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.

FAXTON-ST LUKE'S HEALTHCARE 1656 CHAMPLIN AVENUE UTICA, NY 13503 Jan. 12, 2015
VIOLATION: PATIENT RIGHTS: PRIVACY AND SAFETY Tag No: A0142
Based on findings from observations and interviews, the emergency department (ED) exam rooms used for potential mental health patients were not safe for individuals with suicidal, psychotic or self-injurious behaviors. Specifically, the room contained 2 potential ligature hazards.

Findings include:

-- During tour of the ED on 1/8/15 at 1100, in room # 011 a red button extending from the wall 3 inches was observed. Also, the television was encased in Plexiglas which was secured by an exterior hasp and padlock (a hasp is the slotted hinged plate that is part of a locking device - it fits over a metal loop and is secured with a padlock).

During the tour the Assistant Vice President of Nursing Emergency Services and Psychiatry identified the red button as a panic button to be pressed if an emergent situation arises - an alarm will go off. At 1110, the Mental Health Director confirmed that the panic button and the exterior hasp and padlock constituted ligature hazards.
VIOLATION: EMERGENCY SERVICES Tag No: A1100
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on findings from document review, medical record (MR) review, and interview, the facility failed to ensure emergency department (ED) services were provided in accordance with generally accepted standards. Specifically:

(1) ED providers did not ensure completion of a mental health assessment (MHA) for 3 of 8 patients who presented with signs of possible psychiatric conditions (Patients A, D and E). An attending ED physician was not aware of the correct procedure for ordering a MHA by a social worker (Patient A);

(2) Nursing did not document complete suicide risk assessments for 6 out of 8 patients who presented to the ED with suicidal ideations and/or attempts (Patients A, C, D, E, F and G). A policy and procedure (P&P) addressing the nursing suicide risk assessment being used in the ED was lacking;

(3) Potential patient problems warranting attention were not all addressed or followed up (e.g., alcohol ingestion and/or substance abuse, low potassium) in 3 of 8 MRs reviewed (Patients E, F, and G);

(4) The Emergency Provider Records were illegible, incomplete or lacking in 6 out of 8 MRs reviewed (Patients A, C, D, E, F and G);

(5) The ED lacked a policy and procedure (P&P) describing assessment criteria for suicidal and homicidal risks. Criteria for homicidal risk assessments were described on an inpatient nursing assessment form but were not defined in the outpatient ED forms.

(6) The ED exam rooms used for potential mental health patients were not safe for individuals with suicidal, psychotic or self-injurious behaviors. Specifically, the room contained 2 potential ligature hazards - See findings in Tag A 142;

(7) The facility did not provide appropriate post exposure prophylaxis (PEP) to a patient who had been sexually assaulted. Further, the facility P&P did not address the latest New York State Department of Health guidelines regarding PEP for a sexual assault victim - See findings in Tag A 1104.

Findings include:

-- New York State Mental Hygiene Law, Section 9.41, addresses emergency psychiatric admissions for immediate observation, care, and treatment. It directs that any peace officer, when acting pursuant to his or her special duties, or police officer who is a member of the state police or of an authorized police department or force or of a sheriff's department, may take into custody any person who appears to be mentally ill and is conducting himself or herself in a manner which is likely to result in serious harm to the person or others. It notes that such officer may direct the removal of such person or remove him or her to a hospital or comprehensive psychiatric emergency program (CPEP).

-- A form titled "EMERGENCY or C.P.E.P.** EMERGENCY ADMISSION (Sections 9.41, 9.45, 9.55 and 9.57 Mental Hygiene Law)," dated 12/2009, is completed by a peace officer / police officer when section 9.41 of the form is used. Hereafter in this document the form will be referred to as the 9.41 form.

-- Review of Patient A's MR reveals the following:

He (MDS) dated [DATE], accompanied by local police department staff (LPD) and in handcuffs. Documentation on the 9.41 form and the Law Enforcement Request for Examination form listed the following for description of Patient A: alleged animal abuse, hostile, belligerent, overly suspicious, feelings of persecution, confused and disoriented, hearing voices, a danger to him/herself and/or others.

The electronic medical record (EMR) contains an order for "Consult Case Management ED Referral Needs: Discharge Planning." (Per interview of Physician #1 on 1/12/15 at 1130, this is what he/she selects in the EMR when intending to order a MHA. Per interview of Licensed Clinical Social Worker (LCSW) #2 on 1/12/15 at 1230, the correct selection for ordering a MHA is "Consult Case Management ED- Mental Health." The physician then enters via a free text under "Referral Needs" - "Mental Health Eval").

A free text late entry by LCSW #1, dated 1/7/15 and timed 1132, indicates he/she "...met with the patient per Physician request. Patient is calm and cooperative.....Discussed with the ED physician...if not admitted then will follow up with outpatient referral next business day." This documentation did not constitute a MHA - the MR lacked documentation of a MHA.

-- During interview with LCSW #1 on 1/8/15 at 1320, he/she stated that he/she did not complete a MHA for Patient A.

Nursing documentation on the "Suicide/Safety Evaluation" section of the EMR only addresses 1 out of 11 questions regarding the patient's risk factors for suicide risk (male gender) and lacks a suicide risk score (due to the 10 questions not answered).

Approximately 3/4 of the documentation on the Emergency Provider Record was illegible, requiring deciphering by Physician #1 during interview on 1/8/15 at 1530.


