HospitalInspections.org

This CONDITION is not met as evidenced by:

Based on medical record review, document review, video review, and interview, it was determined that the facility failed to protect and promote the rights of all patients as evidence by:
While in the psychiatric emergency department, Patient #1 swallowed two plastic spoons that required surgical intervention (A-0144). A hospital public safety assistant punched Patient #3 in the face/head multiple times while they were being manually restrained by four hospital public safety assistants and/or staff members (A-0145). This event resulted in an Immediate Jeopardy, posing a serious risk of harm to patients.

On 11/02/23 at 02:50 PM, an Immediate Jeopardy situation was identified for the CoP of Patient Rights. The facility provided immediate corrective actions that included in-person re-education to all staff and providers working in the psychiatry areas of the hospital on the following policies: "Prevention of Abuse," "Restraint and Seclusion," and "Occurrence Reporting, and Employee Patient Relationships." All incidents of alleged abuse will be acted upon immediately to include administrative leave for the accused staff member, a full investigation, and corrective disciplinary actions if warranted. Auditing on staff education and for all restraints & seclusion events will be conducted to ensure staff compliance with policies and to identify any incidents of abuse so that appropriate actions, reporting, and corrective follow up can be conducted.

On 11/03/2023 at 10:25 AM, the Immediate Jeopardy was removed based on onsite surveyor's observations, document review, and staff interviews which verified that the corrective action plan was fully implemented.

Cross Reference:

482.13(c)(2) Patient Rights: Care in Safe Setting.
482.13 (c)(3) Patient Rights: Free from Abuse/harassment. 482.13 (c)(3) Patient Rights: Free from Abuse/harassment.

Based on policy review, medical record review, document review, and interview, staff did not allow the patient or their representative the right to make informed decisions regarding care provided to all patients.

1. Staff did not notify the patient and/or the patient representative/guardian/healthcare proxy about a change in condition for one of nineteen patients (Patient #1). Patient #1 swallowed two plastic spoons in the comprehensive psychiatric emergency program/department and required surgical intervention to remove the spoons.
2. Staff did not provide discharge instructions to the patient, the group home staff, or the patient representative/guardian/healthcare proxy for one of nineteen patients (Patient #1).

Findings #1:

Review of the policy "Informed Consent" last revised June 2022 indicated that consent must be obtained for endoscopies below the level of larynx (organ in the top of the neck involved in breathing and producing sounds) and above the anal canal. A patient with the mental capacity to understand the risks, benefits and alternatives of treatment may consent to treatment. A health care proxy/agent may consent for a patient who does not have the mental capacity to understand the risks, benefits, and alternatives to treatment.

Review of the medical record for Patient #1 revealed on 05/27/23 at 10:10 PM, Patient #1 arrived in the emergency department with a history of PICA (condition where a person compulsively swallows non-food items) and suicidal ideation with a plan. Patient #1 has an intellectual disability and resides in a group home. Patient #1's mother is the appointed healthcare proxy/guardian. On 05/28/23 at 12:44 AM, Patient #1 was sent to the psychiatric emergency department on suicide observation. On 05/28/23 at 06:40AM, Patient #1 swallowed two plastic spoons. At 10:29 AM, Patient #1 was sent to the emergency department for evaluation. An x-ray confirmed Patient #1 swallowed the spoons. On 05/28/23 at 01:49 PM, consent for general anesthesia and an esophagogastroduodenoscopy (a flexible tube to examine esophagus, stomach, and small intestine) procedure was obtained from Patient #1. (No evidence was found in the medical record to indicate the mother/healthcare proxy/guardian were notified that Patient #1 swallowed two spoons and required surgical intervention for their removal).

Interview on 10/25/23 at 10:57 AM with Staff (B), Emergency Department Manager, verified these findings.

Findings #2:

Review the policy "Emergency Department Discharge Planning," last revised May 2022 indicated that staff members issuing instructions must determine that the patient or significant other understands the instructions and can verbalize the understanding. When prepared discharge instructions are used, the patient and/or significant other is asked to sign noting receipt and understanding of the instructions. When discharging a patient to a facility, a copy of the emergency department visit and paperwork will be sent with the patient, including discharge instructions which includes prescriptions, medications, discharge instructions with follow-up, referrals, the provider report, the supervisory notes, consults, and the history & physical. The registered nurse or provider will contact the facility to notify them that the patient has been discharged, and is on their way back, indicating the mode of transportation. This will be documented in the nursing care record. Documentation must be made by the nursing staff related to any instructions rendered and copies that are sent in the electronic medical record nursing care record. Every attempt will be made to involve family and/or the significant other in all aspects of emergency department patient care.

