HospitalInspections.org

Based on medical record review, document review, video surveillance review and interview, in two (2) of 27 medical records reviewed, it was determined the facility failed to maintain the safety and well-being of patients. Specifically, the facility failed to:

(a) Identify that a patient was brought to the hospital Emergency Department (ED) as an emotionally disturbed person from a police precinct.
(b) Identify a patient's elopement from the ED and implement the facility's elopement policy.
(c) Conduct a complete search of the facility for a patient who walked out of the ED.
(d) Ensure the appropriate use of restraints to subdue a patient before using a tazer (weapon).
(e) Utilize the least restrictive measures before the use of restraint to manage a patient with agitated behavior.
(f) Ensure that staff were trained and demonstrated knowledge of the least restrictive interventions for management of agitated patients.
(Patients #1 and #3).

These failures placed patients at risk for harm and death.


Findings include:

Patient #1: Review of the medical record for patient #1 revealed the ED arrival information indicate this is a 19-year-old patient who arrived at the ED on 8/23/2020 at 11:12 PM by EMS. She was triaged at 11:18 PM with a complaint of abdominal pain for two (2) weeks. She also stated that she might be pregnant and that she had a miscarriage in the past. Her vital signs were normal except for a heart rate of 108 (normal range 60-100).

Review of the EMS report revealed the ambulance was dispatched to the precinct for an emotionally disturbed person "(EDP) - psychiatric patient." The EMS report documentation revealed the chief complaint was "general malaise." The EMT's physical, neurological and vital signs assessments of the patient were normal.

The primary nurse assessment on 8/23/2020 at 11:51 PM included a Columbia Suicide Severity Rating Scale screen which revealed the patient was at no risk for suicide. The assessment also noted the patient used Marijuana and she had a negative history for alcohol consumption.

The ED physician's assessment at 12:10 AM on 8/24/2020, documented that the "patient was a poor historian, often zoning out, needs constant redirection to answer questions." The review of the patient's systems was negative except for the abdominal pain. The plan was to "treat symptomatically, get urine and reassess." The physician noted "STD testing, urine, pregnancy, Tylenol and reassessment."

At 1:16 AM on 8/24/2020, a doctor documented that the patient was "not found in her assigned room. Overhead 2x without response. Will D/C as eloped." The physician's note at 1:23 AM indicated there was no phone number to contact the patient.

Shortly before 6:00 AM on 8/24/2020, the patient's dead body was found on the roof of an adjacent building and her belongings were found on the roof of the hospital.


See findings at Tag A 0144


Patient #3: A review of the facility Incident Reports from July to August 2020, showed that patient #3 was tased and handcuffed for aggressive and hostile behavior when he presented to the Emergency Department (ED) for chest pain on 8/31/2020 at 7:12 PM. At the entryway to the ED, the patient was asked to put his belongings through the metal detector and empty his pockets, He did not fully comply with the instructions and he got into an altercation with the police officer. He was tased in the abdomen and handcuffed by this off-duty Police Officer who was working, and he was paid by the hospital.

The facility failed to ensure the appropriate use of restraints to subdue a patient before using a tazer (weapon) as a means of restraint. (Patient #3).

See findings at Tag A 0154.



The facility failed to utilize the least restrictive measures to de-escalate the situation before the use of restraint to manage a patient with agitated behavior. (Patient #3).

See details findings at Tag A 0165


The facility failed to ensure that staff were trained and demonstrated knowledge of the least restrictive interventions for management of agitated patients. (Patient #3).

See details findings at Tag A 0200

Based on medical record review, document review, video surveillance review and interview, in two (2) of 27 medical records reviewed, it was determined the facility failed to maintain the safety and well-being of patients. Specifically, the facility failed to:
(a) Identify that a patient was brought to the hospital Emergency Department (ED) as an emotionally disturbed person from a police precinct, (b) Identify a patient's elopement from the ED and implement the facility's elopement policy, (c) Conduct a complete search of the facility for a patient who walked out of the ED. (Patients #1).

