HospitalInspections.org

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Based on review of CCTV( closed circuit television) video observations, review of medical records, policies, and interviews during a complaint investigation, it was determined that the Governing Body is not maintaining it's responsibilities for the oversight and operation of all services provided by the facility (including hospital security) as evidenced by the severity of the deficiencies cited below and remains non compliant with the Conditions of Participation Patient Rights 482.13 and Conditions of Participation Emergency Services 482.55.

The Governing Body failure (is) that patient care services provided to the psychiatric population met generally acceptable standards of professional practice:

1. The Governing Body failed to ensure all delineated and policy specified Health Care Practitioners including Psychiatrists responded to "Behavioral Emergency Support Team (BEST) Rapid Response for Behavioral Situation Emergencies" in all areas of the hospital (including ED and inpatient units designated to house the psychiatric population) as required by their own policies.

2. The Governing Body failed to ensure that the Hospital Police Officers (hospital security) acting as front line responders to behavioral emegencies utilized the appropriate and New York State Office of Mental Health (NYSOMH) approved PMCS techniques when applying physical restraints and during manual take-downs of aggressive mentally ill patients.

3. The Governing Body failed to ensure the patients right to safety and receive respectful humane treatment consistent with freedom from all forms of abuse and harassment.

4. The Governing Body failed to ensure that the Hospital Police Officers (hospital security) activities that involved direct patient care (physical interaction with patients) and relative to Performance Improvement/ Quality Assurance were integrated with the Hospital wide Quality Assurance/Performance Improvement Committee meetings and the Governing Body quarterly reports and the Governing Body annual report submitted to the Board of Directors.

5. The Governing Body failed to ensure the appropriate medical re-evaluations, medical treatment plan, collection of collateral information including accessing New York State Office of Mental Health (NYSOMH) Psychiatric Services and Clinical Knowledge Enhancement System (PSYCKES) database and the facilities own "Quadramed Access Patient Database System" for safe disposition from the Psychiatric Emergency Services

6. The Governing Body failed to develop and implement an effective procedure for the safe disposition of patients with medical and psychiatric needs from the Emergency Department (ED), including appropriate risk assessments for suicidal ideation/plan, patients signed acknowledgement of their individualized crisis prevention "safety plan" and appropriate community resources for vulnerable patients at risk for self harm.

See Citations under tags: 115, 144, 145,154, 160, 165,167,174, 194, 196, 202, 206, 273, 1100, 1104, 1112

These failures placed all patients at risk for harm.

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Based on record reviews, staff interviews, and review of CCTV video recordings during the Federal Allegation Survey, it was determined that the facility did not comply with the Condition of Participation for Patient Rights.

The facility failed to implement procedures to ensure the patients' rights to safe, humane and respectful treatment consistent with freedom from all forms of abuse and harassment.


Findings:


The facility failed to ensure the patients' right to receive care in a safe setting. (Refer to Tag A 144)

The facility failed to ensure the patients' right to be free from all forms of abuse and harassment. (Refer to Tag A 145)

The facility failed to ensure the patients' right to be free from any form of retaliation from staff. (Refer to Tag A 154)

The facility failed to ensure the patients' right to have policies and procedures in place that define under what conditions they may receive medications against their will. (Refer to Tag A 160)

The facility failed to ensure the least restrictive restraints were applied to patients housed on an inpatient psychiatric unit. (Refer to Tag A 165)

The facility failed to develop a policy and procedure for use of spit guards during take-downs of aggressive patients (Refer to Tag A 167)

The facility failed to monitor a patient in four point restraints. (Refer to Tag A 174)

The facility failed to ensure that all required staff had periodic retraining in behavioral crisis interventions (PMCS). (Refer to Tag A 194)

The facility failed to ensure the patients' right that all staff who apply physical restraints are educated on hospital policies relative to their job descriptions and work functions. (Refer to Tag A 196)

The facility failed to educate indepth all staff with direct patient contact on hospital policy for the safe application of restraints.
(Refer to Tag A 202)

The facility failed to ensure that all staff are able to recognize and respond to signs of physiological distress when applying restraints (for example, positional asphyxia). (Refer to Tag A 206)

These findings placed all patients at risk for harm.

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Based on review of CCTV video observations, interviews, and documents including medical records and hospital policies and procedures, during the complaint investigation, it was determined that the facility failed to ensure implementation of existing Behavioral Health (psychiatric) policies,

Specifically, Physicians failed to respond to the "Behavioral Emergency Support Team (BEST) Rapid Response for Behavioral Situation Emergencies." when activated by clinical providers, as they are required to do by this policy. This was evident in three (3) of three (3) video observations and medical records (Patients #L, #M, #N,)

These failures place the safety and welfare of all patients with suicidal or homicidal displays of aggression at risk for physical, emotional or mental harm (including psychological trauma) during Behavioral Situation Emergencies.


Findings:


Review of the hospital policy titled "Psychiatric Emergency Services, Behavioral Emergency Support Team (BEST): Rapid Response for Behavioral Emergencies" dated August 2014, states,

" The purpose of the Behavioral Emergency Support Team (BEST) is to assist with the safe and humane management of patients presenting with behaviors that are physically/or verbally out of control. BEST can be activated in any area of the hospital. The goal of activating BEST is to provide an immediate response to Behavioral Emergencies. A behavioral emergency is defined as a situation where, in spite of de-escalation efforts, a patient is highly agitated for reasons having to do with diagnosed psychiatric illness and are physically or verbally out of control and are posing an imminent danger to harming self or others and /or property.

The team is activated by an RN or MD or other clinical provider when a patient is displaying potentially harmful or escalating behaviors that cannot be managed with standard de-escalation interventions. BEST is activated by calling the Central Call Center #5858. The BEST team will respond within 5 minutes and response times will be logged and monitored.

The Behavioral Emergency Support Team (BEST) will include: Attending Psychiatrist,
Associate Director of Nursing (or Administrator on Duty for weekends, nights and holidays)
an RN from Psychiatric Emergency Services,
a Behavioral Health Associate and
a member of the Hospital Police (Patrol Officer).

When the team arrives, the team will operate under the leadership of the psychiatrist.
The physician and/or nursing staff must be present and must participate in the management of the crisis until the situation is resolved.

The BEST personnel will assist in calming the patient with verbal and nonverbal interventions approved by the New York State Office of Mental Health " Preventing and Managing Crisis Situations " curriculum. These interventions are aimed to manage a psychiatric crisis with the appropriate response.

In addition to completing documentation in section 1 and section 2 of the BEST Log ( Forms) a (clinical) note will be entered into the medical record by the psychiatrist.
It is strongly recommended that a debriefing session occur after each activation of BEST.
An occurrence report may also be required and must be completed by unit personnel."

Review on 08/25/15 of policy noted it failed to delineate the role and responsibilities of the Hospital Police Officer (HPO) within the support Team.

On 08/24/15 in the afternoon, closed circuit television (CCTV) surveillance (DVD #1) recorded in Unit 10 A was reviewed with Staff #18 and revealed two concurrent behavioral emergencies for aggressive patients were in progress on 05/17/15 at 12:35 PM .

Multiple members of the Hospital Police department responded to these behavioral emergencies and their presence is seen in the video but the support team lacked a Psychiatric Attending leading the management of the crisis and a physicians presence is not seen in the video.

Video observations revealed HPO ' s manually restrained Patient #M.

This was confirmed by Staff #18 on 08/24/15 who was able to identify nursing staff standing in the area and Hospital Police Officers (HPO) but no physician.

Review of medical record on 08/25/15 for Patient #M revealed an 18-year-old female taken to the hospital on 05/13/15 via New York Police Department precipitated by homicidal ideation towards her grandmother. The patient was admitted with mood disorder and past medical history of Bipolar Disorder and Asthma on 05/13/15 into the Acute Inpatient Behavioral Health (Psychiatric) Unit 10 A.

The medical record for Patient #M lacked documentation by a physician that the patient was highly agitated for reasons having to do with her diagnosed psychiatric illness and was "physically or verbally out of control" and posed "an imminent danger to harming self or others and /or property" and that a rapid response for this behavioral emergency had occurred on 05/17/15.

The medical record lacked documentation by a physician on 05/17/15 and 05/18/15 of a physical examination, whether any injuries were sustained or diagnostic testing was indicated.

On 05/19/15 at 2:41 PM the physician documented, " Patient claimed she was punched by hospital police on her face (left side). There is a 3 x 3 cm bruise and swelling with minimal tenderness on the left mandible area. Per patient the abrasion occurred on Sunday. She said she was in restraints and hit her left jaw sustaining an abrasion. No difficulty chewing or jaw pain." X-ray was obtained on 05/19/15 and no fracture was identified by the physician.

Additional observations made on CCTV DVD #1 revealed Patient #N had been restrained in physical holds around the neck and mechanical restraints (police issued metal handcuffs).

Review of medical record on 08/25/15 for Patient #N revealed a 49-year-old male admitted on 05/08/15 with psychosis, paranoia and delusional parasitosis disorder into the Acute Inpatient Behavioral Health (Psychiatric) Unit 10 A.

