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Based on medical record review, document review, and interview, in two (2) of 30 medical records reviewed, the facility failed to maintain a safe environment for patients. Specifically, the facility failed to prevent unauthorized access of people into patient care areas.
(Patient #1 & #22)

(a) Patient #1: A patient was sexually assaulted by an unauthorized person. A registered nurse reported she observed a stranger in the patient's room "with his mouth on the breasts" of the patient, who was unconscious.

(b) Patient #22: A registered nurse observed a stranger in the patient's room, who claimed to be the patient's grandson. The stranger escorted the patient to the dialysis area along with a staff member. The patient's spouse arrived looking for the patient and stated the patient does not have a grandson.

These findings placed all patients at risk for harm.

See Tag A 144.

Based on document review and interview, in six (6) of fourteen 14 grievance files reviewed, it was determined that the hospital failed to implement its policy to (a) identify and investigate all patient complaint/grievances and (b) send a written response to the patient/patient's representatives. (Patients # 23, 24, 25, 26, 27, 29)

Findings include:

Review of the facility's Policy and Procedure titled "Patient Complaint/Grievance, Concerns, Complaints, Referral Mechanism," revised 07/19/2017, states:
Definition:
A "patient grievance" is a formal or informal written or verbal complaint that is made to the hospital by a patient or the patient's representative, regarding the patient's care (when the complaint is not solved at the time of the complaint by a staff present)..."

Policy:
C. "The hospital will review, investigate, and resolve each patient's grievance within (7) days ....
D. A copy of the grievance will be sent to the appropriate chiefs of service or heads of departments and response is expected back within seven (7) calendar days of receipt of the grievance that acknowledges receipt of, or resolution of the grievance ....
E. The hospital's written response to the complainant will contain the name of the hospital contact person, the steps taken on behalf of the complainant, the results of the grievance process and the date of completion ..."


Review of facility's Grievance Record from 1/2/2019 to 10/23/2019 identified:

Patient #23: On 1/8/2019, the patient's daughter filed a grievance regarding the patient's discharge from the facility on 1/3/2019. This grievance was forwarded to the Medical Department. A telephone call was made to the complainant on 1/15/2019. The steps taken on the investigation were not documented. The complainant was not provided a written response on the outcome of the investigation.

Patient # 24: On 1/11/19, the patient filed a grievance with the facility's Department of Guest Relations, regarding improper discharge planning. Documentation showed the social worker called the patient to address her concerns. The facility was unable to provide evidence that a written response was sent to the patient with the steps taken to investigate and resolve the grievance.

Patient # 25: The patient contacted Guest Relations Department on 8/21/19 to request an update regarding written allegations of sexual assault grievances filed with the facility. As per documentation, staff stated: "she explained to the patient that her complaint did not meet the criteria for sexual assault because when she got into the unit, she was not wearing G-string." The actions taken to investigate/resolve the grievance were not documented, and a written response was not provided to the complainant.

Patient # 26: On 1/11/2019, the patient informed the Guest Relations staff that "one of the Guest Relations staff met with me and I had complaints, but no one reached out to me." There was no documented evidence that the facility investigated the grievance and provided the patient a written response.


Patient # 27: On 3/28/19, the patient filed a grievance with the facility regarding a bad experience with an X-ray technician. The documentation indicated that on 3/28/2019 the supervisor was not available but would be available on 3/29/2019. The Patient Relation staff was unable to contact the patient by telephone and left a voice message. This complaint was not identified as a grievance and was not investigated. A written response to the patient was not generated.

Patient #29: On 10/01/2019, the complainant informed Guest Relations staff that Patient #29 (a pediatric patient) was brought to the facility for a foot infection. She signed a refusal of any medication due to religious reasons and the patient was given antibiotics and other treatment. There was no documented evidence that this complaint was investigated and that a written response was provided to the complainant.

During an interview with Staff N, Director of Patient Experience, on 11/7/19 at approximately 11:37 AM, the findings were discussed. When asked about grievances, staff defined patient's grievances as written complaints submitted to the facility.

Based on medical record review, document review, and interview, in two (2) of 30 medical records reviewed, the facility failed to prevent unauthorized access of people into patient care areas. (Patients #1 & 22).