These failures placed patients at risk for harm and death.


Findings include:

Patient #1: Review of the medical record for patient #1 revealed the ED arrival information indicate this is a 19-year-old patient who arrived at the ED on 8/23/2020 at 11:12 PM by EMS. She was triaged at 11:18 PM with a complaint of abdominal pain for two (2) weeks. She also stated that she might be pregnant and that she had a miscarriage in the past. Her vital signs were normal except for a heart rate of 108 (normal range 60-100).

Review of the EMS report revealed the ambulance was dispatched to the precinct for an emotionally disturbed person "(EDP) - psychiatric patient." The EMS report documentation revealed the chief complaint was "general malaise." The EMT's physical, neurological and vital signs assessments of the patient were normal.

There was no documentation in the triage assessment that the patient was picked up from the jail as an EDP-psychiatric patient.
During interview on 9/8/2020 at 3:30 PM, Staff B, the triage nurse, stated that she could not recall a discussion with EMS about the patients "EDP-psychiatric patient" status in the jail.


The primary nurse assessment on 8/23/2020 at 11:51 PM included a Columbia Suicide Severity Rating Scale screen which revealed the patient was at no risk for suicide. The assessment also noted the patient used Marijuana and she had a negative history for alcohol consumption.

The ED physician's assessment at 12:10 AM on 8/24/2020, documented that the "patient was a poor historian, often zoning out, needs constant redirection to answer questions." The patient told the doctor she had crampy abdominal pain for 2-3 weeks and she was requesting sexually transmitted disease (STD)/pregnancy tests. She also stated, "I have bacterial vaginosis." The abdominal pain was mid-epigastric and cramping, and without radiation. The review of the patient's systems was negative except for the abdominal pain. The plan was to "treat symptomatically, get urine and reassess." The physician noted "STD testing, urine, pregnancy, Tylenol and reassessment."

At 12:19 AM on 8/24/2020, Staff F, a nurse documented, "patient noted behaving strangely with delayed reactions. Verbalized that she took 'poisonous LSD x 3 weeks ago.' Verbalized that she is miscarrying. Negative pregnancy test. Requested HIV test then refused when tourniquet applied, verbalized 'I don't need this.' Refusing to change into hospital gown. MD aware."

At 1:16 AM on 8/24/2020, a doctor documented that the patient was "not found in her assigned room. Overhead 2x without response. Will D/C as eloped." The physician's note at 1:23 AM indicated there was no phone number to contact the patient.

At 2:23 AM, Staff F, RN documented that the "patient was alert and oriented X 3 with decisional capacity, had walked out. Respirations even and unlabored, skin pink, warm and dry, ambulatory with steady gait. Left ED with all belongings. Attending doctor aware."

During interview on 9/8/2020 at 1:00 PM, Staff F, RN stated that she did not see the patient when she was leaving the ED on 8/24/2020.


Review of the video surveillance indicated: On 8/24/2020 at 12:25 AM, a female with her back towards a camera was standing in a corridor wearing a red skirt and blouse. Staff A, The Director of Security who was present at the time of the review of the video camera, identified the female as Patient #1 and he stated that she pulled the fire alarm.
At 12:44 AM, the female/patient was next seen at the back of the Neonatal Intensive Care Unit (NICU) located on the 11th floor. The location was confirmed by the Director of Security.
At 12:45 AM to 12:59 AM, the female/patient was walking back and forth on the first floor of the Winston Building. After 12:59 AM, she was no longer seen on the camera footage.


A review of a document titled "Security Incident Report" revealed: on 8/24/2020 at 12:25 AM, an alarm (Code Red) went off throughout the facility. Once the alarm went off, the Fire Department of New York (FDNY) was dispatched and they arrived at approximately 12:25 AM. Once FDNY was aware that the 'Code Red' was under control they departed. The report also indicated "Note: Upon camera review female patient noted as pulling the pull station and activated the system. Patient exited before security arrived."

