HospitalInspections.org

Based on medical record review, document review and interview, in two (2) of 25 medical records reviewed, it was determined the facility failed to conduct timely triage and assessments to ensure that patients presenting for detoxification received care in a safe environment. (Patients #1 and #2).

Findings include:

Review of the security "BHS Patient Log" revealed Patient #1's name and arrival at 3:47 PM on 7/22/19 were documented in the log in the Patient Welcome Center at the Park Care Pavilion.

Review of the medical record revealed Patient #1 was registered at the Patient Welcome Center at 4:46 PM and the reason for her visit was detoxification.

A nurse practitioner documented at 7:39 PM that the patient had a long history of alcohol dependence and was at the facility seeking admission for detoxification. "The patient was found in the parking lot at Park Care. The patient was groggy, pupils respond to light with increased light sensitivity. The patient responds to name and able to assist self with standing. Unable to cooperate to do a breathalyzer test. Multiple abrasions were noted on the patient's right facial area, right arm and left hand. The patient was transported to Andrus ED (main campus) via ambulance. After the patient was transported to the ED, a witness reported that this patient was sexually assaulted in the Park Care parking lot."

A nurse documented at 9:29 PM that the patient was "found by security staff outside, on the side of the streets, intoxicated and sleeping. The patient was alert and oriented x 3. The patient was assisted by staff to the Patient Welcome Center. Vital signs were 133/87, pulse 84 and respiration 17.``

The policy titled "Emergency severity Index (ESI) and Rapid Triage" which was last revised April 2017 states, the purpose of triage is "to evaluate all incoming patients and determine the types of services needed based on the priority of care. Patients are screened to determine level of acuity."

There was no evidence that the patient was triaged.

During an interview conducted on 8/27/19 at 10:02 AM, Staff B, an Intake Coordinator, Behavioral Health Services (BHS) Admissions stated, Patient #1 walked into the facility and was pre-registered. The patient was very intoxicated, she had slurred speech and she was not walking in a straight line. The patient did not have any bruises and her clothes were not clean. After the patient was registered, she was sent to the waiting area where Staff B observed the patient walking in and out of the waiting area.

Review of Medical Record #2 revealed the patient's name was entered in the Patient Welcome Center "BHS Patient Log" at 4:15 PM on 7/22/19. The patient was registered at 5:29 PM and the reason for his visit was noted as detoxification on the registration documentation. The patient was triaged at 7:59 PM and the reason for his visit was noted as detoxification from alcohol. The patient's vital signs were within normal limits and he acknowledged symptoms that included "little interest or pleasure in doing things, feeling depressed and hopeless, trouble falling and staying asleep, feeling tired and having little energy, poor appetite and trouble concentrating on things such as reading" for several days.

The "BHS Patient Log" indicated the patient was "escorted by Yonkers PD at 0015" on 7/23/19 and returned to the hospital at 4:00 AM on 7/23/19.

There was no documentation in in the patient's medical record after he was registered at 5:29 PM on 7/22/19 until 7:59 PM when he was triaged. There was no documentation in the medical record for approximately 8 hours, from 7:59 PM on 7/22/19 until 4:00 AM on 7/23/19, when he returned from the police precinct.

Review of facility documents titled "Witness Statement" revealed that this patient was allegedly involved in an incident of sexual assault which occurred at approximately 7:00 PM on 7/22/19 at the facility.

Based on observation, interview and document review, it was determined that the facility failed to demonstrate its reasons for the restriction or limitation on patient visitation rights.

Findings include:

During a tour of the Maternity Department on 8/21/19 at 10:00 AM visiting hours posted on the Post-Partum unit noted visiting hours as 1:00 PM to 8:00 PM. During an interview conducted during the tour with the Director of Maternity Services ,Staff I, she stated that fathers are allowed unlimited visiting privileges and all other visitors are allowed to visit between the hours of 1:00 PM to 8:00 PM.

Patient #5 in Room J 603 -1 was interviewed on 8/23/19 at 11: 40 AM. The patient reported that her nurse discussed the visitation hours with her on admission to the unit. She stated that that she was told that the visiting hours were 11:00 AM - 8:00 PM daily. The patient indicated that the Patient Guide Handbook was given to her on admission and she was informed that the visiting hours were in the Patient Guide Handbook.

The Nurse Manager, Staff J, assigned to the 7 West Unit was interviewed on 8/27/19 at 1:50 PM. This Nurse Manager stated that the Visiting Policy was 11:00 AM to 8:00 PM. She admitted that they do make exceptions and allow family to stay longer than the visiting time or come in earlier when requested.

The Security Officer, Staff K, sitting at the Information Desk, was interviewed on 8/27/19 at 1:45 PM. The Security Officer reported that the visiting hours were 11:00 AM - 8:00 PM daily, for all inpatients; 1:00 PM to 8:00 PM and fathers have unlimited visiting privileges. He stated after 8:00 PM security officers check all floors and inform visitors that visiting time is over and that everyone must leave the facility. The Security Officer stated that he is not permitted to allow visitors to enter the facility before or after visiting hours, however an exception can be made if a visitor makes a request to visit a patient and it is granted by the nurse on the unit.

None of the staff interviewed were able to explain the reasons for the limitation or restrictions imposed
on visitation.

