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Based on review of medical records, staff interviews, and review of facility documentation, it was determined that the facility failed to ensure the protection and promotion of patient's rights as evidenced by: failing to provide written notice of the decision that contained the name of the Patient Advocate, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for grievances filed by patients (A0123); failing to ensure the policy and protocol for falls was implemented (A0144); failing to ensure the assessment and monitoring of patients in restraints (A0175); failing to ensure provider face-to-face assessment/reassessments of patients in restraints were documented in accordance with facility policy (A0178); and failing to ensure that orders for one-to-one (1:1) monitoring were implemented for a patient determined to be high risk for suicide (A0144). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patients.

On October 12, 2023 at 2:00 PM, an IJ finding was identified for the facility's failure to ensure that orders for one-to-one (1:1) monitoring are implemented for a patient determined to be high risk for suicide per facility policy. On 10/12/23 at 2:05 PM the IJ template was provided to administrative staff and a removal plan was requested. On 10/12/23 at 1:31 PM an acceptable removal plan was received. The IJ was resolved on October 13, 2023 at 2:32 PM after the State Survey Agency verified that the hospital had completed immediate intervention for the re-education of all the emergency department patient care staff, security personnel and emergency department care providers on the process and policy for the ordering and ensuring of one-to ones for patient safety.


Cross Reference:

482.13(a)(2)(iii) Patient Rights: Provision to the patient of a written notice of the hospital's resolution of a grievance
482.13(c)(2) Patient Rights: Care in a safe setting (IJ)
482.13(e)(10) Patient Rights: Monitoring of the condition of a patient who is in restraint or secluded
482.13(e)(12) Patient Rights: face-to-face within 1 hour of a patient after the initiation of restraints or seclusion

Based on staff interview and review of facility documents, it was determined that the facility failed to provide written notice of the decision that contained the name of the Patient Advocate, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for two of two grievances filed by patients.

Findings include:

Facility policy titled, "Patient Grievance and Complaint Resolution", dated March 2023, stated, "... Complaints and grievances related to patient care and services at Carepoint Health-Bayonne Medical Center are addressed according to the following guidelines. All patient complaints/grievances will be handled efficiently, with timely follow-up and resolution. ... All responses to a grievance must be in writing. ... Name and contact information of Patient Advocate. Steps taken on behalf of the patient to investigate the grievance. The results of the grievance process ..."

Review of the "SERVICE EXCELLENT PATIENT REPORT" indicated grievances were filed by Patient (P) 3 on 5/5/23 and by P5 on 6/7/23. P3 received a facility response on 5/15/23 and P5 received a facility response on 6/14/23 stating, "... Please note that we take these complaints very seriously. The Site Manager for Patient Experience and Executive team investigated the matter and have taken appropriate steps pursuant to our hospital's policies and procedures ... ."

On 10/11/23 at 1:00 PM a request was made to Staff (S) 3, Chief Nursing Officer Quality, for additional responses for resolution of the grievance for P3 and P5. Upon interview with S3 on 10/12/23 at 11:30 AM, he/she confirmed there were "no other responses." Both patients, P3 and P5, received the same written response that lacked the name and contact information of the facility Patient Advocate, the steps taken on behalf of the patient to investigate the grievance, and the results of the grievance process.

Based on medical record review, staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure: 1). orders for one-to-one (1:1) monitoring are implemented for a patient determined to be high risk for suicide in one of 20 medical records (Patient (P) 6) reviewed; and 2). the policy and protocol for falls was implemented in one of 20 medical records reviewed.

Findings include:

1.Facility policy titled, "Suicide Assessment and Prevention", Effective July 2023, stated, "... B. Reassessment of Suicide Risk: ... 6. All patients who are being discharged shall be reassessed for suicide risk prior to discharge. ... C. ... 2. Patients who are assessed to be at moderate or high risk for suicide may be placed on line of sight observation or on a one to one (1:1) observation status ... 4. An observation level can only be decreased with a physician's order ... ."

