HospitalInspections.org

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Based on document review and interview, the facility failed to remove alleged persons from patient care responsibilities, ensure timely and thorough investigations of abuse allegations were performed, and report allegations of abuse.

These failures potentially placed all patients at risk of abuse.

See Tag A-145.

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Based on document review and interview, in 3 (three) of 3 (three) cases reviewed, the facility failed to: (1) Remove alleged persons from patient care responsibilities; (2) Ensure timely and thorough investigations of abuse allegations were performed; and (3) Report incidents of abuse.

These failures potentially placed all patients at risk of abuse.

Findings for (1) included:

The facility policy and procedure (P&P) titled "Abuse, Neglect, Mistreatment, Harassment," last revised 7/13/18, stated the following: "Patients,...visitors, or other persons must be protected at all times during the investigation of any allegations of abuse, neglect, mistreatment or harassment ...If after thorough investigation, the allegations are unsubstantiated, the 'alleged' person may return to active duty."

The facility Grievance Reports dated from 2/2019 to 8/2019 identified the following:

On 4/16/19 at 11:49AM, Patient #4's family member complained that at 4:00AM, she witnessed Patient #4 was naked and up against the bed rail, while a Registered Nurse (RN) and a Nurse Aid (NA) were "slapping" her.

The Investigation Report, dated 4/16/19, noted the alleged RN was interviewed on 4/16/19 and denied the allegations. The alleged NA was not interviewed until 4/19/19, 3 (three) days after the allegation of abuse was reported.

The facility Staff Schedule, dated April 2019, revealed both the RN and the NA returned to direct patient care responsibilities on 4/17/19, 2 (two) days before the completion of the investigation on 4/19/19.

This finding were confirmed with Staff H (Chief Nursing Officer) on 8/13/19 at 3:00PM.
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On 2/27/19 at 3:43PM, Patient #6's family member reported that a physician became verbally aggressive and physically intimidating with him in the patient's room with the patient present. The family member also identified two other staff members, a nurse and another Physician, as potential witnesses to the incident.

There is no documented evidence that the alleged physician was removed from patient care responsibilities during the investigation.

Per interview of Staff J (Director of Patient Experience) on 8/13/19 at 1:16PM, Staff J confirmed these findings.

Per interview of Staff C (Vice President of Performance Improvement) on 8/13/19 at 2:00PM, the facility does not have the ability to track consulting physicians providing patient care.
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The NYS Incident Management and Reporting System Form [system to report allegations of abuse to the NYS Justice Center], dated 7/5/19, noted Patient #1 had reported that Staff G (RN/Registered Nurse) physically and verbally abused him.

The facility Investigation Report, undated, did not identify Staff G as the alleged person nor that Staff G was removed from patient care responsibilities during the investigation.

Per interview of Staff D (Nurse Manager Access and 1 East) on 8/12/19 at 2:50PM, Staff D confirmed these findings and acknowledged that she was not aware that staff needed to be immediately removed from patient care when an allegation of abuse had been reported.
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Findings for (2) included:

The facility P&P titled "Abuse, Neglect, Mistreatment, Harassment," last revised 7/13/18, stated the following: "The investigation must be concluded and documented within 7 days of the report."

Review of the facility Grievance Reports between 2/2019 and 8/2019 identified the following:
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On 2/27/19 at 3:43PM, Patient #6's family member reported that a physician became verbally aggressive and physically intimidating with him in the patient's room with the patient present. The family member also identified two other staff members, a nurse and another Physician, as potential witnesses to the incident.

The Investigation Report for this complaint was not completed until 3/12/19, 13 (thirteen) days after the allegation of abuse was reported. Neither of the two identified witnesses were interviewed during this investigation.

Per interview of Staff J (Director of Patient Experience) on 8/13/19 at 1:16PM, Staff J confirmed these findings and acknowledged that only the accused and the patients are interviewed for complaints.
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The NYS Incident Management and Reporting System Form, dated 7/5/19, noted Patient #1 reported that Staff G (RN/Registered Nurse) physically and verbally abused him.

