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Based on document review and interview, the facility failed to ensure:
1. Data collected from Incidence/Occurrence reports was used to identify and analyze problems and to improve clinical performance;
2. In its clinical review, problems with timely assessment of a pregnant woman with abdominal trauma and fetal demise were identified and corrected.

These failures may have placed patients at risk for adverse outcomes.

Findings include:

Review of QAPI minutes for June 2021 to June 2022 revealed there was no tracking, analysis, trending and corrective actions implemented for the following indicators: Falls with Injury, Elopements, Airway Management (self-extubations).

In the clinical review of a pregnant woman with abdominal trauma and fetal demise, problems with timely evaluation of the patient were not identified and there was no evidence the facility implemented any of the proposed corrective actions documented in the report.

See A0273, A0283, A0286.

Based on document review and interview, in three (3) of four (4) quality indicators reviewed, the facility failed to utilize its Quality Assessment and Performance Improvement Program to ensure that serious patient incidents/occurrences were quantified, analyzed and corrective actions implemented.

Findings include:

Review of QAPI minutes for June 2021 to June 2022 revealed there was no tracking, analysis, trending and corrective actions implemented for the following indicators: Falls with Injury, Elopement, Airway Management (self-extubations).

Data for June 2021 to June 2022 revealed the following:
174 falls with injuries of which 22 were considered major injuries (Major injuries are defined as injuries that "resulted in surgery, casting, traction, required consultation for neurological, e.g. skull fracture, hematoma, internal injuries...)"

201 elopements (Unauthorized departure from the hospital).

Airway Management incidents that included 12 Adult self-extubations.

There was no documented evidence in the QAPI minutes that these indicators (Falls with Injury, Elopement, Airway Management including self-extubations) were investigated, analyzed and a plan developed and implemented to improve patient outcome.

During interview on 7/8/2022 at approximately 11:00 AM, Staff J, Head Nurse/Nursing Quality reported that the Electronic Incident reporting system does not capture all incidents due to staff non-compliance with incident reporting.

During interview on 7/11/22 at approximately 11:00 AM, Staff Bb, Director of Quality Management acknowledged findings.

Based on document review and interviews, the hospital failed to utilize its Quality Assessment Improvement Program (QAPI) to:
1. Identify opportunities for improvement, and implement corrective actions that could lead to improved quality of care.
2. Review and address patient grievances to ensure patient safety and improve patient outcome.

Findings include:

1. Review of the QAPI minutes from 3/31/21 to 3/25/22 showed no documented evidence that the hospital reviewed, investigated, and implemented corrective actions for incidents that may impact negatively on patient outcome.

During interview on 5/12/22 at 12:35 PM, Staff Dd, (Associate Director of Clinical Standard) acknowledged the findings and stated the hospital does not "do a formal review of patient incidents." She also stated that there was no system in place to quantify the number of incidents and occurrences. She further stated that it was a complicated process, and there were too many incidents to quantify.

On 5/12/22, the hospital provided an Incidence/Occurrence Report for 5/1/21-5/1/22 that showed more than 200 unplanned adult extubations.

On 5/17/2022 at 2:37 PM, Staff Aa, (Director of Regulatory Affairs) reported that the Incidence/Occurrence Report for 5/1/21-5/1/22, was a system wide document for multiple hospitals and they are unable to identify which incidents are specific to this hospital.

On 7/18/2022, the hospital provided a revised list of Incidence/Occurrence Report from June 2021 to June 2022 that showed 12 unplanned adult extubations.

There was no evidence that the hospital investigated or analyzed these events to identify problems and implement corrective actions.

The incident report did not include a significant patient event that occurred on 12/30/21 where a patient self-extubated and went into cardiac arrest. The patient was discharged to a long-term care facility with a discharge diagnosis of anoxic brain injury secondary to cardiac arrest.


The Hospital Quality Assurance and Performance Improvement (QAPI) Plan for 2022-2023 states that the hospital will: Establish a quantifiable performance improvement goal and objective which will be monitored by metric-based performance indicators.