On 10/12/23 at 10:30 AM, the medical record of P6 was reviewed and the following was noted: P6 arrived at the ED (Emergency Department) on 7/13/23 at 12:15 PM via ambulance. The Triage Note written at 12:24 PM by Staff (S) 31, ED Registered Nurse, stated, "Patient presents to ED via EMS (Emergency Medical Services) /BPD (Bayonne Police Department) for SI (Suicidal Ideation) without a plan. ESI (Emergency Severity Index) Level: 3-Urgent." A Columbia Suicide Severity Rating Scale (C-SSRS) was completed during triage by S31 that determined the patient's risk level was 13 and was assessed to be High Risk (High risk scale: 6-23). Safety interventions were documented by S31 as follows: " ... Do not leave patient unattended and place on 1:1 ..."

A nursing note completed by S31 at 12:16 PM stated, "... Upon arrival, patient has flight of ideas, manic, and easily irritable ... Pt (patient) in front of nurses station for safety. No 1:1 available at this time as per nursing office. Will continue to monitor ..." The medical record lacked documentation that P6 was monitored at the nursing station pending an available staff member for 1:1 monitoring.

Review of additional facility documentation identified an incident on 7/13/23 in which the patient had spit at, punched, and threw a food tray at an ED staff member. This incident occurred after an order for a one-to-one should have been implemented.

The above findings were confirmed on 10/12/23 at 11:05 AM with S19, ED Patient Care Director. S19 confirmed that the facility failed to implement safety measures including 1:1 monitoring for a patient assessed to be a high risk for suicide per the facility policy, titled "Suicide Assessment and Prevention."


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2. Facility policy titled, "Fall Protocol & Response" dated September 13, 2023, states, "It is the policy of Bayonne Medical Center to have an established process to identify and communicate with patients who are at risk for falls with the potential of injury, by assessing their risk and implementing strategies interventions to minimize or reduce the risk of falling. ... Procedure Patients will be assessed for falls in the Emergency Department ... A nurse will assess each patient's risk for falls using the Morse Fall Risk assessment ...at the time of preadmission or admission ...."

The medical record of P15 was reviewed. P15 presented to the ED on 6/19/23 at 11:08 PM. The Nursing Assessment from 6/19/23 at 11:08 PM, stated, " ... Triage-Assessment Chief Complaint Altered Mental Status Triage Comment Pt was wandering around the street. Pt also had fall yesterday, abrasions noted to head, and left arm. No bleeding notted [sic]. ... ESI Level 3 Urgent ..." At 11:08 PM the Nursing Assessment stated, "The Morse Fall Risk Assessment ... History of Falling No ... Fall Risk Assessment Score 0 ...". The Morse Fall Risk Assessment did not identify P15's history of falls. The facility failed to properly assess P15 risks for falls.

Based on staff interviews, medical record review, and review of facility documents, it was determined the facility failed to ensure that patients in restraints were assessed and monitored in accordance with facility policy, in one of five medical records reviewed (Patient (P) 4).

Findings include:

Facility policy titled, "Restraints: Patient Safety / Behavioral / Seclusion," dated 5/2023, stated, "... Procedure: Assessment and Documentation Process... Reassessment: The Patient will be monitored by staff that is trained and competent. ...The evaluation will include i.) Patient reaction to intervention ... Behavioral Management: Monitoring is accomplished by continuous in person observation by an assigned staff member who is competent and trained. At the initiation of restraint and at least every fifteen minutes thereafter, monitor the patient for safety and comfort ... Restraints are released every two hours. Range of motion and assessment for release will be assessed by the Registered Nurse at this time ... Documentation: Use the restraint flow sheet/plan of care for documentation. Each episode of use is recorded. Documentation includes: Complete monitoring flow sheet ... Each in person evaluation and re-evaluation of the individual ... continuous monitoring ... Description of patient behavior and interventions used, ... Patients response to the intervention ... ."

On 10/12/23 at 10:30 AM, in the Emergency Department (ED), an interview was conducted with Staff (S) 26, a Registered Nurse (RN), S27, the charge nurse, and S28, an agency RN. During the interview, S26, S27, and S28 all stated that patients in 4-point restraints were monitored every 15 minutes. S26 stated that if a patient was "chemically restrained" the restraints will be removed. S27 stated that staff receive training for restraints "during skills lab" and that the last training was a year ago. S28 stated that agency nurses receive a two-day training during orientation. S28 stated that he/she also received a three-day department specific orientation upon hire.

