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Based upon medical record review, review of policies and procedures and interviews, it was determined that the facility failed to meet the Condition of Participation for Patient Rights as evidenced by failure to develop a written protocol to address patient allegation of abuse and neglect, failure to ensure prompt resolution of grievances and failure to formally delegate the responsibility to a grievance committee.

Findings:

See citations issued under:
Tag A 119
Tag A 122
Tag A 145

Based on staff interview and the review of facility's Patient Complaint Procedure, it was determined that the hospital's governing body did not have an effective grievance process as evidenced by: 1) formally delegating the responsibility of patients grievance to a grievance committee and 2) ensuring the prompt resolution of all grievances that the facility receives.

Findings include:

Staff # 2 was interviewed on 7/28/2015 at 3:00 PM. Staff #2 stated that the governing body has not delegated a committee to be responsible for patient grievances. Staff #2 also stated that the Patient Relations Department is responsible for coordinating patient/patient's representative's grievances. She stated that she has one staff member working with her. Staff #2 also stated that there is no data collected regarding patient grievances and other complaints. In addition, she does not report to any committee and grievances are not incorporated in the hospital's Quality Assessment and Performance Improvement (QAPI) Program.

The policy titled: "Patient Complaint Procedure," Administrative effective June, 2015, was reviewed on 7/28/2015. It was noted that this policy does not address the prompt resolution of patients' grievances.

Based on staff interview, review of Complaint log, Grievance files and Patient Complaint Procedure, it was determined that the facility does not to have an effective grievance process that ensure the prompt resolution of all grievances. This was evident in ten (10) of twelve (12) grievance files reviewed (Files #A, #B, #C, #D, #E, #F, #G, #H, #I & #J).

Failure to ensure prompt resolution of grievances denies all patients the assurance of having their complaints addressed within a timely manner.

Findings include:

Review of the Grievance files on 7/28/15 identified the following:

File #A: The facility received a complaint from the mother of a five year old patient on 10/2/14. The allegation was that the parent was unhappy with the care the patient received in the facility's Emergency Department. It was noted that the written response to the complainant was dated 11/5/2014, over 30 days, after it was received by the facility.

File #B: The patient filed a complaint with the facility regarding care rendered in the clinic on 2/10/2015. The facility received the complaint on 2/12/2015 but the written response to the complainant was dated 3/25/2015.

File #C: The facility received a written complaint, dated 2/24/2015, regarding poor treatment rendered in the ED on 2/20/2015. It was noted that the written response on the outcome of the investigation was dated 3/31/2015.

File # D: The facility received a written complaint from the patient's family member, while the patient was an inpatient on 10/24/14, alleging that the patient was physically abused by a staff. It was noted that the hospital investigated the allegation and spoke to the family member. The family was not provided with a written response on the outcome of the investigation.

Similar findings noted in Grievance files #E, #F, #G, #H, #I & #J for grievance responses that were not timely.

The facility's policy titled "Patient Complaint Procedure Policy" No: 9200-056, last reviewed on 7/28/2015 indicated that "Patient Relations coordinates patient investigations" and that "Every effort will be made to provide a written response to Director of Nursing for Patient Relations within 30 days." However, the policy did not specify a time frame, when the complainant will receive a written response on the outcome of the investigation of the grievance.

The facility's failure to have a policy with time frame for written response to grievances does not ensure compliance with the regulation.

The facility's Grievance Process was discussed with Staff # 2 on 7/28/2015 at 3: 00 PM. This staff was aware that the facility was not responding to grievances in a timely manner.

Based on staff interview and document review, the facility the facility failed to; develop a written protocol to address patient allegation of abuse and neglect, including methods to protect its patients whether from staff, other patients or visitors. This was evident in three (3) of four (4) medical records reviewed (MR #10, #11 & #12).
The failure of the facility to develop a written protocol to respond to allegations of abuse and neglect does not ensure the safety and protection of all patients.

Findings include:


Four (4) occurrence reports, regarding the nature of the occurrence of physical and sexual abuse, were reviewed on 7/29/2015.

1. Occurrence Report, dated 10/17/14 at 8:90 AM, indicated that the patient called the NYPD (New York Police Department) to report assault by another patient. The police interviewed the patient through a glass door. Police ascertain no crime was committed.
In MR # 10, the social worker (SW) progress note, dated 10/15/2014, indicated that the SW met with the patient on the unit for a lengthy period of time. Patient discussed being assaulted by another resident and contacting the police. SW consulted with the physicians regarding contacting the police. SW discussed discharge planning with the patient. There was no documentation that the allegation was investigated.

2. Occurrence Report, dated 10/24/14 at 2:00 AM, indicated that the patient was alert and oriented x 1-2 with periods of confusion, and alleged physical abuse by staff. Patient reported abuse by staff to family and the family called NYPD to file a report. Supervisors spoke with both patient and family.
Documentation from MR #11 was reviewed on 7/29/2015. Medicine House staff "Event note," 10/24/14 06:27 documented "Family reports that patient told them he was being abused by hospital staff. Patient was asked a series of questions to which he couldn't fully respond. He was deemed Alert and oriented x 1."

