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Based on observation, document review, interview, and in five (5) of 24 medical records reviewed, it was determined that the facility failed to meet the Condition of Participation for Patient's Rights. Specifically the facility failed to (a) provide care in an environment that will ensure the safety and protection of all patients, (b) ensure patient's right to be free from restraint, and (c) ensure that patients were given the opportunity to exercise their rights in accordance with Patient's Rights requirements.

These failures may have placed patients at risk for harm.


Findings include:

During interview with Staff Cc, Director of Facility and Safety, and Staff Dd, Director of Security, on 4/17/17 at 3:30 PM, these staff members did not acknowledge holding a patient as a form of restraint. They stated the security officers may assist clinical staff in holding patient for interventions, but they do not restrain patients.
The hospital staff did not recognize the use of manual hold as a form of restraint.

See Tag 159.


During interview with Staff R, Security Officer, on 4/7/17 at 3:45 PM, this staff stated he has assisted clinical staff in holding patients down for intervention and may apply soft wrist restraints or vest restraints (Posey) if ordered. At interview with Staff P, Q, S, and T on 4/18/17, these security officers stated they have assisted medical staff in holding patients for interventions.
At the interview with Security Administrators on 4/17/17 at 3:30 PM, they stated that security officers were not trained in the application of restraints.

Review of Security Occurrence Reports noted security officers assisted medical staff in the application of vest and wrist restraints to combative patients. In one occurrence report dated 3/2/17, a security officer was hit by a patient while restraining the patient. His partner was exposed to blood from the patient's intravenous site (IV); this employee received medical attention and completed an employee incident report.
The use of untrained staff in the application of restraints places both patients and staff at risk for harm.

See Tag 194.


Review of Security Occurrence Reports for 2016 through 2017 notes incidents in which security officers are called to assist clinical staff with management of disruptive patients.

At interview with Staff Cc, Director of Facility and Safety, and Staff Dd, Director of Security, on 4/17/17 at 3:30 PM, they stated all security officers were trained in nonviolent crisis intervention (CPI).
Review of a list of 49 security personnel employed by this facility and documentation of their certification in nonviolent crisis intervention (CPI) revealed that only 4 security officers received certification in CPI.
The four security members who were certified in CPI did not have current certification.

See Tag 200.


Review of the Security Occurrence Reports for 2016 through 2017 notes incidents in which security officers are called to assist clinical staff in restraining patients and performing manual holds.
Review of seven (7) of seven (7) security staff personnel files identified that the security staff lacked training in the use of First Aid techniques and were not certified in Cardiopulmonary Resuscitation.

During the interview with Staff Cc, Director of Facility and Safety, and Staff Dd, Director of Security, on 4/17/17 at 3:30 PM, they confirmed that the facility's security officers have no training in First Aid and Cardiopulmonary Resuscitation.

See Tag 206.


Review of the facility's Occurrence Report, dated 5/2/16, noted documentation on the report: "Patient states she was left naked in the treatment room. She was using a bed pan when the medical assistant (MA) made an inappropriate comment about her body. He later forced her to take his phone number. Patient states she felt unsafe so she took the number."
Additional information in the report stated: "phone number supplied by patient indicated that it was the employee's telephone number."

Staff L, AVP of Performance Improvement, was interviewed on 4/13/17. Staff L stated that the facility does not have a policy to address how the facility handles patients' allegations of abuse/harassment and also does not address how the facility plans to protect patients during its investigation.

See Tag 145.



During a tour of the facility's Emergency Department (ED) on 4/13/17, a parent was interviewed. This parent stated that the facility staff gave him a bunch of papers to sign but there was no explanation provided. In addition, he was not given a Patient Right's Handbook or any other Patient Rights information, as per the hospital's policy.

During a tour of the facility inpatient units, the medical records (MR's) for Patients #10, #11, #23, & #24 were reviewed. These patients were identified as Medicare beneficiaries. It was noted that the standardized notice, "An Important Message from Medicare" (IM), was not provided to these patients within 2 days of admission, as required.

See Tag 117.


Review of Medical Record (MR) for Patient #1 noted this 55 year old homeless female, with significant medical and substance abuse/dependence history, who presented in the Emergency Department (ED) on 2/22/2017, complaining of left leg pain. The patient had a history of multiple ED visits. The patient's discharge plan was placement in a skilled nursing facility. The patient requested a transfer to another facility; however, this request was denied but the reason for the denial was not fully explained to the patient. There was no documention of a social services assessment to address her homeless situation and multiple ED visits. The patient was not involved in the discharge planning and she was not given a choice to exercise her rights to participate in her plan of care.