The facility Investigation Report (undated) stated "Employees were interviewed based on statement received and review of patient medical record, the accusations appear to be unsubstantiated." The investigation was completed 7/23/19, 18 (eighteen) days after the allegation was reported. The investigation did not include statements from all staff members present during the incident including Staff G. A staff member's written statement was not dated, timed nor signed by the staff member.

Per interview of Staff D (Nurse Manager Access and 1 East) on 8/12/19 at 2:50PM, Staff D confirmed these findings and stated that she was not aware an investigation needed to be immediately implemented.
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Findings for (3) included:

The facility P&P titled "Abuse, Neglect, Mistreatment, Harassment," last revised 7/13/18, stated the following: "A proactive approach must be maintained to identify events and occurances that may constitute or contribute to abuse, neglect, mistreatment, or harassment" and "An incident report must be completed, and immediate notification made to the department's supervisor."

The facility's Grievance Reports dated from 2/2019 to 8/2019 revealed no internal facility incident report had been completed for an allegation of abuse reported by Patient #1 on 7/5/19.

Per interview of Staff F (RN) on 8/14/19 at 9:00AM, Patient #1 had complained to Staff F that Staff G (RN) had physically and verbally threatened him on 7/4/19.

No documented evidence was found that an internal facility incident report had been completed or that Staff F had immediately notified a supervisor of the allegation of abuse per facility policy.

During interview of Staff C (Vice President of Performance Improvement) on 8/12/19 at 1:30PM, Staff C confirmed that there was no internal facility incident report for this allegation.

Per interview of Staff D (Nurse Manager Access and 1 East) on 8/12/19 at 2:50PM, Staff D confirmed these findings.

Based on medical record (MR) review, document review and interview, in 16 (sixteen) of 18 (eighteen) MRs, the facility failed to: (1) Ensure patients were re-evaluated and/or monitored by a physician after being transferred to the Emergency Department [Psychiatric] Access Center (EDAC); and (2) Provide timely psychiatric consultations for patients in the EDAC (See Tag A-1103).

These failures potentially placed patients and staff at increased risk of harm.

Findings pertinent to (1) included:

The facility policy and procedure (P&P) titled "Behavioral Health Patients in the Emergency Department [ED]," last revised 7/11/19, stated, "The ED Physician will be responsible for all medication orders for the patient who have been cleared medically for acute care but continue to require orders for medical medications after transferring to the ACCESS Center. The psychiatrist is on duty from 9:30(AM)-9:00(PM). If the patient is transferred after 8:00PM, the patient will not be seen until the following day at 9:30AM."

Review of Patient #12's MR identified the following: This patient was brought to the ED by ambulance on 6/27/19 at 9:06PM with a chief complaint of wanting to hurt himself. At 11:05PM, the ED physician medically cleared the patient and ordered a psychiatric consultation.

On 6/28/19 at 12:50AM, Patient #12 was transferred from the main ED to the EDAC. At 1:35AM, Patient #12 began punching and kicking the walls, resulting in bodily injuries, and challenging the staff to a fight. Security was called. The Medical Director of Psychiatry, the Nurse Manager of Psychiatry and the on-call (able to be contacted in order to provide a professional service if necessary, but not formally on duty) Psychiatrist were notified. The on-call Psychiatrist instructed [staff] to "seek the help of the police."

The on-call Psychiatrist, ordered Ativan, Benadryl and Geodon which were administered at 2:34AM; then Ativan, Benadryl and Haldol which were administered at 2:51AM. The on-call Psychiatrist instructed staff to "transfer the patient back to the [main] ED where patient can be put under medication safely." At 5:19AM, the patient was transferred back to the main ED. At 11:51AM, the Psychiatrist documented the psychiatric consultation.