Findings include:

Review of facility policy titled "Access Control," effective 6/30/17, states:
"Policy: To ensure that any individual requiring access to any area is in possession of appropriate identification. Human resources department identifies the staff members who are authorized to enter and remain in the hospital. All other individuals entering the facility will be issued a color-coded sticker or a visitor pass.

Guidelines: Hospital Police Post Locations and Responsibilities:
1. Hospital police personnel are stationed at the following first floor posts in order to control access.
- Main elevators
- Medical and Psychiatric Emergency Room
- Infant Units

2. The officers at the designated posts are responsible to enforce all access control policies and provide directions, when necessary:
- All persons issued a hospital identification card are required to wear it on the upper body; visible at all times.
- All patient visitors must obtain the appropriate visitor's pass from the information desk before being allowed access to patient areas.
-All other individuals requesting access will be directed to the main lobby hospital police desk ..."


Review of the "Hospital Crime and Incident Report #19-05-0456," revealed that on 5/13/19 at 3:16 PM, security was called when an unidentified person was found in a patient's room (Patient #1). Security officers were unable to intercept the individual on the patient's unit or on the hospital grounds.

During interview on 11/5/19 at 12:55 PM with the Director of Quality Management, Associate Director Nursing, Chief Operating Officer, Associate Director Patient Safety and Director of Security, they acknowledged that an unauthorized individual gained access to a patient's room and sexually assaulted Patient #1, on 5/13/19.



Review of the medical record for Patient #1 identified: On 5/12/19 this 68-year-old female was admitted to Unit 9B, Medical Floor. The patient had altered mental status and was unconscious since admission.
On 5/13/19 at 6:45 PM, the physician documented that he was alerted that there was an incident with the patient. The Registered Nurse informed the physician that a stranger was noted in patient's room doing something with the patient's breast. Hospital police were called but the stranger left before being arrested. The patient was examined by the Attending Physician and the Resident.
On 5/13/19 at 7:01 PM, a Registered Nurse noted that the "Charge Nurse witnessed a sexual assault on the patient and police was called immediately..."
Documentation by the nurse on 5/14/19 at 8:00 AM noted that the "patient was under NYPD (New York Police Department) protection as victim of sexual assault.... Rape kit evidence procurement was also performed."

During interview on 11/8/19 at 10:48 AM, Staff H, charge Nurse stated: "I was the first to enter the room when the roommate called us by ringing the bell and Staff J, Registered Nurse, came and told me that there was a stranger in the room, maybe we need to call the police. On entering the room, I saw the stranger with his mouth on the patient's breast. I screamed and yelled "stop, this is not supposed to happen." The patient's breast was exposed, he lifted the gown and covered the breast. He yelled back at me in a language I did not understand. I stepped out and called hospital police and the Associate Director of Nursing. When I stepped out, he was still in the room and the roommate was also there. When I went back to the room he was gone."



Review of the "Hospital Crime and Incident Report, Control #19-10-1012" revealed that on 10/26/19, an unauthorized individual was found in another patient's room. (Patient #22).
According to the report, the nurse observed a male stranger in the patient's room at 3:15 PM. On questioning by the nurse in the presence of the patient, he stated he was the female patient's grandson. The patient did not object to the statement at the time. The male, who did not have a visitor pass, was allowed to follow the patient and staff to a dialysis unit for treatment. The patient's husband then came in for a visit and when told that the patient was in dialysis with her grandson, he stated that the female patient had no grandson. Security was alerted, went to dialysis and removed the suspect at 4:10PM. There is a written statement dated 10/26/19, in Spanish, from the patient, requesting that her room be kept free of intruders. This statement was obtained by the hospital police.

During interview on 11/7/19 at 3:45 PM with the leadership facility staff, the incident which occurred on 10/26/19 where another stranger presented to the room of a patient without a visitor pass, was discussed. The leadership staff members acknowledged the findings. Staff stated that the suspect had visited the Emergency Department via ambulance for treatment but did not wait to be seen and then wandered from the Main lobby and was able to ride the elevator to the 9th floor to gain access to the Patient's #22, Room 132A.



