HospitalInspections.org

Based on document review, policy review, and interview, the facility failed to ensure all patients are free from all forms of abuse, neglect, and harassment. Specifically:
1. Staff (Z), RN made derogatory comments to Patient #1 regarding Patient #2.
2. One of eleven staff members does not have annual training related to abuse, neglect, and related requirements per facility policy.

Findings Include:

1.Review of the Confidential Facility Quality Investigation revealed on 02/20/23 at 02:51 PM, a grievance was submitted by Patient #1. Patient #1 reported that on 02/12/23, the nurse stated, "I hope this is the only ankle monitor you wear in life," when removing the security tag from Patient #2.

Review of the email report by Staff (CC), RN, Assistant Nurse Manager Women's Care Unit, dated 03/23/23 at 01:02 PM (associated with the quality investigation) revealed a conversation with Patient #1. Patient #1 stated that when Staff (Z), RN took off the security tag (from Patient #2), Staff (Z) said "I hope this is the only ankle bracelet you will see in your lifetime." Patient #1 reported being appalled and felt the statement was made because the parents were African American.

Review of the policy "Patient Rights and Responsibilities Procedure," last revised 10/2021 indicates that the New York State (NYS) Handbook "Your Hospital Rights as a Patient in NYS," which includes the document "Patients' Bill of Rights in a Hospital," will be distributed to all inpatients. The "Patient Bill of Rights" document indicates that as a patient in a NYS hospital, you have the right, consistent with law to:
-Receive treatment without discrimination as to race, color, religion, sex, gender identity, national origin, disability, sexual orientation, age, or source of payment.
-Receive considerate and respectful care in a clean and safe environment free of unnecessary restraints.

Review of policy "Human Resource Guide Standard Operating Procedures & Policies," dated 11/17/22 revealed that harassment, sexual harassment, discrimination, and disruptive behavior will not be tolerated. Any employee or individual who engages in harassing, sexually harassing or disruptive behavior, discrimination or retaliation will be subject to remedial and/or disciplinary action, up to and including termination. Steps in the performance management process may be progressive and become more severe if performance does not improve. The steps include verbal counseling, a written warning, and a Performance Improvement Plan/final warning. In verbal counseling, the documentation should remain with the leader, unless the performance concern continues, at which time the leader will determine if the concern needs to be formalized in a written warning or Performance Improvement Plan.

Interview on 07/06/23 at 03:06 PM with Staff (E), RN- Nursing Director of Women's Care Services, revealed speaking to Patient #1. When removing the band off Patient #2's ankle, Staff (Z) RN said, "I hope this is the only bracelet you have to wear." Staff (Z), RN admitted to making the comment. The Interim Officer for Diversity Equity and Inclusion recommendation was to educate Staff (Z), RN who made the comment and re-educate/council staff.

Interview on 07/07/23 at 09:52 AM, Staff (Z), RN, stated they were preparing Patient #2 for discharge and removing the security alarm off Patient #2's ankle. Staff (Z) stated "hopefully this is the last ankle bracelet Patient #2 has to wear." Staff (Z) made a statement and gave it to Human Resources.

Interview on 07/07/23 at 02:18 PM with Staff (C), RN- Senior Director Office of Clinical Regulatory Compliance, verified the findings.

2. Review on 07/07/23 of the personnel file for Staff (K), Certified Nurse Midwife, revealed a hire date of 05/04/20. The last annual mandatory education/training for Patient Rights, Abuse, Neglect, Domestic Violence, and Physical Restraints was done on 11/26/21 and the HIPAA Privacy training was done on 09/29/21.

Review of policy " Patient Abuse Policy," last revised 7/2023 included that the NYS law requires hospitals to ensure hospital staff are aware of reporting obligations. Periodic in-service and continuing education programs confirm reporting obligations of all licensed personnel.

Interview on 07/07/23 at 11:34 AM with Staff (EE), Human Resources Compliance Manager verified the personnel file findings for Staff (K), Certified Nurse Midwife, indicating these trainings are required to be completed annually for all staff. At 02:18 PM, Staff (C), RN- Senior Director Office of Clinical Regulatory Compliance, also verified these findings.