HospitalInspections.org

Based on policy review, medical record review, document review, video surveillance review, and staff interviews, it was determined that for 9 of 25 medical records reviewed the facility failed to protect and promote the rights of all patients as evidence by: the hospital failed to provide constant observation or special constant observation for two of two patients (Patient #1 and #2) at moderate or high risk for suicide in the emergency department (Tag A-0144). Additionally, a physician order was not obtained for constant observation for moderate/high-risk suicidal patients for 9 of 25 patients (Patient #1, #2, #3, #5, #6, #7, #8, #9, and #12) (Tag A-0144).

Reference:
482.13(c)(2) Patient Rights: Care in a Safe Setting.
482.13(c)(3) Patient Rights: Free from all Forms of Abuse or Harassment.

Based on policy review, medical record review, video surveillance review, and staff interviews, the facility failed to provide care in a safe setting.
1. The hospital failed to provide constant observation for two of two emergency department patients (Patient #1 and #2). This resulted in the inappropriate touching of Patient #1 by Patient #2.
2. The hospital failed to ensure physician orders were obtained and interventions implemented for constant observation and special constant observation in the emergency department for 9 of 12 patients (Patient #1, #2, #3, #5, #6, #7, #8, #9, and #12). This resulted in the inappropriate touching of Patient #1 by Patient #2.

Findings #1:

Review on 06/18/24 of the policy "Psychiatric Evaluation of Patients in the Emergency Department," last reviewed 03/22/24, revealed a person in need of a mental health evaluation may come to the emergency department and a psychiatric evaluation will be initiated. The patient is to remain under constant observation (staff continuously observing and keeping a patient in sight with hands visible at all times) until an appropriate level of lethality (capacity to cause death or serious harm) and needed level of observation is assessed.

Review on 06/17/24 of the policy "Assessing Patient Risk For Suicide," dated 11/29/23, revealed "constant observation staff continuously observes, keeping the patient in sight at all times. The patient's hands must be visible at all times. Constant observation must be completed in the bathroom and for any medical testing. Patients on constant observation may have issues that jeopardize their safety or the safety of others. If a patient's screen or assessment is positive for suicide after completion of a Columbia Suicide Severity Rating Scale (an assessment tool that helps to determine an individual's suicide risk) or if a provider orders a psychiatric care attendant, suicide precautions and interventions will be determined by the identified suicide risk level (high, moderate, or low). Monitoring should be constant, and a staff member should be assigned to observe only one patient at all times (one staff member to one patient), that would allow the staff member, or other staff member, to immediately intervene should the patient attempt self-harm."

Review on 06/18/24 of the policy "Care Attendant Utilization and Observation of Patients," dated 02/01/24, revealed "a psychiatric care attendant provides constant observation or special constant observation to assigned suicidal or behavioral health patients under the direction of the registered nurse, physician, or provider with prescriptive authority. The request for a psychiatric care attendant for suicidal or behavioral health patients requires the order from a physician. Nurses may initiate constant observation or special constant observation of a patient for the safety of a patient until an order is secured. Discontinuation of a psychiatric care attendant can only be completed with a physician's order. The psychiatric care attendant will have limited direct care responsibilities so that the patient remains in direct eyesight or as ordered, within arm's reach at all times. As a result, the psychiatric care attendant may not complete other care or activities of daily living for the patient that would require the psychiatric care attendant to leave the room or turn their back on the patient. Staff functioning in the psychiatric care attendant role will be informed of the reason that the patient requires a psychiatric care attendant by the assigned nurse. The use of radios, headphones, and/or any other electrical device by the care attendant for personal use is prohibited. Psychiatric care attendants may be used in non-behavioral health departments. Constant observation staff continuously observes and may interact individually with the patient while keeping the patient in sight at all times. The patient ' s hands must be visible at all times to the observation staff. Constant observation must also be completed in the bathroom and when the patient leaves for any medical testing. Special constant observation staff continuously observes the patient within arm's distance. Additionally, the patient's hands must be visible at all times to the staff. Special constant observation must also be completed in the bathroom and when the patient leaves for any medical testing. This level of observation is used when it is necessary to have the staff close to the patient to prevent the patient from injuring themselves. Constant observation or special constant observation is to be maintained without disruption, so the patient is in direct eyesight at all times. For patients identified at high or moderate risk for suicide, with constant observation, utilize a ligature resistant (modified to reduce the number of points that may be used for hanging/strangulation) bathroom, if not available, observe the patient while the patient is in the bathroom. For patients identified at high or moderate risk for suicide, with special constant observation, observe the patient while in the bathroom."

