HospitalInspections.org

Based on observation, document review and interview, the facility did not develop and implement a long-term plan that provides the needed capacity for its admitted patients.

As a result, patients were frequently placed in temporary locations.

Findings include:

During tour of inpatient units located in Klaus and North West on 4/11/17 at approximately 11:00 AM to 1:00 PM, there were 30 patients placed in temporary locations in Hallways, Day rooms, and Treatment rooms.

Review of facility statistics of admitted patients placed in temporary locations from 11/8/16 to 5/10/17 revealed that patients were placed in Day rooms, Treatment rooms, and Hallways daily, except on 4/15/17.
For example:
November 22, 2016 - 15 patients.
January 16, 2017 - 49 patients.
February 16, 2017 - 37 patients.
April 25, 2017 - 29 patients.
May 10, 2017 - 24 patients.

The facility's policy titled "Overflow Patient Placement of Admissions From The Adults Emergency Department" last revised May 2015 notes "The purpose of the Overflow Patient Placement Policy is to avoid and/or alleviate ED overcrowding, as per the Department of Health's (DOH) memorandum of 4/8/2002". The policy further states that over flow placement protocol will be considered in effect at all times since regular beds are only infrequently available to admitted ED patients due to chronic conditions of overflow.

The New York State Department of Health guidelines Titled "Guidance Document of Hospitals Overcrowding/Emergency Preparedness," issued 4/8/2002 and revised 1/1/2017 notes, "During peak periods of overcrowding, as a temporary emergency measure, beds in solariums and hallways near nursing stations can be utilized consistent with a facility-wide plan to alleviate hospital overcrowding and provide capacity."

There was no indication that the facility adhered to the DOH guideline regarding placement of patients in temporary locations only as an emergency measure during peak periods.

During interview with Staff G, Director of Regulatory Affairs, on 4/11/17 at approximately 10:30 AM, she stated that DOH permitted the placement of patients in temporary locations to alleviate ED overcrowding. Staff acknowledged that the practice of housing overflow patients from the ED is utilized on a regular basis due to chronic overcrowding conditions at the facility.

Based on observation, interview and document review, the facility failed to ensure that potentially suicidal patients were appropriately screened, assessed and /or monitored. This finding was evident in eight (8) of 12 medical records reviewed (Patients # 2, 3, 4, 5, 6, 9, 10, 11).

Specifically, the facility failed to:
(a) ensure staff maintained monitoring, rounding and constant observation for patient safety on the medical units.
(b) initiate further evaluation to patients who were identified with clinical depressive features.
(c) ensure that the facility's policy for "Suicide Screening" is consistent with their current practice.

These failures to maintain a safe patient care environment resulted in patient deaths.


Findings include:

Observation of video tape for Patient #2 identified, that for multiple hours on 3/28/17 at 4:30 AM, prior to being discovered hanging by a belt in a shower stall on a Medical Telemetry Unit, nursing rounds to assess and reassess the patient, were not performed as per facility policies. Review of the Rounding Log for room 300 on NW 3 where the patient was housed, identified that on 3/25, 3/26, 3/27 & 3/28/17, there were gaps and inconsistencies in the hourly nurse rounding documentation.

Review of the medical record revealed that Patient # 3 presented to the hospital emergency room on 10/11/16 at 4:10 AM complaining of feeling suicidal and hearing voices, he stated he wanted to kill himself. On 10/11/16, 4:57 AM the Physician ordered Constant Observation.
There was no documented evidence that the patient received the constant observation as ordered by the physician.

Similar finding was identified for Patient # 4 who was placed on constant observation for agitation and expressed suicidal thoughts, and there was no evidence of nursing documentation for the constant observation.

Review of the medical record for Patient # 5, identified a 58 year old terminally ill patient was admitted to Palliative Care Unit 7 North West on 2/11/17. During the depression screen assessment on 2/12/17, the patient was asked, "Over the past two weeks, have you felt down, depressed or hopeless?" Patient #5 replied "yes."
There was no documented evidence that the hospital did further assessment or developed a plan of care to address the patients expressed feelings of depression and hopelessness.