During a tour of the facility's Unit 9B, on 11/4/19 at approximately 11:30 AM, the surveyors observed an unidentified male without an identification badge or visitor pass. This was brought to the attention of the Director of Quality, who accompanied the surveyors on the tour.

During a tour of the facility's entrance on 11/8/19 at approximately 11:55 AM, the surveyors observed two (2) security guards posted at the Main public elevator lobby and there are 8 elevators at the location. It was noted that unidentified persons with no ID (Identification Badges) or visitor passes walked by security without being challenged. The 3rd elevator lobby is close to the Emergency Department. A contractor with a dumpster and an incomplete visitor pass was allowed to go into the elevator without being challenged by the two (2) security guards who were present at the location.

These observations were made in the presence of the Staff F, Security Director, Staff D, Chief Operating Officer and Staff M, Director of Risk, who acknowledged the findings.

Based on document review and interview, the hospital did not implement its policy for a patient/ patient representative to gain access to the patients' medical records (Patient # 28).

Findings include:

Review of the facility "Complaint Case Sheet" identified: On 6/10/2019, the complainant went to the Guest Relations Department stating he would like a copy of his wife's medical record (Patient #28). The complainant also informed Guest Relation staff that Medical Records Department was not assisting because he was not the Health Care Proxy (HCP). The Guest Relation staff informed the complainant that without the HCP, nothing could be done.

There was no documented evidence that the complainant was provided information on "Patient's Personal Representative" or if it was identified that the complainant was/was not the patient's representative.

The Patient Relation staff assigned to this case could not be interviewed, as this staff member no longer worked at this facility.

During an interview on 11/7/19 at 11:00 AM, Staff O, Clerical Associate Medical Record, stated "the complainant needed to be the patient's HCP or obtain a court order, in order to obtain a copy of the spouse's medical record."

During interview on 11/7/19 at 2:23 PM, Staff P, Director Medical Record stated, the staff information was incorrect. Staff P stated, "if the spouse was the patient's representative, he should have gained access to the medical record."

The facility's Policy and Procedure, titled " Health Insurance Portability and Accountability (HIPAA) Privacy Policy Access to Protected Health Information," dated 05/31/2019, states: "Personal Representative: means an individual who has the legal authority to act on behalf of a Patient for purposes of HIPAA and its implementing regulations."

This policy also states, "in the event of a denied request for assess or inspection, the facility must provide a written notice of the denial."

Based on document review and interview, the facility failed to: (a) Fully implement their corrective action plan for a patient who was sexually assaulted by a stranger /visitor in the patient's room, and ensure that training/education on the action plan was provided for all employees. (b) Re-evaluate their corrective measures when a stranger presented
to another patient's room.

This failure placed patients at risk for potential harm.

Findings include:

Review of the facility Incident Report dated 5/13/19 identified an incident where an unauthorized individual gained access to patient's room. (Patient #1).

On 11/6/19 at 11:40 AM during a meeting with facility leadership staff: Director of Quality Management, Associate Director of Nursing, Chief Operating Officer, Associate Director Patient Safety and Director of Security, staff acknowledged the case of Patient #1, who was sexually assaulted by a stranger/visitor in the patient's room, on 5/13/19. The facility presented a written plan to prevent a re-occurrence. The plan included staff training; physical environmental modification; and enhanced security, with additional usage of security staff at the main entrance and the elevator banks on the ground floor.

Staff training on "Inpatient Visitor Security Management" was implemented on 5/16/19 by a memo. Review of the training documents and attendance sheets identified that only 3 departments had documented evidence of receipt of this training. On 11/6/19 at approximately 12:30 PM, Staff B, Director of Quality Management, acknowledged this finding.

During interview on 11/7/19 at 5:51 PM facility staff presented a written "Enhanced Security Action Plan" with a date of implementation of 11/8/19, which was during the survey.


Review of the facility Incident Reports identified a similar incident of an unidentified individual, found in patient's room on 10/26/19. There was no documented evidence that this incident has been fully investigated and that the action plan after the 5/13/19 incident was re-evaluated and corrective actions developed.

During interview of facility leadership staff on 11/7/19 at 3:45 PM, the facility acknowledged the findings.