The nurse documented on 05/17/15, " On or about 12:30 PM the patient became angry and accused another patient (Patient #O) of taking his shirt. Verbal altercation ensued. Medicated with Haldol 5 mg and Ativan 2 mg intramuscular injection on 05/17/15 at 12:40 PM."

The physician documented on 05/17/15, " Nursing reports that Patient #N was observed banging his head against the wall during the process of medication administration."

There was no documentation by a physician that Patient #N had been placed in police issued manual restraints for an hour and five minutes.There was no documentation in the medical record that a physician had ordered use of restraints/seclusion for Patient #N. There was no documentation in the medical record entered by Nursing or the Administrator on Duty that the patient had been manually restrained and confined in handcuffs for an hour and five minutes.

Review of the facility BEST Log Forms lacked documented evidence dated May 17th 2015 that the Physician responded to a Behavioral Emergency in Unit 10 A at 12:39 PM and there was no debriefing information in any Quality Assurance/Performance Improvement documents that could be provided after the rapid response to either event.

The facility provided a Hospital Police Crime and Incident Report (known internally as a "587" report). However an occurrence report completed by unit personnel was not available and could not be provided.

On 08/24/15 in the afternoon, CCTV video surveillance DVD #2 recorded on 08/10/15 at 8:43 PM was reviewed with Staff #18 and observations revealed the Medical Emergency Department "B" Area -DD 1.

Observations made during viewing of CCTV DVD #2 revealed Patient #L highly agitated for reasons having to do with his diagnosed psychiatric illness and was "physically or verbally out of control" and posed "an imminent danger to harming self or others and /or property" and that a rapid response for this behavioral emergency was initiated.

Patient #L was observed standing alone outside of a bathroom and gesturing with a three inch thermometer probe in his hand in the general direction of nine Hospital Police Officers who had formed a semi circle around the patient. The patient remained fixed in the same location for over six minutes and did not step forwards towards the police officers at any time and did not display any overt acts of physical violence towards any other individual present in the video. Observations revealed patient #L was disabled of the thermometer probe by an officers tactical weapon (baton), then "taken down" by the officers and subsequently placed in a manual hold by the officers. The manual holds continue after the patient is placed on a stretcher at 9:00 PM.

There was observational evidence in the CCTV video that the Hospital Police Department responded to this behavioral emergency and their presence is seen in the video with reinforcements of HPO's arriving intermittently throughout the video. There is observational evidence that members of the Nursing Department responded to this behavioral emergency.

However, the behavioral crisis support team lacked a Psychiatric Attending leading and directing the management of the interventions and a physicians presence is not seen in the video. This was confirmed by Staff #18 on 08/24/15, who was able to identify nursing staff standing in the area and Hospital Police Officers but no physician.
Staff # 18 stated, " I don't think a physician was ever involved at any time in this situation."

Medical record review on 08/25/15 revealed Patient #L is a 33 year old male admitted to the Medical Emergency Department (MER) on 08/10/15 at 8:15 pm with chief complaint of paranoia and schizoaffective disorder. The patient stated to an RN (Registered Nurse) at Triage his chief complaint was " There ' s an infestation all over the streets and I want to get away from it. "
The Triage nurse documented that at home the patient takes Haldol and Ativan by mouth and has not been compliant with taking these medicines.

The ED psychiatrist (Staff #14) saw the patient on initial consult 08/10/15 at 8:39 PM and documented, " Patient was noted to be very irritable and uncooperative with the interview."

Review of the Medication Administration Record dated 08/10/15 for Patient #L revealed Haldol 5 mg and Ativan 2 mg Intramuscular injection was given at 9:00 PM.

Review of the "Restraint/Seclusion Record Order/Monitoring form for patients with violent or self destructive behavior" dated 08/10/15 revealed that four point restraint was applied to Patient #L at 9:05 PM and removed at 10:10 PM. The facility failed to provide a Post Seclusion/Restraint Debriefing Tool.

On 08/10/15 at 9:37 PM the ED medical (internist) physician documented, "Patient is medically optimized for PES,"

The Psychiatric Emergency Services (PES) nurse documented on 08/10/15 at 10:10 PM, "The patient was received from area B at 10:05 PM with an abrasion to his face on the left cheek and nose. He was medically cleared for admission to PES and he is a little agitated but cooperative."

Review of the facility BEST Log Forms did not have documented evidence dated August 10th 2015 that the Physician responded to a Behavioral Emergency in the MER at 8:40 PM and there was no debriefing information in any Quality Assurance/Performance Improvement documents that could be provided by the facility regarding this rapid response event.

There was no documentation immediately post the event dated 08/10/15 by a physician that the patient had a thermometer removed from his hand by an police officers weapon (baton) and then immediately was placed in manual restraint by the police officers. There was no documented evidence that the physician examined the right hand and arm area for any injuries sustained and no indicated whether an x ray or other diagnostic testing should have been obtained of the patients hand, ulna or radial bones to his right upper extremity.

The facility provided a Hospital Police Crime and Incident Report (known internally as a "587" report). However an occurrence report completed by MER unit personnel was not provided.

During interviews conducted with HPO stationed in the PES area on the morning of 08/24/15, Staff # 19 stated at 10:10 AM, "we work eight hour tours but do a lot of overtime and we go many times every day to assist the nurse's with combative patients. The nurses in PES and upstairs in the (psychiatric) units carry panic alarms or they call us. We go help them and hold the patients so they can give the medicines or do other things they need to do." Staff #19 was asked what the name of these rapid responses for behavioral emergencies are called and he stated, "We don't have a name for it. The call comes over our radios from Central Command that an Officer or a nurse needs assistance with an aggressive patient and we go help as quickly as we can."

During an interview on 08/24/15, Staff # 20 stated at 10:20 AM, " I am working a second tour now. I have been at work since just before midnight and I may leave here around 4:00 PM today, maybe, unless they need me to stay for another tour. I couldn't tell you how many of these patient situations I am called to go to in a day, there are so many. At least four or five, maybe some days more like seven or eight. They happen all the time. We help the nurses by keeping the patients from moving so they can get their medicines and injections."
Staff #20 was asked what the name of these rapid responses for behavioral emergencies are called he stated, " I don't know what the name of the response is called. We protect the staff from getting injured and the hospital property from damage."

Review of the Hospital Police Department Security shift (tour) Report Ledgers for May, June, July and August 2015 revealed more then hundred (100) entries when police officers were dispatched to respond to situations with aggressive patients and facilitate and assist clinical staff with interventions to defuse the behavioral emergencies.

Based on video observations, staff interviews, and review of documents, during the Federal Allegation Survey, the facility failed to ensure
the Hospital Police Officers utilizing physical take-downs and manual restraints to patients were consistent with recognized and endorsed techniques from New York State Office of Mental Health (NYSOMH) "Preventing and Managing Crisis Situation" (PMCS) Training. (These findings were observed in two of three closed circuit television (CCTV) surveillance DVD's. Patients #M, #N and #L)

This failure places all patients at risk for abuse by facility staff.


Findings:


Medical record review for Patient #M revealed an 18-year-old female taken to the hospital on 05/13/15 escorted by New York Police Department precipitated by homicidal ideation towards her grandmother. The patient was admitted with mood disorder and past medical history of Bipolar Disorder and Asthma on 05/13/15 into the Acute Inpatient Behavioral Health (Psychiatric) Unit 10 A.

On 08/24/15 at 2:45 PM, closed circuit television (CCTV) surveillance DVD #1 recorded on 05/17/15 at approximately 12:30 PM was reviewed with staff #18.

Observations revealed the rear nurses station area of inpatient Psychiatric unit 10 A.

Observed at DVD video time stamped 05:30 five male hospital police officers (HPO) are seen struggling with Patient #M. One HPO (Staff #38) is observed to pull the patients hair causing her head and neck to hyper-extend backwards. One of the HPO's places an open palm hand into the patients face causing the patient to move backwards up against a wall. One of the HPO's right elbow makes contact with the left side of Patients #M ' s face. Three (possibly four) punches with a closed fist to the left mandible are observed. The patient is briefly placed in a choke-hold. Then three minutes into this struggle four HPO's are observed taking the patient down to the ground. One HPO places a knee into the patient ' s left thigh area and pulls the left leg outwards. The patient drops backwards to the ground and no one is holding the head or neck area during the fall. The patient ' s head hits the ground.

The patient is positioned on the floor with one HPO kneeling and pinning down the patient's upper torso. A second HPO is observed kneeling on the patients left shoulder. A third HPO is standing upright with his booted left foot on the top of the patient ' s left socked foot. A fourth HPO is observed standing upright with his booted right foot standing on the patient ' s anterior right ankle. Four HPO's are observed returning the patient to an upright position while continuing with the manual hold. The patient is then pushed backwards by one HPO whose right hand is placed on the upper tracheal to lower neck region of the patient ' s body and a second HPO is seen placing his open palm hand on the patients head and face. Four HPO's are observed manually holding the patient and coercing her to walk in a backwards direction towards her room. These events are observed from video recording time stamp 05:30 to 09:28 minutes.

During interview on 08/24/15 Staff #18 stated, " The reason why Patient #M was so upset was because she wanted to go to her room but was told no she couldn't because it was near where this fight was taking place between two other patients. That ' s what set her off and got her so combative. After the situation is managed by the HPO's then they take her to her room where the nurses medicated her. The patient was fighting the Officers and spit at one of them. When they took her to her room because she was still spitting at them the patient's head was covered with a bed sheet."

