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Based on document review, medical record review, and staff interview, the facility failed to maintain a safe and protective environment for patients who are at risk for (a) elopement and self-harm and (b) patients exhibiting violent/aggressive behavior. These findings were noted in three (3) of 13 Medical Records reviewed. (Patients #1,
#5, #8).

Findings include:

Review of the medical record (MR) for Patient #1 revealed a 47 year- old female who presented to the Emergency Department (ED) on 5/29/18 at 3:49 PM. The ED Triage Nurse documented chief complaint, "patient stated she has depression and suicidal ideation with a plan to jump in front of a train." The patient was placed on close watch for safety and security observation was implemented. She was medically cleared and admitted to CPEP (Comprehensive Psychiatric Emergency Program) where she remained overnight under safety watch and close observation.

On 5/30/18 at 5:48 PM, the Psychiatrist evaluation and disposition documented: "Patient with erratic, labile behavior with suicidal statements and history of suicide attempts," with the disposition for transfer to an outside psychiatric hospital with security escort, as an involuntary admission.

The Psychiatric Social worker noted on 5/30/18 at 9:45 PM, "Nursing Supervisor from the receiving hospital called CPEP and reported that when patient arrived the EMS team was lowering the stretcher from the Ambulance and the stretcher fell over. The Attending Doctor is going to send the patient back this evening for a medical evaluation."

The Ambulance report indicated the patient returned to the ED on 5/30/18 at 10:17 PM, with the security escort. The documentation indicated the reason for being brought back to the ED was back pain.

On 5/30/18 at 11:23 PM the Triage Nurse documented, " Patient walked out before triage and did not want to be evaluated."

During interview on 6/21/18 at 10:00 AM, Staff D, ED Triage Registered Nurse stated, "the ambulance worker gave report and said the patient had back and elbow pain. There was no security officer present when I took report and no one said she was an involuntary psych admission. The patient was walking around the triage area and she refused vital signs and requested to leave. She said, 'I don't want to be here.' The patient walked out of the ED before I could triage her."

The facility's "Levels of Observation, Clinical Assessment for Elopement Risk" Policy, last revised 10/2016 states: Transfer of a patient on Security Observation to another facility will require a Security Officer to accompany (escort) the patient during transport. During Escort and Security Observation, the Security officer is responsible for observing the patient at all times and precludes all other tasks or activities and is responsible for hand-off communication to the nurse and any relieving Security officer on pertinent patient behavior and reason for security observation.

Review of the facility's Policy "Hand-off and reporting of patient information- communication standardization," revised 9/2016 states: standardized handoff will occur when transferred from/to another facility. A handoff report, which includes opportunity for the receiving caregiver to ask questions, must be given when the care of the patient is transferred to another caregiver."

There was no documented evidence that these procedures were followed.

During interview on 6/21/18 at 10:00 AM, Staff H, Security Officer stated: he went with the patient in the ambulance to the psychiatric hospital. The patient fell from the stretcher and was brought back to the ED for evaluation. When they got to Triage, he left to call the security desk officer on the phone and asked to be relieved because his shift had ended. He gave report and was told someone would be sent, so he went home.

There was no evidence that appropriate handoff was made. Staff H left the ED after his shift ended and the patient was left unattended.


Patient #5: Review of the facility's Incident Log for 2018, noted an event of a patient to staff assault, without injury, in the facility's Adult Emergency Department (ED) on 1/29/2018.
A report documented by Security Department on 1/29/2018 @ 2:00 PM noted: security officer responded to staff's scream for security officer. Upon arrival, the registered Nurse was already on the phone with 911, and staff reported to the officer, that the patient struck the doctor. The patient was kept in the ER waiting room by another security officer to wait for New York Police Department (NYPD). NYPD officer arrived, the patient was discharged, placed under arrest and escorted off the premises.

Review of medical record (MR) for patient #5 identified: Patient was brought to the facility's Emergency Department (ED) by ambulance on 1/29/2018 12:40 AM. The triage nurse noted the patient's chief complaint was psychiatric evaluation; the patient had a suicide risk assessment and the patient was identified as a suicidal risk.