Based on medical record review, document review and interview in two (2) of five (5) medical records reviewed, it was determined the nursing staff failed ensure that patients identified as a high risk for elopement, were adequately monitored. (Patient #19 and #30)

Findings include:

Review of medical record for Patient #19 identified: a 62- year-old patient with a psychiatric history who was evaluated on 6/5/19 for treatment of psychosis. The patient was agitated and verbally aggressive, requiring physical restraint and medication management. The Attending physician's assessment noted an order for admission to a medical unit with psychiatric follow-up.
On 6/5/19 at 11:23 PM a physician ordered 1:1 monitoring for manic behavior.
On 6/6/19 at 2:18 PM a psychiatrist's assessment identified the patient at risk for elopement and that he needed medication optimization and inpatient psychiatric treatment, once a bed is available. The patient was admitted to a medical unit, while awaiting admission to the psych unit.
On 6/6/19 a nurse on the medical Unit 8B documented that the patient left the unit at 6:25 PM while being monitored by a PCA. The hospital police were notified.

Review of the Crime and Incident Report #19-06-0545, revealed that the hospital police had seen the patient at the 149 th street exit video camera, prior to the overhead announcement of the elopement and had reported the incident to NYPD at 7:32 PM on 6/6/19.

On 6/7/19 at 2:24 PM, nursing reassessment documentation in the medical record indicated that the patient returned to the facility and was brought back to the Psychiatry Emergency Department accompanied by nursing staff and hospital police, for safety and to prevent elopement. The patient was still wearing hospital pajama.

There was no documented evidence of one-to one monitoring of the patient on 6/5/19.
On 6/6/19 gaps in monitoring were identified:
11:45 PM to 12:30 AM - No documentation
3:30 AM to 4:14 AM - No documentation
8:00 AM and 10:15 AM - No documentation
6:15 PM - No documentation.
This was brought to the attention of Staff B, Director of Quality Management, on 1/8/20 at approximately 10:00 AM, when the surveyors were presented with the monitoring documents.


Review of medical record of Patient #30 revealed a 62-year-old female patient who was brought to the facility on 5/29/2019 at approximately 3:41 PM, for management of psychiatric disorder. The patient received a Medical Screen Examination and was evaluated by the psychiatric provider. Diagnosis of Schizoaffective Disorder, Bipolar Unspecified, and Diabetes Mellitus Type II was made; orders were given for close observation. The patient was re-evaluated by Emergency Department physician at 5:27 PM then at 10:03 PM, when a decision was made to transfer the patient to a medical unit for further management with psychiatry follow-up.

On 6/6/19 at 8:20 PM, the Behavioral Emergency Support Team (BEST) team was activated, as the patient became agitated/aggressive and wanted to leave the medical unit.
On 6/7/19 at 11:30 AM, the patient was noted by staff to have left the unit. The hospital police and staff were alerted. They searched for the patient, but they were unable to find her. Staff was able to reach the patient at her residence at 2:30 PM, and arrangement was made to have her returned to the facility for treatment.

During an interview conducted on 1/14/2020 at 2:50 PM, Staff Q, a PCA who was assigned to the patient, confirmed that the patient eloped from the facility while under on one-to-one observation.

Review of the "Special Observation Flowsheet" identified gaps in the documentation of monitoring. Examples:
5/29/19 - No documentation 7:45 AM to 9:00 AM and 12:00 PM to 12:45 PM.
5/30/19 - No documented monitoring flowsheet.
6/1/19 - No documentation 7:45 AM to 12:45 PM and 2:15 PM to 3:30 PM.
6/2/19 - No documentation 12:45 PM to 3:30 PM and 5:15 PM to 7:45 PM.
6/6/19 - No documentation from 8:00 PM to 6/7/19 when the patient eloped.

Review the policy titled "Levels of Observation and Patient Monitoring for At-Risk-Behaviors in all Patient Care Settings," notes: One to One, Six (6) Feet (Requires a Doctor's Order). One (1) staff member to One (1) patient with constant visual contact at all times and maintained at a distance not to exceed six (6) feet with no physical barrier present. RN assessment/reassessment must be done once every 12-hour shift and documented in the medical record. Ancillary staff assigned to monitor the patient must document the patient's behavior/activities every 15 minutes on the "Special Observation Flowsheet".