Re-review on 08/24/15 of the CCTV surveillance (DVD #1), noted at DVD time 06:48 Patient #N was in a manual restraint ("choke hold") by a hospital police lieutenant (HPL).

The hospital police lieutenant had placed his right arm fully around Patient #N's neck and the HPL was observed coercing Patient #N to walk through the inpatient unit, while in the choke hold Patient #N was simultaneously held in manual holds by two HPO. One HPO held Patient #N left lower forearm and one HPO held Patient #N's right upper extremity near the deltoid area and to walk from his bedroom towards the seclusion room.

On 08/24/15 at 3:15 PM, CCTV surveillance DVD #2 recorded on 08/10/15 at approximately 8:40 PM was reviewed with Staff #18. Observations revealed the Medical Emergency Department "B" Area -DD 1.

Patient #L is observed standing in the MER. Noted at video time 00:01 one hospital police officer (HPO) is standing in the area near Patient #L. One female patient is sat in a chair in the area. At 00:45 three clinicians who were in the area leave and two additional HPO ' s arrive.

At 01:20 Patient #L is observed standing with a HPO at his side. At 02:00, Patient #L is seen holding onto a " Vital Signs " mobile piece of medical equipment. At 02:34 three additional HPO ' s arrive, totaling six HPO ' s. There are no clinical staff in view. The female patient is still sitting in a chair.

At 02:54 Patient #L picks up a thermometer in his right hand that was protruding out of the top of the mobile medical equipment. All six HPO ' s are standing around him facing him in a semi-circle. At 03:00, Patient #L makes a fist holding onto the thermometer.

At 03:14, the female patient on her volition stands up and moves away from the area. No nurses or clinicians are in view.

At 03:39, two additional HPO ' s arrive, totaling eight HPO ' s. All eight HPO ' s are observed wearing handcuffs in their belts and carry ASP Batons. The eight HPO ' s continue to stand around the patient in a semi-circle. At 04:03, the HPO ' s are still standing, two with their hands on their hips, and two others put on their black leather police issued gloves. At 04:48, a third HPO is also wearing black police issued gloves and is adjusting the strap on the gloves. At 05:09, no clinical staff are in the area and the patient continues to hold the thermometer in his hand.

At 05:12, one of the HPO ' s moves a piece of furniture out of the area.

At 05:19, two nurses arrive and stand back behind the HPO ' s. They do not appear to be interacting verbally with the patient and their lips are not observed to be moving. One of the nurses is holding a four point restraint in her hand.

At 05:29, Patient #L remains positioned in the same area (the patient never moved forwards at anytime in the recorded video) while still holding the thermometer and gestures in a down wards thrusting motion in the air.

From 05:29 to 06:04 this situation continues with eight HPO standing in a semi-circle facing the patient and the clinical staff standing behind the HPO ' s. During this time a HP Sargent is observed verbally interacting with the patient.

Noted at 07:32, an additional Police Officer arrives now totally nine Officers. At 08:29, a HP is observed making strap adjustments to his police issued gloves.

Observations made at video time 08:32 a Hospital Police Officer (Staff # 40) is observed to draw his tactical impact baton (weapon) and strikes in a down wards thrusting motion towards the patient #L ' s right hand and arm area three times in succession.

At 08:36 seven HPO ' s move forwards in unity towards Patient #L. Noted at 08:39 nine HPO ' s are observed huddled over Patient #L and physically restrain him. The two licensed nurses and one patient care assistant are observed in the background while the HPO ' s place Patient #L onto a waiting stretcher.

At 09:56, the nurses apply cloth restraints to the upper right wrist, the upper left wrist, the lower right ankle and the lower left ankle. While they apply the restraints to the patient, eight HPO ' s are observed holding the patient in a manual restraint on the stretcher.

At 11:48, a ninth HPO arrives and is carrying a white cloth like appearing item in her hands, she hands it to one of the eight HPO ' s standing around the stretcher.
At 12:26, the white cloth like item is observed covering the patient ' s mouth and nose area.

At 12:35, the patient is wheeled away out of view.

The HHC Crime and Incident report (Form 587) dated 08/10/15 was reviewed and witness statement by Staff #44 documented, " On Monday 8/10/15 in the evening, nine HPO ' s responded to a call (made by another HPO) in the Adult B Area of the Emergency Department. Upon arrival, Patient #L was standing in the doorway of the patient ' s bathroom holding a thermometer which was attached to the vital signs cart. Patient #L was verbally threatening to use the thermometer as a weapon if anyone approached him. This writer attempted to gain control of the situation with dialogue but to no avail. At this time HPO Staff #40 extended his ASP Baton and began striking Patient #L two to three times on the arm/hand area attempting to knock the thermometer out of his hand. Staff #40 was not instructed by any of his three supervisors present to use the baton. Patient #L did not walk, approach or lunge towards any Officers that would justify use of a baton. Patient #L was placed on a stretcher and then medicated by staff RN and placed into a four point restraint. "

Review on 08/25/15 of the facility policy titled, "Patient Bill of Rights" dated 10/13 states, " Patients in the facility have the right to receive care in a safe setting and be free from all forms of abuse and harassment."

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Based on video observations, staff interviews, and review of documents, during the Federal Allegation Survey, the facility failed to ensure the patients right to be free from all forms of retaliation by staff. This was evident in one of three CCTV video DVD #3.

This failure places all patients at risk for physical and/or mental harm by facility staff.


Findings:


On 08/24/15 at 3:45 PM, closed circuit television (CCTV) surveillance DVD #3 recorded on 03/08/15 at approximately 4:10 PM was reviewed with staff #18.

DVD #3 revealed inpatient Psychiatric Unit 10 A and shows the front entrance and the right corridor of the unit.

At video time stamp 00:40 observations were made of Staff #48 a (Behavioral Health Associate) walking behind Patient #Q. The patient is observed opening a door to the day room and disappears inside. Patient #Q is an eighteen year old male admitted on 02/19/15 for suicidal ideation with Bipolar Mood Disorder with a positive history for suicide attempts. Staff #48 remains outside the room and has a conversation with another patient. Patient # Q emerges from the room and walks down the length of the corridor and out of view of CCTV. Staff # 48 follows behind the patient keeping within six feet as per "special observation" protocols and procedures.

Patient #Q returns into view and then Staff #48 appears behind Patient #Q and is accompanied by two female patients walking with him.

Patient #Q, stops at the Nursing Station and is observed talking with someone out of view.

During interview on 08/25/15 Staff #18 stated, " The patient is asking that Staff #48 not be the person doing the one to one observation and he wants a different staff person assigned to his one to one. But I don't believe they had any other available staff to take over the assignment so the patient was told no that couldn't happen."

Noted at video time stamp 01:50 a HPO arrives via the front door and into the unit. The HPO stands between Staff # 48 and the patient and has his back towards Staff #48 and is facing Patient #Q.

During interview on 08/25/15 Staff #18 stated, "the HPO arrived because he is doing his patrol "

At 02:00 Patient #Q is talking and is using his hands as he talks, gesturing towards Staff #48.

At 02:12 a Nurse enters through the door of the front entrance and one of the female patients standing close by is saying something to the Nurse gesturing towards Staff #48 and Patient #Q. The nurse walks away and into the Nurses Station out of view.

At 02:54, Staff #48 and Patient #Q walk down the corridor and into view of a second CCTV camera angel from the right corridor.

At 03:06 Patient #Q is observed taking one step towards Staff # 48 and Staff # 48 responds by placing the patient into a choke hold. A struggle ensues and Staff # 48 thrusts his body into Patient # Q left side at the rib cage area. Staff # 48 throws some papers to the ground and then strikes out and punches Patient #Q twice in the left side of the patient ' s upper torso and upper extremity areas. Three HPO's appear immediately and separate the two of them and place Patient #Q into a physical hold.

Review of medical record for Patient # Q revealed a physician ' s note, dated 03/08/15 timed 4:15 PM documented, " the RN notified MD that patient has been threatening and assaulted a staff member and is in need of medication and seclusion. Medication of Haldol 5 mg IM and Ativan 2 mg IM Stat prn ordered."

The patient was placed in seclusion on 03/08/15 immediately following this encounter and remained in seclusion from 4:15 PM to 5:50 PM.

Staff # 48 did provide a written signed statement dated 03/08/15 4:10 PM, " My name is (Staff # 48), I was Patient #Q one to one before our problem patient turned aggressive with another patient. He was using improper words with her because she was talking to him in Spanish and he threatened to throw a cup of coffee on her. I told him he needs to be a gentleman because she is a lady. Suddenly he went to the Nurses station and complained about me and requested another one to one for him. The nurse told him there isn't any more staff who could stay with him. The patient started yelling he doesn't want me anymore as his one to one and he was turning more aggressive. One minute later Patient # Q was yelling at me improper words and tried to grab the observation sheet and I could see fury in his eyes so I tried to hold him and restrain him."

10 A Unit Personnel did not complete an occurrence/accident report for the event.

The Police Incident and Crime Report (form "587") was provided to the SA Surveyors and the event was reported to the Justice Center on 03/10/15.

