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Based on interviews, review of documents, records, video recording, and procedures, it was determined the facility's Governing Body did not ensure effective accountability for all hospital operations as required.

Findings include:

The governing body did not exercise its responsibility for the monitoring and implementation of effective operations and clinical services in the facility as evidenced by sustained and repeat noncompliance with the following regulatory requirements:

?482.13 Condition of Participation: Patient's Rights
?482.55 Condition of Participation: Emergency Services .

1. Condition level noncompliance was identified for Patient's Rights.

The facility was cited in June 2013 for an unsafe environment of care related to incidents that occurred in the emergency department. The facility has demonstrated repeat noncompliance in the failure to provide a safe environment of care in accordance with patients' rights requirements:

a. Sustained noncompliance is cited for the failure to maintain a safe environment of care for adolescents who are held for extended periods in a room within the psychiatric area of the emergency room without sufficient monitoring; (Cross refer to findings noted under A144)

b. The facility failed to protect patients from criminal activity in the Emergency Department waiting room. (Cross refer to findings noted under A144)

c. The facility failed to provide complete investigation of patients grievances. (Refer to findings detailed under Tag #A118)

d. The facility failed to provide written responses to complainants that entail documented comprehensive findings of the results of hospital grievance investigations. (Refer to findings detailed under Tag #A123.)

Refer to findings detailed under Tag #A115, A118, and A144.

2. Condition level noncompliance remains for Emergency Services.

a) The facility did not provide care to patients that met generally accepted standards of emergency practice.(Cross refer to Tag #A1100 and Tag # A1100 in the 2567 form corresponding to Allegation NY 00141524, Event ID # J9D311)


b) The facility failed to provide medical screening examinations for two patients, one of whom expired after being found slumped and in cardiac arrest in the emergency waiting room more than eight hours after presentation;
(Cross-refer to Tag # A1100 and under Tag # A1100 in the 2567 form corresponding to Allegation NY 00141524, Event ID # J9D311)

Note that the facility therefore failed to comply with EMTALA regulations, cited under the 2567 for Allegation #NY00141529, Event ID # J2RQ11.


c) The hospital failed to implement practices that require timely reassessment and monitoring of emergency patients in the waiting room;
(Cross-refer to Tag # A1100 and under Tag #s A1100, A1104 in the 2567 form corresponding to Allegation NY 00141524, Event ID # J9D311)


d) The facility failed to protect patients and others from criminal activity in the emergency department waiting room;
(Cross refer to Tag # A144 and under Tag # A1100 in the 2567 form for Allegation NY 00141524, Event ID # J9D311)


e) The facility failed to maintain a safe environment for adolescents who required psychiatric emergency care due to placement of these patients in a holding room for extended periods with insufficient monitoring;
(Cross refer to Tag # A144 and under Tag # A1100 in the 2567 form for Allegation NY 00141524, Event ID # J9D311)

f) The facility did not establish sufficient policies and procedures for patient care monitoring and care planning of adolescents held for emergency psychiatric care.
(Cross refer to Tag # A1104 and under Tag # A1104 in the 2567 form for Allegation NY 00141524, Event ID # J9D311)

g) implement consistent policy and procedure that ensures effective supervision of patients who require special monitoring in the emergency room, particularly for patients who are assaultive, suicidal, homicidal, or who require who require enhanced monitoring.
(Cross refer to Tag # A1104 and under Tag # A1104 in the 2567 form for Allegation NY 00141524, Event ID # J9D311)









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Based on observation, interviews, and review of documents, it was determined the hospital did not establish effective compliance requirements that protect and promote Patient's Rights in the facility, particulary in the Department of Emergency Services.

Noncompliance with the Condition of Participation of Patient Rights is a repeat of Condition level noncompliance that was identified during a previous survey of 6/14/13.

Findings include:


The facility did not comply with requirements for the protection and promotion of patients' rights as required.

The facility failed to meet the Condition of Participation for Patient Rights due to sustained non-compliance with requirements as follows:

1. The facility did not provide a safe and secure environment for patients in the psychiatric emergency room . (MR #1, #3, and #4)

The facility failed to provide monitoring of adolescent patients who were held in an enclosed room in the psychiatric area of the hospital's emergency department for extended periods.