Review on 10/25/23 of the medical record for Patient #1 revealed on 05/27/23 at 10:10 PM, Patient #1 was brought to the emergency department by ambulance. Patient #1 had a history of PICA (the eating or craving of things that are not food) and suicidal ideation with a plan. Patient #1 has an intellectual disability and resides in a group home. Patient #'s mother is the appointed healthcare proxy/guardian. On 05/28/23 at 06:40 AM Patient #1 swallowed two plastic spoons and required an esophagogastroduodenoscopy to remove the objects. On 05/29/23 at 12:07 AM, the patient signature page to document receipt of the discharge instructions was signed by the registered nurse and an unknown individual, not by Patient #1, the group home staff, and/or the healthcare proxy/guardian. On 05/29/23 at 12:09 AM, Patient #1 was discharged back to the group home.

Interview on 10/26/23 at 11:15 AM with Staff (L), Vice President of Transplant & Renal Services (covering for the vacationing Vice President of Nursing) stated that after discussion with the information technology staff, they were unable to determine if Patient #1, the group home staff, and/or the healthcare proxy/guardian received discharge instructions.

Based on policy review, medical record review, and interview, the facility failed to provide care in a safe setting as evidenced by:
1. Patient #1 had a history of PICA (the eating or craving of things that are not food) and swallowed two plastic spoons while on level one observation in the comprehensive psychiatric emergency program/department, that required surgical intervention for removal.
2. Nursing staff failed to provide ongoing assessment and monitoring of vital signs for four of sixteen patients (Patient #2, #3, #21, and #31) in the emergency department.

Findings #1:

Review of the policy "Levels of Patient Observation in Psychiatry" last revised November 2022 indicated that each patient will be observed according to the level of observation ordered by the physician, and the observation will be documented in the patient's medical record. Rounding intervals as per provider order for Level 1 are observations every 15 minutes.

Review on 10/25/23 of the medical record for Patient #1 revealed on 05/27/23 at 10:10 PM, Patient #1 arrived at the emergency department with a history of PICA (condition where a person compulsively swallows non-food items) and suicidal ideation with a plan. Patient #1 has an intellectual disability and resides in a group home. Patient #1 has a history of swallowing items, such as coins and screws, and has had multiple procedures in the past to remove them. On 05/28/23 at 12:44 AM, Patient #1 was admitted to the comprehensive psychiatric emergency program/department on Level 1 observations (every 15 minutes) ordered by the physician. On 05/28/23 at 06:40AM, Patient #1 swallowed two spoons which were visualized on an abdominal x-ray. On 05/28/23 at 02:27 PM, the spoons were surgically removed under general anesthesia.

Interview on 10/26/23 at 10:20 AM with Staff (T), Vice President of Behavioral Health stated that there is no formal process or protocol for the collection of meal trays and silverware.

Interview on 10/26/23 at 10:54 AM with Staff (OO), Clinical Manager of Behavioral Health stated through investigation it was found that Patient #1 took spoons off the tray, went into the bathroom, and swallowed two spoons and a Band-Aid. There is no process to account for silverware.

Interview on 10/26/23 at 11:08 AM with Staff (S), Comprehensive Psychiatric Emergency Program Behavioral Health Manager verified the findings and stated that snack carts contain juice, crackers, cereal, and yogurt. The cart is brought out into the milieu once a shift. Silverware is not typically stored on the cart. However, a spoon is needed to eat cereal and yogurt. Staff do not check to ensure patients the return utensils. There is no formal education provided to the staff regarding utensil collection.