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Based on documentation review and interviews, the hospital failed to develop a policy for administering medications against a patient's will when verbal and all other interventions fail to reduce aggression or when oral medication is refused by the patient who is imminently endangering himself or others. (Patients # L, #N, and #Q)

These findings place all patients at risk of harm when administering medication (Haldol 5 mg IM given concurrently with Ativan 2 mg IM) against patients will during manual holds (restraint) by facility Staff including HPO.

Findings:


Medical record review on 08/25/15 revealed Patient #L is a 33 year old male admitted to the Medical Emergency Department (MER) on 08/10/15 at 8:15 PM with paranoia and schizoaffective disorder.

The patient stated at Triage his chief complaint was " There ' s an infestation all over the streets and I want to get away from it. "The Triage nurse documented that at home the patient takes Haldol and Ativan by mouth.

The physician (Staff #14) saw the patient at 8:39 PM and documented, " patient was noted to be very irritable and uncooperative with the interview, verbally abusive toward this writer. As this writer walked away from the patient, he threw his carton of milk at the wall in a threatening manner. Warranting Haldol 5 mg and Ativan 2 mg IM (intramuscular) once for agitation."

Nursing staff documented on the medication administration record that Haldol 5 mg and Ativan 2 mg IM (intramuscular) was administered at 9:00 PM.
Review of the patients medical record lacked documentation for the Violence Behaviour Assessment/Therapeutic Intervention form.

The patient was observed on CCTV DVD #2 in a manual hold 08/10/15 at 9:00 PM and the patient was placed in four point cloth restraints at 9:05 PM.

Review on 08/25/15 of signed interview statements dated 08/21/15 staff #45 documented, " at my time of arrival to the scene in the MER Area B on 08/10/15 at 8:45 PM I was informed that Patient #L was refusing to take his medicine. I approached the patient to find out why he was so upset and he said that they ordered it different from the way he usually takes the medicine. I told the patient I would speak with the doctor for him. The medical staff emphasized the patient has to take the medication or else he would be restrained and tied down."

Review on 08/25/15 of signed interview statements dated 08/21/15 by facility staff #46 documented, " I was advised by Central Command to respond to Area B to assist with a patient medication. When I arrived Patient #L was yelling out he wasn ' t going to take any medication. Except by mouth was the only way he would take it. If he decided to take it. Once the patient was placed on the stretcher the nurse medicated the patient and then he was placed in restraints."

Review on 08/25/15 of signed interview statements dated 08/21/15 by facility staff #47 documented, " I responded to Area B at 8:43 pm on 08/10/15 and all measures were exhausted from hospital police standpoint and medical staff refusing to make contact with the patient to calm him down...after tackling the patient and putting him on the stretcher we held him down to help the RN medicate the patient with Haldol and Ativan."

Medical record review on 08/25/15 revealed Patient #Q is an eighteen year old male admitted on 02/19/15 for suicidal ideation with Bipolar mood disorder. The physicians note, dated 03/08/15 timed 4:15 PM documented, " the RN notified MD that patient has been threatening and assaulted a staff member and is in need of medication and seclusion PRN medication of Haldol 5 mg IM and Ativan 2 mg IM Stat for agitated ordered."
Nursing staff documented on the medication administration record that Haldol 5 mg and Ativan 2 mg IM (intramuscular) was administered at 4:20 PM.

Review of Hospital Crime and Incident report dated 03/08/15 timed 4:30 PM documented, "responding officers and a staff member were having a physical confrontation and we separated the complainant (staff #48) and patient and placed the patient in the seclusion room where the patient was medicated by the RN and then left in the seclusion room."

Review of medical record on 08/25/15 for Patient #N revealed, the nurse documented on 05/17/15, " On or about 12:30 PM the patient became angry and accused another patient of taking his shirt. Verbal altercation ensued. Medicated with Haldol 5 mg and Ativan 2 mg intramuscular injection on 05/17/15 at 12:40 PM."

Review of Hospital Crime and Incident report dated 03/08/15 documented, " two HPO ' s had combative patient (Patient #N) held down to his bed, the patient was bleeding from his mouth as a result of fighting with another patient. I gave verbal commands to the patient to calm down and stop resisting with negative results. The patient was manually restrained on 05/17/15 at 12:32 PM to 1:37 pm."

Review of the inpatient psychiatric safety contract provided to patients who are admitted to the inpatient units 10 A and 10 C. The patient's signature is required on the contract at time of admission. Review of this safety contract form revealed,
"The staff of 10 A and 10 C believe that recovery from emotional problems requires a calm environment. We also know that sometimes a persons mental illness makes them behave in ways they would not when well. More specifically, emotional problems can often make a person anxious, nervous and irritable. Occassionally, a persons mental illness may make them lose control of their temper. Our staff is trained to help you when you are beginning to lose control.
Staff will speak with you to help you identify the cause of your uneasiness and provide direction and discuss ways to resolve problems. Staff may offer you medications, even if you have not requested it.
In the event this does not help you to feel calmer, to prevent you from hurting yourself or others staff may do the following:
(1) Medication will be given in liquid form or by injection. You may take the medication voluntarily or it will be given against your will.
(2) Staff will escort you to the seclusion room. This is a locked room where you are away from noise and distractions. This will help you calm down and regain control.
(3) If staff feels it is necessary to prevent you from hurting yourself or others, you will be placed in a bed and the movements of your arms and legs will be restricted through the use of restraints."

Medical record lacked documentation for a "Violence Behaviour Assessment/Therapeutic Intervention."

Review of hospital Policy titled "Restraints/Seclusion" dated 09/2014 states, "Guidelines: Patients Rights. Where ever possible every attempt should be made to avoid the use of restraint/seclusion, as it is known to be potentially harmful both physically and mentally. Restraint/seclusion should be used only in unusual circumstances and only after all reasonable less restrictive alternatives have been attempted or considered and rejected for reasons related to the patients well being. This facility does not use chemical methods of restraints."

On 08/26/15 in the morning, a request was made to Staff #5 by SA surveyors for the facility policy describing the hospital procedures in the behavioral management of aggressive patients who are placed in manual holds (restraints) by staff including HPO's and then medicated by pharmaceuticals of intramuscular benzodiazepines and neuroleptic drugs.

Specifically, the policies for when administration of medications occurs with Patients who become severely agitated and pose an immediate threat to others or a danger to self and involve a physician one time only order for medication against a patients will if the situation is needed and required.

Staff #5 informed the SA surveyors in the afternoon that the facility did not have any of these policies to provide.

08/26/15 in the afternoon, Staff #5 provided the HHC Office of Behavioral Health "Guidelines for IM (intramuscular) benzodiazepines and neuroleptic use over objection for Behavioral Management" dated October 2010.

The guidelines reviewed state, " facilities should have policies that specify the elements/indications of a complete PRN and STAT medical order which are consistent with and inclusive of these guidelines."

However, no policy was developed for medications given against a patients will from October 2010 to August 26th 2015.

This was confirmed a second time by several HHC Corporate executives who were present at the survey exit on 08/27/15 at 4:45 PM.

Staff # 49, a corporate director stated, "we looked around at our other hospitals but could not find any policies that address this."

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Based on review of CCTV surveillance, hospital documents and interviews the hospital failed to apply the least restrictive restraints to a patient housed on an inpatient psychiatric unit. Patient #N was restrained by mechanical metal device (handcuffs) for one hour and five minutes on an inpatient pyschiatric unit.

These findings place all patients at risk for harm.


Findings:



On 08/24/15 at 2:45 PM, closed circuit television (CCTV) surveillance DVD #1 recorded on 05/17/15 at approximately 12:30 PM was reviewed with staff #18.

Observations revealed the rear nurses station area of inpatient Psychiatric unit 10 A.

Observed at DVD video time stamped 12:01, Patient #N is observed walking across the unit accompanied by Staff #39, who is a HP Lieutenant and three other HPO's. Patient #N has both arms behind his back and his hands are criss crossed in the standard position assumed when placed in handcuffs. Police issued metal handcuffs are observed restraining Patient #N's wrists behind his back as he is walked across the unit.

During interview on 08/24/15 Staff #18 stated, "The Hospital Police Officers ' s were responding to combative patients on 10 A involving two male patients fighting and having an altercation, one of the patients fighting was Patient #N. The seclusion room door was broken. So I believe the Officer placed Patient #N into handcuffs for that reason. "

Review on 08/25/15 of the New York City Hospital Health Corporation , Hospital Police Department interview statement dated 05/17/15, Staff #39 documented, " I along with two other HPO ' s escorted combative Patient #N to the seclusion room. One HPO (Staff #41) grabbed patient by left arm and another HPO (Staff #42) grabbed patient by the right arm. I grabbed patient from behind placing my right arm around his body and his right arm to his lower back. Once we reached the Seclusion room we were informed by staff that the key to the Seclusion room just broke in the cylinder. For the safety of the patient and HPO ' s at 12:32 PM I applied mechanical restraints on said patient and attempted to remove the broken key from cylinder with negative results. The patient said he would calm down and was returned to his room. At 1:37 PM the mechanical restraints were removed by Staff #38. The Administrator on Duty, (Staff #43) was present at the time of these incidents."