Review on 06/18/24 of the medical record for Patient #1 revealed the following:
On 06/09/24 at 02:17 PM, Staff (FF), Registered Nurse documented a triage note indicating Patient #1 (minor under the age of 18) presented via ambulance to the emergency department under the authority of Section 9.41 of the Mental Hygiene Law of New York State (mental hygiene law that permits police officers or peace officers to take into custody any individual who is demonstrating behavior which is likely to result in harm to self or others and have the individual transported to a hospital or comprehensive psychiatric emergency program for psychiatric evaluation and treatment.) for attempts to throw themselves out of a second story window. When Patient #1's guardian stopped them, Patient #1 attempted to throw themselves into moving traffic. Patient #1 was screened as high risk for suicide on the Columbia Suicide Severity Rating Scale (a unique suicide risk assessment tool that supports suicide risk assessment through a series of simple, plain-language questions that anyone can ask).
On 06/09/24 at 02:50 PM, Staff (TT), Physician placed an order for Patient #1 to be admitted to the inpatient behavioral health unit for the diagnosis of impulse control disorder (a group of behavioral conditions that make it difficult to control one's actions or reactions).
From 06/09/24 at 03:00 PM through 06/10/24 at 09:00 PM, Staff (K), Patient Care Technician documented constant observation checks every hour.

Review on 06/18/24 of the medical record for Patient #2 revealed the following:
On 06/10/24 at 01:00 AM through 10:00 AM, the "Constant Observation Flowsheet" revealed hourly constant observation documentation completed by Staff (K) Patient Care Technician.
On 06/10/24 at 01:25 AM, Staff (QQ) Registered Nurse documented a triage note indicating Patient #2 presented with the police department to the emergency department under the authority of section 9.41 of the Mental Hygiene Law of New York State for hearing voices and having thoughts of hurting themselves and others. Patient #2 would not elaborate on their thoughts.
On 06/10/24 at 01:31 AM, Patient #2 screened moderate risk for suicide on the Columbia Suicide Severity Rating Scale.
On 06/10/24 at 09:37 AM, a nurse practitioner placed an order for Patient #2 to be admitted to the inpatient behavioral health unit for the diagnosis of schizophrenia.

