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Based on interview, the hospital did not ensure a contractor that furnished security services to it complied with New York State Department of Health (NYSDOH) surveillance staff request for interview of security staff and review of their personnel files. This impedes investigations of complaints.

Findings include:

-- On 5/3/19 at 10:30 am, Staff A (Security Officer) was contacted by phone for interview. Staff A declined interview stating that he/she was instructed by his/her supervisor not to speak with "anyone from the state" until a human resources representative was present. Staff A was not aware of a time when a human resource representative would be present for interview.

-- During interview of Staff B (Chief Nursing Officer) on 5/3/19 at 2:00 pm, he/she stated that the contracted security services company had refused to provide Staff A's and Staff C's personnel file for review by surveyors at that time. He/she was not aware of the reason that the personnel files were not provided and acknowledged that it was not the hospital's common practice to not provide requested information to surveyors.

Based on document review, medical record (MR) review and interview, the facility failed to ensure that contracted security staff who assist in the application of restraints and/or monitor patients in restraints received hospital restraint training, first aid training and certification in the use of cardiopulmonary resuscitation (CPR). These failures place patients at risk for potential harm.

Findings include:

The facility failed to ensure that:

-- All security officers who assist in restraints and monitoring, have demonstrated competency in the use and application of restraints.
See Tag A0196

-- All security officers who assist in restraints and monitor patients in restraints are trained in the use of first aid techniques and certified in the use of CPR.
See Tag A0206.

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Based on medical record (MR) review, document review and interview, the hospital did not comply with the Parent's Bill of Rights as required by New York Codes, Rules and Regulations (NYCRR), Title 10, 405.7. Specifically, 6 of 6 MRs (Patients #1 to #6) reviewed of patients less than 18 years of age, lacked documentation that each patient's parent/guardian received a copy of the Parent's Bill of Rights. Additionally, the hospital did not have a policy and procedure (P&P) that addressed the Parent's Bill of Rights. This could lead to a lack of awareness of the rights of pediatric patients for parents.

Findings include:

-- Review of Patient #1's to Patient #6's MRs revealed each lacked documented evidence that patient's parents were provided a copy of the Parent's Bill of Rights.

-- Review of the facility's P&P titled "Pediatric Rights and Responsibilities of Parents and Guardians," last revised 1/2019, revealed it did not address the Parent's Bill of Rights or indicate that a copy should be provided to a pediatric patient's parent/guardian.

-- During interview of Staff D (Patient Access Registration Clerk) on 5/2/19 at 9:10 am, he/she revealed pediatric patient's parents/guardians initial the "Authorization for Emergency Treatment" form indicating they received the Patient's Bill of Rights.

-- During interview of Staff E (Director of Quality and Patient Safety) on 5/3/19 at 1:30 pm, he/she acknowledged the above findings.

Based on document review, medical record (MR) review and interview, 4 of 4 MRs (Patients #7 to #10) of patients greater than 18 years of age lacked documentation that advance directive (AD) information was provided when the patient presented to the Emergency Department (ED). Three of 4 MRs (Patients # 8 to #10) lacked documentation indicating whether the patients had executed an AD. This lack of documentation could lead to a patient's wishes concerning their provision of care to not be followed.

Findings include:

-- Review of the facility's policy and procedure (P&P) titled, "Advance Directives," last revised 3/2019, indicated ED triage nurse should ask patients about ADs and document it on the triage form. All ED patients should receive the New York State publication, "Planning in Advance for Your Needed Treatment." The AD information attached to the P&P is titled, "Deciding About Your Healthcare, A Guide for Patients and Families," dated 2/2018.

-- Review of Patient #7's MR revealed the triage nurse documented he did not have a MOLST (Medical Orders Life Sustaining Treatment ) form completed. There is no further documentation indicating whether the patient had executed an AD or that the patient was provided or accepted AD information.

-- Review of Patient #8's to Patient #10's MRs revealed each lacked documentation indicating whether they had executed an AD or that the patient was provided or accepted AD information.

-- During interview of Staff E (Director of Quality and Patient Services) on 5/3/19 at 1:30 pm, he/she acknowledged the above findings.

Based on document review, medical record (MR) review and interview, in 2 of 6 pediatric patient medical records reviewed, the facility did not ensure that staff followed the facility's policy and procedure (P&P) for emergency department (ED) observation of pediatric patients at risk for suicide. This places patients at risk for increased harm.