Record review on 08/25/15 of the Administrator on Duty (Staff #43) tour report dated 05/17/15 stated, " at 12:22 PM this AOD was notified by staff #24 of a patient disturbance on Unit 10 A,and that a patient struck one of the glass panels in the large patio and it is cracked. AOD proceeded to the Unit and on the way encountered HP in force running to the unit. When AOD entered the 10 A unit Patient #N was being subdued by HP. They attempted to place him in the Seclusion room and could not open as the key is broken in the cylinder. Patient #M was also being subdued by HP. Patient #M was yelling and screaming. Patient #M was placed in her room and eventually calmed down. Patient #O who had hit the glass in the patio and shattered the panel was already medicated and in his room. "

Additional review of medical record for Patient #N lacked any documentation by Physicians, Nurses or Administrators on Duty that the patient was restrained by mechanical metal device (handcuffs) for one hour and five minutes on 05/17/15 from 12:32 PM to 1:37 PM. There was no documented evidence in the medical record that a physician ordered restraints or seclusion.

Review of hospital Policy titled "Restraints/Seclusion" dated 09/2014 states, " Restraint does not include handcuffs applied by law enforcement officials for custody, detention and public safety reasons. "

Although the hospital policy does not explicitly state that handcuffs may be not be used in the inpatient acute care areas. The Center for Medicare Sevices definition of these devices are they are considered law enforcement devices and are not acceptable health care restraint interventions for use by facility staff to restrain patients.

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Based on review of CCTV Surveillance video, documents and interviews the facility failed to develop a policy and procedure for "spit guards" facial shields routinely used during take-downs of aggressive patients. Evident in two (2) of two (2) patients. (Patient #L and #M.)

These findings of unsafe interventions and using non approved barriers could potentially obstruct the patients airway or impair breathing capacity and puts all patients at risk for physical and psychological harm.

Findings:

On 08/24/15 at 3:15 PM, CCTV surveillance DVD #2 recorded on 08/10/15 at approximately 8:40 PM was reviewed with Staff #18.

Observations revealed the Medical Emergency Department "B" Area -DD 1 where a rapid response to Patient # L's behavioral emergency was in progress.

Hospital Police Officers applied physical restraints to Patient #L and placed him on a stretcher so Nursing staff could administer intramuscular medications and tie the patient in bilateral ankle and bilateral wrist restraints. Immediately after these interventions were performed, a HPO was seen carrying a white appearing item in her hands, this item was passed to another HPO and then placed over patient #L's mouth and nose. The white item is clearly seen in the CCTV video at time stamp 12:26.

Interview with Staff # 21 on 08/25/15 at 2:30 PM was conducted who confirmed an unauthorized item was placed over the patients mouth and said it was a surgical mask. When the Officer was questioned why the patients mouth was covered Staff # 21 stated, "in case he spits at us." The Officer was asked whether the patient had spit or threatened to spit, Staff # 21 stated, "No."

Interview with a second HPO, who was present in the room while video was being watched on 08/25/15 at 2:35 PM stated, "why cant we use something to cover their (patients) mouths. We get spit at all the time. When I worked in corrections we always put a spit guard over the face whenever we had to transport them (prisoners)."

On 08/24/15 in the afternoon CCTV surveillance DVD #2 recorded on 03/17/15 at approximately 12:30 PM was reviewed with Staff #18.

Observations revealed that patient #M is positioned on the floor with one HPO kneeling and pinning down the patient's upper torso . A second HPO is observed kneeling on the patients left shoulder and left chest body area. The patient is held in this position for approximately three minutes. The patient is returned to an upright position and escorted to her room.

During interview on 08/24/15 Staff #18 stated, " The reason why Patient #M was so upset was because she wanted to go to her room but was told no she couldn't because it was near where a fight was taking place between two other patients. That ' s what set her off and got her so combative. After the situation is managed by the HPO's then they take her to her room where the nurses medicated her. The patient was fighting the Officers and spit at one of them. When they took her to her room because she was still spitting at them the patient's head was covered with a bed sheet."

Review of hospital Policy titled, "Restraints/Seclusion" dated 09/2014 makes no mention of any hospital approved facial shields spit guards or masks procedures to cover the patient with during take downs and physical holds.

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Based on record review and interview the facility failed to monitor a patient in four point restraints. In two (2) of (5) five medical records reviewed. (Patients #P and #R)

This finding placed all patients at risk of harm.

Findings:

Review of Medical Record revealed Patient #R was admitted via the ED on 5/22/15 at 4:52 AM. Patient is a 22 year female diagnosed with Anxiety Disorder and panic attacks. The patient was repeatedly yelling in the ED she wanted to go home and was yelling, uncontrollable and attempted to abscond from the ED. The patient was medicated and placed in 4 point restraints at 8:40 AM and were discontinued at 10:40 AM. The patient was taken to the PES and she became agitated, banging doors, and crying and 4 point restraints were reapplied at 2:45 PM. At 3:00 PM the patient was reported by the nurse as agitated and crying. At 3:15 PM,3:30 PM,3:45 PM,and 4:00 PM, the nurse documented the patient was agitated and crying. At 4:15 PM the nurse documented the patient was asleep and the restraints discontinued.

On 03/22/15 at 4:30 PM the patient was transferred to unit 10 A and the admission nurse documented at 6:15 PM, "Patient is admitted to 10 A from Psychiatric ED. Patient was brought to the floor on a stretcher and 4 point restraint from the PES. Staff had been informed that the restraint order was discontinued but they removed the restraints upon arriving to the unit, Charge Nurse and Doctor are made aware.

Review of Medical Record revealed Patient #P was admitted via the ED on 8/12/15 and restraints to bilateral wrists were applied at 7:30 PM and monitored through to 9:00 PM and there is no documented time of release.

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Based on record review and staff interview the facility failed to develop a policy (in alignment with NYSOMH annual recommendations) that specify s what the interval is between mandatory PMCS training for Hospital Police Officer staff who apply physical restraints in aggressive patients.

This was failure placed all patients at risk for harm.

Findings:

Review of ninety one (91) of ninety one (91) personnel files for Hospital Police Officers on 08/26/15 revealed that HPO staff members all received preventing and Managing Crisis Situations (PMCS) on date of hire during orientation.

Review of the personnel files lacked evidence that in-service training was provided in PMCS techniques/interventions during their mandated annual core requirements.

Review of HPO job descriptions state their knowledge and skill set must include Physical Restraint and Seclusion of Patients and Crisis Prevention and Interventions.

During interviews on 8/26/15 in the afternoon, Staff #18 stated, "we don't have a policy that says they should get retrained in PMCS yearly. We do train everyone (all HPO's) when they are first hired."
Staff #5 was present during this interview.

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Based on review of records, policies, and interviews, the hospital failed to ensure that Hospital Police Officers who regularly have direct patient contact including application of restraints are educated in depth on hospital policies, (1) "Restraints/Seclusion" and (2) "Psychiatric Emergency Services, Behavioral Emergency Support Team (BEST): Rapid Response for Behavioral Emergencies"

This failure to ensure patient safety when HPO's are responding to behavioral emergencies and applying restraints put all patients at risk for harm.


Findings:

(1) Review of a sample of fourteen (14) of ninety one (91) personnel files for Hospital Police Officers on 08/26/15 revealed that HPO staff members do not receive in-depth education for hospital policy titled "Restraints/Seclusion."

Review of hospital Policy titled "Restraints/Seclusion" dated 09/2014 states, "Restraint is any manual method, mechanical device, or pharmacological measures that immobilizes or reduces the ability of a patient to move his or hers arms, legs, body or head freely. Seclusion is the involuntary confinement/placement of a patient alone in a room, or area from which the patient is physically prevented from leaving. The following are considered restraints, Use of manual or physical method by using your body to manage the patient violent or self-destructive behavior that threatens the patients, staff or others safety. The use of manual restraint, orders must be limited in duration to 30 minutes and must be limited to the duration of the emergency situation regardless of the length of the order."

During interviews on 08/24/14 at 3:45 AM Staff #18 stated that "The Hospital Police Department wasn't doing in-depth training on the "Restraints/Seclusion" policy because they don't apply the four point restraints, the nurses do that."

Survey activities throughout the Federal Allegation Survey, including observations and record reviews verified that Hospital Police Officers put hands on patients and apply physical holds (restraints). Police Officers assistance may include a physical take down and restraining of violent patients.

(2) Review of fourteen (14) of ninety one (91) personnel files for Hospital Police Officers on 08/26/15 revealed that HPO staff members do not receive in-depth education for hospital policy titled "Psychiatric Emergency Services, Behavioral Emergency Support Team (BEST): Rapid Response for Behavioral Emergencies"

Review of the policy titled "Psychiatric Emergency Services, Behavioral Emergency Support Team (BEST): Rapid Response for Behavioral Emergencies" dated August 2014 documented BEST is initiated to manage aggressive patient behavior. The rapid response support team includes Hospital Police Officers.

Survey activities throughout the Federal Allegation Survey, including observations and record reviews verified that Hospital Police Officers frequently respond to rapid response for behavioral emergencies. However, the policy fails to delineate the role and responsibilities that the police officers have in the Support Team.