-- Review of Patient C's MR reveals the following:

He (MDS) dated [DATE], self-referral with suicidal/homicidal ideation. The patient was admitted .

The nursing "Suicide/Safety Evaluation "section of the EMR was blank.

Approximately 3/4 of the documentation on the Emergency Provider Record is illegible.


-- Review of Patient D's MR reveals the following:

She presented to the ED via private vehicle accompanied by her parents. The middle school she attended sent her to have a mental health evaluation due to cutting herself on upper thighs. The patient was transferred to an adolescent mental health facility.

The MR lacked documentation of a MHA.

The nursing "Suicide/Safety Evaluation" section of the EMR was incomplete, 4 out of 11 questions were not answered and a suicide risk score is lacking.

Approximately 2/3 of the documentation on the Emergency Provider Record is illegible.


-- Review of Patient E's MR reveals the following:

He (MDS) dated [DATE], accompanied by the LPD. Documentation on the 9.41 and the Law Enforcement Request for Examination form indicated overdose of Xanax medication.


The MR lacked an Emergency Provider Record (the ED physician's patient assessment, treatment and diagnosis form), documentation of a MHA, and discharge instructions.

The nursing "Suicide/Safety Evaluation" section of the EMR was blank.

Laboratory test results in the EMR indicate the patient's potassium level was decreased (2.9 with the normal range being 3.5-5.3). The patient received potassium chloride 20 meq/15 ml orally and potassium chloride 20 meq ER (extended release) tab orally. There is no evidence the low potassium was followed up during the ED visit and/or arrangements for outpatient follow up were made.


-- Review of Patient F's MR reveals the following:

He (MDS) dated [DATE], via the LPD. Documentation on the 9.41 form and the Law Enforcement Request for Examination indicated the patient placed himself in dangerous situations, made verbal threats of harm to self, and there was presence of weapons/danger. Nursing documentation revealed the patient was drinking and upset at home about an incident, and walked into the garage with weapon threatening to kill himself. The patient was admitted .

The nursing "Suicide/Safety Evaluation" section of the EMR was incomplete, 8 out of 11 questions were not answered and a suicide risk score is lacking.

An alcohol abuse assessment is not documented. Also, while an ethanol level was ordered and returned with a result of 204 (normal being 0-10), the documentation on the Emergency Provider Record lacks indication (in an area provided) that the patient had ingested alcohol.

Approximately 90% of the documentation on the Emergency Provider Record is illegible.


-- Review of Patient G's MR reveals the following:

He (MDS) dated [DATE] via ambulance due to overdose/suicidal ideation. He had taken a handful of sleeping pills along with 40 ounces of beer in hopes of harming himself.

The nursing "Suicide/Safety Evaluation" section of the EMR was incomplete, 8 out of 11 questions were not answered and a suicide risk score is lacking.

While an ethanol level was ordered and returned with a result of 13 (normal being 0-10), the documentation on the Emergency Provider Record lacks indication (in an area provided) that the patient had ingested alcohol. An alcohol abuse assessment is not documented. The suicide risk assessment on the Emergency Provider Record does not contain the clinician's estimation of suicide risk, the progress and interventions section of the form are blank. The patient was admitted and the disposition time is illegible.


-- During interview with the Medical Director on 1/12/15 at 1530, ED physician illegibility and incomplete documentation were acknowledged and discussed, respectively.


Findings specifically regarding (5) above on page 3 include:

-- Review of the EMR Print Screen titled "Suicide Risk Assessment - ED," reveals the assessment requires nursing to address 11 questions. The EMR then calculates the Risk Score based on the answers selected by nursing. A second Print Screen titled "Suicide Risk Assessment - Inpatient" was presented by Director of Risk Management on 1/9/15 at 1350. This screen also contained a "Homicidal Risk Screen" with 2 questions - these questions are not part of the physician or nursing homicidal assessments completed in the ED.

Per interview with the Director of Risk Management on 1/9/15 at 1350, he/she stated that the facility did not have a written P&P for Suicidal and/or Homicidal Assessments.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
Based on findings from document review and interview, the facility did not provide appropriate post exposure prophylaxis (PEP) to a patient who had been sexually assaulted. Further, the facility policy and procedure (P&P) did not address the latest New York State Department of Health guidelines regarding PEP for a sexual assault victim.

Findings include:

-- Review of Patient K 's medical record (MR) revealed the patient arrived at the emergency department (ED) at 2120 with a chief complaint of sexual assault. The physician orders include Azithromycin 250 mg 4 tabs, ciproflozacin 500 mg, Flagyl 500 mg and levorgesterl 0.75 mg which were all administered orally to the patient. The discharge orders did not include providing the patient with a seven (7) day starter pack of HIV PEP and arrangement of an appointment for medical follow-up related to HIV PEP (as required by New York State Public Health Law, Chapter 39, Section 1, Paragraph c of subdivision 1 of section 2805-i, effective November 27, 2012.)

-- Review of the facility P&P titled "Care of the Patient with Sexual Assault," dated 9/2007, revealed it does not require hospital staff to provide a victim of sexual assault with a seven (7) day starter pack of HIV PEP and to arrange for an appointment for medical follow-up related to HIV PEP .

-- During interview with the Vice President of Quality Management on 1/09/15 at 1420, the above findings were discussed.