hospital on April 23 - 28, 2024 Involving Jefferson Security Officers and Sergeants” revealed neither EMP6 nor EMP17 were told the patient was held on a 302 medical hold [an involuntary psychiatric situation in which the patient may need psychiatric hospitalization and admission to treat psychiatric medical conditions]. EMP15 heard EMP6 “gloating” over having “had to slam somebody” . EMP7 reported the incident to EMP18 who was a charge nurse. EMP18 notified EMP19 of the event. EMP7 stated in an email, which is part of the investigation, “My best information is that Nursing Administration is aware (besides being on the scene late the AOC this weekend is in Nursing so it -almost- goes without saying most or all of Nursing leadership is aware). “ Review on May 16, 2024, of EMP6’s personnel file, revealed EMP6 completed the “Handle with Care” training and “CPI- Crisis Prevention Intervention” trainings on July 24, 2023. These trainings teach staff how to de-escalate patients in crisis situations and verify staff’s competency in doing so. Interview on May 16, 2024, at 2:32 PM with EMP9 confirmed “no” , after viewing video footage, when asked if patient physically or verbally aggressive. When asked about direction of patient ambulating EMP9 confirmed patient was “not going toward exit”. Interview on May 16, 2024, at approximately 5:20 PM with EMP6 confirmed being involved in altercation on April 23, 2024, at approximately 11:06 PM with PT1”