The facility failed to provide a safe environment that protected patients from alleged criminal activity in the emergency department .

Refer to findings detailed under Tag #A144.

2. The facility failed to meet requirements that mandate the complete investigation of patients grievances.

Refer to findings detailed under Tag #A118

3. The facility failed to provide written responses that entail comprehensive findings of the results of hospital grievance investigations.

Refer to findings detailed under Tag #A123.






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Based on review of grievance records, procedures, and interviews with staff, it was determined that the hospital did not conform to facility procedures due to lack of complete documentation of investigation of grievance issues and thus did not fully resolve patient grievances.

Findings include:

Review of the hospital policy titled " Patient Complaint Grievance program " on 1/30/14 finds that the complaint issues shall be resolved by staff, reported to the departmental managers who will attempt to resolve the grievance, and also reported to Patient Relations departmental staff.

The facility did not conform to its own procedures because 9 of 13 grievance files reviewed on 1/30/14 did not include documentation of complete investigations as follows:

Grievance file #1
The file noted the patient complained on 7/10/13 that she waited 1 hour in the waiting room for chest pain. The security officer blocked her from entering to speak with the nurse and that he harassed her telling her he would throw her out and she would not be seen. The patient threw her cell phone at the security officer. An investigation was conducted by the hospital which included witness interviews with Security and nursing staff. It was concluded that while the patient was angry, the officer did not maintain professionalism and was counseled.
There was no investigation to determine if the patient ' s wait was excessive. Review of the patient ' s emergency record on 1/31/14 found that the patient was triaged at 9:37 PM on 7/3/14 with complaint of chest pain and classified as emergency severity index, ESI 2. The patient ' s EKG was timed at 9:14 PM and noted sinus tachycardia.
Review of the investigation file found that grievance information was not consistent with information that was documented in the patient's medical record reviewed. The grievance investigation did not address the length of the wait for triage. The investigation not address a finding for why the patient was ordered to have a security watch at 12:02 PM on 7/3/13 for purposes of psychiatric evaluation and that this obsevration was discontinued at 5:42 PM on 7/3/13. (which was more than nine hours prior to documented triage). At interview with the staff #2 on 1/31/14, no explanation could be provided for why the patient was placed on security watch 9 hours prior to medical triage.


Grievance file #2
Review of the grievance file on 1/29/14 found this patient ' s mother complained on 9/24/13 that her daughter was improperly cared for while in the psychiatric adolescent area in ED-3. It was alleged her daughter attempted to hurt herself twice and that staff were not watching her child. Medical and nursing staff reported the child was on continuous supervision but another hospital reviewer indicated an extra nursing attendant had started that week. The email responses did not address all the grievance concerns including the allegation that the patient was not bathed. The investigation did not evaluate or conclude if staff supervision was adequate.

Grievance file #3
A written complaint submitted by the partner of a patient who reported witnessing security staff punch another patient in the emergency room on 7/31/13. When reporting this situation, the complainant and her partner (the patient) were allegedly told to leave by the Nursing Director. The investigation file included a review by the Nursing Director of ED who reported the patient and complainant became threatening when the partner was asked to leave the emergency room with the other visitors until a situation involving a violent intoxicated patient was under control. A security department review was not submitted with the grievance file for review by the surveyor. The investigation did not evaluate if actions taken were appropriate with the violent patient, including a review of the patient's record.


Grievance file #6
Patient ' s family filed a complaint on 10/17/13 that the patient had been discharged from the emergency room wandering the street in a hospital gown. Additional complaints were filed about cleanliness in the emergency room during a return visit and that the ED Nursing Director Staff #2 was rude and pointed in the family ' s face. In the complaint file, the hospital reviewer described follow up which found there was a verbal interaction between the family member and the ED Nursing Director that required Security involvement. The nurse manager acknowledged the agency nurse who discharged the patient in a gown was dismissed. However, the grievance file contained documentation by the hospital's reviewer, who noted that it could not be substantiated that the patient had left in hospital gown. The reviewer did not address this inconsistency in findings obtained. The case was closed on 10/23/13 and there was no evidence the facility followed up on these contradictory findings noted about the manner in which the patient was dressed at discharge.