Findings #2:

Review of the policy "Nursing Assessment/Reassessment and Emergency Department Documentation" last reviewed March 2023 indicated that assessments may be ongoing per acuity and patient condition. Acuity is determined by the emergency severity index rating system. Patients with an emergency severity index score (a scale of 1-5 with a score of 1 being the most serious) between one and three will have a registered nurse initial assessment and vital signs assessed at triage or upon entry to the treatment area. Re-assessments and vital signs will be repeated at least every two hours, with any change in condition, and within 30 minutes of discharge. A complete set of vital signs is considered: blood pressure, heart rate, respiratory rate, blood-oxygen saturation, and temperature assessments. Assessments and re-assessments must be documented in the electronic medical record or the emergency department nursing care record.

Review of the policy "Emergency Department Nursing Protocols" last reviewed December 2021 indicated that patients who arrive to the emergency department with a condition of an overdose, are to be placed on a cardiac monitor, monitor the EKG rhythm strip every two hours, and as needed, obtain a full set of vital signs, and administer oxygen to maintain a blood oxygen saturation of greater than or equal to 95%.

Review of the medical record for Patient #2 revealed on 08/01/23 at 06:58 PM, Patient #2 presented to the emergency department with a complaint of head pain following a motor vehicle accident. At 07:01 PM, Patient #2 was assessed, and vital signs were obtained. At 07:04 PM, an emergency severity index score of three was assigned by the triage nurse. (No vital signs were documented during the time frame from 08/01/23 at 07:04 PM to 08/02/23 at 12:10 AM). On +08/02/23 at 12:10 AM, the provider departure note indicated that Patient #2 left without being seen).

Review on 12/25/23 of the medical record for Patient #3 revealed on 08/01/23 at 06:56 PM, Patient #3 presented to the emergency department with a complaint of status post motor vehicle accident with neck pain. At 06:58 PM, Patient #3 was assessed, and vital signs were obtained. At 07:02 PM, an emergency severity index score of three was assigned by the triage nurse. (No vital signs were documented during the time frame from 08/01/23 at 06:58 PM to 08/02/23 at 12:10 AM. On 08/02/23 at 12:10 AM the registered nurse departure note indicated that Patient #3 eloped at 12:10 AM.

Review on 10/25/23 of the medical record for Patient #21 revealed on 07/25/23 at 01:10 PM Patient #21 presented to the emergency department with a complaint of coughing up blood and had blood clots in the foley catheter. Patient #21 was immediately placed on a cardiac monitor, vital signs were obtained, and an emergency severity index score of two was assigned by the triage nurse. (No vital signs or cardiac rhythm assessments were documented during the time frame from 07/25/23 at 01:10 PM to 07:15 PM when vital signs were obtained).

Review on 10/26/23 of the medical record for Patient #31 revealed on 08/01/23 at 06:56 PM, Patient #3 presented to the emergency department with a complaint of status post motor vehicle accident with neck pain. At 07:02 PM, Patient #31 was assessed, vital signs were obtained, and an emergency severity index score of three was assigned by the triage nurse. (No vital signs were documented during the time frame from 08/01/23 at 07:02 PM to 08/02/23 at 12:10 AM). On 08/02/23 at 12:11 AM, the registered nurse departure note indicated Patient #31 left the emergency department, the disposition was documented as elopement.

Interview on 10/25//23 at 10:57 AM with Staff (C), Assistant Vice President of Emergency Department and Critical Care, verified these findings.

Based on policy review, video review, medical record review, document review, policy review, and interview, the facility failed to ensure that all patients are free from all forms of abuse, neglect, and harassment for one of three patients (Patient #32).
1. Patient #32 was punched in the face/head three times by a hospital patient safety assistant while being manually restrained.
2. Staff did not report the alleged abuse that occurred on 07/22/23 related to Patient #32.
3. The facility failed to thoroughly investigate and identify allegations of abuse reported by Patient #32, that occurred on 07/22/23, in a timely manner.

Findings #1:

Review of the policy "Restraint and Seclusion -Psychiatry" last reviewed February 2023 indicated the purpose of the policy is to guide staff in the steps necessary to support patient and staff safety and how to respond if imminent dangerousness persists and is risking the safety of patient and staff. Hospital Patient Safety Assistants will be required to attend annual in-service to include early identification of risk situations, alternative interventions and de-escalation strategies, safe physical interventions, and holding the patient while the nursing staff apply restraints.

