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Based on patient and staff interviews, review of medical records, facility ' s policies, and other documents, it was determined that the hospital did not effectively notify and communicate information to patients/ patients ' representatives about patients ' rights as hospital patients. This was noted in three of nineteen medical records reviewed. (MR#12, MR#20, MR#25)


Findings included:


1) MR # 12 was reviewed on 8/24/15 at approximately 11:00 AM during a tour of Unit 4E. It was noted that this 80 year old female was brought to the facility from home on 8/21/15 and she was admitted. The chief complaint was difficult urination and a glucometer blood sugar reading of 500. The patient was still inpatient on 8/24/15 receiving intravenous fluids and medication to control her diabetes. The record indicated that the patient's insurance was Medicare. It was noted that the copy of An Important Message (IM) Medicare form was not located in the hard copy portion of the record. Review of the facility ' s electronic medical record for the patient, conducted with the guidance of staff # 3, the nurse manager, failed to reveal entries made by the facility care management team, the team responsible for providing a copy of the IM to all Medicare patients. Documentation in the patient's electronic medical record confirmed that the patient had consented to receiving treatment on her own behalf.

The Director of Risk Management/Compliance Officer, who was present during the review on 8/24/15, acknowledged that the IM was not in the record. Therefore this patient was not provided with the required patient's rights information.

Interview of the patient referenced in MR # 12 on 8/24/15 at approximately 10:30 AM, the patient was unable to remember if a member of the care team had spoken with her regarding her rights as a Medicare patient.

2) MR # 20 was reviewed on 8/24/15 at approximately 12:00 PM during a tour of Unit 4E. It was noted that this 80 year old female was brought to the facility from home on 8/22/15 and she was admitted. The patient was experiencing difficulty breathing and was treated for chronic obstructive pulmonary disease and pneumonia. The patient was still an inpatient on 8/24/15 receiving intravenous medications and oxygen therapy. The medical record indicated that the patient's insurance was Medicare. It was noted that the An Important Message (IM) Medicare form was present in the hard copy part of the record but the words "Unable to sign" appeared on the signature line. Review of the facility's electronic medical record for the patient was conducted with the guidance of staff #3, the nurse manager.
The review failed to reveal entries made by the care management team which documented discussion of Medicare patient's rights.

The Director of Risk Management/Compliance Officer, who was present during the review on 8/24/15, acknowledged that the patient was not provided with the required patient's rights information.

Interview of the patient referenced in MR # 20 on 8/24/15 at approximately 12:30 PM, the patient stated that the care management team had discussed many clinical and discharge related issues with her but that she was certain the team had not provided the IM or discussed her rights as a Medicare patient.


3) MR # 25 was reviewed on 8/25/15 at approximately 3:00 PM during a tour of Unit 5F. It was noted that this 67 year old female was admitted on 8//12/15 in a medically complex state, which included altered mental status. The record indicated that the patient's insurance was Medicare. It was noted that the An Important Message (IM) from Medicare form was present in the hard copy part of the record but the words "Unable to sign" appeared on the signature line. Review of the facility's electronic medical record for the patient was conducted with the guidance of staff # 4.

The record failed to reveal entries by the care management team which would have confirmed that the patient's son, who was her health care proxy, had been contacted to discuss his mother's rights as a Medicare patient or that the IM had been forwarded to him.


The Director of Risk Management/ Compliance Officer, who was present during the review on 8/25/15 acknowledged that the patient's son was not provided with the required patient's rights information.

The facility policy and procedure titled "Delivering Important Message from Medicare (IM) and Detailed Notice of Discharge (DND)", last reviewed 12/30/14, described the following: Staff (Care Management Team) will issue An Important Message from Medicare notice, explain the purpose and secure a signature from the patient/representative. This will take place no more than two days after admission for all elective, urgent and emergent Medicare, Medicare Advantage, dual eligible(Medicare and Medicaid) and Medicare as secondary payer beneficiaries.

The facility failed to follow its own policy and procedure for issuing the IM Medicare Notice.

Based on medical records reviews, policy reviews and staff interviews it was determined the facility failed to ensure that the staff utilized de-escalation techniques when patients behavior was disruptive, became agitated and/or when they posed a danger to themselves and others.
This was noted in 2 of 7 medical records reviewed (MR#8, MR#10).

Findings include:

(a) A review of MR #8 on July 10, 2015 revealed this forty-one year old patient underwent an urgent elective esophagogastroduodenoscopy (EGD) on February 9, 2015 for blood in her stool the previous day, nausea, vomiting and gastroesophageal reflux disease (GERD). The patient had multiple previous medical history which included Hypertension, Diabetes Mellitus type 2, GERD, Herniated disc, Chronic Sinusitis, Hemorrhoids and Asthma, and she had undergone several previous surgeries. The patient was disabled due to back problems and she was taking several different types of medications.

A review of the medical record #8 on July 10, 2015 revealed the patient was given Diprivan 250 mg and Lidocaine 40 mg intravenously starting at 9:57 AM until 10:26 AM that morning. Multiple random cold biopsies were done for esophagitis. A nurse documented that at 10:50 AM the patient became disruptive, combative, abusive and was refusing care. The patient was also climbing out of the bed and she stated that she was leaving. A stat 50 (emergency behavioral code) was called but she became increasingly combative. She took and tore her discharge instructions and threw them in the garbage. She tried lighting up a cigarette (she had a smoking history of 1-2 cigarettes/per day) and was spitting at the staff. She refused to wait for someone to take her home. The record indicated the patient was contained and escorted to the ED by security and police officers from White Plains Police Department.