During an interview conducted on 9/1/2020 at 3:10 PM, Staff A, the Director of Security stated, the patient accessed the roof via the hospital's elevator motor room through a door which had a damaged lock, and another door which did not have a lock. After gaining access to this room the patient made it to a roof via a stairway and a roof top hatch. He stated shortly before 6:00 AM on 8/24/2020, the patient's dead body was found on the roof of an adjacent building and her belongings were found on the roof of the hospital.

During an interview conducted on 9/30/2020 at 3:35 PM, Staff O, a Security Supervisor stated, after the patient pulled the alarm on 8/24/2020, he searched the hospital from the 1st - 7th floor, then he went to the ED and asked the nursing staff if an "African American female wearing a red skirt" had eloped or was missing from the ED. He stated that a nurse stated the patient (patient #1) had not eloped from the facility that day. The patient's primary nurse stated the patient left before treatment was completed. As a result, Staff O stated he ended his search for the female (Patient #1.)

The policy titled "Patient Elopements-Unauthorized Patient Departure," last reviewed in 6/2018, states; the definition of a patient that has eloped from the ED is a patient who leaves the facility after a medical screening examination has been completed. The policy also states when an ED patient is discovered to have eloped from the hospital, the steps to be taken immediately include:
Elopement review form will be implemented.
Notification of security department and nursing administration.
Determination of potential risk of harm to the patient and others.
May also require NYPD contact.

Staff E, the ED Nurse Manager stated on 9/1/2020 at approximately 11:05 AM, that security is notified whenever a patient elopes from the ED and that a search is conducted.

During an interview on 9/30/2020 at approximately 10:05 AM, Staff D, the Senior Director Quality Initiative stated the elopement review form had not been completed for this patient who had eloped from the ED on 8/24/2020.

There was no evidence that the ED staff identified the patient's elopement from the facility, and notified security.
A complete search of the facility was not done for the patient.

Based on medical record review, document review and interview, in one (1) of 27 medical records reviewed, the facility failed to ensure the safety and wellbeing of all patients. Specifically, the facility failed to ensure the appropriate use of restraints to subdue a patient before using a tazer (weapon) as a means of restraint. (Patient #3).

Findings include:

A review of the facility Incident Reports from July to August 2020 revealed: On 8/31/2020 at 7:12 PM, a 26-year-old patient and his wife walked into the hospital. At the entryway to the ED, he was asked to put his belongings through the metal detector and empty his pockets, He did not fully comply with the instructions and he got into an altercation with the police officer. He was tased in the abdomen and handcuffed by this off-duty Police Officer who was working, and he was paid by the hospital.

Review of the medical record for patient #3 indicated; the patient was brought into the ED Resuscitation Room on 8/31/2020 at 8:08 PM, where two (2) taser prongs were removed from his abdomen and some bleeding was noted at the sites.
He was medically evaluated and found to be awake and alert, however he refused to have all vital signs taken as well as an ECG, labs and a chest X-Ray.
During the medical evaluation, the patient stated he came into the hospital to seek help for chest and shoulder pain. He left the hospital against medical advice.

On 8/31/20 at 9:16 PM, the same physician wrote that after the patient left the emergency room, he went outside to advice the patient to return for a re-evaluation. He explained to the patient that he was at risk for a heart attack and other dangerous health conditions. The patient acknowledged his concerns but stated that he wanted to go to another hospital.

Facility documentation showed no evidence that the staff used any effort to de-escalate the situation before using the tazer (a weapon) and a handcuff as a restraint.

During an interview conducted on 9/2/2020 at 12:20 PM, Staff A, Director of Security, acknowledged that the patient was tased by a New York Police Department (NYPD) off-duty officer. Staff A stated, the officer felt threatened by the patient. The officer and the patient got into an argument and the officer was pushed by the patient. The officer called a "code orange," which is the coded phrase used by the hospital to call security for assistance to cope with an agitated or disruptive patient.