Review on 06/18/24 of security surveillance video of the behavioral health hallway located within the emergency department, dated 06/10/24 revealed:
At 05:40:06 AM, Staff (K), Patient Care Technician was sitting at a stationed desk, eating, and looking at a cell phone that was positioned on the desktop, while Patient #1 appeared to be asleep on a stretcher in the hallway across from the desk.
At 05:41:00 AM, Patient #2 entered the hallway from a patient room adjacent to Patient #1. Patient #2 approached the desk where Staff (K) sat and appeared to speak to Staff (K) who looked up at Patient #2 briefly and then back down at the cell phone multiple times.
At 05:42:05 AM, Patient #2 is seen standing close to the head of the stretcher where Patient #1 appeared to be asleep, looking at Patient #1. Staff (K) was seated at the desk looking down at the cell phone positioned on the desktop when Patient #2 approached Patient #1 on the gurney.
At 05:42:08 AM, Patient #2 rested a hand upon Patient #1's shoulder. Patient #2 removed the hand from Patient #1 and turned back to approach Staff (K) who was sitting at the desk with their head down looking at their phone, spoke to Staff (K) and was seen walking away from the desk, leaving the video frame.
At 05:42:28 AM, Patient #2 re-entered the video frame, approached the desk and appeared to be speaking to Staff (K).
At 05:42:37 AM, Patient #2 turned from the desk and approached the gurney where Patient #1 appeared to be asleep.
At 05:42:37 AM, Staff (K) was seen visualizing Patient #2 touch the leg of Patient #1 and appeared to be speaking to Patient #2 who turned away from the gurney and approached Staff (K) at the desk.
At 05:42:39 AM Patient #2 placed their right hand upon Patient #1's leg near the knee and slid their hand from the knee to the buttocks before removing the hand to turn towards Staff (K) at the desk.
At 05:42:49 AM, Staff (K) stood up from the chair while speaking to Patient #2.
At 05:42:55 AM, Staff (K) picked up the desk telephone to make a call.
At 05:43:08 AM, Staff (P), Security Officer was seen entering the video frame from a door positioned next to the desk.
At 05:43:10 AM, Patient #2 approached the stretcher and tried to touch Patient #1 on the leg. Staff (P) intervened by blocking Patient #2's right hand before contacting Patient #1.
At 05:43:12 AM, Patient #2 reached over Patient #1 with their left-hand touching Patient #1's left buttocks before Staff (P) pulled Patient #2 back and stood between the gurney and Patient #2.
At 05:43:13 AM, Staff (O), Physician Assistant entered the video frame from behind the nursing station, appeared to speak to Staff (K) and Staff (P) before walking around the nursing station desk.
At 05:43:25 AM, Patient #2 was escorted to a room across the hallway from the nursing station desk by Staff (P) and Staff (O) and the door was closed.

Interview on 06/17/24 at 02:00 PM with Staff (A), Clinical Director Nursing/Quality revealed a high-risk suicide patient would have a 1:1 constant observation sitter. A low or moderate risk suicide patient would require line of sight monitoring so they could potentially be a 2 to 1 (two patients to one staff ratio) if line of sight is maintained. If a patient is in the hallway and another is in their room, a 2 to 1 observation would not be possible as they would not be able to maintain line of sight monitoring.

Interview on 06/18/24 at 03:00 PM with Staff (D), Emergency Department Director revealed Patient #1 and Patient #2 should not have been monitored on constant observation with the same patient care technician.

Findings #2:

Review on 06/18/24 of the medical record for Patient #1 revealed the following:
On 06/09/24 at 02:17 PM, Staff (FF), Registered Nurse documented a triage note indicating Patient #1 presented to the emergency department via ambulance for a 9.41 mental health evaluation (mental hygiene law that permits police officers or peace officers to take into custody any individual who is demonstrating behavior which is likely to result in harm to self or others and have the individual transported to a hospital or comprehensive psychiatric emergency program for psychiatric evaluation and treatment) after an attempting to jump out of a second story window, and then attempted to run into moving traffic. Patient #1 was screened as high risk for suicide on the Columbia Suicide Severity Rating Scale (an assessment tool that helps to determine an individual's suicide risk).
On 06/09/24 at 02:50 PM, Staff (TT), Physician placed an order for Patient #1 to be admitted to the inpatient behavioral health unit for the diagnosis of impulse control disorder (a group of behavioral conditions that make it difficult to control one's actions or reactions).
From 06/09/24 at 03:00 PM through 06/10/24 at 09:00 PM, Staff (K) Patient Care Technician documented hourly on the "Constant Observation (staff continuously observe and keep a patient in sight with their hands visible at all times) Flowsheet."
On 06/11/24 at 12:37 AM, Staff (PP), Physician ordered Patient #1 to be discharged.
On 06/11/24 at 02:11 AM, Patient #1 was discharged home in stable condition with a legal guardian.

There was no evidence found in the medical record that constant observation or special constant observation was ordered by a physician for Patient #1.