The QAPI Plan for 2022-2023 did not identify and specify Incidents/Occurrence as one of the Quality Indicators to be reviewed.


2. Review of the QAPI meeting minutes from 3/31/2021 to 3/25/2022, showed no evidence that the hospital discussed, quantified, and analyzed grievances to identify trends and develop corrective actions if necessary.

Review of the hospital Complaint/Grievance log for 4/2021 to 3/2022, showed allegations regarding:
*Shortage of staff
*A Physician performed an improper procedure
* A patient sustained injury in the hospital, and failure of the hospital to inform the family.
*A patient alleged that her "HIPPA rights were violated.", by two physicians
*Lack of communication by the medical team.

On 1/29/22, a 28-week pregnant patient complained that after falling and being taken to the Labor and Delivery Unit, she waited approximately 45 minutes before she was evaluated by a physician. The failure of a timely Physician's assessment may have resulted in the death of her newborn son.

Review of the Complaint/Grievance log revealed this complaint was not documented and there was no evidence that opportunities for improvement were identified and prioritized, with appropriate corrective actions as described in the QAPI Plan.

The hospital's Quality Assurance & Performance Improvement Plan for 2022-2023, states that "Opportunities for improvement shall be identified and prioritized with appropriate corrective actions." Patient Complaint & Grievance is one of the criteria that was listed in the plan.

These findings were shared with Staff Aa, Director of Regulatory Affairs on 5/17/22 at approximately 11:00 AM.

An Immediate Jeopardy (IJ) situation was identified on 07/08/2022 at 5:21 PM, due to the facility's failure to quantify and analyze serious patient incidents/occurrences such as falls with injuries, elopements, and airway management (self-extubations) and implement corrective actions.

The facility provided an IJ Removal Plan to survey staff on 07/08/2022 at 9:40 PM that notes the following:
- Incidents are collected and categorized daily by risk management to identify reportable events, sentinel events, and quality indicators, including Falls with Injury, Elopement and Airway Management including self-extubations.
- Departmental leadership will track, trend and analyze relevant quality indicators and appropriate corrective actions will be developed and implemented.
- Indicators with appropriate analysis will be reported at the monthly QAPI Council meeting.
- On a quarterly basis, Executive Quality Council (EQC) tracks performance to ensure improvements are sustained, or intervenes when targets are not met.

The IJ was lifted on 7/18/2022 at 11:07 AM based on an acceptable Plan of Removal.

Based on document review and interview, the facility failed to ensure that in its clinical review of a pregnant woman with abdominal trauma and fetal demise, problems with timely evaluation of the patient were identified and corrected.

This failure may result in serious adverse outcome to patients.

Findings include:

Review of the medical record of Patient #1 revealed there were gaps in the fetal heart tracing. There was also a delay in recognizing decreased fetal heart rate which may have contributed to an adverse outcome.

At interview on 5/6/22 at 12:56 AM, Staff B, Attending Physician stated: "I saw the patient briefly after she was triaged, acknowledged her history of fall and abdominal pain with decreased fetal movement." Staff B reported there was no examination of the patient and an ultrasound was not done before she left the L&D unit to take care of an emergency in the Emergency Department.

During interview on 5/9/22 at 12:00 PM, Staff C, on-call Attending Physician stated: "There was a period of time on the external monitor where there were periods of in-continuity (of fetal heart tracing)..."

During telephone interview on 5/9/22 at 1:13 PM Staff D, RN Triage Nurse and covering Charge Nurse at the time stated: "Staff B, attending physician came and inquired why baby was off the tracing and stated it looks like she was decelerating. She was placed back on the monitor. Staff B did a sono and said it was ok. I placed the IV. Baby came off monitor again. Staff E, RN came to offer help. I contacted Staff B, attending who was in a huddle. She went to get the sono. The heart rate was in the 90s. She identified where to find the heart rate. I placed the monitor. The heart rate was in the 80s. I repositioned. Staff B stated to prepare the OR."