Grievance file #7
On 1/16/14 the patient complained a security officer placed his hands on him for no reason. The patient complained he sustained scratches on the neck during the event and provided a physical description of the officer (but no name was provided). Security Department review noted on 1/20/14 that an investigation could not be conducted due to insufficient detail provided and that two voice mails were left for the patient with no response. The review included no chart review, no review of the schedule roster for the date matching the patient encounter, and no attempt to contact the complainant by mail correspondence.

Grievance file #8
On 4/30/13, the patient complained of the experience having surgery in the Ambulatory Surgery center. He complained he was not assisted with a wheelchair by security, the nurse failed to provide pain medication, there was a excess delay on transport, the dietary meals was of poor quality, and about temperature control in that the room was too cold. The hospital review indicated the patient ' s report about the failure to assist with a wheelchair was inaccurate. While the dietary issue was addressed, the grievance file lacked follow up resolution of the transport issue. The record lacked follow up investigation of the pain medication issue.

Grievance file #10
The patient complained on 12/4/13 she waited in the ER for 11 hours with no asthma treatment in the emergency room. The grievance file contained actions taken to visit the patient who was anxious and who was receiving medication via mask and able to take medication. She was upset about waiting too long for a bed. On 12/5/13 the hospital staff visited the patient, who had been admitted and she was satisfied. Although the facility determined the patient was satisified, there was no notation by facility staff to address the potential delay in treatment.


Grievance file #12
On 1/16/14, a patient ' s sister complained the emergency room was too crowded with lack of privacy. She reported the stretchers are too close together and she requested transfer. The patient was requesting a breast pump. Staff noted situation is resolved but did not describe if the complaint was validated or describe actions taken other than provision of breast pump. The hospital representative followed up and acknowledged the patient ' s receipt of the pump and redirected medical concerns to her physician. The investigation lacked review of concerns about overcrowding and privacy.

Grievance file #13
On 10/2/14, the patient ' s daughter in law complained the patient was not provided with diabetic medication for more than eight hours in the emergency room. The complaint was referred to ED administrative staff including the Medical Director of Emergency, the evening supervisor, and to the Nursing Director of Emergency.
The administrator spoke with the husband and another relative, and reviewed the record for time and treatment. The patient and the family left the emergency department (ED) without signing out against medical advice (AMA). Outcome in file notes patient/family " satisfied ", that a response was given to the patient, and the complaint was closed out on 10/7/13. However, the investigative file did not identify the results of record review to ascertain if the treatment delay was verified.
At interview with Staff #1, it was reported that overall issues with grievance resolution are ongoing for improvement and will be managed by Patient Relations staff .

Based on review of grievance records, procedures, and interviews with staff, it was determined that the hospital did not fully respond to complainants in writing with feedback that incorporated the steps taken to investigate each complaint issue and complete results of the hospital's grievance investigations.

Findings include:

Review of the hospital policy titled " Patient Complaint Grievance program " on 1/30/14 notes that any complaint not resolved in 24 hours will become a grievance and if not resolved within 6 calendar days an interim letter will be prepared indicating that the facility is still attempting to resolve the grievance. A final letter will be sent within 30 days from the date the grievance was received. It is required this document contain: " the name of the hospital employee for contact, the steps taken to investigate the grievance, the results of the investigation, the date the investigation was completed, and notice of the right to contact the Department of Health and/or the Joint Commission by telephone or writing "

The facility did not conform to its own procedures since review of 10 of 13 patient grievance files on 1/29/14 and 1/30/14 lacked documentation of the provision of any response. Three of 13 grievance files reviewed included provision of a written response, but the correspondence lacked sufficient detail of the specific findings obtained or notification of the option to contact external regulatory or accreditation agencies in the event the complainant is dissatisfied with the response.

The following grievance files did not conform to its grievance procedure that requires provision of complete written responses as follows:

Grievance file #1
The file noted the patient complained on 7/10/13 that she waited 1 hour in the waiting room for chest pain.
The response letter provided to the complainant was delayed (dated 8/6/13) and did not discuss the specific findings. The letter contained vague language about " incorporating actions for meaningful improvement " . There was no information about the option of how to contact regulatory agencies for independent reviews, other than reference to a patient Bill of Rights enclosure. The investigation and written response letter did not address all of the allegations. For example, the response did not include an explanation to determine if the patient ' s wait was excessive.