During a tour of the medical unit on 04/03/17 at 11:35 AM, Patient #6 was observed on "Constant Observation."
Upon review of the form used by the assigned staff to document the constant observation, the Surveyor noted the form was dated 04/02/17 and was missing the required initials by the staff for 7:00 AM, 8:00 AM, 9:00 AM, 10:00 AM and 11:00 AM. When it was pointed out that the form is for 04/02/17 and asked where the form is for today's date of 4/3/17, Staff W stated, "this is the one I was given to use for today."

Review of the medical record for Patient #9 identified the patient presented to the Emergency Department (ED) on 4/3/17 with Pancreatic Cancer. The Nursing Triage Assessment performed at 8:24 AM did not include a suicide risk screening.

Similar findings were identified for Patient #10 and Patient #11 who presented to the ED on 04/03/17 and the nursing Triage documentation failed to include completed suicide risk screenings.

During interview on 4/4/17 at 11:25 AM Staff Q, Director Professional Practice, stated that currently, every patient who comes to the facility are screened for risk of suicide and depression.
This is not consistent with their current policy for suicide screening which states, "Suicide screening is required for patients treated with a primary diagnosis or primary complaint of an emotional or behavioral disorder."


See Tag 0144

28406

Based on observation, interview and document review, the facility failed to provide patient care in an environment to protect the emotional health and safety of patients in the Medical Units. These findings were found in nine (9) of twelve (12) medical records reviewed (Patients #1, 2, 3, 4, 5, 6, 9, 10, 11).


Findings include:


Review of Medical Record identified Patient #1 presented to the hospital's Emergency Department on 3/19/17 with Metastatic Lung Cancer and requested End of Life (EoL) care. The 77 year old male patient was admitted to the Palliative Care Services on 3/19/17, with Malignant Pleural Effusion (fluid in the lungs) and dyspnea (shortness of breath). The patient was awaiting bed acceptance/availability with Hospice and was a Do Not Resuscitate (DNR). The patient screened negative for suicide risk at Triage and negative for Depression screening at inpatient admission.

The nurse documented the patient was dependent on staff assistance for all activities of daily living, including mobility secondary to his debilitated condition. The patient was assessed as a Falls Risk and precautions that included placement of a Bed Alarm were implemented.

There was no indication that the bed alarm that was implemented to ensure the patient's safety was activated.

On 3/21/17 at 5:25 PM, the primary nurse (Staff B) documented: "Patient #1 not in bed, bed alarm turned off. Bathroom door closed, attempts to open door prohibited by weight, force was required to open door. Noted a rope tied to the outside of door handle up to the front of the door over the top. Patient found with noose around neck. Patient found not breathing and no pulse."

During interview on 4/3/17 at 12:15 PM, Staff B, RN assigned to Patient #1 stated: "My colleagues and I were in and out of patient #1's room because he had a bed monitor and because the bed alarm was sounding a lot. At around 5:30 PM, I went into the room and the bed monitor was not turned on or making any alarm sound, I think maybe the patient had turned it off, and the patient wasn't in his bed. So I looked in the bathroom and I found him sitting in the bathroom on the floor with his back against the door. I was able to open the door a crack and saw a thick heavy white and blue rope around his neck. It had special type of knot that I was able slide down wards and then I was able to remove the rope from off his neck. The patient was a DNR we didn't do CPR and patient expired."

On 04/10/17 at 11:30 AM during tour and interview on NW7 Palliative Care Unit, Bed Alarm Monitors were in use and demonstration was done for volume to see if staff would respond on hearing the alarm. Staff V, Charge Nurse was asked about the efficiency of the alarm. She stated, "Patients who are not cognitively impaired and who are alert and oriented can and have turned off the alarm and by turning off the alarm it becomes deactivated and no alarm will sound. It's a known problem with this system."

Review of Medical Record for Patient #2 identified: 76 year old male patient arrived to the hospital ED on 3/25/17 at 11:50 AM, having been overcome with grief and emotion at a friend's funeral and where he reported feeling dizziness with a near syncope episode (a temporary loss of consciousness caused by a fall in blood pressure). The ED physician documented during the initial examination, "patient with very depressed affect."