Review of facility's clinical review of this case documented:

- Standard of care: Assessment pending autopsy results.

- Corrective actions under consideration:
1) "ICU leadership will consider solutions to mitigate risk of falls without compromising patient care or safety."

2) "OB to review staffing structure and consider potential solutions to predictable variations (in medical staff coverage) that occur on Friday mornings."

3) "Evaluation and management of abdominal trauma in a pregnant woman appears to have met our current standard of care. However, if autopsy confirms this or another diagnosis, that standard will be re-evaluated by OB. Peer review will be requested to assess compliance with standard of care in this case."

There was no documentation of corrective actions for the inconsistent fetal heart tracing or of a delay in physician assessment of the patient and recognition of decreased fetal heart rate.

There was no evidence the facility implemented any of the proposed corrective actions.

During interview on 5/9/22 at approximately 12:30 PM, Staff Y, Attending and Chief of Services for OB/GYN stated: "We initiated a clinical review... We have not yet done a Root Cause Analysis. We were missing information from the Medical Examiner. We haven't received the autopsy report." Staff Y added that usually pregnant women are taken to the OR for stat c-section if the tracing is in the 100s to 110s. The fetal heart tracing revealed there were moments of drop offs where there were no tracing and we didn't really know what was going on.

Based on medical record review, document review and interview, the medical staff failed to ensure a timely assessment and intervention of a pregnant patient following a fall with complaints of abdominal pain and decreased fetal movement. This was identified in one (1) of seven (7) medical records reviewed.

This failure may have resulted in serious adverse outcome for the patient and places all patients in the Labor and Delivery Unit at risk for serious adverse outcomes.

Findings include:

Review of medical record for Patient #1 revealed a lack of timely evaluation and treatment of a 28 week pregnant patient who was post fall and presented to labor and delivery with complaints of abdominal pain and decreased fetal movement. The decreased fetal heart rate and inconsistent fetal heart tracing were not timely evaluated and treated.
See Tag 0360.

Based on medical record review and interview, in one (1) of seven (7) medical records reviewed, the physician failed to conduct a timely assessment and intervention for a patient at 28 weeks gestation status post fall with complaint of abdominal pain and decreased fetal movement.

Findings include:

Review of the medical record of Patient #1 revealed the patient arrived in the Labor and Delivery Triage on 1/21/22 at 6:46 AM.
At 7:05 AM, Triage note documented the patient stated she tripped, and she fell on the lower left side of her abdomen.
At 7:08 AM, Vital signs were Temperature 97.7 degrees Fahrenheit (oral), Heart Rate 90, BP 117/74, Respiration 18, No uterine contractions.
At 7:10 AM, Fetal Heart Rate (FHR) via external fetal monitor was documented at 155 beats per minute (BPM) with occasional moderate variability (a difference between 6 and 25 bpm in a fetus's heart rate for a given period of time).
At 7:15 AM, Fetal Heart Tracing (FHT) documented FHR at 100 (Bradycardia), (normal is 120 to 160 BPM)
At 7:53 AM, Staff D, RN documented: "FHR audible but difficult to obtain from 7:35 AM to 7:53 AM (18 minutes). Help requested from other RNs. MDs unavailable at this time. (Attending to emergency in ED) FHR finally noted at 7:53 AM."
At 8:38 AM, RN documented " Placed back on monitor after speculum exam and sono. "
At 8:48 AM, FHR was 100 (Bradycardia).
At 9:01 AM, nine (9) minutes later the FHR is documented at 135.
At 9:17 AM, FHR documented 90 BPM.
At 9:35 AM, Staff D RN, documented:" Audible deceleration noted. Repositioned. IV bolus open wide, and Staff B, Attending Physician, called to bedside for sonogram. Difficulty locating FHR with external monitor from 9:20 AM to 9:30 AM (10 minutes)"

An emergency c-section was performed at 9:47 AM. A baby boy was delivered at 9:50 AM. The baby was breech presentation, blue with cord around the neck times one (1) and cord around the body times one (1) and APGAR 0. Resuscitation attempts failed and the baby did not survive.