Upon request, S26 provided a copy of the facility document titled, "Behavioral Restraint Management Assessment Flowsheet." The flowsheet was divided into 15-minute increments spanning a 24-hour period.

The medical record of P4 was reviewed in the presence of S19, the ED Director, and the following was revealed:

The section titled, "Nursing Assessments /Treatments," stated, "Restraint Daily flow sheet: Restraint initiated Date: 5/15/23, Time: 19:15 [7:15 PM] ... High risk for self-injury as evidenced by: Risk for fall ... High risk for injury to others as evidenced by: Attempting to assault and bite staff ... Alternatives and less restrictive measures attempted prior to restraint /seclusion use: Verbal de-escalation, Positioning, Medication ... Type of restraint: 4-point ... Notification: HCP[healthcare provider] next of kin notified by RN regarding the initiation of restraint ... Education to patient: Reason for restraint explained ... Behavior that led to the use of restraints or seclusion: Risk for self-harm ... Restraint documentation ... Order for restraints: yes ... Reason for restraint: behavioral ... One to one observation required: yes ... one to one sitter at bedside; patient is a flight risk, due to patient combativeness, for patient safety, for staff safety ..."

On 5/15/23 at 8:00 PM, it was documented that P4's restraints were removed. The medical record lacked evidence that the "Behavioral Restraint Management Assessment Flowsheet" was completed indicating that the patient was monitored while in restraints.

The section titled, "Nursing Assessments /Treatments," stated, "Restraint initiated Date: 5/15/23, Time: 23:58 [11:58 PM] ... High risk for self-injury as evidenced by: attempting to get out of bed while unsteady gait ... High risk for injury to others as evidenced by: Attempting to bite staff ... Alternatives and less restrictive measures attempted prior to restraint /seclusion use: Verbal de-escalation, Positioning, Medication ... Type of restraint: 4-point ... Notification: HCP[healthcare provider] next of kin notified by RN regarding the initiation of restraint ... Education to patient: Reason for restraint explained ... Behavior that led to the use of restraints or seclusion: Risk for self-harm ... Restraint documentation ... Order for restraints: yes ... Reason for restraint: behavioral ... One to one observation required: yes ... one to one sitter at bedside; patient is a flight risk, for patient safety, for staff safety ..."

On 5/16/23 at 4:30 AM, it was documented that P4's restraints were removed. There was no documented evidence that the "Behavioral Restraint Management Assessment Flowsheet" was completed indicating that the patient was monitored while in restraints.

Based on staff interviews, medical record review, and review of facility documents, it was determined that the facility failed to ensure a provider face-to-face assessment/reassessment of patients in restraints or chemical restraints were documented in accordance with facility policy in two of 20 medical records reviewed (P4 and P6).

Findings include:

Facility policy titled, "Restraints: Patient Safety / Behavioral / Seclusion," dated 5/2023, stated, "... Procedure: Assessment and Documentation Process...All in an Emergency Situation, When the patient is engaging in activity that presents an imminent risk to the patient or others and a physician is not available on the unit, a qualified registered nurse (RN) present may initiate restraints or seclusion...The physician will conduct face to face evaluation within an hour of the initiation of restraint or seclusion. ... All Reassessment: The Patient will be monitored by staff that is trained and competent. The one-hour face-to-face evaluation must be conducted by a provider who has been trained and competent. The evaluation will include... ... If restraints are discontinued prior to the expiration of the original order or when the order expires, a face-to-face reassessment by the physician and a new physician order is required before restraint or seclusion can be re-applied ... Documentation: Use the restraint flow sheet/plan of care for documentation. Each episode of use is recorded. Documentation includes: ...The physician evaluation within an hour of initiation..."

The medical record of P4 was reviewed and the following was revealed:

A Physician order placed on 5/15/23 at 7:20 PM, by S8, an ED physician, stated, "Restraint: Restraint/Seclusion for Violent Behavior Routine ... Type of Restraint Ordered: '4-point' restraints ..."