On 3/26/17 at 6:46 AM, the physician documented a History and Physical examination which showed Patient #2's, "Psychiatric and Behavioral System review" and indicated he was "confused, nervous and anxious.
On 3/26/17 at 1:35 PM, the Physician noted, "Patient recently has been under a lot of stress due to medical issues and personal issues including current living situation. Yesterday, he went to a Memorial Service which caused him even more stress. He described seeing some floaters and feeling drowsy."
On 3/26/17 at 3:12 PM, Physician noted, "Assessment and Plan: patient presented with dizziness and fall with etiology unknown. Patient reports he fell because he was having a dizzy spell. No clinical history of vertigo (a sensation of feeling off balance and dizzy). Will try to obtain more history from patient. The patient is not the best historian, and is having difficulty with staying on topic and focused. Will get Physical Therapy and Social Work Consults.

There was no documented evidence that the hospital did a further exploration of the patient's feelings or developed a plan of care including a psychiatric consult referral to address the patients "very depressed affect" and emotional state.

On 3/28/17 at 5:07 AM, the physician documented, "Rapid Response Team was called because patient was found hanging himself in the restroom around 4:30 AM. Was found with strap around neck hanging from shower. Last seen normal around 4:00 AM. Patient was found by Patient Care Associate thirty minutes after last seen. Patient was pronounced dead at 4:55 AM."

During interview on 4/4/17 at 1:40 PM, Staff X, ED Physician stated: "When I wrote that the patient had a very depressed affect I meant that he seemed like most people who live here in the Bronx...you know life is hard and it's not easy for people who get older and have health issues to live here. I didn't refer him for a psychiatric consult because he didn't say the words I want to harm or kill myself."

Interview on 4/4/17 at 11:00 AM was conducted with Staff I, Staff J, Staff K and Staff Q (Medical Chair of Psychiatry, Director of Psychiatry liaison to medical services, Attending Psychiatrist and Director of Nursing). Staff J stated, "It would have been good to have had a conversation with Patient #2. He would have been an appropriate consult. He was sad and depressed after being overcome with emotion and collapsing at a friend's funeral causing his admission. Yes, he would have been someone who we would have liked to have seen before he died."
Staff J was asked if this was a missed opportunity to perform a psychiatric consultation for this patient and replied, "Yes, after reviewing his medical records I believe that he would have been someone we would have wanted to find out a little more about what was going on with him. He presented as someone who was probably likely depressed given what happened at his friend's funeral and yes this would have been an appropriate consult to have received."

The facility failed to provide interventions to the patient who was identified as needing further evaluation regarding his mental status.

On 3/28/17 at 7:40 AM, the nurse noted for Patient #2: "On 3/27/17 at 8:00 PM, hourly rounds were performed and at 9:30 PM medication was administered. At 10:00 PM through to 4:00 AM Hourly rounds were performed by nursing staff.

Review of the Rounding Log for North West 3 Room 300 (a private room), where Patient #2 was housed, dated 3/25/17 to 3/28/17, identified gaps and inconsistencies in the hourly nursing documentation.
On 03/28/17 at 2:00 AM - No hourly rounds were documented.
On 03/27/17 at 10:00 PM, 2:00 PM, 12 noon, 10:00 AM, 7:00 AM, and 5:00 AM, hourly rounds were not documented.
Other gaps were identified:
On 03/26/17 at 6:00 PM, 4:00 PM, 2:00 PM, 12 noon, 10:00 AM, 8:00 AM, 6:00 AM, 3:00 AM, - hourly rounds were not documented.
On 3/25/17 at 10:00 PM - hourly rounds were not documented.

Review of video surveillance for the hallway showing NW3 Room 300 where Patient #2 was housed, and time stamped 03/28/17 3:00 AM to 5:00 AM, showed the nurses did not conduct rounds at 3:00 AM and 4:00 AM. It was noted on the video that a nurse attendant entered the room at 4:32 AM.

During interview on 04/05/17 at 11:25 AM, Staff H, AVP Nursing stated, "I re-reviewed the video tape of the hallway showing the door to Patient #2's room NW 300. I have looked at it extensively from the night Patient #2 died. The nurse responsible for doing rounds is very distraught, she did not go into the room and do rounds as documented and she did not go into the room until 4:30 AM. It was based on this information from the nursing assistant that the nurse documented the patient was rounded on during the night. But the video tape shows that it was not done."