Review on 11/01/23 of the video with Staff (L), Vice President of Transplant and Renal Services (covering for the vacationing Vice President of Nursing) revealed on 07/22/23 at approximately 04:44 AM, Patient #32 was noted to be standing near the locked exit door of the comprehensive psychiatric emergency program. Staff (XX), Community Mental Health Technician was sitting in a chair (in front of the nursing station) to the left of Patient #32, writing on a clip board. Staff (XX) stood up and motioned with his right hand at the exit door window as if gesturing someone to come to them. Security staff enter the unit through the door and Staff (XX) pointed to Patient #32. Staff (CCC), Hospital Public Safety Assistant placed their left open palm on Patient #32's chest and motioned Patient #32 away from the door. Staff (WW), Hospital Public Safety Assistant entered through the exit door. Staff (CCC), Hospital Public Safety Assistant placed two open palms on Patient #32's chest and bent down to retrieve an item off the floor. Staff (XX), Hospital Public Safety Assistant Correct placed their hands on Patient #32, who grabbed and lifted Staff (WW), off the ground and dropped Staff (WW), onto a row of blue plastic chairs. Staff (CCC) took a hold of Patient #32's hooded sweatshirt with his right hand and pulled the sweatshirt over Patient #32's head. a third Hospital Public Safety Assistant enters through the exit door and places hands on Patient #32's upper arms from behind. Staff (CCC), Hospital Public Safety Assistant; Staff (WW), Hospital Public Safety Assistant and a third Hospital Public Safety Assistant struggle with Patient #32 to the floor. The struggle between staff and Patient #32 continues the floor while additional Comprehensive Psychiatric Emergency Program staff respond and move chairs out of the way. Staff (WW) can be seen using a closed fist to punch Patient #32 in the face/head three times, while Patient #32 was being manually held down by four hospital patient safety assistants and clinical staff.

Review of the medical record for Patient #32 revealed that on 07/22/23 at 09:27 AM, the registered nurse documented that Patient #32 stated they were hurt during an altercation with staff and requested a medical evaluation. At 12:13 PM, Patient #32 complained of a pain level of seven (zero for no pain, ten for the most severe pain) in the back of the head and lower back, Patient #32 indicated it resulted from being punched and restrained. No visible signs of injury was found on exam. Patient #32 denied any other symptoms. Patient #32 denied imaging or pain medication stating, "I would rather go to my primary care provider to be checked out, I just want to go home." There is no documentation of the event in the medical record.

Findings #2:

Review of the policy "Code of Conduct" last reviewed 01/10/23, indicated that all employees, management, volunteers, and others, virtually everyone staff encounters have an affirmative duty to bring forward any compliance related concerns. Inappropriate conduct includes any activity designed to eliminate by encouraging system-wide integrity, including sub-quality care, patient abuse, harassment, fraud and abuse and other illegal activities, especially those that have compliance issues. We shall ensure that all patients are free from abuse or neglect. All employees have a duty to report any instances or suspected instances of such behavior.

Review of the policy "Professionalism Policy" last reviewed April 2021 indicated that all employees conduct themselves in a professional and cooperative manner within the hospital facilities. Staff will take prompt and appropriate action to address reports of unprofessional behavior by any member of staff. Reports may be made online using the electronic occurrence reporting system and utilizing the chain of command. Patients and visitors are referred to the Patient experience team. Examples of unprofessional conduct includes unprofessional physical contact with another individual or other aggressive behavior that is threatening or intimidating.

Review of the policy "Occurrence Reporting" last reviewed June 2020 indicates that any staff member may identify an occurrence anonymously into the electronic reporting system. The staff member should notify the supervisor. A physician will examine the patient and the supervisor will notify hospital administration. A mandated reporter's failure to report of suspected reportable incident is a serious matter with consequences to an individual and to program's operating certificate including discipline, termination, loss of credential or certification caused by failure to report. The purpose of reporting and subsequent investigation is to ensure that persons receiving services who are compromised physically, mentally, and emotionally are protected from avoidable actions or inactions of staff who are entrusted with their care who would have opportunities to cause them harm (physical or mental). Incidents are reportable (abuse or neglect) to the Vulnerable Persons Central Register (VPCR). Abuse and Neglect reporting must be initiated made by a mandated reporter to the VPCR immediately after a reportable incident is discovered.