At 11:54 AM, Staff B, OB Attending documented the patient's history and physical: "I arrived at L&D and received a sign-out on this patient at 7 AM today. I saw the patient around 7:20 or 7:30 AM and took a history. At that time, patient reported +abdominal pain and decreased fetal movement but denied VB (Vaginal Bleed) or LOF (Loss of Fluid). Between ~7:40am-8:05 AM, I was in the ED responding to a delivery and then subsequently moved and managed that patient in a delivery room. After signing out to the CNMs, I went to see the patient again, who
was in the bathroom. I performed a speculum exam and did an ultrasound..."

There was no documentation that Patient #1 who presented to the Labor and Delivey at 6:46 AM with abdominal trauma was evaluated by Staff B until after the staff returned to the Labor and Delivery after 8:00 AM. The time of physician assessment was unknown; however, a nurse documented at 8:38 AM that patient had a speculum examination and a sonogram. There was no indication that at the time of Staff B's initial contact with the patient "around 7:20 or 7:30 AM," a review of the fetal heart tracing was not done; therefore, the 7:15 AM bradycardic event (FHR 100) was missed. The length of time the FHR remained abnormal was not assessed and no intervention was provided. The patient was on the unit for almost an hour from 6:46 AM before a stat OB in the ED was called at 7:41 AM.

At 8:48 AM, the FHR was documented at 100 BPM. There was no documentation of a provider assessment or treatment of the patient.

Review of the FHR tracing revealed there were several gaps and the rational for these gaps was not documented.

The intervention to treat the patient began at 9:17 AM, when the FHR dropped to 90 BPM. A delay of approximately two (2) hours from the initial fetal bradycardia noted at 7:15 AM.

The physician documented the patient's overall assessments at 11:54 AM which was after the stat c-section.

At interview on 5/6/22 at 12:56 PM, Staff B, Attending Physician acknowledged seeing the patient after she was triaged. She acknowledged that she did not do a speculum exam, ultrasound, or other assessment of the patient, prior to being called to the ED to do an emergency delivery. Staff B and the other OB Attending responded to the ED emergency. On her return to the unit, between 8:30 AM and 9:00 AM, she evaluated the patient, did an ultrasound and speculum exam. She indicated the baby was not moving but had a positive FHR. The patient reported to her that she had not felt fetal movement in about 45 minutes. Staff B commented "That was an unusual cycle for the baby not to have moved" She went to attend the 9:00 AM huddle and noticed the FHR was not tracing for about 10 minutes. That led to her further assessment and decision to take the patient to the OR for an emergency c-section."

During a telephone interview on 5/10/22 at 10:45 AM, Patient #1 said that she saw Staff B at 7:45 AM. She obtained a history but did not examine her. She left and said she would come back to do the ultrasound. Staff B came back about 30 minutes later. During that time the nurse had difficulty getting the FH.

The findings were shared with Staff B Attending Obstetrician during interview on 5/6/22 at approximately 1:15 PM.

An Immediate Jeopardy (IJ) situation was identified on 07/08/2022 at 5:21 PM, due to the facility's failure to provide timely assessment to a patient in the Labor and Delivery Unit.

The facility provided an IJ Removal Plan to survey staff on 07/08/2022 at 10:49 PM.
The plan included:
a) A revised Escalation Policy (effective 5/2021) directing physicians in the Labor and Delivery Unit to assess patients within five (5) minutes of notification of a clinically unstable patient by the nurse.
b) Creation of a MCH (Maternal Child Health) Escalation of Care/Use of Chain of Command Policy (effective 5/2022) detailing a specific course of action for administrative and clinical lines of authority.
c) A revised Fetal Monitoring Policy (effective 5/2022) detailing, indications, contraindications, precautions, assessment, and documentation of fetal heart.

d) Education for all staff on the C-16 Nursing Escalation Policy as well as all MCH staff on the Fetal Monitoring and MCH Policies. Staff not currently active will receive training prior to start of shift upon their return.