The following was identified:

When the patient became a threat to himself and others, Staff I (EDAC RN/Registered Nurse) contacted the on-call Psychiatrist for the medication orders, instead of the ED physician. Without evaluating the patient, who was in crisis, the psychiatrist ordered medications for the patient twice. The patient, who was a danger to himself and others and required medication, was not evaluated by a physician for approximately 9.5 hours after the medication was ordered and administered.

When the patient was transferred to the Main ED, there was no documented evidence that an ED physician assumed care of the patient during the 5 (five)-hour period in the main ED.

Per interview of Staff A (ED Director) on 8/14/19 at 11:50 AM, she confirmed all findings and stated "I can't identify which ED physician assumed care of the patient."

Per interview of Staff I 8/15/19 at 2:50PM, when a patient needs medications in EDAC during the day, Staff I calls the scheduled Psychiatrist on duty. After 9:00PM at night, he calls the on-call Psychiatrist for medication orders.


Review of Patient #1's MR identified the following: The patient was brought to the ED by police 7/3/19 at 5:02PM for a psychiatric evaluation. At 6:52PM, the ED Physician medically cleared the patient and ordered a psychiatric consultation. At 9:33PM, Patient #1 was transferred to the EDAC. On 7/4/19 at 6:38AM, Patient #1 became a threat to staff. The on-call Psychiatrist ordered Haldol 5mg, Ativan 2mg, and Benadryl 50mg, which were administered at 6:46AM. At 10:56AM, the on-call Psychiatrist documented a psychiatric evaluation.

The following was identified:

When Patient #1 became a threat to others, Staff I contacted the on-call Psychiatrist for medication orders instead of the ED physician.

Without evaluating Patient #1, the on-call Psychiatrist ordered medications for the patient.

Patient #1, who was determined to be a danger to others and required medication, was not evaluated by any physician for approximately 4.5 hours after the medication was ordered and administered.

Per interview of Staff B (ED Medical Director) on 8/13/19 at 2:30PM, Staff B stated "the doctor should have come in to evaluate the patient before ordering medication" and "I think it's odd that he would order meds (medication) on a patient he never saw for 5 (five) hours after prescribing medications."


Review of Patient #20's MR identified the following: This patient was transferred from the ED to the EDAC on 7/21/19 at 8:10PM. An ED physician documented the following on 7/22/19 at 8:31AM, twelve (12) hours after the patient was transferred: "Called by Access to give patient medication for agitation. I have not been involved in the care of this patient. Advised nurse that they need to be calling the Psychiatrist, however because I am immediately available I will assist in the immediate situation."

The ED physician prescribed Ativan 2mg for Patient #20 in the EDAC. There is no documented evidence that the ED physician physically evaluated Patient #20 before or after prescribing the medication.

Patient #20 was not re-evaluated by any physician for more than 19 (nineteen) hours after being transferred to the EDAC. Patient #20 was seen by the Psychiatrist at 5:06PM, more than 7 (seven) hours after receiving the medication.

The same delay in medical evaluation and/or re-evaluation for patients in the EDAC was found in the MR for Patient #21.

Review of Patient #9's MR identified this patient was transferred to EDAC on 7/13/19 at 12:06AM. There was no documented evidence any physician observed or re-evaluated this patient for more than 26 (twenty-six) hours after being transferred to the EDAC.

Per interview of Staff F (ED Physician) on 8/14/19 at 10:30AM, if the patient is in Main ED when he receives report at the start of his shift, Staff F will "eyeball evaluate" [observe or view] the patient. But, if the patient has already been transferred to the EDAC, Staff F stated that he would not go to see the patient unless there was a problem and he was called by the EDAC nurses.

During interview of Staff F (ED Physician) on 8/14/19 at 10:30AM, when informed that Patient #26 was not re-evaluated by a physician for 26 (twenty-six) hours after transfer to the EDAC, Staff F stated, "Oh my!" and stated that it was "inappropriate" for emergency patients to not to be seen by a physician for such long periods of time. Staff F added that he had never seen a Psychiatrist come to evaluate Emergency psychiatric patients during the overnight shift.