Review on 06/18/24 of the medical record for Patient #2 revealed the following:
- On 06/10/24 at 01:00 AM through 10:00 AM, Staff (K) Patient Care Technician documented hourly on the "Constant Observation (staff continuously observe and keep a patient in sight with their hands visible at all times) Flowsheet."
- On 06/10/24 at 01:25 AM, Staff (QQ), Registered Nurse documented a triage note revealed Patient #2 presented with the local police department to the emergency department under the authority of Section 9.41 of the Mental Hygiene Law of New York State for hearing voices stating to hurt others. Patient #2 would not elaborate on the specific thoughts or what the voices said.
- On 06/10/24 at 01:31 AM, Patient #2 screened as a moderate risk for suicide on the Columbia Suicide Severity Risk Scale.
- On 06/10/24 at 02:21 AM, Staff (O), Physician Assistant performed a medical screening exam revealed Patient #2 was signed out to the oncoming provider for disposition after their mental health counselor examination.
- On 06/10/24 at 09:37 AM, Staff (SS), Nurse Practitioner ordered admission to inpatient behavioral health for the diagnosis of schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions).

There was no evidence found in the medical record that constant observation or special constant observation was ordered by a physician for Patient #2.

Review on 06/18/24 of the medical record for Patient #3 revealed the following:
- On 04/15/24 at 06:01 PM, Staff (L), Registered Nurse documented a triage note that indicated Patient #3 presented ambulatory to the emergency department for feeling suicidal and being afraid of going into alcohol withdrawal (symptoms that may occur when a person who has been drinking too much alcohol on a regular basis suddenly stops drinking alcohol). Patient #3 was screened as high risk for suicide on the Columbia Suicide Severity Rating Scale. Staff (L) documented constant observation began and Patient #3 was brought into the behavioral health preferred hallway and changed into a safety gown with supervision.
- On 04/15/24 at 06:29 PM, Staff (O), Physician Assistant performed a medical screening exam indicated that after a mental health evaluation, Patient #3 would benefit from a mental health admission.
- From 04/15/24 at 07:00 PM through 04/16/24 at 12:00 PM, the "Constant Observation Flowsheet" revealed Patient #3 had hourly observation documentation.
- On 04/15/24 at 10:52 PM, Staff (O), Physician Assistant placed an order for Patient #3 to be admitted to the inpatient behavioral health unit for the diagnosis of major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).

There was no evidence found in the medical record that constant observation or special constant observation was ordered by a physician for Patient #3.

Review on 06/18/24 of the medical record for Patient #5 revealed the following:
- On 04/28/24 at 12:08 AM, Staff (W), Registered Nurse documented a triage note that indicated Patient #5 presented ambulatory to the emergency department for suicidal ideation with a plan to slice their wrists. Patient #5 stated they were drunk and got into a fight, fell, and reported pain of six out of ten (numeric pain scale with 0 equals no pain and 10 equals severe pain), in the right rib cage. Patient #5 was screened as high risk for suicide on the Columbia Suicide Severity Rating Scale.
- On 04/28/24 12:20 AM, Staff (FF), Registered Nurse documented constant observation was started while Patient #5 was in triage.
- On 04/28/24 at 12:24 AM, Staff (GG), Physician Assistant performed a medical screening exam revealed there was no emergency department crisis counselor available for a mental health evaluation on the overnight shift, so Patient #5 boarded in the emergency department until a mental health evaluation could be completed the next day.
- On 04/28/24 at 07:23 AM, Staff (HH), Mental Health Counselor documented Patient #5 denied suicidal and homicidal ideations, auditory and visual hallucinations, delusions, and paranoia. Patient #5 stated they want to be discharged from the hospital. Psychiatry was consulted via phone and recommendations were provided for discharge.
- On 04/28/24 at 08:21 AM, Patient #5 was discharged home in stable condition.

There was no evidence found in the medical record that constant observation or special constant observation was ordered by a physician for Patient #5.