The IJ was lifted on 7/11/2022 at 4:28 PM based on the onsite validation of the IJ Removal Plan which included: (a) Staff interview verification of training on the updated and new policies, (b) medical record review, (c) Staff record of training participation.

Based on document review, medical record (MR) review and interview, in one (1) of seven (7) medical records reviewed, nursing staff failed to exercise responsibility for the escalation of difficulties in obtaining a consistent fetal heart rate for a mother who was post trauma with complaints of abdominal pain and decreased fetal movement.

This failure may have contributed to an adverse outcome for one (1) patient and placed all patients in the Labor and Delivery Unit at increased risk of adverse outcomes.

Findings include:

Patient #1 who was 28 weeks pregnant presented to Labor and Delivery (L&D) on 1/21/22 at 6:46 AM after a fall incident with complaints of abdominal pain and decreased fetal movement. Nurses' difficulties in obtaining a consistent fetal heart rate and periods of bradycardia on the 28-week fetus were not escalated to the Nursing Supervisor or Attending Physician. As a result, there was no timely assessment and intervention for the patient.

See Tag 0392

Based on medical record review, document review and interview, in one (1) of seven (7) medical records reviewed, nursing staff failed to escalate difficulties in obtaining and assessing Fetal Heart Rate (FHR) in Patient #1.

This failure may have delayed a prompt physician assessment and treatment of the patient.

Findings include:

Review of the medical record of Patient #1 revealed the patient arrived on the Labor and Delivery Unit at 6:46 AM. The patient provided a history of post fall with abdominal pain and decreased fetal movement.

At 7:10 AM, external Fetal Heart Monitor (FHM) documented Fetal Heart Rate (FHR) of 155 with occasional moderate variability.
At 7:15 AM, the FHR was documented at 100 beats per minute, bradycardia (normal is 120-160).
At 7:53 AM, Staff D, RN and Charge Nurse documented: "FHR audible but difficult to obtain from 7:35 AM to 7:53 AM. Help requested from other RNs. MDs unavailable at this time. (Attending to emergency in ED) FHR finally noted at 7:53 AM.
9:35 AM, Staff D, RN, and Charge Nurse documented: ..."Difficulty locating FHR with external monitor from 9:20 AM to 9:30 AM."

The patient was taken to the OR emergently for an emergency c-section. A baby boy was delivered at 9:50 AM. The baby was breech presentation, blue with cord around the neck times one (1) and cord around the body times one (1) and APGAR 0. Resuscitation attempts failed and the baby did not survive.

Review of FHR tracing revealed there were several gaps in which the FHR was not captured. The rational for these gaps was not documented.

Review of facility's policy titled "Clinical Escalation: Guidelines for Activating Chain of Command (Effective 05/2021)" states: Definition 3, Page 2. In instances where there are concerns for patient related to physician orders or medical management of the patient, the nurse should initiate the chain of command process for obtaining medical intervention in care.
4. The staff nurse will proceed to take the concerns to the following people in the following order until such concerns have been alleviated:
Order of Escalation - Medical Issues
a. Resident
b. Attending Physician or designated call coverage physician
c. Clinic Service Chief
d. Chief Medical Officer (CMO) and Risk Manager (as directed by CMO) and Administrator on-call (as directed by CMO)

Order of Escalation - Nursing Issues
a. Staff member
b. Head Nurse/Charge Nurse
c. ADM/ADPM/DON
d. Chief Nursing Officer/Nursing Administrator on-call Designee

There was no documented evidence of an intervention or escalation to a physician, midwife, or nursing supervisor.

At interview on 5/9/22 at 1:13 PM, Staff D, RN and Charge Nurse stated that between 7:00 AM and 8:00 AM, when she noticed that the fetal heart was not picking up on the tracing, she went to the resident's room to look for a physician, but there was no one there.
During interview with Staff B, Attending Physician on 5/6/22 at 12:56 AM, she stated: "No one told me about the tracing."