The same lack of medical oversight by a physician for ED patients after transfer to the EDAC was found in the MRs for Patients #1, 10, 12, 15, 19, 21, 22, 23, 24, 25, & 26, with times ranging from 15 (fifteen) to 26 (twenty-six) hours without medical re-evaluation by a physician.

Per interview of Staff B (ED Medical Director) on 8/13/19 at 2:30PM, Staff B stated that the ED physicians should be "eyeballing" the EDAC patients after receiving "handoff" report. However because the EDAC is on a different floor, it makes it difficult for the ED physicians to see the EDAC patients. Staff B confirmed that the ED physicians are responsible for the patients in the EDAC until the Psychiatric Consultation is completed.

Staff B also stated "the expectation is the [EDAC] nurses should be calling the ED physicians" for medical intervention, and that the ED physicians should be going to the EDAC to evaluate the patient before and after prescribing medications.

Per interview of Staff C (Vice President of Performance Improvement) on 8/14/19 at 12:30PM, Staff C acknowledged these findings.
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Based on medical record (MR) review, document review and interview, in 13 (thirteen) of 14 (fourteen) MRs reviewed, the facility failed to provide timely psychiatric consultations for patients in the Emergency Department Access Center (EDAC).

This failure placed patients at increased risk for harm.

Findings included:

Review of Patient #9's MR identified the following: This patient presented to the Emergency Department (ED) on 7/12/19 with suicidal ideation (thoughts) and hallucinations. He was triaged (assigned a level of urgency to determine the order of treatment) at 1:32PM. The Physician Assistant (PA) evaluated the patient at 6:02PM. The Attending Physician ordered a psychiatric consultation (consult) at 8:11PM. At 10:03PM, the PA noted the psychiatric consult was still pending.

The patient was transferred to the EDAC on 7/13/19 at 12:06AM. At 12:27AM, the Attending Physician documented that Patient #9 "was to be seen by the psychiatrist but he is not able to see the patient until the morning...[the Psychiatrist] doesn't believe this is a safe discharge."

The Psychiatric Consult was completed on 7/13/19 at 10:49PM, 26 (twenty-six hours and 38 (thirty eight) minutes after the initial order.


Review of Patient #8's MR identified the following: This patient presented to the ED on 7/6/19 with suicidal ideation and was triaged at 12:28PM. The patient was evaluated by the ED physician at 3:52PM. At 7:14PM the Attending Physician requested a psychiatric consult.

The patient was transferred to the EDAC on 7/6/19 at 8:32PM. The Psychiatric consult was completed on 7/7/19 at 6:05PM, 23 (twenty-three) hours and 9 (nine) minutes after the initial order.

The same delay in psychiatric consultations were found in the MRs for Patient #'s: 1, 10, 12, 15, 19, 21, 22, 23, 24, 25, & 26.


During interview of Staff A (Director of ED) on 8/14/19 at 10:20AM, Staff A confirmed these findings.

The facility policy and procedure (P&P) titled, "Behavioral Health Patients in the Emergency Department," last revised 7/11/19, stated the following: "The psychiatrist is on duty from 9:30AM to 9:00PM. If the patient is transferred after 8:00PM, the patient will not be seen until the following day at 9:30AM."

However, it was also identified that emergency consultations on the night shift were also not completed timely during regular on-duty hours, as per facility policy. They were delayed from 9 (nine) to 13 (thirteen) hours after the Psychiatrist came on duty at 9:30AM. (See Tag 1104)

Per interview of Staff B (ED Medical Director) on 8/13/19 at 12:15PM, Staff B stated his expectation for an emergency consultation would be "as soon as possible," and that the up to 26-hour wait for emergency Psychiatric consultations was "too long to wait" and "inappropriate."