3. Occurrence Report dated 10/28/14 at 2:30 PM. Occurrence notes: "I was contacted by nurse manager that the patient had contacted the NYPD to file a rape occurrence report. Police officers came to her room, and spoke with them and they documented her claims. Per patient, she claims that she was raped yesterday during one of her seizure episodes. She filed a report with the police and a rape kit was requested by NYPD. Rape kit was conducted and samples will be sent to the NYPD."

MR # 12 was reviewed on 7/29/2014. There was no documentation, in the record, that the patient reported to the facility prior to calling the NYPD.

During the entrance survey conference on 7/23/2015, the facility's policy and procedure on how the facility address all patients' allegation of physical/sexual abuse and harassment, was requested from the facility. A second request was made to Staff #3 on 7/29/2015 at approximately 9:30 AM. On 7/29/2015 at approximately 3:30 PM, the facility's Policy & Procedure- Administrative subject: "Patient Complaint Procedure" was submitted to the surveyor and was reviewed on 7/30/2015. This policy indicated that "Patient complaints which alleged mental abuse, physical abuse, sexual abuse or any other inappropriate behavior on the part of the hospital staff, will be investigated immediately by the Director of Nursing for Patient Relations and a multi-disciplinary team."

This policy does not address how the facility handles its patients ' allegations of patient to patient or visitor to patient abuse/harassment and also does not address how the facility plans to protect patients during its investigation.

Based on staff interview and review of medical record, it was determined that the facility did not effectively integrate emergency services with all other departments so that the emergency needs of patients are met. This was evident in two (2) of eighteen (18) emergency records reviewed (MR# 8 and #9)

Findings include:

Review of MR # 8 noted that this 54 year old homeless patient with history of alcohol abuse, seizure disorder (non-compliant with anti-epileptics), multiple visits to the Emergency Department (ED) due to falls and intoxication, was brought to the facility's ED by ambulance on 10/9/14, after seizure witnessed by bystanders. The patient was diagnosed with change mental status. The patient was admitted for further evaluation and treatment. On 10/14/2014 at 9:30 AM, the patient eloped from the hospital with PICC (peripherally inserted central catheter) line intact.
The patient returned to the ED, by ambulance, on 10/14/14 17:48 (5:48 PM). The patient was triage 10/14/14 at 6:21 PM. The chief complaint was ETOH (alcohol) intoxication. The medical evaluation was performed on 10/14/14 11:41 PM. The physician noted that the patient reported that he was assaulted. The medical differential diagnosis was alcohol intoxication. The patient was provided with educational materials on alcohol intoxication and he was discharged from the ED on 10/15/14 2:43 AM.
This patient was not referred to social services to assess the homeless, non-compliant and substance abuse issues.


MR # 9 was reviewed on 7/27/2015. It was noted that the patient, 18 year old female, was seen in the facility's Pediatrics Emergency Department on 2/3/2015 5:44 PM after domestic violence. The patient was triaged on 2/3/2015 6:05 PM. The chief complaint was assaulted injury to left cheek bone. The vital signs as follows: Temperature 97.5; Pulse 113; Respiration 20 and Blood Pressure 136/71. The patient was assigned triage classification ESI (Emergency Severity Index) 3- urgent. It was noted that pain severity was not assessed.
The patient had an Emergency Medical Screening on 2/3/2015 18:10 (6:10 PM). The physician noted that the patient was assaulted today; hit in the left temporal area. The patient complained of pain and swelling to the area. The physician noted that a social service consult was placed but the patient left prior to getting information about Safe Horizons.
The discharge and social service consult orders were reviewed. It was noted ED Discharge was ordered 2/03/2015 7:05 and the Social Services Consult was ordered 2/03/2015 7:09 PM. There was no documentation that the patient was informed that she was referred to social services at the time of discharge.
Case Management notes dated 2/5/2015 10:04 AM indicated that patient was referred to social work by ED staff and a message was left for the patient. It was noted that this follow-up was done two days after the patient was seen in the ED.
Staff #2 was interviewed on 7/28/2015 at approximately 3:00 PM. This staff stated that there was no social services coverage in the ED after 5:00 PM.

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Based on interview, review of Emergency Department (ED) log, medical records and other documents, it was determined the facility did not ensure that each patient presenting to the Emergency Department was assessed or treated in accordance with its' written policy which requires staff to re-triage/reassess all patients waiting to be seen by the physician after 2-3 hours. This finding was noted in seven (7) of eleven (11) ED records reviewed: MR#1, #2, #3, #4, #5, #6, #.