The facility's policy titled, "Rounding on Patients by Nursing Associates (RN) and Leadership," dated 5/15 states: "Rounding is conducted on all inpatient units around the clock. The goals of rounding are to vigilantly check (Nursing Attendant), to assess and reassess (Registered Nurse) patients. The nurses will round in order to anticipate patient needs ... and to provide assistance to the bathroom. Rounding will be initiated upon admission and maintained in the patient's rooms. RN's round during even hours and Nursing Associates/Patient Care Technicians round during odd hours. The NA/PCT informs the RN of significant changes discovered during rounds within a timely manner."

Further review of Medical Record for Patient #2 revealed the ED Nurse documented on 3/25/17 at 3:04 PM, "the patient had an un-witnessed fall when walking from the bathroom in the ED" and he was identified as a high risk for falls based on the Morse Fall Risk assessment score of seventy five (high risk for falls is scoring greater than 45). The patient was admitted to Telemetry/Medical Unit on 3/25/17 and placed on "falls risk prevention precautions".

Facility policy titled, "Fall Reduction/Prevention," dated 7/15 states, "Nursing Staff shall perform hourly rounds..."
There is no documented evidence of hourly rounding specific to falls risk monitoring for Patient #2.

Review of the Medical Record identified Patient #3, a 42 year old male with a history of polysubstance addiction, depression and suicidal ideation. He presented to the hospital emergency room on 10/11/16 at 4:10 AM, complaining of feeling suicidal and hearing voices. He stated he wanted to kill himself. On 10/11/16, 4:57 AM, the Physician ordered Constant Observation.
The Registered Nurses documented on 10/11/16 from 5:03 AM to 8:34 PM, the patient was placed on "constant observation for safety."

Review of the documentation dated 10/11/16, identified the patient was monitored every fifteen minutes on "Periodic Awareness" and not constant observation as ordered by the Physician.
Review of the hospital's policy titled "Behavioral Management of Patients on non-psychiatric units: Risk of Harm to Self /Others (B 9)," last revised 10/16, states: "Constant Observation is a level of Observation in which a designated care provider monitors a selected patient who is kept within sight and arms reach at all times ..." The Policy also states: "Enhanced Observation or Periodic Awareness is a lower level of care than Constant Observation.

The patient was not provided the level of monitoring as ordered by the physician.

During interview on 4/3/17 at 11:40 AM, Staff G, Director of Regulatory Affairs, stated, "the requirements for Periodic Observation is different than for patient on constant observation."
During interview on 4/4/17 at 10:40 AM, Staff Q, Director of Professional Nursing, confirmed, "that patients on Constant Observation are to be monitored every 15 minutes and that the hospital uses a designated form."

Review of the Medical Record identified Patient #4 was admitted to the facility on 5/20/16 with anemia and low platelet count. On 6/23/16 at 8:51 AM, the nurse noted the patient was agitated and expressed suicidal thoughts and was placed on Constant Observation.
There was no documented evidence of physician orders for "Constant Observation" (CO) and no evidence of nursing documentation for the CO.

Patient #6 was observed on constant observation, 04/03/17 at 11:30 AM on the Medical Telemetry Unit. Patient #6 was admitted on 3/26/17 with depression and suicidal ideation and was assigned to Staff W, Nursing Attendant, who was in the room and sitting near him. Staff W confirmed that her shift had started on 04/03/17 at 7:00 AM and she was assigned to do "Constant Observation for Patient #6."
Staff W stated, "This is the form where I am to write down that I am doing the constant observation. I sign my name every hour to show that I am doing the one to one."
Upon review of the form, the Surveyor noted the form was dated 04/02/17 and was missing the required initials by Staff W for 7:00 AM, 8:00 AM, 9:00 AM, 10:00 AM & 11:00 AM. When it was pointed out that the form is for 04/02/17 and asked where the form is for today's date of 4/3/17, Staff W stated, "this is the one I was given to use for today."

Review of the Medical Record for Patient #5 identified a 58 year old female brought into the hospital's emergency room on 2/11/17. The patient was terminally ill with stage four (IV) lung cancer with metastasis to the bone and was on home hospice. The patient was admitted to Palliative Care Unit 7 North West, and during the depression screen assessment on 2/12/17, the patient was asked, "Over the past two weeks, have you felt down, depressed or hopeless?" Patient #5 replied "yes."