See Tag 130.

Based on observation and document review, it was determined that the facility failed to ensure that each patient, or when appropriate, the patient's representative, is provided patient's rights information.
This finding was evident in five (5) of twenty four (24) medical records reviewed ( Patients #2, #10, #11, #23 & #24) .

Findings include:

During tour of the Emergency Department on 4/13/2017 at 11:10 AM, the parent for Patient #2 was interviewed. This parent stated he was given a bunch of papers to sign but he was not provided with any patient's right information or patient right's booklet.

Review of the Medical Record (MR) for Patient #2 noted: This 10 year old child was seen in the facility's Emergency Department (ED), on 04/13/17, for evaluation of swelling and tenderness to the right great toe.
Acknowledgement receipt of the booklet, "Your Rights as a Hospital Patient in New York Department of Health" form, was signed by patient's father on 4/13/17 at 1052. The form was not completely filled out, as the information given to the patient's parent was not checked off. The representative who provided the patient rights information to this parent was not listed.

The facility's policy titled "Patient Rights," revised 3/15, stated: "New York State and the Federal government require that all hospital patient be given certain information and materials when admitted to a hospital. Upon admission all patients will be given the booklet Your Rights as a Hospital Patient in New York State."
This policy did not include how or what information is given to patients in the Outpatient Departments or Emergency Department.

At interview with Staff Hh, Director of Admission, on 4/18/17 at 10:23 AM, this staff stated all patients (Inpatient, Out- patient, and Emergency Department) are provided with the facility's handbook. The admitted patients are provided with additional information, as they are given "Your Rights as a Hospital Patient in New York State" booklet.

During the tour of the ICU (Intensive Care Unit) on 4/13/17 at 12:20 PM, medical records for Patient #10 and #11 were reviewed. Patient #10 was admitted on 3/28/17 and Patient # 11 was admitted on 3/29/17. The records identified these patients as Medicare Beneficiaries and lacked signed copies of the IM (Important Message from Medicare) forms.
Similar findings were noted for Patient #s 23 & #24, admitted Medicare Beneficiaries, whose medical records lacked signed IM forms.

Review of the medical record for Patient #10 noted: This 76 year old nursing home resident, was admitted to the facility on 3/28/17. It was documented in the record that the patient had bouts of confusion. A Medical Power of Attorney document listing his agent, was located in the record. There was no documentation that the patient's agent was provided with patient's rights information on behalf of the patient.

Staff E, Director of Nursing, was interviewed on 4/13/17 at 12:30 PM. This staff stated IM forms are given to patient/patient's representatives at the time of discharge.

At interview with Staff Hh, Director of Admission, on 4/18/17 at 10:23 AM, this staff stated the IM form is a generated form which comes in triplicate. She stated all Medicare patients receive IM forms. According to Staff Hh, the registration staff goes over the form with the patient on admission, and the case manager reviews the form at the time of discharge.

There was no documentation that the facility's staff fully complied with this process for distribution of patient's rights information.

Based on document review and staff interview, the facility failed to ensure a timely resolution of grievances, and establish a policy to address steps to be taken if an investigation will not be completed within 7 days.
This was found in nine (9) of 16 grievances reviewed.

This is a repeat citation from a prior survey conducted on 1/8/2016.

Findings include:

Review of the facility's Complaint/Grievance binder from 2016 and 2017 revealed:

Grievance #1 was received by the facility on 1/24/17, an acknowledgement letter was sent to the complainant on 1/27/17, and a final letter regarding the outcome of the investigation was sent to the complainant on 2/28/17. The resolution of this grievance was completed in 32 days.

Grievance #3 was received by the facility on 2/13/17, an acknowledgement letter was sent to the complainant on 2/28/17, and a final letter regarding the outcome of the investigation was sent to the complainant on 4/3/17. The resolution of this grievance was completed in 34 days.

Similar findings were noted for Grievance #s 6, #7 & #9, where final letters regarding the outcome of the investigations were sent to the complainants in 28, 30, and 38 days respectively.

Grievance #2 was received by the facility on 2/7/17 and an acknowledgement letter was sent to the complainant on 2/28/17, 21 days later. There was no indication that the grievance was investigated and that the result of the investigation was sent to the complainant.
Similar findings were noted for Grievance #s 8, #10, #12 where acknowledgement letters were sent to the complainants in 27, 13, & 21 days respectively. These examples lacked any indication that the results of the investigations were sent to the complainants.