Findings include:

Review of the facility's central ED log on 7/24/2015 indicated that the patient eloped from the hospital.
MR #1 was reviewed on 7/27/2015 electronically and hard copy (certified) reviewed on 7/29/2015. The patient a 35 year old, was brought to the facility's ED by ambulance on 2/18/2015 at 5:39 PM. The reason for the visit was depression; suicidal. The patient was not triaged and there was no nursing assessment while the patient was in the ED. The disposition was home; patient left without being seen.

On 2/19/2015 at 2:18 PM, the nurse noted that the patient eloped from the ED and attempts were made for the patient to return to the ED. The initial call to the patient's home was made on 2/18/2015 at 6:47 PM and message was left for the patient to return to the ED.

The Occurrence Report was reviewed on 7/29/2015 at 9:30 AM. This report indicated that the patient eloped on 2/18/2015 at 6:30 PM. The Occurrence notes indicated that the patient arrived via ambulance, complaining of depression and suicide but no plan. The patient was sitting in chair #2 and while being triaged, the patient walked out while triage nurse was obtaining equipment for a chemstrip.

Staff # 1 was interviewed on 7/29/2015 at 3:00 PM. He stated that he signed the Occurrence Report form because he saw the patient before the patient left the hospital. Staff # 1 stated that the patient was alert and oriented x 3, no distress noted and she did not verbalize suicide to him. Staff #1 also stated that the patient informed him that she was leaving the hospital. There was no documentation he discussed with the patient the reason she presented to the hospital and that she informed ambulance staff "I want to hurt myself."

It was brought to the physician's attention that there was no documentation that he saw the patient before the patient left the hospital.
The physician's updated note on 2/19/15 at 12:36 was submitted for review on 7/30/2015. This notation was reviewed on 7/30/2015 at 10:00 AM. "Updated on 2/19/15 12:26 PM - ED Disposition "left without being seen (modified)." Comments: patient was being triaged and eloped prior to completion of the triage. She was not seen by a Physician. "Patient did not verbalize suicidal or homicidal thoughts NAD (no apparent distress) (modified ").

It was noted that the physician's updated note was not located in the certified copy reviewed.

Policy & Procedure- Administrative Policy No: 6041-123 reviewed: October 2012 was reviewed on 7/30/2015. This policy indicated that triage is never to be unmanned. This policy was not properly implemented therefore this patient who presented with suicidal ideation walked out when the triage nurse left to obtain equipment.



Review of MR #2: a 32 year old presented to the facility's ED on 2/1/2015 at 2:44 PM with complaint of chest pain radiating to the left arm with shortness of breath since the AM. The patient was triaged on 2/1/2015 at 3:05 PM with vital signs as follows: Temperature 96.6; Pulse Rate: 106, Blood Pressure: 119/60, Respiration: 20; Oxygen Saturation: 98%; pain rated at 7 on a scale of 1-10. The patient was placed in triage classification ESI 3- urgent. It was noted that an electrocardiogram (ECG) on 2/1/2015. The patient had a normal ECG. The patient was noted to have left the ED on 2/1/2015 at 10:16 PM without a nursing reassessment. This patient waited over seven hours after time of arrival without a reassessment as per the facility's policy.

Review of MR #3: 21 year old, presented to the ED on 2/26/2015 at 1:20 AM with complaint of abdominal pain. The patient was triaged on 2/26/2015 at 1:23 AM. The triage noted that the patient complained of body aches, nausea, vomiting and diarrhea with abdominal cramping onset yesterday, history of gastric sleeve placement (weight loss surgery where the surgeon removes about half the stomach and staples what remains into a sleeve like structure). Vital signs as follows: Temperature 98.7, Pulse 80, Oxygen Saturation: 99 %, Respiration 20 and Blood Pressure 119/61. The patient was placed in triage classification ESI 3- urgent. It was noted that the severity of the patient's pain was not assessed. It was noted that the nurse called to reassess the patient on 2/26/2015 at 5:39 AM, four hours after the patient presented in the ED. This patient left without a reassessment as per facility's policy.

MR #4: patient was brought to the facility's ED via ambulance on 4/4/2015 with complaint of heal laceration after a fall. The patient was triaged on 4/4/2015 at 5:53 PM. The vital signs: Temperature 97.8, Pulse 86, Respiration 18, Blood Pressure 148/88; pain scale at 6 on a scale 1-10. The patient was placed in triage classification ESI 3. This patient left the hospital without a medical screening evaluation 4/4/2015 at 10:38 PM, five hours after presenting to the ED.

Staff #1 was interviewed on 7/29/2015 at 3:30 PM regarding the delay in medical screening. Staff #1 reviewed MR # 4 electronically and he stated that the patient had a nursing reassessment on 4/4/2015 at 8:00 PM. It was noted that the nursing reassessment was not included in the certified medical record provided for reviewed on 7/28/2015 at 10:38 AM.

Similar findings were identified in MR #5, MR #6 and MR #7, when the Nursing staff did not comply with the policy titled "Re-Triaging of Patients," last reviewed October 2012, which required staff to re-triage/reassess all patients waiting to be seen by the physician after 2-3 hours.