ED Physician Documentation, dated 5/15/23 at 7:20 PM, stated, "... the patient is combative and attempting to elope. He/She is clearly not capable of clear decision making. I have again [sic] security and the staff to restrain the patient ... Treatment/Disposition ... ED Course: The patient was seen immediately upon arrival. Due to the patient's failure to understand instructions and is clearly a danger of falling and further injury the patient will be temporally restrained and sedated with benzo [benzodiazepine (Ativan)], Haldol, and Benadryl."

A Physician order placed on 5/16/23 at 11:58 PM, by S8, stated, "Restraint: Restraint/Seclusion for Violent Behavior Routine ... Type of Restraint Ordered: '4-point' restraints ..."

The medical record lacked documented evidence of a provider face-to-face assessment or re-assessment following the application of 4-point restraints. Upon discovery, the above findings were confirmed by S19.



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On 10/11/23 at 1:30 PM, the medical record of P6 was reviewed and the following was revealed:

P6 arrived at the facility Emergency Department (ED) on 7/13/23 at 12:15 PM via ambulance. The Triage Note written at 12:24 PM by Staff (S) 31, ED Registered Nurse (RN), stated, "Patient presents to ED via EMS (Emergency Medical Services) /BPD (Bayonne Police Department) for SI (Suicidal Ideation) without a plan. ESI (Emergency Severity Index) Level: 3-Urgent."

The nursing note written at 14:16 (2:16 PM) by S31 stated, "Patient became agitated aggressive and combative ... (Patient) came to the nurses station and began physically attacking RN. It was difficult to calm patient down and redirect...Patient spit punched and pulled RN hair. ED MD ordered medication to restrain patient ... ."

At 14:15 (2:15 PM), S23 (ED Physician), signed medication orders for P6 to be administered Lorazepam 2 mg (milligrams) IM (intramuscular) and Haldol 10 MG IM STAT (immediately). P6 was administered Lorazepam 2 mg IM at 14:33 (2:33 PM) and Haldol 10 mg IM at 14:34 (2:34 PM) as per the "Medication Discharge Summary."

The medical record of P6 lacked documented evidence the patient was assessed by a physician within one hour after Haldol and Lorazepam were administered per facility policy.

On 10/12/23 at 11:30 AM, S19 (ED Director), confirmed that a provider "should have completed a physician assessment after this patient was administered Haldol and Lorazepam since the nurse documented that the ED physician ordered the medications to restrain this patient." S19 confirmed that the medical record lacked documented evidence that P6 received a physician assessment after the medications were administered.

Based on the review of medical records, staff interviews and review of facility documents, it was determined that the facility failed to meet the needs of emergency department patients in accordance with acceptable standards of practice as evidenced by: failing to ensure that all patients that have received a medical screening exam and do not wish to stay for further treatment are accurately dispositioned (A1104) and failing to ensure that the policies for leaving AMA (Against Medical Advice), patient elopement, and discharge from the emergency department were implemented (A1104).

Cross Reference:

482.55(a) Emergency Services: Ongoing monitoring of the implementation of the policies and procedures established for the emergency department

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Based on medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to ensure: 1.) that all patients that do not wish to stay for treatment are accurately dispositioned in two of eight medical records reviewed (Patient (P) 5 and P10); and 2.) that the policy for discharge from the emergency department was implemented for two of eight medical records reviewed (P2 and P3).

Findings include:

Facility policy titled, "Patients Wishing to leave Against Medical Advice" effective date July 2020, stated, "... Any patient that has been seen by a physician, received a medical screening and does not wish to wait for discharge or admission is considered to leave the department against medical advice (AMA) ... Before a patient can leave AMA, the Physician must assess the patient's understating of his/her condition. He/she must determine and document in the EMR [electronic medical record] that the patient is alert and oriented, and the likely risks of leaving AMA have been explained to the patient, and that the patient understands them. Every effort should be made to convince the patient of the need for treatment. The AMA form will be completed by the physician and signed by the patient ... an effort will be made to provide necessary treatment to the patient, and a discharge against medical advice will be an avenue of last resort. In all cases, an incident report will be completed and submitted ..."