The facility's policy and procedure titled "Complaint and Compliment Policy," revised July 2014, stated: "The Assistant Vice President of Performance Improvement or her designee will write an acknowledgement letter to the patient /family within 7 business days and forward the complaints to the Department Director/Manager. The Department Director/Manager will investigate the complaint and submit the results of their investigation to the Performance Improvement Department within 10 business days of receiving the complaint. The Assistant Vice President of Performance Improvement or designee will write the response letter to the patient/family."

The time frame for a written response to grievances was not established in the policy.
The policy additionally does not address what steps will be taken if an investigation will not be completed within 7 days.

During interview on 4/17/17 at approximately 2:00 PM, Staff L, AVP Performance Improvement and Staff Ii, VP Patient Relations, acknowledged the findings.











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Based on document review and interview, it was determined that the governing body failed to be responsible for the effective operation of the grievance process.

Findings include:

A review of the Board of Trustees (Governing Body) Minutes, dated April 11, 2016 through April 2017, showed no evidence that the governing body is aware of the status of grievances. There was no mention of grievances in any of the minutes.
During interview on 4/18/17 at approximately 1:00 PM. Staff L, AVP, Performance Improvement, stated she was aware that the status of grievances was not in the minutes.

Based on interview and document review, it was determined that the facility failed to ensure that a patient exercised her rights to participate in the development and the implementation of her plan of care. This was found in review of medical record (MR) for Patient #1.

Findings include:

Review of the medical record for Patient #1 noted: 55 year old homeless female, with significant medical and substance abuse /dependence history, presented in the Emergency Department (ED) on 2/22/2017 complaining of left leg pain. The patient had prior multiple ED visits on 1/31/17, 2/10/17, 2/11/17, 2/14/17, and 2/16/17. She was admitted on 2/17/17 with a diagnosis of left tibia plateau fracture and she signed out AMA (against medical advice) on 2/19/17. She returned on 2/22/17 with a similar complaint. There was no documented evidence that the patient was followed by social services to assess the patient's homeless situation and frequent ED visits.

On 2/23/17 at 15:17 (3:17 PM), the case management staff documented "patient is in agreement to SNF (skilled nursing facility)." On 2/24/17 at 20:35 (8:35 PM), the nurse documented the patient wants to be transferred to a specified facility and the MD was informed. On 2/25/17 at 1658 (4:58 PM), the physician documented "the patient requested to be transferred to another facility. The patient was informed the transfer was not appropriate at this time as we were capable of treating her." There was no documentation that the patient was informed of the process of transferring a patient to another facility.

The attending physician, Staff Bb, was interviewed on 4/18/17 at 2:00 PM. This staff stated Orthopedics evaluated the patient and recommended immobilizer and bed rest. This staff stated the patient would not stay in bed and she took off the immobilizer. According to the staff, the patient kept asking for more pain medication. It was explained to the patient the need to stay off her left leg. Staff Bb stated the patient signed AMA because she refused to give her any more pain medication. Staff Bb stated no rehabilitation would accept the patient until she had completed detoxification. According to Staff Bb, the patient had to complete detoxification in this facility first before the patient could go to a SNF (skilled nursing facility) for PT (physical therapy). There was no evidence that this admission criteria was discussed with the patient.

The facility's policy titled "Transfer Policy," revised 7/10, stated "In patient - transfer to another facility is made after the Attending Physician determines that the facilities, equipment and care which the patient requires is beyond capability of the hospital or upon the request of the patient or surrogate."

Based on staff interview and document review, the facility failed to develop a written protocol to address patients' allegations of abuse and neglect, including methods to protect patients, from staff, other patients, or visitors.

Findings include:

Review of an Occurrence Report, dated 5/2/16 documented: "Patient states she was left naked in the treatment room. She was using a bed pan when the medical assistant (MA) made an inappropriate comment about her body. He later forced her to take his phone number. Patient states she felt unsafe so she took the number."
Additional Information in the report stated: "Phone number supplied by patient indicated that it was the employee's telephone number."

The hospital's investigation summary, dated 5/6/16, was reviewed. The investigator found "although how the patient got the staff telephone number was still unresolved, it was impossible to come to any conclusion." The employee's suspension pending investigation was reversed.