Review on 06/18/24 of the medical record for Patient #6 revealed the following:
- On 04/16/24 at 12:09 PM, Staff (II), Registered Nurse documented a triage note that indicated Patient #6 presented to the emergency department for a 9.41 mental health evaluation (mental hygiene law that permits police officers or peace officers to take into custody any individual who is demonstrating behavior which is likely to result in harm to self or others and have the individual transported to a hospital or comprehensive psychiatric emergency program for psychiatric evaluation and treatment) for suicidal ideations with a plan of cutting themselves (self-injury).
- On 04/16/24 at 12:00 PM to 08:00 PM, the "Constant Observation Flowsheet" revealed Patient #6 had hourly observation documentation.
- On 04/16/24 at 12:10 PM, Staff (II), Registered Nurse documented that a patient care technician was in the bathroom with Patient #6 while Patient #6 changed. The patient care technician provided constant observation.
- On 04/16/24 at 12:11 PM, Patient #6 was screened as high risk for suicide on the Columbia Suicide Severity Rating Scale.
- On 04/16/24 at 04:45 PM, Staff (JJ), Physician performed a medical screening examination that indicated Patient #6 continued to verbalize a desire to commit suicide by cutting. A mental health evaluation was pending.
- On 04/16/24 at 08:20 PM, Staff (O), Physician Assistant wrote an addendum to the medical screening exam revealed the Staff (KK), Mental Health Counselor spoke with Patient #6 and did not find any risk of lethality. The mental health counselor discussed the case with the on-call psychiatrist who stated that Patient #6 was okay to be discharged home.
- On 04/16/24 at 08:30 PM, Patient #6 was discharged home.

There was no evidence found in the medical record that constant observation or special constant observation was ordered by a physician for Patient #6.

Review on 06/18/24 of the medical record for Patient #7 revealed the following:
- On 04/19/24 at 11:55 PM, Staff (FF) Registered Nurse documented a triage note that indicated Patient #7 presented with police to the emergency department for a 9.41 mental health evaluation (mental hygiene law that permits police officers or peace officers to take into custody any individual who is demonstrating behavior which is likely to result in harm to self or others and have the individual transported to a hospital or comprehensive psychiatric emergency program for psychiatric evaluation and treatment) after being found standing on the side of a building threatening to jump. Patient #7 was verbally agitated and had been drinking alcohol. Patient #7 was assigned an acuity level two (urgent). Patient #7 was screened as high risk for suicide on the Columbia Suicide Severity Rating Scale (an assessment tool that helps to determine an individual's suicide risk).
- On 04/19/24 at 11:56 PM, Staff (FF), Registered Nurse documented Patient #7 was deemed high risk for suicide and constant observation was started in triage.
- From 04/20/24 at 12:00 AM through 04/22/24 at 08:00 AM, hourly observations were documented on the "Constant Observation Flowsheet."
- On 04/20/24 at 12:00 AM, Staff (MM), Physician Assistant performed a medical screening exam that indicated Patient #7 denied any suicidal or homicidal ideation, but when asked why Patient #7 was on the edge of a six-story building, Patient #7 stated "you know why I was up there". Patient #7 was awaiting a mental health evaluation and to be more awake for a thorough evaluation.
- On 04/21/24 at 11:08 AM, Patient #7 was admitted to inpatient behavioral health status.

There was no evidence found in the medical record that constant observation or special constant observation was ordered by a physician for Patient #7.

Review on 06/18/24 of the medical record for Patient #8 revealed the following:
- On 05/01/24 at 01:42 PM, Staff (NN), Registered Nurse documented a triage note that indicated Patient #8 presented ambulatory to the emergency department for suicidal ideation with a plan. Patient #8 had a history of suicide attempts. When asking about the suicide plan, Patient #8 stated "I don't know".
- From 05/01/24 at 01:00 PM through 05/03/24 at 08:00 AM, the "Constant Observation Flowsheet" revealed Patient #8 had hourly observation documentation.
- On 05/01/24 at 01:54 PM, Patient #8 was screened as high risk for suicide on the Columbia Suicide Severity Rating Scale.
- On 05/01/24 at 02:00 PM, the "Constant Observation Flowsheet" revealed Patient #8 was changing into safety clothes.
- On 05/01/24 at 04:00 PM, Staff (GG), Physician Assistant completed a medical screening exam that indicated Patient #8 was evaluated by the crisis counselor who recommended admission to inpatient behavioral health. Patient #8 agreed to the plan and was admitted.
- On 05/01/24 at 06:43 PM, Patient #8 was admitted to inpatient behavioral health status.