The hospital's policy and procedure titled, "Management of the Agitated Intoxicated Patient," last reviewed 5/2018 states: "The use of physical restraint must strictly follow hospital policy and adhere to regulatory guidelines. The officer will attempt verbal de-escalation measures which includes:
Set clear limits.
Establish verbal contact.
Identify needs and wants.
Be concise.
Other etiology should be considered for the patient's agitation as soon as possible (hypoglycemia, trauma, withdrawal)."

The policy also states that the use of force should be used only as the last resort.

Based on medical record review, document review and interview, in one (1) of 27 medical records reviewed, the facility failed to utilize the least restrictive measures before the use of restraint to manage a patient with agitated behavior. (Patient #3).

Findings include:

Review of the facility Incident Reports for July to August 2020, revealed: On 8/31/2020 at
7:12 PM, a 26-year-old patient and his wife walked into the hospital. At the entryway to the Emergency Department (ED), he was asked to put his belongings through the metal detector and empty his pockets, He did not fully comply with the instructions and he got into an altercation with the police officer. He was tased in the abdomen and handcuffed by this off-duty Police Officer who was working at the entrance of the ED.

Review of the medical record for patient #3 identified: this 26-year-old patient who was brought into the ED resuscitation room on 8/31/2020 at 8:08 PM, where two (2) taser prongs were removed from his abdomen and some bleeding was noted at the sites.
He was medically evaluated and found to be awake and alert, however he refused to have all vital signs taken as well as an ECG, labs and a chest X-Ray.
During the medical evaluation, the patient stated he came into the hospital to seek help for chest and shoulder pain. He left the hospital against medical advice.

Facility documentation showed no evidence that the hospital attempted to use the least restrictive measures to de-escalate the situation before using the tazer (a weapon) and a handcuff on this patient.

During an interview conducted on 9/2/2020 at 12:20 PM, Staff A, the Director of Security, acknowledged that the patient was tased by a New York Police Department (NYPD) off-duty officer. The officer and the patient got into an argument and the officer was pushed by the patient. The officer called a "code orange," which is the coded phrase used by the hospital to call security for assistance to cope with an agitated or disruptive patient.

The hospital's policy and procedure titled, "Restraint and Seclusion" which was last revised 7/2019 states, "the use of restraints has the potential for serious adverse effects and should be used only after other measures have been found to be ineffective." The policy also states least restrictive measures include "involve the patient in conversation, explain procedures to reduce fear and convey a sense of calm, use active listening to elicit the patient's feelings and attempt to verbally redirect behavior."

The policy does not list tazers or handcuffs as restraints that can be used in the facility and there was no evidence that any of the staff attempted these least restrictive measures.

These findings were confirmed during an interview conducted on 9/11/2020 at 9:35AM with Staff C, the Vice President of Quality Initiatives.

Based on medical record review, document review and interview, in one (1) of 27 medical records reviewed, the facility failed to ensure that staff were trained and demonstrated knowledge of the least restrictive interventions for management of agitated patients.
(Patient #3).


Findings include:

A review of the facility Incident Reports from July to August 2020, showed that patient #3 was tased and handcuffed for aggressive and hostile behavior when he presented to the Emergency Department (ED) for chest pain on 8/31/2020 at 7:12 PM. At the entryway to the ED, the patient was asked to put his belongings through the metal detector and empty his pockets, He did not fully comply with the instructions and he got into an altercation with the police officer. He was tased in the abdomen and handcuffed by this off-duty Police Officer who was working, and he was paid by the hospital.

During an interview conducted on 9/2/2020 at 12:20 PM, Staff A, the Director of Security, acknowledged that the patient was tased by a New York Police Department (NYPD) off-duty officer. The officer and the patient got into an argument and the officer was pushed by the patient. The officer called a "code orange," which is the coded phrase used by the hospital to call security for assistance to cope with an agitated or disruptive patient.

