HospitalInspections.org

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Based on medical record (MR) review, document review, and interview, in one (1) of ten (10) MRs, the facility failed to maintain a safe environment for patients.

This failure placed all patients at increased safety risk.

Findings:

- The facility failed to identify contraband during a safety search as per facility policy.
(See Tag A-0144).
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Based on Medical Record (MR) review, document review and interview, the facility failed to provide a safe environment for patients. Specifically, facility staff failed to adequately search Patient #1's belongings on two (2) occasions prior to transfer to a psychiatric facility for in-voluntary admission, as per facility policy. Patient #1 arrived at the receiving psychiatric hospital and was found to have a loaded gun on their person.

This failure placed all patients and staff at increased risk of harm by a patient with access to a firearm during ambulance transport, and upon arrival to the receiving psychiatric facility.

Findings:

Facility policy and procedure (P&P) titled, "Safety Search and Contraband," last reviewed 6/19/2021, stated, "All patients who are at risk either to themselves or others ...will have their belongings searched by the nurse aide."

Facility P&P titled, "Patient Property and Belongings," last reviewed 04/29/2020 stated, "All patients who are at risk either to themselves or others ...will have their belongings itemized and secured."

Patient #1's MR identified that on 3/18/2022 at 4:19PM, Patient #1 presented to the hospital via ambulance after a motor vehicle accident. The patient screened negative on the triage assessment for suicidal risk on initial presentation to the hospital. Nurse progress note dated 3/18/2022 at 8:12PM identified the patient verbalized suicidal ideation "in conversation with the doctor." Constant (1:1) observation was ordered by the physician and initiated.

A search of Patient #1's belongings was documented on 3/18/2022 at 9:00PM. Staff E (Nursing Assistant) identified Patient #1 had three (3) large black bags of clothing and toiletries. No contraband was identified, and the belongings were secured. Patient #1's belongings were not thoroughly searched or itemized, as per facility policies.

Psychiatric Evaluation Note dated 3/19/2022 at 2:00AM stated that Patient #1 "wanted to kill himself and if he could get his hands on a firearm that he would shoot himself." Patient #1 was certified by a psychiatrist at the sending hospital to be at risk for self-harm.

Patient #1 was escorted to the Emergency Department Behavioral Health Unit (ED Access Area) on 3/19/2022 at approximately 8:00PM for continued close observation. A second search of personal effects was performed on 3/19/2022 at approximately 8:00PM.

Facility P&P titled, "Patient Belongings-Behavioral Health," last dated 6/19/2019, stated "During the admission process (to psychiatric area), the staff inventories all items that patient has brought with him/her to the hospital."

The patient belongings behavioral health form titled, "Inventory of Personal Effects," dated 3/19/2022 at approximately 8:00PM documented Patient #1's belongings as three large black bags containing personal items such as clothing and toiletries. No contraband was identified. The patient's items were not inventoried thoroughly as per facility policy.

These findings were confirmed with Staff F (Behavioral Health Associate) on 3/22/2022 in the afternoon, who stated during interview with Human Resources "I did not go deeply enough through the patient's items."

On 3/22/2022 at 12:15PM, Patient #1 was transferred to a psychiatric facility for inpatient admission. Upon arrival to the receiving facility, Patient #1 was reported to have had a loaded gun on their person.

Email correspondence between the receiving facility and the Office of Mental Health (OMH) dated 3/22/2022 at 10:45PM stated, "...Patient...arriving as Psych 'designee' status from [sending facility] emergency room accompanied 'in hand' with the attached belongings and a sandwich bag contains [sic] a 'fully loaded 38 Smith and Wesson Gun.' "

Email correspondence between the receiving facility and the New York State Department of Health (NYS DOH) dated 3/29/2022 at 4:22PM confirmed, "Gun in bag on lap (brown sandwich bag)."

These failures made it possible for Patient #1 to transport a concealed, loaded firearm on their belongings and placed Patient #1, and all patients and staff, at increased risk of harm.
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Based on document review and interview, the facility did not ensure nursing staff provided report to ambulance transport staff prior to patient transport, in three (3) of three (3) medical transfers.

Findings:

The facility's policy and procedure (P&P) titled, "Transfer of the Emergency Department Patient to Another Facility," last reviewed on 11/4/2021 stated, "If a patient is to be transferred for medical necessity, the following must be followed: 'Nursing Staff ...Documentation shall include, but not limited to: report given to transport team ..."

Review of Patient #11's MR identified this 69 year old presented to the Emergency Department (ED) on 10/20/2021 with bilateral ureter stones. Patient was triaged and a medical screening examination (MSE) was performed. The facility did not have a Urologist on premises and Patient #3 was transferred to another facility. There was no documented evidence the nursing staff provided a report to the transport team.

Review of Patient #12 MR identified this 36 year old presented to the ED on 11/9/2021 with abdominal pain. Patient was triaged and a MSE performed. Following an abdominal CT-scan and ultrasound, Patient #7 was diagnosed with gallstones and worsening hydronephrosis. The facility did not have a Urologist on premises, and Patient #7 was transferred to another facility. There was no documented evidence nursing staff provided a report to the transport team.

These findings were confirmed by Staff D (Director of the Emergency Department/ED) on 3/28/2022 at 12:20PM.

Review of Patient #13 MR identified this 71 year old presented to the ED on 10/5/2021 with an abdominal hernia rupture. Patient was triaged and a MSE performed. The facility did not have a Urologist on premises, and Patient #19 was transferred to another facility. There was no documented evidence nursing staff provided a report to the transport team.

This finding was confirmed by Staff L (Nurse Educator/ED) on 3/30/2022 at 11:45AM.