The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

MILFORD HOSPITAL, INC 300 SEASIDE AVENUE MILFORD, CT 06460 Oct. 2, 2014
VIOLATION: CONTRACTED SERVICES Tag No: A0084
Based on review of the clinical record, review of hospital policy, review of hospital documentation and interviews with hospital personnel for 1 (Patient #3) of 10 patients reviewed for abuse, documentation and interviews failed to reflect that the hospital's governing body ensured that the Emergency Services performed under a contract were provided in a safe and effective manner. The findings include:


Patient #3 was admitted to the hospital's Emergency Department (ED) under police custody on 8/30/14 at 3:14 AM with suicidal ideation, alcohol intoxication and multiple facial abrasions. Review of the ED record and interview with RN #1 on 9/30/14 at 12:30 PM identified that Patient #3 was diaphoretic, tremulous and anxious at 11:30 AM on 8/30/14. The patient was in 2 point forensic restraints (wrists) requesting his/her medication, including Suboxone. Review of Patient #3's ED record and interview with RN #1 on 9/30/14 at 12:30 PM identified that on 8/30/14 at 11:30 AM, RN #1 observed MD #1 in Patient #3's room (Room 9). While Patient #3 was restrained, MD #1 raised his/her right arm with an open right hand, RN #1 heard one slap and heard MD #1 saying "Snap out of it". Review of the record and interview with the ED Technician on 9/30/14 at 2:00 PM indicated that the ED Technician recalled MD #1 saying loudly "Snap out of it" and observed MD #1, with his/her right hand, slap Patient #3 on the left cheek. Review of hospital documentation, and interviews with RN #1 and the ED technician identified that a policeman, Officer #1 was present at the time of the event.
Review of the ED record and interview with the ED Medical Director on 9/30/14 at 1:15 PM identified that he/she was notified of MD #1's behavior by the nursing supervisor on 8/30/14. The ED Medical Director requested MD #1 (via telephone) to sign out his/her ED patients to the other ED physician (MD #2) and leave the premise. The ED Medical Director identified that upon his/her arrival to the ED, MD #1 was gone. MD #1 did not return to work and resigned on 9/2/14.
Review of Patient #3's ED record and interview with the covering ED physician, MD #2 on 10/2/14 at 1:00 PM identified that MD #1 signed out Patient #3 to MD #2 on 8/30/14 after the 11:30 AM incident. MD #2 indicated that he/she did not witness the incident between MD #1 and Patient #3. MD #2 identified that he/she was not fully informed of the incident and "did not remember exactly what happened". MD #2 indicated that he/she did not assess Patient #3 for any injuries after the patient was slap by MD #1. The patient was discharged to police custody on 8/30/14 at 2:50 PM. Documentation and interviews failed to reflect that the patient received care in a safe setting and/or was free from abuse and/or was assessed for injuries from the abusive act.
Interview with the VP of Physician Integration and Risk Management on 9/30/14 at 2:35 PM identified that the incident was not reported to the State Agency because the hospital counsel directed that the incident did not need to be reported.
Review of hospital documentation identified that Emergency Services was a contracted service of the hospital. Documentation and interviews failed to reflect that the hospital's governing body ensured that the Emergency Services performed under a contract were provided in a safe and effective manner.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of the clinical records, review of hospital policies, review of hospital documentation and interviews with hospital personnel for 1 (Patient #3) of 10 patients reviewed for patient rights, documentation and interviews failed to reflect that the patient received care in a safe setting, was free from abuse and/or was assessed for injuries sustained from the abuse.

Please see A0144 and A0145.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of facility documentation and interviews for 2 (P#1 and P#2) of 4 patients reviewed who filed a grievance with the hospital, the facility failed to provide an initial response and/or follow-up response within the time frame identified in the Complaint/Grievance Policy. The findings include:

A. Patient #1 was admitted on [DATE] with coffee ground emesis with aspiration of vomitus. Review of the clinical record indicated that the patient's past medical history included multiple sclerosis and gastroesophageal reflux disease (GERD). A gastrointestinal (GI) consultation was completed on 3/27/13 and the GI Progress Note dated 3/28/13 identified that the H. pylori IgG was positive and that treatment was initiated and should be continued for 7 days. A Physician Order dated 3/27/13 at 4:58 PM directed the H. pylori treatment: levoflaxin 250 mg every day (QD) at breakfast; omeprazole 40 mg QD at breakfast, nitazoxanide 500 mg twice a day (BID) with meals; doxycycline 100 mg QD at dinner, all x 7 days. The patient was discharged to a rehabilitation facility on 3/28/13. Review of the Transfer Summary dated 3/28/13, the Inter-agency Patient Referral Report (W-10) and interview with the attending physician, MD #3 on 9/30/14 identified that Patient #1 was discharged without the H.pylori medications ordered (prescribed by the GI service). The patient returned to the hospital on [DATE] with coffee ground emesis and again, did not receive the H. pylori treatment. Review of hospital documentation and interview with the VP of Risk Management on 9/29/14 identified that a grievance was submitted to the hospital on [DATE]. Follow up phone calls were conducted on 6/28/13, 7/5/13, 3/26/14 and 4/26/14 to address the billing issues (not the treatment issues). Review of the Grievance Management Process Policy identified that all grievances would be acknowledged in writing within 7 calendar days from the receipt of the grievance. Also, the resolution would be a written response within 4 weeks of receipt of the grievance.