Findings include:

-- Review of the hospital's P&P titled "Suicide Precautions/Drug Overdose Recreational or Intentional," last revised 2/2019, indicated that departments that routinely care for pediatric patients should use the ASQ (Ask Suicide Screening Questions) Suicide Screening Tool on all pediatric patients age 10 to 18. (The ASQ Suicide Screening Tool consists of 5 questions to assess suicide risk). For an acute positive screen (Patient answers yes to question #1 to #5), the nurse should immediately implement 1:1 nursing observation and safety precautions, notify provider and prepare to order a psychiatric consultation.

-- Per MR review, Patient #1, a 15-year-old female, presented to the ED on 3/23/19 at 9:21 pm via law enforcement on a 9.41 MHL (Mental Health Law) admission after threatening to kill self and family members. At 9:50 pm, ED nursing staff screened Patient #1 for suicidal risk using the ASQ scale. Patient #1 answered "yes" to the 5 screening questions in the risk tool and was placed on 15-minute observational checks by security staff from 9:30 pm on 3/23/19 to 3:25 pm on 3/24/19.

-- Per MR review, Patient #2, a 17 year old female, presented to the ED via emergency medical services on 3/24/19 at 11:12 pm with an intentional Tylenol overdose. At 9:50 pm, ED Nursing staff screened the patient for suicide risk using the ASQ scale. Patient #2 answered "yes" to the 5 screening questions and was placed on 15 minute observational checks by security staff from 11:15 pm on 3/24/19 to 5:45 am on 3/25/19 when the patient was transferred to another hospital.

There is no documentation in the MRs noted above indicating that the patients were placed on 1:1 nursing observation, per the hospital's P&P.

-- During interview of Staff B (Chief Nursing Officer) and Staff E (Director of Quality and Patient Safety) on 5/3/19 at 10:40 am, both acknowledged the above patients should have had 1 to 1 nursing observation per hospital P&P.

Based on document review, medical record (MR) review and interview, 1 of 1 (Patient #7) MRs reviewed of a patient in 4 point restraints lacked documentation of a 1-hour face-to-face evaluation by a practitioner. This could place a patient in restraints at risk for untoward outcomes.

Findings include:

-- Review of the facility's policy and procedure (P&P) titled "Restraints," last revised 2/2019, indicated that within 1 hour of the initial application of all types of restraints for behavioral reasons, a practitioner trained in restraints should assess the patient face-to-face. The practitioner should write a progress note regarding the assessment of the patient.

-- Review of Patient #7's MR indicated on 3/25/19 at 1:51 am, he presented to the emergency department (ED) accompanied by 2 police officers, he was combative and refused to follow orders. Patient #7's behavior continued to escalate, putting staff at risk. He was placed in 4 point restraints and medicated with the assistance of 4 officers. There is no documentation in the MR indicating a 1 hour face-to-face was performed by the ordering practitioner.

-- During interview of Staff E (Director of Quality and Patient Safety) on 5/3/19 at 11:30 am, he/she acknowledged the above finding.

Based on document review, medical record (MR) review and interview, the facility failed to ensure that contracted security staff, who assist with restraint or seclusion, monitor and access patients in restraint or seclusion, received training pertaining to restraints. These failures place patients at risk for potential harm.

Findings include:

-- Review of the facility's policy and procedure (P&P) titled "Restraints," last revised 2/2019, indicated all direct care staff are required to receive ongoing training and demonstrate competence in minimizing the use of restraints and the safe application and removal of restraints. The P&P does not identify the titles of the direct care staff who require restraint training or address the role of security officers related to restraint application.

-- Review of the facility's document titled "Oswego Hospital Security Orientation Emergency Department," (undated), indicated that security should assist staff with restraining patients after all other means are attempted. Restraints should be applied at the direction of the registered nurse (RN). Security officers should complete the Oswego Hospital restraint competency.

-- Review of Patient #7's MR indicated he presented to the emergency department (ED) on 3/25/19 at 1:51 am accompanied by 2 police officers and was combative and refused to follow orders. His behavior continued to escalate, putting staff at risk. He was placed in 4 point restraints and chemically restrained with medication and the assistance of 4 officers. Documentation on a form titled, "Emergency Department 15 minute Observation Sheet," last revised 2/2016, revealed that after the patient was placed in restraints, he was monitored by security staff.