Grievance file #2
Review of the grievance file on 1/29/14 found this patient ' s mother complained on 9/24/13 that her daughter was improperly cared for while in the psychiatric adolescent area in ED-3. The child had attempted to choke herself with her hospital gown in the psychiatric area of the emergency room where adolescents are held. The case was closed on 10/1/14 but despite attachments referenced for the investigation, no letter of response to the complainant was attached with the results of the grievance review.

Grievance file #3
A written complaint submitted by the partner of a patient who reported witnessing security staff punch another patient in the emergency room on 7/31/13. When reporting this situation, the complainant and her partner (the patient) were allegedly told to leave by the Nursing Director . The final response letter provided to the complainant dated 8/8/13 indicated an investigation was performed and that no further action is to be taken, The response letter did not disclose the specific findings nor the results of the security review.

Grievance file #4
On 9/27/13 the patient complained to medical staff that she observed her intravenous fluid bag had the name of another patient. The event was substantiated. While staff did speak with the patient, no formal letter of response was provided with the investigative results in the grievance record.

Grievance file #5
On 7/25/13 a complaint was filed by the family of a patient where it was alleged that on 7/24/13, the security officer hit the patient around the face . Review of the response letter provided to the complainant dated 7/30/13 noted " an investigation was undertaken into this matter with involved staff. Upon review of this case, it did not indicate any further action is to be taken. " No explanation of findings was documented.
Grievance file #6
Patient ' s family filed a complaint on 10/17/13 that the patient had been discharged from the emergency room wandering the street in a hospital gown. The case was closed on 10/23/13 and there was no written letter of response attached to the grievance file with evidence of a written response provided to the complainant.

Grievance file #7
On 1/16/14 the patient complained a security officer placed his hands on him for no reason. The patient complained he sustained scratches on the neck during the event and provided a physical description of the officer (but no name). The review included no chart review, no review of the schedule roster for the date matching the patient encounter, and no attempt to contact the complainant by mail correspondence.

Grievance file #8
On 4/30/13, the patient complained of the experience having surgery in the Ambulatory Surgery center. The patient was contacted and the bill was written off. There was no documentation of a written response provided . The case file was closed and while attachments were referenced, none were provided for review.

Grievance file #9
Patient ' s mother complained on 12/12/13 that the Emergency Department Medical Director threatened her with physical harm and calling the Police. No written letter of response was provided in accordance with hospital grievance policy.
Grievance file #10
The patient complained on 12/4/13 she waited in the ER for 11 hours with no asthma treatment in the emergency room . No written response was attached.

Grievance file #11:
On 1/15/14, a complaint was received from a patient ' s significant other who alleged the Security staff punched the patient in her chest following the patient ' s refusal to remove her jacket and that the jacket was ripped off by the staff. The grievance record provided during the survey contained no documentation of written letter of response provided to the complainant with findings, despite notation on a summary form that a response was provided. Attachments were referenced but not enclosed in the file provided. Follow up documents including a response letter were not provided by the facility until 2/11/14.
Grievance #12
On 1/16/14, a patient ' s sister complained the emergency room was too crowded with lack of privacy. The grievance record contained no written letter of response provided to the complainant with findings, despite notation in the grievance file that a response was provided. Attachments were referenced but not enclosed in the file provided. The case was closed on 1/17/14.

Grievance #13
On 10/2/14, the patient ' s daughter in law complained the patient was not provided with diabetic medication for more than eight hours in the emergency room. Outcome in grievance file notes patient/family " satisfied " ,that a response was given to the patient, and closed out on 10/7/13. However, there was no verification of documentation of a written response provided to the complainant in accordance with hospital policy.

Based on observation, interviews, and review of procedures and records, it was determined that the facility did not provide a safe environment for patients in the emergency department due to failure to:
1) provide a safe environment of care and monitoring to adolescents arriving for emergency psychiatric treatment; and
2) provide a safe environment free of alleged criminal activity in the emergency department .