Review on 11/01/23 of the video with Staff (L), Vice President of Transplant and Renal Services (covering for the vacationing Vice President of Nursing) revealed on 07/22/23 at approximately 04:44 AM, Staff (WW), Hospital Patient Safety Assistant can be seen using a closed fist and punching Patient #32 in the face/head three times, while Patient #32 was being manually held down by four hospital patient safety assistants and clinical staff. Multiple other staff members and hospital patient safety assistants can be seen standing in the vicinity and observing the manual hold placed on Patient #32.

Review of the Vulnerable Persons Central Register incident report for abuse and neglect was filed on the incident date of 07/22/23 at 09:15 AM by the victim (Patient #32). Patient #32 reported being slammed to the floor and punched in the head/face. An unknown staff member tried to smother Patient #32 with their shirt. An unknown staff member administered a medication injection in the right shoulder of Patient #32. (There is no evidence that any staff member filed an occurrence report, adverse event report, security report, or an incident report related to the alleged abuse that occurred during the restraint event on 07/22/23 at 04:44 AM).

Interview on 11/02/23 at 2:00 PM with Staff (L) Vise President of Transplant & Renal Services (covering for the vacationing Vice President of Nursing) verified the findings.

Findings #3:

Review of the policy "Occurrence Reporting" last reviewed June 2020 indicated that examples of reportable events include disruptive actions, concerns that warrant investigation, and events that may result in harm to an individual. The patient safety department will review occurrences via the electronic reporting system with the Chief Safety Officer to determine if any regulatory agency must be notified. Summary reports are provided to executive leadership for action plan implementation and sustainment. Reporting certain events (abuse) to the New York Justice Center is required by law. The purpose of reporting and subsequent investigation is to ensure that persons receiving services who are compromised physically, mentally, and emotionally and are protected from avoidable actions or inactions of staff who are entrusted with their care who have opportunities to cause them harm (physical or mental). Abuse and Neglect reporting must be made by a mandated reporter to the Vulnerable Persons Central Register (New York State Justice Center) immediately after a reportable incident is discovered. The New York State Incident Management and Reporting (Office of Mental Health) reportable incident types include abuse and neglect. Report occurrences to the New York State Justice Center and the New York State Office of Mental Health. The facility is to investigate the occurrence, document the findings, and submit the investigation within 45 days via the web submission of investigation report through the justice center.

Review of the policy "New York State Justice Center for the Protection of People with Special Needs Guidance for Staff and Volunteers," dated August 2018 revealed the Justice Center has authority to investigate all reports of abuse and neglect, can pursue administrative sanctions against staff found responsible for misconduct, and prosecute criminal offenses involving allegations of abuse or neglect. A report must be made within 24 hours of a mandated reporter's (certain professions such as doctors, nurses are mandated by New York State law to report suspected abuse or neglect) discovery. The incident is classified as reportable or non-reportable and is assigned to the appropriate entity for investigation or review. The Justice Center conducts investigations of abuse and neglect allegations based on severity and makes the final determination on the investigation findings.

Review of the report filed by Patient #32 "New York State Justice Center: Vulnerable Persons Central Register Incident Report" for abuse and neglect revealed a complaint was filed on 07/22/23 (incident date) at 09:15 AM by Patient #32. Patient #32 reported they were slammed to the floor and punched in the head/face. An unknown staff member tried to smother Patient #32 with their shirt. An unknown staff member administered a medication injection in the right shoulder of Patient #32. An addendum note to the report dated 07/27/23 at 10:24 AM indicated that Patient #32 had behaviors that warranted restraint, seclusion, and medications. Patient #32 was physically violent and injured staff. Patient #32 alleged staff physically abused them. A medical evaluation did not reveal any injuries. The facility did not provide video footage of the restraint event to the New York State Justice Center for their review. The incident was classified as "non-reportable," (does not meet the New York State Justice Center criteria for review).

Review of the facility complaint Event Log revealed no evidence an incident report was initiated for Patient #32's complaint of abuse that occurred on 07/22/23.