Facility policy titled, "4.03.01 Security Stat- Patient Elopement" effective date September 2023, stated, "Definitions ...Elopement patient- A patient who 'is aware that he/she is not permitted to leave but does so with intent.' ... Policy/Procedure It is the policy of CarePoint Health-Bayonne Medical Center to provide a safe and secure environment for all patients. In the event of patient elopement, it is policy of CarePoint Health-Bayonne Medical Center to implement policies and procedures to locate the patient. ... Documentation piece: 1. The patient progress notes must be updated by the RN and should relate: a. Time/date the patient was noted missing b. All actions taken c. Physician notification c. Family/guardian notification d. police Department notification 2. The Security Department will record time of notification and all actions taken, including hospital, environmental searches, and Police Department Notification into the Electronic Event Reporting System ..."

1. On 10/11/23, a review of P5's medical record indicated that the patient presented to the ED on 6/5/23 at 7:18 PM with complaints of "fever/dental problem." On 6/5/23 at 9:02 PM, the ED Physician documentation stated, "Results and diagnosis d/w [discussed with] the pt [patient], need for admission d/w [him/her] and [he/she] agrees with plan." On 6/6/23 at 7:57 AM, a Nursing Note stated indicated that the patient's friend got upset when the nurse informed them that he/she cannot stay in bed with the patient. A review of the "Patient Discharge Information" indicated that the patient eloped on 6/6/23 at 8:00 AM. Discharge Disposition documented was "ELOPEMENT - ER ONLY ... Patient Belongings Given Back to Patient."

On 10/11/23 at 10:50 AM, P5's medical record review was completed with S19, RN and ED Patient Care Director. S19 stated that the facility staff were aware P5 wanted to leave, and P5 was given back his/her own personal belongings and the IV access was removed. The Facility Policy titled, "Patients Wishing to leave Against Medical Advice" was reviewed with S19, who confirmed that P5's discharge should have been considered AMA, and not an elopement, according to the policy. On 10/11/23 at 11:59 AM, S10 confirmed there was no incident report completed for P5. Further review of the medical record indicated that P5 required inpatient treatment, however, lacked documented evidence that a physician or nursing staff discussed the risks of leaving the facility without the appropriate medical care.

A review of the facility document titled, "Security Staff" dated 2/23/2021, stated, "... Reporting: An electronic Security Incident Report shall be completed on all events that involve: ... patient elopement ..."

A review of P10's medical record revealed that P10 presented to the ED on 8/13/23 at 8:42 AM with complaints of "pregnant/sick." Review of clinical documentation in the section titled, "ED Physician Documentation" indicated that the patient was verbally aggressive to staff, refused vaginal ultrasound, and eloped as the patient did not want to wait, and P10 was "escorted by security." The ED disposition documented was "Elopement." Upon further review, P10's medical record lacked documented evidence concerning the patient's elopement. On 10/11/23 at 10:50 AM, during an interview with S19, the ED Director, it was stated that the patient was escorted out by security, thus did not meet the criteria for the disposition for elopement in accordance to facility policy.


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2. A review of P2's medical record revealed that the patient was brought to the ED on 7/4/23 at 10:29 PM with a complaint of alcohol intoxication. P2 was seen by a provider at 10:46 PM, but the medical record lacked documented evidence of a treatment plan at that time. On 7/5/23 at 1:00 AM, the patient was signed out to a new provider. The 1:00 AM provider note stated, "Patient was pending clinical sobriety ... reached clinical sobriety and eloped without informing staff." An ED disposition written by the ED nurse, on 7/5/23 at 5:15 AM stated, " ... Pt. [patient] requesting to leave. Pt. ambulated with assistance of a walker. Pt. responding appropriately to questions ..." ED Disposition of P2 was updated, by the ED nurse, on 7/5/23 at 6:04 AM as "Elopement." The medical record of P2 lacked evidence of nursing documentation regarding patient elopement per facility policy.