The physician's documentation at 1:52 AM, noted the patient's history of multiple prior psychiatric admissions and three prior suicidal attempts including one by hanging and overdoses. The physician also documented detailed description of patient's past aggressive and combative behavior towards the ED staff. The physician noted that during his attempt to interview the patient, he was punched in the face by the patient.

There is no documented evidence that this patient identified as suicidal risk, was evaluated and treated prior to his discharge in police custody.

During telephone interview with Staff K, Director of Regulatory, on 7/19/18 at 3:30 PM,
Staff K stated that the clinical staff and security staff have training in Management of Aggressive Behavior (MOAB) and the hospital staff is trained to handle aggressive and combative patients.

There was no indication that this psychiatric patient was continuously managed by tained staff.



Patient #8: Review of MR for patient # 8 noted: This 39-year-old with history of mental illness and substance abuse arrived in the Emergency Department on 1/22/2018 at 8:55 PM with suicidal ideation with the denial of a plan. He was admitted to a medical unit on 1/24/2018 at 3:11 AM and was placed on security observation, due to his high risk for elopement.

On 1/24/2018 11:42 PM, the provider noted: called by the RN stating that the patient was agitated and threatening security. Upon arrival to the floor, the physician noted the patient was on the floor and three security officers were restraining the patient. Patient's face was being covered by security guard as the patient had earlier threatened to bite. The patient had a physical examination which revealed left eye swelling, minor laceration on bottom lip with slow oozing bleed. CT scan was completed and showed tissue swelling, presence of air and possible hematoma/fracture.

The Safety/Security Event report documented 1/25/18 states: On 1/24/18 at 9:20 PM, the patient attempted to leave room for coffee (on room restriction) but told by security not to leave. He ignored the security instructions and left room to the patient lounge, he began cursing and making threatening remarks to security. He was redirected to go to his room, but kept cursing. Security struggled with patient to restrain. He was subdued to the floor and eventually escorted back to his room.

Review of facility's policy titled "Patient Elopement/Aggressive Behavior," last revised 12/15/17, states: If a patient attempts to elope from the area of observation, security personnel may verbally redirect, physically redirect by using a "guiding touch", or if required physically restrain the patient to prevent elopement. In all instances, security personnel must immediately communicate to Nursing personnel and Security Communications Center, signs of escalating behavior, or threats of attempted elopement.

This policy was not implemented.

The facility's policy titled "Patient Restraint," last revised 12/15/15, states: "Emergency Conditions - Under the following circumstances, Security Officer may initiate the restraint of a psychiatric patient: if the patient attempts to forcible elope from the hospital or from any area in which is under security watch"--- "In most instances patients will exhibit behavior which may predict their actions; increased agitation, verbal threats, statements regarding a desire to leave, etc. When this activity is noted, it must be immediately conveyed to supervision and medical staff so they may intervene."

There is no evidence that security reported patient's escalating behavior to the clinical staff for appropriate intervention.




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Based on medical record review, document review and interview, the hospital did not ensure that incidents involving patients who sustained injuries during restraint were analyzed to assess the quality of care and patient safety, and identify areas for improvement. This was evident in four (4) of 13 medical records reviewed ( Patient #7, #8, #9 & #10).


Findings include:

Review of Security/Safety event for 2018 identified patients who were injured during restraints application:

Patient # 7: On 4/24/17, patient sustained 2-3 inch laceration to his left eye lid during physical restraint by security, prior to application of chemical restraint.

Patient #8: On 1/24/18, patient sustained injury to his lip and left eye during a struggle with security officers, in attempt to restrain the patient. A CT scan revealed tissue swelling, presence of air and possible hematoma/fracture.

Patient # 9: On 2/26/2018, patient exhibited aggressive behavior towards staff and experienced blunt head trauma while being restrained.

Similar findings noted events for Patient # 10 who sustained injuries while being restrained.


The Safety/Security Committee Meeting reports for 2018, documents the hospital events/investigations on patients injured during restraints It was documented the facility reviewed the individual cases. In the cases reviewed, standard of care was met as the patients were aggressive and not following instructions, resulting in the injuries. No further action was necessary.

There is no evidence that the data collected for aggressive patients who were injured during restraints, is aggregated and analyzed to identify areas for possible improvement.

During interview with Staff J, VP of Patient Care Services on 6/25/2018 at approximately 10:30 AM, Staff J acknowledged the findings.