Findings include:


1. The facility ' s practice entails placement of adolescents of both sexes in a single confined room located within the adult psychiatric emergency room, where they are cohorted, at times for extended periods, while awaiting assessment, observation, and/ or transfer to facilities for psychiatric inpatient care.

During tour of the psychiatric section of the emergency room, " ED-3 " , on 1/27/14 at approximately 1PM, an enclosed room was observed in which one female and four male adolescent patients were seen resting on chairs and/or stretchers while watching television. This enclosed room is located within the setting of the larger emergency suite, (ED-3) where adult psychiatric patients are held for evaluation.
A nursing aide was present at the door entrance and a security officer was posted in the suite area directly outside the room in the adult suite area.

This room is fully visible from the external adult psychiatric emergency suite due to the presence of two windows bordering the enclosed room on two sides. The room measures 18 feet long by 11.5 feet wide, and this space also lacks a sink or bathroom. There are no screens for privacy. The confined space of the room was filled with at least two stretchers and five chairs in close proximity at the time of observation on 1/27/14. The room was dark with a large screen TV. The ED Nursing Director and ED Medical Director reported at interview on 1/27/14 that these adolescents sleep, eat, and watch TV in this single room area.

During interview with the ED Nursing Director (staff #2 ) on 1/27/14, it was stated the facility utilizes this small room in the ED-3 section of the psychiatric area to routinely hold non-violent male and female adolescent patients. It was reported by the ED Nursing Director that the patients remain cohorted in this room until a disposition, discharge, or transfer is arranged to inpatient psychiatric facilities.
It was stated all adolescent patients in the holding room are under 24 hour constant observation by a nurse aide who documents their activity on an hourly basis. A security officer is posted outside of this room in the adult psychiatry emergency suite area for security watch. If the adolescent becomes too agitated or violent, it was also stated that transfer to the adult emergency area, ED-1, would be implemented with constant observation and security watch along with restraints if needed.

1b). The facility did not effectively implement close monitoring and security watch procedures for adolescent patients in the emergency psychiatric area. Three of four patients allegedly engaged in risk behavior despite constant monitoring and security watch. Thus, the facility failed to ensure adequate safety of patients.

In addition , three of four records reviewed on 1/31/14 for adolescents held in the enclosed room in the psychiatric emergency area found these patients had extended stays of six days or greater.

MR # 4
The record for this14 year old patient was reviewed on 1/27/14 and 1/31/14. Patient had a past history of depression with medication noncompliance, self inflicted cutting, and sexual abuse by an uncle. The patient was brought into the psychiatric emergency room (ED) by ambulance on 1/20/14 with a chief complaint of " I ' m confused " . Amber alert and Police notification was initiated and the patient ' s mother reported the teen had been missing for six days. The patient acknowledged using marijuana and alcohol and had blacked out. Initially patient reported she could not recall encounters and denied sexual activity. However, the patient also stated she had sex with one person but thinks she had sex with others as well. The mother reported the child ' s past history of running away and promiscuous behavior. A sexual assault evidence kit was collected on 1/20/14 and authorized by the mother for release to the Police.

The patient was placed on security watch since 1/20/13.
On 1/27/14 at 1 PM the patient was observed in the psychiatric observation room with four male co-patients and a nursing aide. Surveyor spoke with the patient on 1/27/14 briefly who stated she wanted to speak with the doctor who had not spoken with her in several days. Review of the record on 1/27/14 determined an interview with the psychologist on 1/25/14 and MD but no documentation of discussion about coping with the impact of sexual assault other than child's statement she would repeat her runaway and sexual behavior if discharged home. While the plan was to admit the patient to an inpatient facility, the lack of insurance and available psychiatric beds delayed transfer.

The facility did not address the emotional impact of placing this adolescent patient who was the victim of sexual abuse in a common area with four male adolescent patients and monitoring by a nursing assistant. A security officer was posted outside the room who was assigned to monitor the entire emergency psychiatric area. Following discussion with the Staff #2 on 1/28/14 it was reported the patient was moved on a stretcher to the adult area of the psychiatric area because she was acting inappropriately with co-patients. The patient was again observed in the enclosed holding room on 1/31/14 at approximately noon but the move or relocation back to this area was not documented in the record.