There was no evidence found in the medical record that constant observation or special constant observation was ordered by a physician for Patient #8.

Review on 06/18/24 of the medical record for Patient #9 revealed the following:

- On 05/23/24 at 12:04 PM, Staff (OO), Registered Nurse documented a triage note that indicated Patient #9 presented by ambulance to the emergency department after telling their friend they were planning to overdose with pills.
- On 05/23/24 at 12:14 PM, Patient #9 was screened as high risk for suicide on the Columbia Suicide Severity Rating Scale.
- On 05/23/24 at 12:24 PM, Staff (JJ), Physician Assistant performed a medical screening exam that indicated Patient #9 was evaluated by Staff (HH), Mental Health Counselor who reviewed with Staff (PP), On-Call Psychiatrist. Patient #9 was deemed appropriate for involuntary inpatient behavioral health admission.
- On 05/23/24 at 12:00 PM through 06:00 PM, the "Constant Observation Flowsheet" revealed Patient #9 had hourly observation documented.
- On 05/23/24 at 07:14 PM, Patient #9 was transferred to another mental health facility.
There was no evidence found in the medical record that constant observation or special constant observation was ordered by a physician for Patient #9.

Review on 06/18/24 of the medical record for Patient #12 revealed the following:
- On 06/13/24 at 11:00 AM through 03:00 PM, the "Constant Observation Flowsheet" revealed Patient #12 had hourly observation documented.
- On 06/13/24 at 11:28 AM, Staff (E), Registered Nurse documented a triage note that indicated Patient #12 presented ambulatory to the emergency department under the authority of Section 9.41 of the Mental Hygiene Law of New York State for verbalized suicidal ideations at their counselor's office. Patient #12 would not fill out a safety plan and had a recent suicide attempt by jumping in front of a car.
- On 06/13/24 at 11:45 AM, Staff (RR), Physician Assistant performed a medical screening examination that indicated Patient #12 was discussed with Staff (PP), On-Call Psychiatrist and would be admitted for increased depression and suicidal ideations.
- On 06/13/24 at 12:18 PM, Patient #12 was screened as high risk for suicide on the Columbia Suicide Severity Rating Scale.
- On 06/13/24 at 12:07 PM, Patient #12 was admitted to inpatient behavioral health status.
There was no evidence found in the medical record that constant observation or special constant observation was ordered by a physician for Patient #12.

Interview on 06/17/24 at 02:00 PM with Staff (A), Clinical Director Nursing/Quality confirmed these findings.

Based on medical record review, policy review, video surveillance, and staff interviews, the hospital failed to provide care in a setting free from abuse or harassment for one of one (Patient #1) record review. The hospital failed to prevent abuse (inappropriate touching) of Patient #1 (minor-under the age of 18) by Patient #2 (an adult) that occurred on 06/10/24. Additionally, the hospital failed to complete a thorough investigation into the incident to prevent reoccurrence and report the incident to required state agencies.

Findings:

Review on 06/18/24 of the policy "Incident Management", last updated 03/08/24, revealed: "The adolescent and adult mental health units are required to comply with 14 NYCRR Part 524 Incident Reporting Requirements. Incident management includes identifying, documenting, reporting, and investigating individual incidents in a timely basis. Any incidents or allegations of abuse or neglect will be reported and investigated with appropriate corrective action occurring. All allegations of abuse and neglect and significant incidents will be reported to the Vulnerable Persons Central Register, the Office of Mental Health and other required authorities identified by state and federal laws. All incidents reviewable and reportable are reported to the director or administrator on duty in the absence of a director who determines if the incident is reportable to the Office of Mental Health, Justice Center, Department of Health, Joint Commission, or other regulatory organizations. Incidents classified by the Justice Center, or the Office of Mental Health as reportable incidents will be reported to those offices. If a staff has reasonable cause to suspect the patient is the victim of abuse or neglect the staff person will notify the charge nurse who will notify the director. Each mandated reporter who witnesses or hears the original suspicion of abuse or neglect makes a report with the Vulnerable Persons Central Register." (Patient #1 was admitted to the behavior health unit but held in the emergency department to await an open bed).