On 7/5/23 at 5:40 AM, P2 returned to the ED with a stated complaint of "Mental Problem" and a chief complaint of "Psychiatric Evaluation." An ED provider note written at 7:52 AM stated, "... The patient ... who is well-known to the emergency department who was here yesterday for EtOH [alcohol] intoxication returns today stating [he/she] is noncompliant with [his/her] medications and [he/she] is hearing voices and is suicidal." A patient status change order was placed by an ED Provider at 7:55 AM for a "PES [psychiatric emergency services] Crisis Evaluation Stat ... Reason For Exam: Hearing voices and is suicidal." At 11:47 AM, an ED Provider note stated, "The patient becomes verbally abusive and ends up walking out of the ER [emergency room]." The ED Disposition was noted as "Elopement." The medical record of P2 lacked evidence of of nursing documentation regarding patient elopement per facility policy.

On 10/12/23 at 10:50 AM, P2's medical record was reviewed with S19. S19 stated that P2 was well known to the facility as the patient presents often to the ED with alcohol intoxication. When questioned what information regarding community resources were provided to the patient, S19 was unable to provide evidence of resources provided or offered to P2. S19 stated that the patient often becomes verbally aggressive with staff and that the staff will let the patient leave.

P3 presented to the ED on 4/29/23 at 1:30 AM with a complaint of "vomiting." On 4/29/23 at 1:59 AM, the Nursing Assessment stated, "Patient presented in the ED via wheelchair for n/v [nausea and vomiting] today. Patient reports that [he/she] is a heroin addict and states that [he/she] feels [he/she] is in withdrawal. Last use reported around noon of 4/28/23." P3 had an admitting diagnosis of "Opioid Dependence with withdrawal" and the following medications were administered: Zofran (a medication used for nausea and vomiting) 8 mg (milligrams) IVP (intravenous push) administered at 2:30 AM, and Buprenorphine HCL (Hydrochloride) (a medication used to treat opioid use disorder) 2 mg SL (sublingual) at 6:32 AM. At 7:00 AM, the ED Disposition was documented as, "Time Patient Left ED: 06:59 [6:59 AM]; Discharged to: Home; Mode of Discharge: Ambulates with assistance; Form of Transportation: Taxi/Bus; Patient is Accompanied By: Alone; Above person(s) verbalize understanding: No: pt did not want to leave." The ED disposition identified that P3 required assistance to ambulate and was discharged to home alone on a taxi/bus without any assistance provided.

The "ED Course and Treatment" written by the ED Physician stated, "Patient states [he/she] does not wish to use heroin anymore. Informed patient of detox unit in area. Discharged home, f/u detox, return to ED precautions given." The "Patient Signature Page" indicated P3's name and states that he/she received the following patient instructions "Opioid Withdrawal" and "General Discharge Instructions." The Patient Signature Page stated, "I have read and understand the instructions given to me by my caregivers" with an area for a patient signature. The Patient Signature Page lacked P3's signature that indicated P3 received or understood the instructions. On 10/11/23 at 10:50 AM, S19 confirmed that the Patient Signature Page did not contain P3's signature. On 10/11/23 and 10/12/23, the instructions for Opioid Withdrawal and Discharge Instructions that P3 would receive upon discharge were requested from S19 but he/she was unable to provide the instructions. The medical record of P3 lacked evidence that the facility provided resources for contact information for detox centers or that the facility assisted in contacting a detox center for P3.

Facility policy titled, "Discharge From the Emergency Department," effective date August 2023, stated, "... It is policy of the Emergency Department to have every patient discharged with appropriate explanations, instructions, and follow-up care plans prior to leaving the emergency department ... Procedure A. Before a patient is discharged, the physician will discuss the diagnosis and treatment with the patient and with the nurse caring for the patient. B. The physician will provide both written and verbal discharge instructions for each patient and any necessary prescriptions with medication information. C. The nurse caring for the patient will verify the discharge order and review verbal and written discharge instructions and prescriptions with the patient and answer all questions, or if unable to answer questions, will seek clarification from the Emergency Department physician D. The patient or family/significant other will sign on copy of the discharge instructions to confirm that they have received and understand the written instructions. The signed copy will be placed on the patient's chart ..."