At interview on 5/9/22 at approximately 10:10 AM, Staff Head Nurse (HN) stated: "Definitely, I was not reached out to. I was off the floor."

This finding was shared with facility staff during tour of the Labor and Delivery Unit on 5/9/22 at approximately 10:30 AM..

Based on observation, document review, and interview, the facility failed to maintain equipment wiring and tubing to prevent clutter and ensure a safe environment for patients and staff. This finding was noted in three (3) of four (4) units inspected.

This failure may result in harm to patients and staff.

Findings include:

On 05/05/22, at 12:40 PM, during the tour of the Medical Intensive Care Unit (MICU), in the presence of Staff A, MICU Director, Staff G, Charge Nurse and Staff H, RN, a suction tubing was observed on the floor by the bedside of Patient #3 (MICU 7).

Staff H confirmed that it was an old suction tubing that was not connected to suction.

On 05/05/22 at 12:50 PM, in MICU 10, compression boots cables were observed taped to the floor with a surgical tape. The surveyor observed a provider who was by the bedside of Patient #6 tripped over those cables on the floor but did not fall.

On 05/05/22 at 1:07 PM, in Critical Care Unit (CCU 3), a nebulizer mask and tubing were observed on the floor by the bedside of patient #7.

These findings were witnessed by Staff A (MICU Director of Nursing) and Staff G (Charge Nurse).

Review of "Safety Management Program Guidelines" (Revised 05/2022) revealed that the program is designed " ....to provide a physical environment free of hazards, manage staff activities to reduce the risk of injury or incident, educate staff on the Safety Management Program and related policies and procedures, and work in conjunction with the patient safety Committee."

Review of "Safety and Environmental Rounds" policy (Revised 05/2022) revealed that the purpose of the policy is "provide a safe environment for patients, staff, and visitors." According to the policy, "The Safety Department is responsible for scheduling safety and environmental rounds and notifying departments involved."
Review of "Annual Mandated Training" manual for the staff revealed that tripping hazards "such as cables and cords, loose rugs, boxes, etc." shall be removed.

On 05/09/2022, at 12:27 PM, during an interview with Staff W (Safety Management Director), he stated, "We conduct our environmental rounds on a regular basis. The process had been going on for years. The goal is to identify issues such as hazards in the environment especially on the units such as the ICU where there are lots of cables and tubing. Staff W stated that "the staff is responsible for managing the environment and not creating safety hazards." Staff W stated that cables cannot be taped to the floor but there is no standard operating procedure for managing cables.

These findings were discussed with Staff A (MICU Director of Nursing) and Staff W (Safety Management Director).

Based on medical record review, document review, and interview, in two (2) of five (5) medical records, the facility failed to implement its discharge planning policy to ensure that patient's representative was informed of their discharge plan and disposition (Patient # 2).

Findings include:

Review of the facility's policy titled "Transfers Out of NYC Health + Hospitals Bellevue" last updated: July 20, 2020, noted that the Provider will inform the family of the transfer and ensure they are aware of the location of the receiving facility.

Patient #2 is a 35 year-old who was post cardiac arrest with diagnoses of anoxic brain injury, ventilator dependent and requires total care. On 01/18/2022 at 15:05 PM, the patient was discharged to a Skilled Nursing Facility.

There was no documented evidence that the patient's family was notified of the discharge and transfer to a Skilled Nursing Facility for rehabilitation.

Based on the patient's family's written complaint dated 1/28/22, no family member was aware that the patient was transferred to another facility.

On 05/17/2022, at 2:00 PM, during interview with Staff Ii (Supervisor of Social Work), she stated that there was a meeting held with the patient's family members in which the patient's primary doctor discussed possible future disposition of the patient. She said, "The family knew what the expectations were." Staff Ii added that the expectations were that the Social Worker would inform the family of the transfer. She disclosed that the Social Worker on the case was no longer an employee of the facility and cannot be reached for interview.