There was no evidence that the staff in the post anesthesia care unit attempted to de-escalate the situation in that unit.


A similar finding was noted in MR #10 when the medical record was reviewed on July 10, 2015 where it was identified that the patient became combative and aggressive. There was no evidence that de-escalation techniques were utilized to calm the patient nor was there any evidence that physical and/or chemical restraints were used before the police was called because of the patient's behavior.

These findings were confirmed with the facility's administrative staff on July 9, 2015 at 11:30 AM.

Based on medical records reviews, policies and staff interviews, it was determined the facility failed to ensure that the staff utilized de-escalation techniques when patients behavior was disruptive, became agitated and/or when they posed a danger to themselves and others.The facility's staff alerted and requested the local police department to assist in restraining and subduing patients when these conditions occurred.
This was identified in 5 of 7 cases reviewed for the past 6 months.

Findings include:

(a) A review of MR #8 on July 10, 2015 revealed this forty-one year old patient underwent an urgent elective esophagogastroduodenoscopy (EGD) on February 9, 2015 for blood in her stool the previous day, nausea, vomiting and gastroesophageal reflux disease (GERD). The patient had multiple previous medical history which included Hypertension, Diabetes Mellitus type 2, GERD, Herniated disc, Chronic Sinusitis, Hemorrhoids and Asthma, and she had undergone several previous surgeries. The patient was disabled due to back problems and she was taking several different types of medications.

A review of the medical record #8 on July 10, 2015 revealed the patient was given Diprivan 250 mg and Lidocaine 40 mg intravenously starting at 9:57 AM until 10:26 AM that morning. Multiple random cold biopsies were done for esophagitis. A nurse documented that at 10:50 AM the patient became disruptive, combative, abusive and was refusing care. The patient was also climbing out of the bed and she stated that she was leaving. A stat 50 (emergency behavioral code) was called but she became increasingly combative. She took and tore her discharge instructions and threw them in the garbage. She tried lighting up a cigarette (she had a smoking history of 1-2 cigarettes/per day) and was spitting at the staff. She refused to wait for someone to take her home. The record indicated the patient was contained and escorted to the ED by security and police officers from White Plains Police Department.


(b) A review of MR #7 on July 10, 2015 revealed a stat 50 was called that day after the patient became agitated when a nurse attempted to give him his medication because he had not been taking his medication at home and had refused to attend a scheduled psychiatric appointment. The security staff restrained the patient and the nursing staff administered medication to calm him.

During an interview conducted with a registered nurse at 12:30 PM on July 10, 2015 she stated that a technician called the police department even though the facility's security staff restrained patient #7. There was no evidence that there was a justification to call the police.


(c) A similar finding was noted in MR #9 when it was reviewed on July 10, 2015 where on August 30, 2015 the police was called to restrain an eighteen year old patient who presented with complaints of depression.


(d) A similar finding was noted in MR #10 when the medical record was reviewed on July 10, 2015 where it was identified that the patient became combative and aggressive. There was no evidence that de-escalation techniques were utilized to calm the patient nor was there any evidence that physical and/or chemical restraints were used before the police was called because of the patient's behavior.

(e) A similar finding was noted in MR #6 when it was reviewed on July 10, 2015. The patient was found on the street, lethargic and mumbling incoherently after he had used synthetic marijuana that day. The police was called to the ED on June 13, 2015 to help restrain him after he became combative, agitated and had sustained a laceration to the upper lip.


The facility does not have a policy to direct its staff when a police officer is called into the facility to assist with the management of behavioral patients, nor does it have protocol for the role of the officer in the facility.

These findings were confirmed with the facility's administrative staff on July 9, 2015 at 11:30 AM.

Based on medical record reviews, document reviews and staff interviews, it was determined the facility failed to ensure that all patients received care that was consistent with prevailing standards of practice Specifically, assessments were not thorough.
This was identified in 1 of 20 medical records reviewed (MR #1).


Findings include:

1. The physician's assessment was not thorough and it was inadequate in the case of patient (MR) #1.

A review of patient #1's medical record on July 8, 2015 revealed this twenty-six year old patient presented to the emergency department (ED) on March 10, 2015 at 1:49 AM with a sudden onset of left ear pain which had awoken her from her sleep that night. The nurse documented that the patient reported that she had a sore throat a few days ago and was been treated for the flu. The pain score was 9 on a scale of 0 (no pain) to 10 (most severe pain). The patient was seen by the physician at 2:08 AM who noted the patient didn't haven't any symptoms of recent upper respiratory infection which contradicts the triage nurse's finding. The physician's assessment revealed there was minimal erythemia in the left ear and that the lungs were clear. There was no documentation that the patient's throat was examined given the nurse's notation of sore throat and flu symptoms.

Patient #1 was given Motrin 600 mgs at 2:10 AM that night for pain that was throbbing, constant and the patient was grimacing. The patient was discharged at 2:22 AM that morning without a reassessment.

Review of the facility's policy titled "Management of the patient experiencing pain and safe use of opioids" which was last reviewed on 8/27/13 states a "nurse will monitor for effectiveness and any adverse effects based on the medications route of administration in 60 minutes after PO administration."

Patient #1 was discharged from the ED on March 10, at 2:22 AM with instructions to take Motrin for pain. There was no documented evidence that the patient was informed of the dosage and the frequency that the medication should be taken. Nor was there any evidence that the patient was given a prescription to continue this dosage of the drug.

This finding was confirmed during an interview with the nurse manager of the ED on July 8, 2015 at approximately 11:30 AM.