Review on 06/18/24 of security surveillance video of the behavioral health hallway located within the emergency department, dated 06/10/24 revealed:
At 05:40:06 AM, Staff (K), Patient Care Technician was sitting at a nursing station desk, eating, and looking at a cell phone that was positioned on the desktop, while Patient #1 appeared to be asleep on a stretcher in the hallway across from the desk.
At 05:41:00 AM, Patient #2 entered the hallway from a patient room adjacent to Patient #1. Patient #2 approached the desk where Staff (K) sat and appeared to speak to Staff (K) who looked up at Patient #2 briefly and then back down at the cell phone multiple times.
At 05:42:05 AM, Patient #2 is seen standing close to the head of the stretcher where Patient #1 appeared to be asleep, looking at Patient #1. Staff (K) was seated at the desk looking down at the cell phone positioned on the desktop when Patient #2 approached Patient #1 on the gurney.
At 05:42:08 AM, Patient #2 rested a hand upon Patient #1's shoulder. Patient #2 removed the hand from Patient #1 and turned back to approach Staff (K) who was sitting at the desk with their head down looking at their phone, spoke to Staff (K) and was seen walking away from the desk, leaving the video frame.
At 05:42:28 AM, Patient #2 re-entered the video frame, approached the desk and appeared to be speaking to Staff (K).
At 05:42:37 AM, Patient #2 turned from the desk and approached the gurney where Patient #1 appeared to be asleep.
At 05:42:37 AM, Staff (K) was seen visualizing Patient #2 touch the leg of Patient #1 and appeared to be speaking to Patient #2 who turned away from the gurney and approached Staff (K) at the desk.
At 05:42:39 AM Patient #2 placed their right hand upon Patient #1's leg near the knee and slid their hand from the knee to the buttocks before removing the hand to turn towards Staff (K) at the desk.
At 05:42:49 AM, Staff (K) stood up from the chair while speaking to Patient #2.
At 05:42:55 AM, Staff (K) picked up the desk telephone to make a call.
At 05:43:08 AM, Staff (P), Security Officer was seen entering the video frame from a door positioned next to the desk.
At 05:43:10 AM, Patient #2 approached the stretcher and tried to touch Patient #1 on the leg. Staff (P) intervened by blocking Patient #2's right hand before contacting Patient #1.
At 05:43:12 AM, Patient #2 reached over Patient #1 with their left-hand touching Patient #1's left buttocks before Staff (P) pulled Patient #2 back and stood between the gurney and Patient #2.
At 05:43:13 AM, Staff (O), Physician Assistant entered the video frame from behind the nursing station, appeared to speak to Staff (K) and Staff (P) before walking around the nursing station desk.
At 05:43:25 AM, Patient #2 was escorted to a room across the hallway from the nursing station desk by Staff (P) and Staff (O) and the door was closed.

Review on 06/18/24 of the "Public Safety Security Report," dated 06/10/24 at 05:43 AM, revealed Staff (P), Security Officer received a call from Staff (K), Patient Care Technician who requested assistance in the behavioral health hallway of the emergency department. Upon exit of the security office, Staff (P) was immediately informed that an adult patient (Patient #2) had inappropriately touched a sleeping pediatric patient (Patient #1) on the leg. The adult patient attempted to reapproach the pediatric patient and stated, "I am a pedophile." The adult patient was directed to back away from the pediatric patient by Staff (P). Staff (P) stepped in front of the adult patient to block access to the pediatric patient. Staff (P) gently grabbed the adult patient's arms to stop advancement towards the pediatric patient. During the encounter, Staff (O), Physician Assistant entered the area and was briefed on the situation by Staff (K). The adult patient was directed to a room. At 05:45 AM Staff (O), Physician Assistant instructed Staff (P), Security Officer to lock the adult patient's door. The pediatric patient was moved from the hallway into room #127, for more safety and privacy. The pediatric patient appeared to remain asleep during the incident. Staff (K), Patient Care Technician reported that the adult patient exited their room at approximately 05:42 AM and stated, "You know I'm a pedophile, right?" before approaching and caressing the pediatric patient's leg. Staff (L), Registered Nurse and other emergency department clinical staff members were informed of the situation. Staff (L) stated Staff (N), Nurse Manager Emergency Department, would be informed as well as the pediatric patient's parents (the grandmother is legal guardian per medical record).