Interview with Staff #37 on 08/26/15 in the afternoon revealed that since 08/21/15 all staff, including HPO's, are now receiving education with the "Psychiatric Emergency Services, Behavioral Emergency Support Team (BEST): Rapid Response for Behavioral Emergencies" policy.

Based on review of CCTV Surveillance video, documents and interviews the facility failed to ensure that HPO staff had the necessary training on the safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia).

These findings of unsafe interventions and using non approved barriers could potentially obstruct the patients airway or impair breathing capacity and puts all patients at risk for physical and psychological harm.

Findings:

Cross reference to tag 167 and tag 206.

Based on interview and review of personnel files it was determined the facility failed to ensure that Hospital Police Officers had the required training in the use of First Aid techniques and certification in the use of Cardiopulmonary Resuscitation (CPR) for ninety-one (91) out of ninety-one (91) Personnel Records reviewed.

Findings:

Review of ninety-one (91) Personnel Education and Training Records for the Hospital Police Officers who frequently participate in take downs and application of restraints (physical holds) on a daily basis with patients throughout the hospital did not provide evidence of basic First Aid or CPR.

Review of the policy titled "Psychiatric Emergency Services, Behavioral Emergency Support Team (BEST): Rapid Response for Behavioral Emergencies" dated August 2014 documented BEST is initiated to manage aggressive patient behavior. The Support Team includes Hospital Police Officers who put hands on patients and apply physical holds (restraints). Police Officers assistance may include a physical take down and restraining of violent patients.

During interviews on 08/24/14 at 11:45 AM Staff #18 stated that "we have no type of mandatory First Aid for the Hospital Police Officers."

On 08/25/15 in the morning, Staff #18 re-confirmed and stated, "that all Hospital Police Officers including the seven Police Officers who are assigned to do the "Safety Watches" at the hospital points of entry and information desks and who could potentially be involved in patient take downs and physical holds if they were to encounter an aggressive person presenting in these areas do not get First Aid or CPR training." Staff #5 was also present during this interview.

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Based on review of records and interviews the hospital failed to ensure Hospital Police Department debriefings were performed to monitor appropriate procedures were applied during rapid responses to behavioral emergency and other data relative to these responses was aggregated, tracked and trended into monthly hospital Quality Assurance and Performance Improvement and submitted to Governing Body quarterly.

This failure placed all patients at risk of harm.

Findings:


Review of the hospital policy titled "Psychiatric Emergency Services, Behavioral Emergency Support Team (BEST): Rapid Response for Behavioral Emergencies" dated August 2014, states, "The Behavioral Emergency Support Team (BEST) can be activated in any area of the hospital and will include a member of the Hospital Police (Patrol Officer).

The BEST personnel will assist in calming the patient with verbal and nonverbal interventions approved by the New York State Office of Mental Health " Preventing and Managing Crisis Situations " curriculum. These interventions are aimed to manage a psychiatric crisis with the appropriate response.

In addition to completing documentation in section 1 and section 2 of the BEST Log ( Forms) a (clinical) note will be entered into the medical record by the psychiatrist.

It is strongly recommended that a debriefing session occur after each activation of BEST.

An occurrence report may also be required and must be completed by unit personnel.

Quality Review: Each month the BEST activation log forms will be collected from each unit by the Nursing Department and that information will be reported to the Department of Psychiatry ' s Performance Improvement Committee on a monthly basis. "

The Department of Psychiatry ' s Performance Improvement Committee lacked evidence of quality review related to the BEST log activities for units 10 A or 10 C, or the PES or Area B in the Medical Emergency Department (MER).

During interview on 8/26/15 at 4:00 PM Staff #37, " the BEST policy wasn't really meant to be used in the non behavioral areas, it was designed with the intention that the behavioral health areas would know how to handle a psychiatric emergency. So with that in mind we weren't collecting the BEST log forms from the behavioral health areas until Friday August 21 st 2015 when we decided to make this policy a hospital wide response."

Review of hospital security logs for May, June, July and August 2015 revealed more then a hundred Behavioral Emergencies requiring an immediate response from hospital police officers to assist clinical staff throughout the facility with aggressive patients.

During interview on 08/25/15 at 3:30 PM, Staff # 18 was asked whether any debriefings were performed and documented after the HPO's responded to behavioral emergencies and he replied "No."
Staff # 18 was asked whether any performance improvement projects related to the Hospital Police Departments activities when responding to Behavioral Emergencies and he replied, "No."
Staff # 18 was asked if he attended the monthly Hospital wide department heads Quality Assurance and or Performance Improvement Committee Meetings and he replied, "No."
Staff # 18 was asked how the performance activities of Lincoln Medical Center's Hospital Police Department was submitted to the Governing Body and he didn't have an answer.
Staff # 18 was asked what Hospital Committees he did attend and he stated, "the EOC committees." (The Environment of Care Committee.)

Review of the Governing Body Annual report 2014 lacked HP Departmental reports or data related to their activities during rapid responses to behavioral emergencies.

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Based on record review, staff interview and observation, it was determined that the facility failed to comply with the Condition of Participation for Emergency Services. This was evident by the facility's failure to ensure that staff completed medical screenings and evaluations, developed treatment plans and provided a safe disposition plan prior to discharge of psychiatric patients presenting in the ED with actual suicide attempts or suicidal ideations to self-harm, resulting in the death of a patient.

This finding puts all patients at risk for poor outcomes including risk of death.

Findings:


The facility failed to ensure Pyschiatric Emergency Services policies were implemented. (Refer to Tag A 1104)

Based on record review and interview, the facility failed to ensure that staff completed medical screenings and evaluations, developed treatment plans and provided a safe disposition to discharge of psychiatric patients presenting in the ED.

This finding puts all patients at risk for poor outcomes including risk of death.

Evident in eight (8) of eight (8) patients (patient A, B, C, D, E, F, G, and H)

Theses failures place all Psychiatric Emergency Department patients at risk for poor outcomes.


Findings:


Medical record review for Patient # A on 08/25/15 revealed a 25 -year-old male admitted on 06/22/15 at 11:58 AM with chief complaint of suicide attempt by intentionally stepping off a twenty storied building.
The patient stated to the Triage nurse "My life is over".

The patient was brought to the Emergency Department (ED) by New York Police Department (NYPD) who had prevented him from falling. The Fire Department New York (FDNY) " Prehospital Care Report " dated 6/22/15 11:47 AM documented, " found a 25 year old male on top of 20 story building threatening to jump. After one and half hours of negotiations patient was finally subdued by NYPD. Patient says he wanted to kill himself. Taken to LMC ED as a psychiatric Emergency. "

The RN noted the patient ' s sister was present in the ED and reported " patient had been acting different for the past two or three days, after getting into a fight with his girlfriend who has his daughter and the girl friend took his daughter away from him. "

The patient was an acuity Triage level two because of the mode of his suicide attempt.

On 06/22/15 at 11:58 AM, the Triage RN performed the " Columbia Suicide Severity Rating Scale (C-SS/RS)" which resulted in a positive screen.

When a patient has a "Columbia Suicide Severity Rating Scale (C-SS/RS)" with a positive result then according to facility policy that would trigger the physician needing to perform the Columbia Suicide Severity Risk Assessment (C-SS/RA) within 60 minutes. However, this was not performed by the physician on the initial assessment.

The patient was brought to Medical Emergency Room Area B with chief complaint of Depression with suicide attempt.

The patient was seen by a medical doctor who documented at 1:45 PM, " Labs within normal limits pending a urine toxicology. Patient refused to give urine. The patient was seen and examined by me in the medical ED Area B. The patient was brought in with suicidal ideation and found on the roof of a building threatening to jump. He was talked down by police who brought him here. I confirm/reviewed all findings assessment and plan done by the Medical Resident and medically cleared the patient for transfer to psychiatry for further care and evaluation. No past medical history. Ambulating without difficulty. He denies any alcohol or drug use. Neurological status intact, no reported physical complaints including fever, chills or recent illness. He is hemodynamically stable and medically optimized for psychiatric evaluation and management. Will remain on close observation pending psychiatric disposition. Case discussed with Psychiatric ED Attending. Disposition from Medical ED: Admitted as an Inpatient to Psychiatric Services. "

The patient signed consent for PSYCKES data base access. However the PSYCKES recorded history was not obtained during the 6/22/15 to 6/23/15 hospital encounter by the Psychiatrist or the social worker.

The Psychiatric Attending documented an assessment note at 2:00 PM, " Chief complaint, Depressed and suicidal.
The patient denies any past psychiatric history but the patient ' s brother reports that last year the patient was hospitalized for two weeks at Bellevue after the patient jumped in front of a train. The patient ' s brother was called and he doesn ' t feel that the patient is safe to go home " and " sometimes my brother sounds ok but he is not. " The patient ' s brother reported he spoke with the patient for four hours last night and said that two days ago the patient tried to choke his girlfriend and spray painted on his door " the government is trying to kill me. "

He lives by himself and up until recently was working in a warehouse but he lost his job two weeks ago and is now unemployed. He didn ' t say how he lost his job. He says he has a daughter and wants to be a part of her life but his girlfriend moved out and now he cannot see either of them. Patient says he has hit rock bottom. He has lost all faith in himself. He admits to drinking alcohol and used to smoke marijuana until he recently replaced marijuana use with drinking alcohol. He doesn ' t want people to be stressing out about him. At times the patient was speaking tangentially and made paranoid statements like " someone is out to get me. "
Axis I Diagnosis Psychosis rule out substance induced. Axis II Deferred. Axis III family discord, lack of social support, job issues. Axis V GAF 30 Plan: Observe the patient and reevaluate in the morning for disposition Seroquel 100 mg orally at bed time.