Review of the human resource investigation document "Business Partner Investigation Form" (Human Relations investigation of event on 07/22/23) completed by Staff (III), Employee Relations Partner on 07/22/23 indicated that the New York State Office of Mental Health called requesting the facility to check Patient #32's location, well-being, and asked whether Patient #32 was seen by a healthcare provider after Patient #32 self-reported a complaint. Patient #32 reported that they were punched in the face and head, stomped, and tramped over by unknown staff members. Patient #32 was in the Comprehensive Psychiatric Emergency Program unit. Patient #32 was assessed by a provider with no injury or bruises noted. The investigation found that video of the event was saved and reviewed by clinical, public safety and human resources.

Review of the addendum to the report filed by Patient #32 "New York State Justice Center: Vulnerable Persons Central Register Incident Report" (addendum to the report filed by Patient #32) for abuse and neglect dated 07/27/23 at 10:24 AM indicated that Patient #32 had behaviors that warranted restraint, seclusion, and medications. Patient #32 was physically violent and injured staff. Patient #32 alleged staff physically abused them. A medical evaluation did not reveal any injuries. The facility did not provide video footage of the restraint event to the New York State Justice Center for their review. The incident was classified as "non-reportable," (does not meet the New York State Justice Center criteria for review).

Review of the facility submission of the New York State Justice Center "Vulnerable Persons Central Register Incident Report" (report filed by facility staff after review of the video) for abuse and neglect by Staff (JJJ), Vice President of Behavioral Health dated 08/22/23 at 10:54 AM (31 days later), revealed that on 07/22/23, an unknown staff member punched Patient #32 in the head. While investigating the incident, it was found that there was evidence for the claim of abuse and neglect. The recommendation was to re-categorize the event. Review of video footage on 08/18/23 showed an unknown staff member punch Patient #32 in the head in the Comprehensive Psychiatric Emergency Program unit. Patient #32 was seen by a physician and had no reported injuries.

Review of the facility email to the New York State Incident Management and Reporting (Office of Mental Health) dated 08/23/23 at 06:54 AM revealed the facility reported the 07/22/23 incident for abuse and neglect (32 days later). The investigation was delegated to the New York State Justice Center. A return email from the New York Justice Center indicated the case was assigned to investigate the 07/22/23 incident for abuse and neglect.

Interview on 10/25/23 at 09:40AM with Staff (R), Assistant Vice President of Behavioral Health, indicated complaints and grievances are input into the Risk Connect System. Each case is reviewed and addressed by the unit manager. Depending on the level of concern of the case, it may go through the Quality Assurance process. If there is harm or safety concerns, then a root cause analysis would be completed. A case where there is harm would be input into the safety module and investigated.

Interview on 11/02/23 at 12:20 PM with Staff (DDD), House Council that the incident with Patient #32 on 07/22/23 was discussed at the 09/28/23 Incident Review Committee (confidential Quality Committee).

Interview on 11/03/23 at 11:37 AM with Staff (JJJ), Vice President of Behavioral Health stated that "we don't typically review video unless there is an allegation of abuse." Patient #32 called the Justice Center. A report was completed and sent to the Justice Center. "We reviewed the video, identified abuse, and submitted an additional report to the Justice Center." On 08/22/23 the Justice Center determined the case was a significant event and was assigned to the investigation. Once the Justice Center starts an investigation, we must stop our investigation.

Interview on 11/03/23 at 1:54 PM with Staff (III), Employee Relations Partner indicated on 09/25/23, they received a call from Staff (DDD), House Council who asked for the discipline, or any documentation related to the 07/22/23 incident with Patient #32. Staff (III) stated that "we did not have any." The event was closed in Risk Connect (facility incident reporting), although it indicated that the case was assigned to Human Resources. On 09/18/23, a meeting was held, and the video was reviewed. Staff (XX), Community Mental Health Technician waved in the Hospital Patient Safety Assistant and did not utilize de-escalation techniques. The actual take down of Patient #32 and the punching in the head was viewed. Staff (WW), Hospital Patient Safety Assistant was on compensation for suffering a concussion from the incident. Staff (WW), Hospital Patient Safety Assistant filed a police report against Patient #32 for assault. The injuries and police report delayed Human Resources ability to be involved.

Interview on 11/03/23 at 02:14 PM with Staff (L), Vice President of Transplant & Renal Services (covering for the vacationing Vice President of Nursing), verified the findings.