Staff A stated the Officer received orientation on the hospital's policies and procedures. When asked for this evidence, he presented a one-page checklist titled "Off-Duty NYPD Daily Checklist," dated 8/31/2020 at 4:00 PM, and it was signed by both the Security Supervisor and the Police Officer. The checklist showed 19 topics, and it was noted that the checklist does not include the management of agitated or disruptive patients.

The orientation for this officer could not be validated.

A copy of the Officer's personnel file was requested. The Director stated that the hospital does not have a personnel file for "paid details."

During a telephone interview conducted on 9/11/2020 at 9:35AM, Staff C, the Vice President of Quality Initiatives acknowledged that the hospital does not have a personnel file for the officer. These findings were shared with her during the interview.

Based on medical record review, document review, video surveillance and interview, in two (2) of 27 medical records reviewed, it was determined the facility, (a) failed to document all patient encounters and (b) provide care in a timely manner to patients who presented to the Emergency Department (ED).
(Patient #1 and #2).

These failures may have placed patients at risk for harm or death.

Findings include:

Patient #1: Review of a video surveillance camera revealed a female wearing a red blouse and skirt, went to the walk-in triage nurse on 8/23/2020 at 7:38 PM and spoke to the triage nurse for six (6) minutes before leaving the walk-in triage area. She returned to the walk-in triage area at 7:57 PM and spent another 1 ½ minutes speaking to the facility's staff before walking away from the walk-in triage counter.
Staff A, Director of Security, on 9/1/2020 at 3:10 PM, identified the female as Patient #1

During an interview conducted on 9/8/2020 at 3:20 PM with Staff B, the triage RN, she stated the patient approached the walk-in triage window and asked for an ultrasound because she thought that she might be pregnant and because she had a prior miscarriage. Staff B stated she asked the patient when was her last period and the patient stated it was three (3) weeks ago. Staff B also asked the patient if she had any bleeding and the patient replied, you do not want to help me and then she walked away.

There was no documentation of the triage nurse's interactions with the patient when she presented for emergency care at 7:38 PM and 7:57 PM on 8/23/2020.

The policy titled "Triage: Procedure Split Flow," which was last revised 6/2020 states, "the triage nurse will assess the patient's condition and the patient will then have a quick registration. The traditional triage process will include a rapid triage screen obtaining the patient's chief complaint, an infectious disease screen, assignment of an Emergency Severity Index (ESI) level and identification banding."

There was no documented evidence that this was done at 7:38 PM on 8/23/2020.



Patient #2: Review of medical record for patient #2 identified: This 60-year-old patient arrived in the ED at 9:03 PM on 1/12/19 and he was triaged at 9:06 PM with a complaint of left sided headache, blurriness of the right eye and vomiting. He was seen by two (2) residents at
9:22 PM and 9:35 PM respectively, and a CT-Scan of the head without contrast was ordered at 9:53 PM and completed at 10:19 PM.

There was no documentation of the two (2) residents' interactions with the patient at 9:22 PM and 9:35 PM.

The ED attending physician saw the patient at 9:55 PM and the first documented differential diagnosis of stroke was made at that time. Stroke was paged at 10:50 PM which is approximately an hour after the differential diagnosis of stroke was made.

The ED physician documented the patient had a seizure at 11:20 PM, which was not completely resolved with medications and he was intubated at 12:44 AM on 1/13/2019. A CT angiogram of the head and neck was ordered at 11:19 PM and the finding was discussed with the doctor at 1:17 AM. The magnetic resonance angiogram (MRA) without contrast of the head was ordered at 4:21 AM and the result was reported to the physician at 7:15 AM.

These procedures were not performed and resulted in a timely manner.

The patient underwent an embolectomy procedure which began at 7:47 AM that morning.

Care was not consistent with current standards of practice. The facility does not have a stroke policy regarding this issue.

These findings were shared with Staff D, the Senior Director of Quality Initiative, at 12:10 PM on 9/17/2020.