The facility Policy and Procedure titled "Visitors," which was last reviewed in April 20019, stated the following: "Present hospital visiting hours and regulations are defined as: Andrus Pavilion - All patient units except Maternity, Daily visiting hours: 11:00 AM -8:00 PM, Andrus - Maternity Daily visiting hours 1:00 PM to 8:00 PM. Dobbs Ferry- same as Andrus Pavilion. Park Care Pavilion - The visitation for inpatient detoxification is individualized and scheduled as needed with staff. Inpatient Rehabilitation hours are Wednesday by appointment; arrangements to be made by the Counselor and on Saturday visiting hours are 12:45 -3:00 PM."

It was noted that the facility's visitors policy did not set forth any clinically necessary, reasonable restrictions or limitation imposed on visitation.

Review of The Patient Guide Handbook noted that the visiting hours were: Andrus Pavilion - Medical/Surgical Units - 11:00 AM to 8:00 PM; Andrus - Maternity - General visitors 1:00 PM to 8:00 PM. Dobbs Ferry- 12:00 PM to 8:30 PM. Park Care Pavilion - General visitation is limited, please arrange with hospital staff.

Based on the observation, document review and staff interview, the facility failed to provide a functional and sanitary environment for the provision of surgical services.

Each operating room must be designed and equipped so that the types of surgery conducted can be performed in a manner that protects the lives and assures the physical safety of all individuals in the area.

Findings include:

During the tour of the facility's OR in the Dobbs Ferry location on 8/28/2019 at 11:15 AM, it was observed that the soiled utility room in the OR suite had a positive pressure which should be negative pressure relative to the sterile corridor in the OR.

This finding was identified in the presence of the Director of Plant Operations and the Assistant Director of Plant Operations.

During the review of documents it was noticed that only temperature and relative humidity were monitored on a daily basis, however pressure relationship was monitored once per week or as needed.

According to CDC guidelines, OR pressure relationship should be monitored continuously, preferably daily and the results of the monitoring should be documented according to CDC.

Failure to maintain positive air pressure in the OR may lead to contaminants entering the OR from the corridors, and consequently a breach in infection control.

The above finding was brought to the attention of facility's administration during the exit conference on 08/30/2019 at 3:30 PM.

Based on medical record review, document review and interview, in three (3) of three (3) medical records reviewed, the facility's practice to transfer patients who presented with a history of sexual assault to a facility dedicated for the collection of forensic evidence, is not defined in their written policy (Patient #s 1, 2 and 12).

Findings include:

Review of the medical record for Patient #1 identified the following: On 7/22/19 at 4:46 PM, this patient was registered at the Park Care Pavillion and the reason for her visit was detoxification.

A nurse practitioner documented at 7:39 PM that the patient had a long history of alcohol dependence and was at the facility seeking admission for detoxification. The patient was found in the parking lot at Park Care. The patient was groggy and her pupils responded to light with increased light sensitivity. The patient responds to name and able to assist self with standing. Unable to cooperate to do a breathalyzer test. Multiple abrasions were noted on the patient's right facial area, right arm and left hand. The patient was transported to Andrus ED (main campus) via ambulance. After the patient was transported to the ED, a witness reported that this patient was sexually assaulted in the Park Care parking lot.

The ED resident at the Andrus campus, documented at 9:19 PM that the patient was unresponsive and she was found down outside rehabilitation (2 Park Care) for unknown duration. The patient was noted to be hypoxic, oxygen saturation 55% on room air and unresponsive to verbal stimuli. The patient remained unresponsive during trauma resuscitation. In the CT scanner the patient sat up and was responsive to questions. The patient stated she was attacked by 3 (three) unknown assailants at an unknown time. The patient did not recall the event and time. The patient stated she was seeking detox at 2 Park Care for alcohol withdrawal. The patient currently endorses dull, diffuse headache with no identifiable triggers or alleviators.

The resident completed a history and physical examination and reviewed the lab work. Radiology studies were reviewed at 10:30 PM.
The resident documented at 12:06 AM on 7/23/19 that the patient reports being raped by unknown assailant to police at bedside. Police reports witness that visualized rape encounter at outside facility and that the patient was endorsed to a SANE nurse at another facility.

The documentation in the medical record noted at 12:05 AM on 7/23/19, the patient was transferred to a facility which has a sexual assault forensic examiner (SAFE), for collection of the forensic evidence.

Review of medical record for Patient #2 identified: This eight (8) year old patient presented to the ED on 6/10/19 at 9:28 PM with allegations of sexual assault. The ED doctor documented that Child Protective Services and the police were informed and that the patient was transferred to another hospital for further evaluation at midnight.


Review of medical record for Patient #12 identified: This 22 year old patient presented to the ED on 8/17/19 at 10:37 PM because she awoke undressed that morning, after she went home with a coworker the previous night. The patient reported that she did not remember the events of the previous evening or going to his home.

The physician performed a physical examination but did not collect evidence for the sexual assault. The patient was discharged from the hospital after she was offered the opportunity to and agreed to go to another facility for evidence collection.

There was no documented evidence that staff collected evidence from these victims.

The facility's policy titled "Sexual Assault" which was last revised April 2015 does not direct the staff to transfer victims of rape to another hospital, as part of a community plan.

During an interview with the Chief of the ED on 8/28/19 at 11:10 AM, he stated that the facility has the capability to perform assessments and collect evidence from victims of assault and he acknowledged that these patients are transferred out to another facility for the collection of forensic evidence.









35161