During interview with the staff #20 on 1/30/14 at approximately 11 AM it was reported the patient was observed by staff # 20 to be engaging in inappropriate discussion with a male patient on 1/29/14 and reported that a male co-patient (referenced in MR #6) had hugged the patient and at one point had tried to leave the adolescent room when the patient was in the bathroom. She reported no incident report was filed because Security redirected the male patient and the attempt to leave was intercepted..

Follow up review of MR #4 on 1/31/14 found the medical note of 1/29/14 at 8:08 AM in which it was indicated the patient locked herself in the bathroom overnight and did not want to speak. It was noted there was concern about her proximity to another male patient. No follow up action was noted in the patient record.
Review of nursing activity record found that the patient locked herself in the bathroom and was crying at 1 AM on 1/29/14. At 2 AM it was noted she was talking with a peer. No action plan to address this issue was documented. Follow up tour with staff # 2 on 1/31/14 found the bathroom doors could be opened by staff in emergency, but the patient record did not describe how the event was resolved.

Psychiatry notes reviewed did not address the interventions to counsel the patient about the incident or to elicit her feeling about having had the rape kit collected on 1/20/14.

This patient was held in this area for a prolonged period (10 days) due to identified problems with lack of insurance and the lack of bed availability at other facilities. The patient was accepted for psychiatric transfer to another facility on 1/31/14.

MR # 6:
15 year old male with history of major depressive disorder was brought in by ambulance and Police in handcuffs with suicidal and homicidal ideation against himself and his family on 1/23/14. He was placed on Security watch and then transferred to the sequestered room in ED-3 where adolescents are held on 1/24/14. The patient was held in the psychiatric emergency area until he was transferred to another facility for inpatient psychiatric treatment on 1/29/14. He remained for six days in the holding room.. There was no identified documentation in the medical record about the incident that involved the patient ' s alleged contact/ hugging of female peer ( MR #4) as reported during interview with staff #20.

MR # 3
15 year old male was brought in by ambulance on 1/16/14 after running away from home. The patient ' s history was significant for depression and ADHD. The insurance denied authorization for inpatient admission initially and follow up attempts to discharge home were unsuccessful because the mother failed to report back to the hospital. A report was filed to Child Protective Services for alleged abandonment. According to his mother he had been physically assaultive at home resulting in numerous Police reports. Follow up eventually was successful and the patient was transferred for inpatient psychiatric care on 1/28/14.The patient was held in the holding area of psychiatry in the confined room between 1/16 and 1/28/14 (12 days). The 2221 reporting form noted " patient has been sleeping on a recliner since he came in "

MR # 5
MR #5 referenced this 16 year old female with bipolar disorder and ADHD was brought to the hospital ' s ED on 9/21/13 at triaged at 544 PM because she tried to cut herself the day prior with a knife. The patient was brought to the ED-3 psychiatric area. Psychiatric assessment at 11:58 PM on 9/21/14 recommended need for inpatient psychiatric admission and one to one observation for suicide watch. On 9/22/13 at 1320 the physician noted he was called by the nurse who reported the patient was agitated and refusing medication. He saw the patient trying to choke herself with her gown top and the security guard was wrestling the patient to the floor to obtain the gown. A second security guard who arrived helped to hold the patient who tried to run away. The physician noted the security officer reported she had earlier tried to grab a pen from a counter and vocalized she wanted to stab herself. The physician also noted the security guard reported " the patient was running all around ED3 and he cannot keep watching her and all the other patients at the same time. " The patient was transferred to the adult ED for( ED-1) for medication and restraint at 12:57 PM. The nurse noted she became agitated during a call from the mother. The patient calmed down in ED 1 and was transferred back to the adolescent room in the Psychiatric ED -3 at 4:34PM. Review of the nursing hourly rounding log dated 9/22/13 determined documentation of suicidal self destructive behavior between 12 and 1 PM on 9/22/13 but lacked any documentation or action taken following the previous incident as reported by Security staff..

At interview with Staff # 1 on 1/30/14, it was stated this incident occurred prior to the initiation of the facility ' s plan of correction from the prior survey and that there is always an aide stationed in the adolescent room in the ED-3 psychiatric emergency area. Staff interviewed could not explain how these attempts occurred despite the finding the patient was required to be monitored on one to one observation.