B. Patient (P) #2 was admitted on [DATE]. According to a nurse's note dated 4/5/14 P#2 had experienced a fall. A subsequent nurse's note dated 4/7/14 indicated Person #1 notified staff that P#2 was missing articles of clothing and dentures. Person #1 indicated he/she would allow staff 24 hours to find the dentures and if unsuccessful he/she would speak with a supervisor.
According to facility documentation on 4/11/14 the Director of Quality was notified by Manager (Mgr.) #2 of the missing dentures and Person #1's request for replacement. Mgr. #2 was directed to file an occurrence report. On 4/14/14 an occurrence report was filed and the corrective action documented on the occurrence report was to refer the incident to administration. Facility documentation dated 4/23/14 indicated Person #2 called the hospital and requested P#2's dentures be replaced. Facility documentation identified the next communication with P#2 or Person #1 occurred when the Vice President (VP) of Risk Management sent a letter dated 5/15/14 to P#2 indicating the loss of dentures had been investigated. The letter further indicated according to hospital policy the hospital could not accept responsibility for replacing the dentures.
Subsequent facility documentation (electronic mail) indicated additional communication occurred between the VP of Risk Management and Person #1 from 5/23/14 to 7/25/14 and the cost of the dentures were ultimately reimbursed to P#2 by the hospital.

Hospital Complaints/grievances policy indicated all complaints/grievances will be acknowledged in writing by the Risk Management Department within 7 calendar days from receipt of the complaint/grievance.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on clinical record review and interview for 1 (P#2) of 4 patients reviewed for notification of family/representative when a patient has a change in condition, the hospital failed to notify the representative when P#2 had an accident (fall). The findings include:

Patient (P) #2 was admitted on [DATE]. The medical record identified Person #1 as P#2's next of kin and person of contact. According to a nurse's note dated 4/5/14 P#2 had experienced a fall and sustained a right elbow abrasion, bump on his/her right forehead, right hip bruise and abrasions to the right buttock, thigh and knee. A CT scan was done and the results were negative. The medical record lacked documentation that Person #1 had been notified when P#2 had fallen and sustained an injury.

Interview with Nurse Manager #2 on 9/30/14 at 12:00 PM identified that Person #1 had not been notified of P#2's change in condition and he/she had thought the physician was notifying Person #1.

Interview with the Director of Quality on 10/2/14 identified the hospital did not have a policy addressing family/representative notification of a change in condition.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of the clinical record, review of hospital policy, review of hospital documentation and interviews with hospital personnel for 1 (Patient #3) of 10 patients reviewed for patient rights, documentation and interviews failed to reflect that the patient received care in a safe setting. The findings include:


Patient #3 was admitted to the hospital's ED, Room 9 on 8/30/14 at 3:14 AM with suicidal ideation, alcohol intoxication and multiple facial abrasions. The patient's past medical history included intravenous heroin and crack cocaine abuse, alcohol abuse, depression and anxiety. Review of the ED record indicated that the patient was in police custody, arrived in hand cuffs, was agitated, screaming and combative. The patient required 4 point restraints. Intramuscular Haldol 5 milligrams (mg), Benadryl 50 mg and Thiamine 100 mg were administered at 3:15 AM. A head CT at 10:42 AM was negative for intracranial trauma and facial bones were negative for fracture. A psychiatric consultation cleared Patient #3 for discharge.
Review of the ED record and interview with RN #1 on 9/30/14 at 12:30 PM identified that Patient #3 was diaphoretic, tremulous and anxious at 11:30 AM on 8/30/14. The patient was in 2 point forensic restraints (wrists) requesting his/her medication, including Suboxone. RN #1 requested MD #1 to assess the patient. RN #1 observed MD #1 in Patient 3's room, and while the patient was restrained, MD #1 raised his/her right arm with an open right hand, RN #1 heard one slap and heard MD #1 saying "Snap out of it". Interview with the ED Technician on 9/30/14 at 2:00 PM indicated that the ED Technician recalled MD #1 saying loudly, "Snap out of it" and observed MD #1, with his/her right hand, slap Patient #3 on the left cheek. The ED Technician identified that the patient was calm, was not complaining and said nothing. Review of hospital documentation, and interviews with RN #1 and the ED technician identified that the policeman, Officer #1 was present at the time of the incident.
Review of Patient #3's ED record and interview with the ED Medical Director on 9/30/14 at 1:15 PM identified that he/she was notified of MD #1's behavior by the nursing supervisor on 8/30/14. The ED Medical Director requested MD #1 (via telephone) to sign out his/her ED patients to the other ED physician and leave the premise. The ED Medical Director identified that upon his/her arrival to the ED, MD #1 was gone. MD #1 did not return to work and resigned on 9/2/14. The ED Medical Director did not reassess Patient #3.
Review of Patient #3's ED record and interview with MD #2 on 10/2/14 at 1:00 PM identified that MD #1 signed out Patient #3 to MD #2 on 8/30/14 after the 11:30 AM incident. MD #2 identified that he/she did not witness the incident. MD #2 indicated that he/she was not fully informed of the incident, "did not remember exactly what happened" and did not assess the patient for injuries. Review of the record and MD #2 indicated that Patient #3 was anxious, tremulous and had requested Suboxone. The patient received Benadryl 50 mg and Ativan 1 mg intravenously at 1:50 PM with effect. The patient was discharged to police custody on 8/30/14 at 2:50 PM. Documentation and interviews failed to reflect that Patient #3 received care in a safe setting.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on review of the clinical record, review of hospital policy, review of hospital documentation and interviews with hospital personnel for 1 (Patient #3) of 10 patients reviewed for patient rights, documentation and interviews failed to reflect that the patient was free from abuse. The findings include:

Patient #3 was admitted to the hospital's ED, Room 9 on 8/30/14 at 3:14 AM with suicidal ideation, alcohol intoxication and multiple facial abrasions. The patient's past medical history included intravenous heroin and crack cocaine abuse, alcohol abuse, depression and anxiety. Review of the ED record indicated that the patient was in police custody, arrived in hand cuffs, was agitated, screaming and combative. Intramuscular Haldol 5 mg, Benadryl 50 mg and Thiamine 100 mg were administered at 3:15 AM. A head CT at 10:42 AM was negative for intracranial trauma and facial bones were negative for fracture. A psychiatric consultation cleared Patient #3 for discharge.
Review of the ED record and interview with RN #1 on 9/30/14 at 12:30 PM identified that Patient #3 was diaphoretic, tremulous and anxious at 11:30 AM on 8/30/14. The patient was in 2 point forensic restraints (wrists) requesting his medication, including Suboxone. RN #1 requested MD #1 to assess the patient. RN #1 observed MD #1 in Patient #3"s room, raise his/her right arm with an open right hand, RN #1 heard one slap and MD #1 saying, "Snap out of it". Interview with the ED Technician on 9/30/14 at 2:00 PM indicated that the ED Technician recalled MD #1 saying loudly, "Snap out of it" and observed MD #1, with his right hand, slap Patient #3 on the left cheek. The ED Technician identified that the patient was calm, was not complaining and said nothing. Review of hospital documentation, and interviews with RN #1 and the ED technician identified that the policeman, Officer #1 was present at the time of the incident.
Review of Patient #3's ED record and interview with the ED Medical Director on 9/30/14 at 1:15 PM identified that he/she was notified of MD #1's behavior by the nursing supervisor on 8/30/14. The ED Medical Director requested MD #1 (via telephone) to sign out his/her ED patients to the other ED physician and leave the premise. The ED Medical Director identified that upon his/her arrival to the ED, MD #1 was gone. MD #1 did not return to work and resigned on 9/2/14.
Review of Patient #3's ED record and interview with MD #2 on 10/2/14 at 1:00 PM identified that MD #1 signed out Patient #3 to MD #2 on 8/30/14 after the 11:30 AM incident. MD #2 identified that he/she did not witness the incident. MD #2 indicated that he/she was not fully informed of the incident, "did not remember exactly what happened" and did not assess the patient for injuries.

Review of Patient #3's record and interview with MD #2 indicated that Patient #3 was anxious, tremulous and had requested Suboxone. The patient received Benadryl 50 mg and Ativan 1 mg intravenously at 1:50 PM with effect. The patient was discharged to police custody on 8/30/14 at 2:50 PM. Documentation and interviews failed to reflect that Patient #3 was free from abuse and/or was assessed for injuries from the abuse.