Review on 06/18/24 of the "Internal Safety Event Report," dated 06/10/24 at 07:06 AM reported by Staff (L) Registered Nurse, revealed Patient #2 was witnessed attempting to make inappropriate physical contact with Patient #1 who was a minor (a person who has not attained the age of 18). Security was contacted, intervened, and placed Patient #2 into an assigned room with a locked door for seclusion. Hospital follow up was completed by Staff (N) Emergency Department Nurse Manager. Patient #1 and the legal guardian were contacted twice. The legal guardian was satisfied with the internal follow-up and did not wish to press charges or have additional reports made. There was no documentation of video surveillance review, root cause analysis, or steps taken to prevent reoccurrence for other patients. Additionally, there was no documentation of interviews with staff involved with the event.


Interview on 06/17/24 at 02:11 PM with Staff (K), Patient Care Technician revealed Patient #1 was assigned a high-risk level for suicide and required constant observation (staff continuously observe and keep a patient in sight with their hands visible at all times). Patient #1 (pediatric patient) was in the hallway sleeping on a gurney in front of room #126, across from the nurse's station. Patient #2 (adult patient) walked out of an assigned room towards Patient #1. Staff (K) told Patient #2 to stop and called security for assistance. Patient #2 rubbed Patient #1's leg for approximately two seconds. Staff (K) was monitoring both Patient #1 and Patient #2. No other staff members were present in the behavior health area of the emergency department.

Interview on 06/17/24 at 02:20 PM with Staff (N), Nurse Manager of the Emergency Department revealed they were notified of the event with Patient #1 (pediatric patient) by Staff (L), Registered Nurse. Patient #1 asked to stay in the hallway due to feeling uncomfortable in the assigned room. Patient #2 (adult patient) grazed their hand over Patient #1's leg that was covered with a blanket. After the event, Patient #1 was moved into the assigned room with the constant observation (staff continuously observe and keep a patient in sight, with their hands visible at all times) sitter. Patient #2 was immediately redirected away by Staff (K), Patient Care Technician. Staff (N) spoke to Patient #1's guardian on 06/10/24 at 10:30 AM. The guardian seemed content with the interventions provided and did not want to pursue any legal actions against Patient #2. Staff (N) said the guardian did not place a formal complaint to the hospital. Staff (N) said they did not make any notes about the incident or discussion with the guardian.
Interview on 06/18/24 at 09:00 AM with Staff (P), Security Officer, revealed they wrote a public safety report for the incident. No investigation was conducted to confirm whether Patient #2 had a criminal history or was/was not on a public list of sex offenders through the state sex offender registry.

Interview on 6/17/24 at 11:10 AM, 02:00 PM, and 3:37 PM and 06/18/24 at 10:00 AM, and 6/18/24 at 3:16 p.m., with Staff (A), Clinical Director Nursing & Quality revealed the staff members (nurse, patient care technician, and the physician assistant) that were questioned all had the same description of the event and no further investigation was completed. The hospital did not review the video surveillance until today (06/18/24) because all staff questioned had the same description of the event. Staff (A) said if they had viewed the video prior, Staff (K) Patient Care Technician would have needed immediate re-education regarding the duties of a constant observation (1:1) sitter. Staff (A) said that a report to the New York Patient Occurrence Reporting and Tracking System (a mandatory adverse event reporting system established pursuant to Public Health Law) was not completed as a "touch on the knee" did not seem to fit the category of sexual assault. Staff (A) stated in cases of abuse, law enforcement would be notified, however Patient #1's legal guardian did not want to press charges against Patient #2, so the incident was not reported to local authorities. Additionally, Staff (A) stated The Justice Center was not contacted because Staff (A) was previously informed by The Justice Center that it does not oversee cases in the emergency department (Patient #1 was admitted to inpatient mental health).