The psychiatrist failed to access the "Quadra - Med" HHC database system and didn ' t obtain collateral information of the patients recent past psychiatric history from Bellevue Hospital. The psychiatrist failed to access the PSYKES Access system despite patients signed consent to do this.

The patient was medically optimized for psychiatric admission and transferred for continuation of care to the PES at 5:00 PM.

The Social Worker (SW) documented at 05:07 AM, "the patient was electronically referred for social work intervention and met high risk criterion due to history of psych, he is a military veteran, receiving Medicaid, he lives in a private residence, the sibling ' s phone numbers are listed but the patient didn't give verbal consent to contact them at this time. The patient met with SW in the PES area wearing hospital scrubs, poorly groomed, he was alert and oriented and receptive to this writer. He verbalizes adequate understanding of verbal information. The patient endorsed feelings of hopelessness and helplessness when admitted to standing on the edge of a roof top of the twenty story building where he lives. The patient stated he took stock of his life, what made him, what broke and how he is viewed by others seems important to him. He reported that he resides on a world which is divided into groups of people and he wants to conform to society. The patient feels he is an outcast and he is viewed by others as such and this troubles him. He is consumed with worry that people are looking at him and not liking what they see. The patient stated he wants to fix it so others would not look at him as though he does not belong. The patient stated he was happy there were people to help him in his time of need. The physician notes state patient is pending a psychiatrists re-evaluation thus the case is endorsed for social worker follow-up."

The Social Worker follow up note documented at 11:18 AM, " Patient remains in PES pending psychiatrists evaluation. This worker was contacted by the patients NYCHA worker who stated that the property staff contacted EMS yesterday after the patient was found on the roof of his building. The worker also reported that the patient ' s girlfriend moved out three days ago (on Father ' s Day) and took his child with her. This writer contacted NYPCC and they stated that the patient can visit their office anytime between 10:00 AM and 2:00 PM and they will begin the intake process and assign an appointment. The patient was advised to visit NYPCC upon being discharged from the ED."

However the referral request form for outpatient services follow up was not evident in the medical record on review 08/11/15 at 11:30 AM.

The RN documented a note at 6: 20 AM, " This patient brought in with complaints of feeling depressed and suicidal with no known medical history and an unclear psychiatric history. Urine for toxicology is still pending as patient refused to give urine. Patent stayed in his room most of the time, calm and cooperative, and slept well. For pyschiatrist revaluation and endorsed to incoming shift."

There was no Psychiatric Attending revaluation documented since the 2:00 PM note on 6/22/15. The medical record lacked evidence that a psychiatrist reevaluated the patient overnight. The first Attending did the initial psychiatric consult with a comprehensive evaluation at 2:00 PM, and had endorsed a re-evaluation for the psychiatrist working in PES but no follow up re-evaluation was performed until the disposition evaluation on 6/23/15 at 10:25 AM.
The psychiatric evaluation and disposition note documented on 6/23/15 at 10:25 AM, "presented with suicidal ideation and plans to jump off a roof (he was found on a roof). Tox screen not done. Patient states he feels better and denies any signs of acute depression. His affect is constricted and normal. His speech is normal and his thought process is goal directed and logical. He denies any suicidal or homicidal thoughts or intent. He contracts for safety. He has fair judgement, insight and impulse control. He is alert and oriented. The patient is not actively psychotic, suicidal, or homicidal now, therefore there is no need for psychiatric hospitalization at this time.

Diagnosis at Discharge is Depressive Disorder. Discharge today. Patient referred to NYPCC and patient is to go there today to their walk in clinic which is open until 2:00 PM. No medicines prescribed. Patient agrees with plan."

The Psychiatric Attending did not perform the Columbia Suicide Severity Risk Assessment (C-SS/RA) at disposition and there was no safety plan signed by the patient.
Discharge instructions were not signed by the patient.

RN documented a note at 11: 20 AM, " Patient received from tour 1 with a past psychiatric history of psychosis and suicidal ideation. Patient came to the ED due to depression and suicide ideation. The patient denies suicidal ideation and is for discharge."

RN documented a second note at 11: 41 AM, "The Patient was seen and cleared by the psychiatrist. Patient verbalized and understood to stay away from drugs and alcohol and to call 911 in case of emergencies. The patient left the ED alert and oriented and not in any distress. He had a pair of boxer shorts, a pair of socks and shoes and no money and no cell phone and no other valuables to return."

Discharge disposition: Treated and released.

The Social Worker documented a second note on 06/23/15 at 11:29 AM," The patient has been medically cleared for discharge. The patient had remained in the PES pending a psychiatric evaluation. The patient has been evaluated and is now for discharge. The patient has been provided with clothing from the volunteer office and a referral to follow up at NYPCC for outpatient services."

The RN documented on 06/24/15 at 6:48 PM, " At 11:54 AM today this 25 year old male was brought into the ED by EMS status post jumped from a twenty one story building to his death. On arrival the patient was unresponsive, asystole, apneic. (no heart beat, no breathing) Patient was pronounced dead by MD at 11: 12 AM. Patient transferred to morgue."

The MD documented a post mortem note at 2:47 PM. "Brought in by EMS a traumatic cardiac arrest after apparent intentional jump from 21 story building. The patient had no vital signs by EMS first contact. Intubation failed en route to the ED. Presented with full spinal immobilization and no spontaneous respiration's and no cardiac activity. Bilateral pupils fixed and dilated, large hematoma to back and spinal elements feel unstable. Pelvis unstable. Right lower extremity internally rotated and left lower extremity externally rotated. Time of death 11:12 AM. Next of kin notified in person. ME accepted the case."

Discharge Disposition: Dead on Arrival.

During interview on 8/12/15 at 12:30 pm, staff #2 was present during this interview. Staff #13 stated it was likely that Patient # A " probably needed inpatient admission based on her initial assessment but he still needed further evaluation in the PES by the Psychiatrist there. My intention was to move the patient to the PES and have a revaluation done later in the day by the next Physician coming on duty. " When asked why she didn't just admit him herself directly to the inpatient unit under an involuntary emergency legal status. Staff #13 stated " involuntary admissions are done upstairs once they are admitted. We don ' t do that in the ED."

Review of PES Policy titled, " Psychiatric Admissions: legal status." 09/14, " Emergency Admissions (9.39) the examining psychiatrist has determined that patient requires immediate hospitalization and completes the application for admission. "

Staff #13 stated " you don ' t know what its like here, we can't admit everyone. We see so many patients every day. We don't even behave like doctors here. We function more like social workers then doctors. "

Staff #13 was asked why in her treatment plan she wrote the patient should receive Seroquel 100 mg by mouth at bedtime and didn't write the order for nursing staff to administer the medicine.

Staff #13 said that "the treatment plan for medicines would be done later by the next physician on duty. "

When asked why is obtaining the patients prior psychiatric history from " Quadra- Med " important.

" It ' s helpful to know the patients past diagnosis, any medicines and treatment they had. "

Does that help to diagnose and treat the patient? " Yes, the QMed system is accessible for all our City hospitals and it helps in formulating a diagnosis in consideration to the patients past psychiatric history. "

Did you access the Q- Med for this patients past history from Bellevue. " No "

Did you access the PYSKES data base, the patient had given consent for PYSKES to be obtained. " No that ' s the social workers job to do that. "

During interview on 8/12/15 at 12:30 pm, Staff #2 the CMO was present at time of this interview.
Staff #2 was asked to explain how the patient ' s condition improved without any treatment interventions like medications being provided and what was it that caused his emergency medical condition to change from time of arrival and actively suicidal to stabilized for discharge back to his home.
Staff #2 stated " Really it was just time passing. We believe he had a substance induced psychosis and by keeping him here the drugs had sufficient time to pass from his system. "
Staff # 2 was asked with the Toxicology screen not being collected and no result obtained to confirm the diagnosis of a substance induced psychosis how did you determine that.
" Yes. He refused to give a urine specimen but he told us on interview he smoked marijuana."
Why wasn ' t the patient referred for Mentally ill Chemically Addicted (MICA) intensive outpatient or a partial hospital program to address his substance abuses.
"The counseling center would arrange all that if they felt it was necessary. "
Could the patient possibly have an untreated psychosis disorder from when he was discharged from Bellevue and have mentally decompensated prior to this psychiatric crisis on the roof top? " We don ' t know that. "
Staff #14 was interviewed on 8/13/15 at 11:00 AM a and confirmed he was the patients Attending Physician on 6/22/15 from 8:00 pm to 8:00 am on 6/23/15 and he confirmed that he didn ' t perform an evaluation overnight or document a treatment plan or treatment note and stated " it isn ' t our policy to reevaluate overnight unless the nurses bring a change in the patient condition to our attention. "
Staff #8 explained our standard procedures are "the patient gets a comprehensive evaluation done on an initial assessment performed by the consultant psychiatrist and then a reevaluation is performed in the morning for readiness for discharge."