Review of an Occurrence Report, dated 1/11/17 documented the location of the occurrence was in the facility's ED. It was documented on this report, "Technician took portable x-ray in Rm 312 without announcing to patient or staff; fully drawn open patient curtain while patient changing exposing patient to hallway. The patient was unclothed at the time causing significant embarrassment. The Employee involved was coached on ways to enhance his communication with staff and patients."

Review of a Security Services Occurrence report, dated 2/2/17 at 0750 (7:50 AM), documented: "at 0750 YPD (police department) arrived to investigate a patient complaint being abused. Security and police questioned the patient about the incident." The patient alleged that two nurse's smacked her arm. The facility investigated the allegation and found it unsubstantiated.

The facility's policy titled "Adult Abuse/Neglect," revised 12/14, stated "All patients coming to the hospital (Emergency Department, ASU, Direct Admission) will be screened for abuse/neglect. The hospital shall provide assistance to any patient presenting with suspected or confirmed adult/abuse/neglect."

The policy does not address how the facility handles patients' allegations of abuse/harassment and additionally does not address how the facility plans to protect patients during its investigation.

Staff L, AVP of Performance Improvement, stated the facility does not have any other policy on abuse/neglect.

Based on interview and document review, the facility failed to recognize and define the use of manual hold as a form of physical restraint.

Findings include:

Security Services Occurrence Report, dated 7/5/16 at 0140 (01:40 AM), was reviewed. The investigating security officer documented "on above date and time I received a call from the nursing supervisor requesting assistance with patient in 5 South. I proceeded to 5 South with another officer and spoke with nurse who stated the patient was confused and they needed to give him medication, so with the assistance of one of the ER (emergency room) CNA's (certified nursing aide) we held the patient down so he could be medicated."

At interview with Director of Facility and Safety, Staff Cc, and Director of Security, Staff Dd, on 4/17/17 at 3:30 PM, these staff members did not acknowledge holding a patient as a form of restraint. They stated the security officers may assist clinical staff in holding patients for interventions, but they do not restrain patients.

Facility's Policy titled "Restraints-Physical," last revised in 3/15, stated "Definitions: A Physical Restraint is any clinical justified method, device or equipment attached to or adjacent to a patient that restrict freedom of movement or access to one's body in order to protect the patient from injury or self and/or other."

This definition did not include manual hold as a form of restraint.

Based on interview and review of seven (7) of seven (7) security staff documents, it was determined that the facility failed to ensure appropriate staff is trained in the safe implementation of restraints (Staff # U, V, W, X, Y, Z & Aa).

Findings include:


A Security Occurrence Report, dated 7/21/16, was reviewed. The investigating security officer documented, "patient was intoxicated and wanted to leave hospital; patient was verbally abusive, cursing, screaming. Patient was placed in restraints and he was medicated."

Security Services Occurrence Report, dated 3/7/17 at 0300 (3:00 AM), was reviewed. The investigating security officer documented, " On the above date and time while in the process of attempting to restraint a disorderly patient, I and another security officer attempted in re-secure the Posey vest. The patient managed to get loose, while I was tightening the strap on the side of the bed, the patient struck me on the lower back. Then after the house doctor came to evaluate the patient. We attempted to apply wrist restraints on the patient. During the process, the patient kicked and struck the other officer with her fist. After applying, the restraints, the officer went to the emergency department to get treated for blood exposure."

Security Services Occurrence Report, dated 3/7/17 at 0330 (3:30 PM) was reviewed. This investigating security officer documented, "At approximately 0330, the patient became combative to staff. The patient began with verbal threats to security and nurses. The patient broke from hand restraints and officer attempt to put restraint back on, the patient hit with a closed fist to the left shoulder."
Attached to this occurrence report was an Employee Accident Injury form.

Employee Accident/Incident Report, dated 3/7/17, was reviewed. The staff documented, "I was assisting medical staff put hand restraint on patient. Patient's IV came out and patient was throwing her arms trying to resist. Blood was found on my pants, jacket and hands. I had taken my gloves off. I didn't notice blood on my hands until 4:10 AM."

At interview with Staff R, Security Officer, on 4/7/17 at 3:45 PM, this staff stated he has assisted clinical staff in holding patients down for intervention and may apply soft wrist restraints or vest restraints (Posey) if ordered.

At interview with Staff P, Q, S, and T, on 4/18/17, these security officers stated they have assisted medical staff in holding patients for interventions. Staff Q and T stated, although they have never restrained a patient, if ordered, they may apply restraints.


At the interview with Security Administrators, on 4/17/17 at 3:30 PM, they stated that security officers were not trained in the application of restraints.