There was no documented evidence that the hospital did a further exploration of the patient's feelings or developed a plan of care to address the patient's verbalized feelings of depression and hopelessness.

Review of the medical record for Patient #9 identified the patient presented to the Emergency Department (ED) on 4/3/17 with Pancreatic Cancer. The Nursing Triage Assessment performed at 8:24 AM, did not include a suicide risk screening.

Similar findings were identified for Patient #10 and Patient #11, who presented to the ED on 04/03/17, and the nursing triage documentation did not include suicide risk screenings.
This finding was confirmed with Staff A1, Nurse Manager, at the time of review on 04/04/17.

During interview on 04/04/17 at 11:35 AM Staff Q, (Director of Nursing for Professional Practice), stated: "The way we currently screen the patients for risk of suicide and depression is that all patients, everyone who comes here are asked two questions at Triage and if they answer "no" then no more questions are asked. If they answer "yes" then a drop down appears on the screen prompting the nurse to ask two additional questions .... Before we went to the electronic medical records last year, we would only do a suicide risk assessments on patients who presented with their primary complaint in psychiatry, but now all the patients get screened regardless of why they come into the hospital. The nurses were all trained to the electronic system but did not receive formal education specific just to the suicide and depression risk screenings when we went to the electronic system (EPIC)."

This current practice is not consistent with the facility policy for suicide/depression screening titled "Suicide Screening."

Review of facility policy titled, "Suicide Screening," last reviewed December 2015 identified: "....Suicide screening is required for patients treated with a primary diagnosis or primary complaint of an emotional or behavioral disorder. Suicide risk assessment of patients with secondary diagnosis or secondary complaints of emotional or behavioral disorders is encouraged but not required.

28406


Based on document review and interview the hospital did not ensure that data identified, collected and analyzed from incidents of prior suicide attempts, were used to implement changes that would lead to improvement in patient care.
Specifically, the facility failed to ensure that corrective actions identified by the Peer Review and Quality Assurance/ Performance Improvement Committees were fully implemented before two patients were able to successfully commit suicide on the Medical Units (Patients #1 and #2).

These failures resulted in patient deaths.

Findings include:

Review of hospital incidence reports for 2016, showed evidence of two suicide attempts in June and October 2016.
The Peer Review Minutes dated February 13, 2017, documented the first suicide attempt occurred on 6/23/16 & 6/24/16.

Review of medical record identified Patient #4: a 41 year old admitted on 5/21/16 with low platelets and anemia, and a past medical history for Human Immunodeficiency Virus (HIV). On 5/24/17 the patient was noted as teary eyed and upset and did not want her family to know she was HIV positive.

On 6/15/16, the patient was noted to frequently stare into space and not make eye contact. The patient was awake and alert on 6/22/16 and asked staff "when will it end."
On 6/23/16 the nurse noted the patient was agitated during the shift and stated she wanted to die and she refused to take any medicines. On 6/23/16 at 8:00 AM the patient was observed with the telephone cord wrapped around her neck. The patient was placed on a one to one Constant Observation pending psychiatric consult. Psychiatry saw the patient on 6/23/16 at 9:00 AM and noted that the patient was actively suicidal. She reported to the psychiatrist that she was feeling depressed for about seven months and felt suicidal for the past three weeks while in the hospital. On 6/23/16 at 9:15 AM, the nurse documented the patient threw herself on the floor and stated she wanted to die and did not want to live like this anymore.
On 6/24/16 at 2:43 AM, the nurse noted that the patient was discovered trying to use a yankuer catheter piece of medical equipment in an attempt to remove her dialysis catheter. The nurse noted the patient was moving her hands under the blankets and noted the patient was full of blood in her groin area where she had successfully removed the dialysis catheter out of the groin causing blood to gush out. The patient went into hemorrhagic shock and was intubated.
The patient expired on 7/12/16 at 9:20 AM .

On 01/09/17, the Quality Improvement Committee reviewed the case for Patient #4 and determined that the medical management was appropriate and that standard of care was met.