-- During interview of Staff B (Chief Nursing Officer) on 5/3/19 at 2:00 pm, he/she stated that the contracted security services company had refused to provide contracted security staff personnel file for review by surveyors at that time.

-- During interview of Staff E (Director of Quality and Patient Safety) on 5/3/19 at 3:30 pm, he/she indicated there was no documented evidence that the security officer who monitored Patient #3 had training in restraints. Additionally, Staff E revealed the two security officers in the ED at the time of the interview did not have restraint training.

Based on document review, medical record (MR) review and interview, the facility failed to ensure that contracted security staff, who assist with restraint or seclusion, monitor and access patients in restraint or seclusion, received training in first aid and certification in the use of cardiopulmonary resuscitation (CPR). These failures place patients at risk for potential harm.

Findings include:

-- Review of the facility's policy and procedure (P&P) titled, "Restraints," last revised 2/2019, indicated any staff involved in the care or observation of a patient in restraints must be certified in CPR. The P&P does not address the role of security officers or the requirement for first aid training.

-- Review of the facility's document titled , "Oswego Hospital Security Orientation Emergency Department," undated, indicated under general job duties, security should assist staff with restraining patients after all other means are attempted. Restraints will be applied at the direction of the registered nurse (RN). Security officers should complete the Oswego Hospital restraint competency.

-- Review of Patient #7's MR indicated, on 3/25/19 at 1:51 am, he presented to the emergency department (ED) accompanied by 2 police officers, he was combative and refused to follow orders. He behavior continued to escalate, putting staff at risk. He was placed in 4 point restraints and medicated with the assistance of 4 officers. Documentation on a form titled, "Emergency Department 15 minute Observation Sheet." last revised 2/2016, revealed after the patient was placed in restraints, he was monitored by security staff.

-- During interview of Staff B (Chief Nursing Officer) on 5/3/19 at 2:00 pm, he/she stated that the contracted security services company had refused to provide contracted security staff personnel files for review by surveyors at that time.

-- During interview of Staff E (Director of Quality and Patient Safety) on 5/3/19 at 3:30 pm, he/she indicated there was no documented evidence that the security officer who monitored Patient #7 had training in first aid or CPR. Additionally, Staff E revealed both security officers in the ED at the time of the survey did not training in first aid or CPR.

Based on medical record (MR) review and interview, in 4 of 10 of MRs reviewed, the facility did not ensure that signatures in the MRs were legibly written to reflect the name ot title of staff monitoring patients during observation in the Emergency Department (ED). This may lead to an inaccurate portrayal of care provided to patients.

Findings include:

-- Review of the "Emergency Department 15 minute Observational Sheet" found in Patient #1's MR revealed that the patient was placed on 15-minute observational checks which were maintained from 9:30 pm on 3/23/19 to 3:25 pm on 3/24/19. The 15 minute observational sheet is signed by (3) security staff. The signature of each staff member was illegible.

-- Review of the "Emergency Department 15 minute Observational Sheet" found in Patient #2 's MR revealed that the patient was placed on 15-minute observational checks which were maintained from 11:15 pm on 3/24/19 to 5:45 am on 3/25/19. The 15 minute observational sheet is signed by (1) security staff. The signature of the staff member was illegible.

-- Review of the "Emergency Department 15 minute Observational Sheet" found in Patient #3's MR revealed that the patient was placed on 15-minute observational checks which were maintained from 10:15 pm on 3/22/19 to 4:00 pm on 3/29/19. The 15 minute observational sheet is signed by (11) security staff. The signature of each staff member was illegible.

-- Review of the "Emergency Department 15 minute Observational Sheet" found in Patient #7's MR revealed that the patient was placed on 15-minute observational checks which were maintained from 2:00 am on 3/25/19 to 2:00 pm on 3/25/19. The 15 minute observational sheet is signed by (3) security staff. The signature of (2) security staff was illegible. (1) security staff did not sign the form.

-- During interview of Staff B on 10:40 am on 5/3/19, he/she acknowledged the illegibility of the signatures and was unable to determine from the sheet the names of the security staff that signed the form.