Review of personnel files for Staff U, V, W, X, Y, Z & Aa, confirmed that security members were not trained in restraints.


Facility's Policy titled "Restraints," effective January 10, 2009, stated "under the guidance of medical personnel Security will assist as directed during the treatment of violent patients."
The definition of "assist" is not stated in the policy.

Based on interview and document review, it was determined that the facility failed to ensure security members, who are called upon to manage disruptive patients, receive training in de-escalation techniques and that the training is kept current. This is evident in 49 of 49 security staff personnel records reviewed.


Findings include:

At interview with the Director of Facility and Safety, Staff Cc, and Director of Security, Staff Dd, on 4/17/17 at 3:30 PM, they stated that all security officers were trained in nonviolent crisis intervention (CPI). A list of the security personnel and the training in CPI was requested.

On 4/18/17, the facility presented a list of 49 security officer staff and submitted a folder with only four (4) security officers' certification in Nonviolent Crisis Intervention Program (CPI). (Staff L1, Staff Mm, Staff Nn and Staff Oo). The four security members who were certified did not have current certification.
There was no documented evidence that the remaining 45 security staff received CPI training.

This was confirmed by the Director of Facility and Safety, Staff Cc, and Director of Security, Staff Dd, at the time of the finding.

Based on document review and interview, the facility failed to ensure that security staff members who assist with restraints and perform manual holds are trained in the use of First Aid techniques and are certified in Cardiopulmonary Resuscitation. (Staff U, V, W, X, Y, Z & Aa)

Findings include:

Review of a Security Services Occurrence report, dated 7/5/16 at 0140 (01:40 AM), noted that the security officer documented that he was called to assist in the restraint of a patient that required medication administration.

Review of a Security Services Occurrence #1524 noted that a security officer documented that he responded to a call about a combative patient in the ED, and later for the same patient in unit 7 west. The officer documented that he had to restrain the patient.

Review of personnel files for Staff U, V, W, X, Y, Z & Aa , Security Officers, noted that they have no training in First Aid and no certification in Cardiopulmonary Resuscitation.


During interview with the Director of Facility and Safety, Staff Cc, and Director of Security, Staff Staff Dd, on 4/17/17 at 3:30 PM, they confirmed that the facility's security officers have no training in First Aid and Cardiopulmonary Resuscitation.

Based on document review and interview, it was determined that the hospital failed to establish a quality assessment and performance improvement program to include the review of complaints and grievances, and to identify areas for improvement.


Findings include:

On 4/18/17 at approximately 2:00 PM, the surveyor requested the hospital's Performance Improvement Program that would include the status of grievances and measures of improvement. Staff L, AVP Performance Improvement, informed the surveyor that there was no Performance Improvement Program addressing grievances.

A review of Performance Improvement Committee Minutes from January 21, 2016 through March 16, 2017 showed that the Performance Improvement Department reported twice a year, on 2/18/16 and 7/21/16. The Performance Improvement Committee Minutes dated 2/18/16 noted under the title "Complaint Summary," that Staff L gave a brief overview of the type of complaints and the resolutions. Staff L reported that a team has been convened to enhance the complaint process.
The surveyor inquired about this team and Staff L informed the surveyor that the team members are the same as they have now and there is no new team to enhance the complaint process.
The Performance Improvement Committee Minutes dated 7/21/16 noted that a total of 24 complaints were received January through June 2016. The minutes did not contain any data or analysis of the 24 complaints received.

Based on observation, document review, and interview, it was determined that the facility failed to ensure that patient care was provided in a clean and safe environment.


Findings include:


On 04/13/2017, at 11:31 AM, during a tour of the Pending Admission Transfer (PAT) area of the emergency room, the following findings were observed:

a) Two normal saline flush syringes were left on the bedside table next to an unlabeled food tray, which was located between beds 5 and 6.

Review of past Incident Reports revealed a similar occurrence of a 10-ml flush syringe that was left by Patient's #16 bedside, on 02/02/2017, at 10:00 AM.
The patient accidentally ingested the white cap of a 10-ml flush syringe, assuming it was a medication. Unsafe handling of medical supplies compromises patient safety.

b) The light above the sink was not in working condition.
c) The electrical three-prongs socket below the light switch were exposed.
d) The access to the sink was blocked by a red bin (for contaminated materials), floor based sharp container, and garbage bin.

The finding was confirmed with Staff O, RN ED Manager, at the time of the observation.