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2. The facility failed to provide a safe environment that protected patients from alleged criminal activity in the emergency department .
During the tour on 1/28/14 at 2 PM of the Security Department, it was observed that a male was under arrest by the New York City Police Department after being found in the ED waiting room.
Interview with Security Lieutenant on 1/28/14 at 2 PM, it was reported that the perpetrator was allegedly selling heroin from the bathroom, where it was alleged these drugs were stored in the ceiling.
Interview on 1/28/14 of the hospital Security officer confirmed that the male under arrest was arrested for selling and storing heroin in the ceiling of the adult ED male bathroom.

Review of the incident/situation reports on 1/31/14 provided by Hospital Security found that on 1/28/14 at 1135 AM, a female who was waiting in the emergency room waiting area with her son for emergency care reported that "they" were making drug transactions in front of her and directed the officer to the bathroom where the alleged perpetrator was. The male, a visitor, was found in the bathroom placing a needle on top of the sink and sniffing a drug substance through a clear plastic capsule. When asked to stand back, the male tried walking out of the bathroom and threw everything into the garbage. Officers collected two needles and a plastic cap with a white powder inside. The male was arrested by the police precinct and issued a summons for trespassing.


16401

Based on interviews, review of documents, records, video recording, and procedures, it was determined the facility did not provide care to patients that met generally accepted standards of emergency practice due to the following:

1) The facility failed to provide medical screening examinations for two patients, one of whom expired after being found slumped and in cardiac arrest in the emergency waiting room more than eight hours after presentation;
(Cross-refer to Tag # A1100 and details cited under Tag # A1100 in the 2567 form corresponding to Allegation NY 00141524, Event ID # J9D311)

2) The hospital failed to implement practices that require timely reassessment and monitoring of emergency patients in the waiting room;
(Cross-refer to Tag # A1100 and details cited under Tag # A1100, A1104 in the 2567 form corresponding to Allegation NY 00141524, Event ID # J9D311)


3) The facility failed to protect patients and others from criminal activity in the emergency department waiting room;
(Cross-refer to Tag # A1100 and details cited under Tag # A1100 in the 2567 form corresponding to Allegation NY 00141524, Event ID # J9D311)


4) The facility failed to maintain a safe environment for adolescents who required psychiatric emergency care due to placement of these patients in a holding room for extended periods with insufficient monitoring;
(Cross-refer to Tag # A1100 and details cited under Tag # A1100 in the 2567 form corresponding to Allegation NY 00141524, Event ID # J9D311)


5) The facility failed to establish procedures to safely manage the needs of adolescents evaluated within a confined room of the psychiatric area of the emergency room.
(Cross-refer to Tag # A1104 and details cited under Tag # A1104 in the 2567 form corresponding to Allegation NY 00141524, Event ID # J9D311)

6) The facility did not establish and implement consistent practices for observation in the emergency room (ER) that maintain safety of patients who are assaultive, suicidal, homicidal, or who require who require enhanced monitoring. The facility failed to establish and implement clear instructions for implementation of close observation and security watch.
(Cross-refer to Tag # A1104 and details cited under Tag # A1104 in the 2567 form corresponding to Allegation NY 00141524, Event ID # J9D311)


Note the above findings represent sustained noncompliance with the Condition of Participation of Emergency Services is a repeat of similar patient safety violations that identified during a prior survey of 6/14/13.

Based on interviews, and review of documents, records, and procedures, it was determined the facility failed to establish and implement policies in the emergency room to ensure safe delivery of emergency care in the failure to:

1) establish and implement effective practices to monitor the emergency waiting room for patients with presumptive medical needs for provision of required medical screening examinations;

2) develop and implement procedures for the management and safety of adolescents who require emergency psychiatric care and who are held inside a confined room located within the adult psychiatric emergency area for extended periods while awaiting disposition; and

3) implement consistent practices for observation in the emergency room (ER) that maintain safety of patients who are assaultive, suicidal, homicidal, or who require who require enhanced monitoring.

(Cross-refer details cited under Tag # A1104 in the 2567 form corresponding to Allegation NY 00141524, Event ID # J9D311)






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