On 01/09/17, the Peer Review Board met and minutes dated 02/13/17 documented, "The Nursing Quality Improvement Committee concluded human error was attributed to the RN providing Constant Observation coverage and "she was consoled". A systems issue was identified. Members found it would be beneficial to educate all nursing staff on the identification of individual risk factors and to prevent similar occurrences. The following corrective actions were recommended, to include
(a) Identification and appreciation of patient specific risk factors and management to prevent harm for patients that are on Constant Observation will be distributed to all RN's.
(b) As part of leadership rounding, Nurse Managers will ensure that patients placed on suicide precautions are assessed to have appropriate monitoring, safety interventions and precautions consistent with those outlined in the Behavioral Management B-9 Policy.
(c) A Training Simulation Module on how to promote a safe environment for patients on Constant Observation is in development by the Learning Network.

These recommendations were not instituted before 10/17/16.

The Peer Review Minutes dated 10/17/16 identified the second suicide attempt occurred on 10/14/16. The patient was a 42 years old male with a history of depression, suicidal ideation and auditory hallucinations.

Review of the Quality Assurance Executive Board Summary dated 11/15/16 identified: Patient #3 was a 42 year old male with a history of depression, suicidal ideation and auditory hallucinations. Patient #3 presented to the hospital on 10/11/16 intoxicated and stated that he intended to end his life. He was evaluated by psychiatry in the ED Psychiatric Observation Suite and subsequently Triaged in the Medical ED. It is documented by Nursing Staff "His belongings were checked by Security and hazardous items were removed" and he was then placed on Constant Observation. Psychiatric Consultation recommended admission to a medical unit for treatment of Alcohol Withdrawal. The patient was admitted to a Medical unit and placed under Constant Observation.
On 10/14/16 "the patient was observed to have blood on his left wrist and he reported that he cut his wrist with a shaving razor that he had retrieved from his bag." A search of the patient belongings revealed two more razor blades."

On 12/15/16 the Quality Assurance/ Performance Improvement Committee documented that risk reduction strategies would include:
(a) A constant Observation Nursing Practice Alert will be disseminated to all RN's highlighting key components of ensuring a safe environment, identification and management of patient risk factors and communication of care plan.
(b) The Behavioral Management Policy will be revised to include current expectations regarding a search for dangerous items upon admission, removal of hygiene products in patients belongings and guidance on nursing responsibilities during and following visitor interactions with the patient.
(3) A mandatory E-learning Simulation Module will be developed for all nursing staff (RN's and NA's) to complete

On 01/05/17, Nursing Peer Review for the Quality Improvement Committee, documented, "the standards for maintaining a safe environment for a patient with suicide ideation, which includes Constant Observation, was not met.
The risk assessments (or root cause) of the incident was identified as the staffs lapse in Constant Observation monitoring. Specifically, the RN Charge Nurse assigned the patient care, instructed the Nursing Assistant to leave the patient alone. This lapse allowed the patient the opportunity for the patient to harm himself given that he was able to access and retain razors without detection.
The recommendation was that "all nursing staff be re-educated of the Behavioral Management Policy, with focus on patients at risk for suicide and how to best secure a safe environment".

On 02/01/17, Quality Peer Review planned to implement that during the months of February, March and April 2017, all patients who are at risk for harm to themselves or others will be observed by the Unit Manager to ensure:
(a) Environmental safety using an observational check sheet.
(b) Constant Observation is implemented as per policy.
(c) Staff understanding of the rationale for using Constant Observation.
The plan included Suicide Risk Audits using a Tracer Observation Form for Medical Units K6, K8, and NW6 ONLY.

There is no evidence that these recommendations were fully implemented to Units K6, K8, and NW6.

There is no evidence that all corrective actions were developed and fully implemented to include nursing staff house wide or in all the facility's medical units.

During interview on 04/06/17 at 2:30 PM, Staff Q stated, "The E-learning Simulation Module hasn't been piloted yet. It takes time to develop a learning module and it hasn't been completed yet, the people who are developing it are working very hard to finish it though."

During interview on 04/06/17 at 2:35 PM Staff C stated, "We haven't needed to revise the B-9 policy because it's a very good policy. It's probably the best policy you could find for the Management of Psychiatric Patients on Medical Units in any hospital around."

During interview on 04/06/17 at 3:30 PM Staff R1 stated, "The corrective actions from the Peer Review Committee (related to Patient #3 and #4) that met on 02/01/17 have not been fully implemented yet."