Staff #14 was asked if Staff #13 (who was the physician handing off the patients care to him) had spoken with him at the 8:00 PM on 6/22/15 shift handoff and had staff #13 request that he do a reevaluation for this patient and he said "no."

Were you informed by Staff # 13 that the patient needed additional evaluation and a treatment plan developed including prescribing Seroquel at bed time?
Staff # 14 stated, " No. "

During interview on 8/12/15 at 11:15 AM Staff #12 was asked what criteria he used to determine patient A's readiness for discharge and he stated,

" I interviewed the patient and he wasn't expressing any suicidal or homicidal ideation he said he didn't have any intents or a plan to hurt himself. He wasn't describing any feelings of hopelessness or helplessness".

Were the follow up plans for Patient # A to walk from the ED on 6/23/15 to the outpatient behavioral health center.

Staff #12 stated, "He was instructed to go to the outpatient center for counseling and the social worker made an appointment for him that day. "

Did anyone call the patients brother and inform him that the patient was being discharged? " No, the patient didn't want us to. "

When asked whether he had spoken with either Physicians who had preceded him in the continuum of the patients care prior to patients discharge he said " No " .

Staff #13 was also working the morning of 6/23/15 and although she had performed the initial assessment at 2:00 pm the previous day she was not assigned Patient A on 6/23/15. She also confirmed that she had no conversation about Patient # A with Staff # 12 on the morning of 6/23/15.

During interview on 8/17/15 at 11:00 Am Staff #16 was shown the patients medical record and stated " Yes, the medical record does say the patient gave signed consent for PYSKES. "

When asked why the PYSKES database was not accessed for collateral information?

Staff # 16 stated " The patient verbally withdrew his consent and I made a mistake and didn ' t enter that into the patient ' s record. "

When asked why is PYSKES important to access and utilize the databank she said " it ' s tells us their past diagnosis, how many hospital visits they have had and any medicines they are taking. It helps us to provide better services to the patient and helps to decide their after care services. "

Why was there no " aftercare support service plan " in the medical record?
Social Worker Staff #16, "we hand the patient the referrals to outpatient programs but we don't call and schedule the patients appointment. They are told to go make their way there before the center closes. When they get to the center they will schedule with the patient an appointment for when the patient can be seen by a social worker there. We don ' t fax them or send NYCCP any of the patients ' medical information. That ' s not what we do. "

Did anyone call the patients brother and inform him that the patient was being discharged? " I wouldn ' t ' t know. But the patient didn ' t want me to call anyone in his family when I met with him during the night. "

Review of Patient # B medical record revealed on 6/26/15 at 5:35 AM was brought to the ED with suicidal ideation. The patient was treated and released from the ED at 5:57 PM. The psychiatrist failed to perform the " Columbia Suicide Severity Risk Assessment (C-SS/RA) " on admission and the medical record lacked a " Suicide Risk Assessment at disposition. "

There was no safety plan signed by the patient in the medical record.

Review of Patient # C medical record documented on 7/30/15 was brought to the ED with suicidal ideation and Triage note at 1:15 AM noted tried to "jump off of a building." As per patients brother this is the fourth time this month. He was talked down by police who brought him here. The patient was placed on one to one observation in the MER and was seen by the psychiatrist was on 7/30/15 at 4:58 AM. Disposition was on 7/30/15 at 11:21 AM into the community. The patient was instructed to go to NYPCC for outpatient services.

The psychiatrist failed to perform the Columbia Suicide Severity Risk Assessment (C-SS/RA) within the sixty minute time frame and the medical record lacked a Suicide Risk Assessment at disposition.
There was no safety plan signed by the patient.


Review of medical record revealed Patient # H was brought to the ED on 7/10/15 at 8:58 AM with suicidal ideation and the Columbia Suicide Severity Rating Scale was not done by the Triage RN and no Columbia Suicide Severity Risk Assessment was done by the doctor on admission or discharge. Disposition was treated and released on 6/11/15 at 11:05 AM.

There was no safety plan signed by the patient.

Patient #H did not sign consent for PSYCKES data base access. PSYCKES recorded history was not obtained during the 7/10/15 hospital encounter by the Psychiatrist, RN or the social worker.

The Psychiatrist failed to identify whether this was a clinical emergency allowing PSYCKES to be accessed for 72 hours without the need for patient consent as per policy.

Similar findings were found in Patient #D, E, F, G.

Hospital Policies reviewed on 8/25/15 revealed:

1) PES Policy titled, " Suicide Risk Assessment and Management in Psychiatric Emergency services and inpatient Psychiatric Unit: with ' Columbia Suicide Severity Rating Scale Tool ' and 'Columbia Suicide Severity Risk Assessment' attachments provided. Dated 05/2015

" If the patient has a positive screen, as part of the overall comprehensive assessment and formulation processes, the C-SSRS Risk Assessment shall be completed with an interdisciplinary treatment plan that addresses modifiable suicide risk factors.
A " Patient Safety Plan " will be developed and implemented in close collaboration with patients who are discharged from PES or the psychiatric inpatient units who are deemed at moderate or high risk for suicide.
Definitions: Suicidal patient is any person who has recently made an attempt in the last 12 months or has a plan (with or without intent)
High Risk: a patient has made an attempt within the past three months or has a plan with intent to kill him/her self.
Moderate Risk: patient has no immediate plan, or a low risk plan and their intent to die from their actions is low
Low or No Risk a patient who exhibits strong protective factors, may have thoughts of death but no plan for suicide.

Patient Safety Plan: is a prioritized written list of coping strategies and sources of support that patients can use who have been deemed at risk for suicide. Risk Factors are variables that increase the risk for suicide being attempted is likely.
A Safety Plan covers warning signs, coping strategies, personal and professional support options and environmental safety. A patient can use these strategies before or during a suicidal crisis.
Positive Screen is a positive response to the questions to the questions of having a plan or intent or having made an attempt within the past 3 months on the Columbia Suicide Severity Rating Scale Tool
Upon admission to PES all patients are screen using the ' Columbia Suicide Severity Rating Scale Tool '

When a patient has a positive the patient must be classified as emergent and seen by a Psychiatrists within sixty minutes for evaluation using the "Columbia Suicide Severity Risk Assessment' (Using the tool attached in policy).
The patient must be assigned a risk level by a Psychiatrists and an individualized interdisciplinary care plan developed to address suicide risk factors.
Upon discharge the patient must have another "Columbia Suicide Severity Risk Assessment' (Using the tool attached in policy).
Completed by a Psychiatrists to determine safety to leave the hospital and that all modifiable risk factors have been addressed.

Patients deemed at moderate risk for suicide, a Patient safety Plan shall be completed with the patient prior to discharge with resources for community support clearly identified.
Every attempt should be made to provide and communicate the patient ' s history of suicide risk to the family and after care provider.
All relevant clinical documentation will be sent to the next level of care provider for all patients who are given follow up appointments.
Patients discharged from PES will have an appropriate plan for follow up care including a Safety Plan developed with the patient.

2) PES Policy titled, "Hand Offs" dated 09/14 states, " To provide guidelines for effective handoff communication at change of shift and change of providers in the PES. To ensure appropriate medical information is shared among all providers to allow for continuity of care across shifts.

3) PES Policy titled, " Clinical assessments and documentation " dated 09/14 states,
" All patients triaged or consulted to the PES at LMC will receive accurate assessments and appropriate documentation.
The RN is responsible for ensuring coordination of care among other disciplines and support staff based on the initial patient assessment and ongoing on interval assessments. "
The Physicians, Nurses and social workers are responsible for collection of data through mechanisms such as observation, interview and diagnostic tests. This data is analyzed to create information necessary to determine the approach to meeting care needs and to identify any additional information required. Decisions are made and executed regarding delivery of care on the basis of the assessment.

The Physician ' s Reassessment is the Reevaluation of the patient at regularly specified times according to the patients course of treatment, response to treatment or when a significant change occurs in the patient ' s condition and/or diagnosis.
Reassessments will be initiated according to acuity of the patient ' s condition. Reassessments are required at minimum on a daily basis and are reflected in a progress note or consult follow up note. "

PES Policy titled, " Psychiatric Services and Clinical Knowledge Enhancement System (PSYCKES) " dated 09/14 states " To facilitate access by hospital Behavioral Health providers to the Psychiatric Services and Clinical Knowledge Enhancement System is a web base of Medicaid enrollees who had a behavioral health services, diagnosis or psychotropic medication in the past five years. Access to this database is designed to support clinical evaluation, treatment planning, and coordination of care and quality improvement. All patients requesting or requiring acute psychiatric care at LMMHC who are or were enrolled in Medicaid will be asked to sign consent to allow access to Psychiatric Services and Clinical Knowledge Enhancement System.
In the PES when a patient is brought in and refuses to consent or is unable to consent, the psychiatrist can identify this as a clinical emergency allowing PSYCKES to be accessed for 72 hours.
A copy of the patients profile can be printed and kept in the PES until transfer or discharge at which point all paper chart material is sent to Medical Records and will be scanned into Quadramed. The responsibility for obtaining consents and accessing PSYCKES is all members of the interdisciplinary staff.