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.

SAMARITAN MEDICAL CENTER 830 WASHINGTON STREET WATERTOWN, NY 13601 Dec. 13, 2017
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on medical record (MR) review, document review and interview, the hospital failed to thoroughly investigate an allegation of patient abuse in 1 of 16 MRs (Patient #1) reviewed and the hospital lacked a written policy and procedure (P&P) for investigating allegations of abuse and neglect. This could lead to future incidents of patient abuse, neglect or harassment.

Findings include:

-- During interview of Staff I (ED Assistant Nurse Manager) on 12/11/17 at 2:35 pm, he/she indicated that while Staff L placed a patient in 4- point restraints, the patient spit on him/her. Staff L then smacked that patient on the forehead. Staff I indicated that she initially found out about the incident because Staff L wrote a letter about it and placed it under his/her door. Staff I stated that he/she immediately took the letter to Human Resources (HR) for review. Also, Staff I had stated he/she was required to report patient abuse of any kind to HR.

-- Review of the hospital's investigation undated, revealed a documented statement from Staff L (RN) that he/she had slapped the patient after Patient #1 had spit on him/her. The investigation also included hand written statements and emails by hospital staff (a security guard, a security aide, a nursing supervisor, and the charge nurse) that witnessed and/or heard Staff L slap Patient #1.

-- During interview of Staff F (Director of Clinical Quality and Safety) on 12/12/17 at 10:00 am, he/she indicated that the Justice Center was notified and then the Human Resources (HR) department initiated an investigation of the abuse.

-- During interview of Staff G (HR Manager) and Staff H (Vice President of HR) on 12/12/17 at 11:00 am, they both indicated that the investigation was complete when Staff L resigned on 10/27/17. They confirmed there was no formal written conclusion, no further investigation as to what may have led to the abuse, or education of staff to ensure that this type of patient abuse did not happen again.

-- During interview of Staff F (Director of Clinical Quality and Safety) on 12/12/17 at 10:00 am, he/she confirmed there was no P&P for investigating abuse.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
Based on document review, medical record (MR) review and interview, in 3 of 4 (Patients #3, #12, #11) MRs reviewed of patients requiring restraint application (chemical and/or mechanical), after deescalation techniques were ineffective, the physician orders did not contain all the necessary information. This could lead to improper restraint of patients.

Findings include:

-- Review of the facility's policy and procedure (P&P) titled "Restraint and Seclusion," last revised 4/2017, indicated physician orders for restraints and/or seclusion should include the following: date and time of order, reason for restraint, alternative interventions attempted, time limit of restraint and type of restraint to be used. To assist staff in making the determination of when to remove restraints the physician should note in the order a description of specific behavior that would indicate the patient is no longer a threat to themselves or others (i.e., "the patient is no longer hitting staff").

-- Review of Patient #3's MR revealed, on 11/14/17 at 8:02 pm, nursing staff entered a physician telephone order to administer Haldol 5 milligrams (mg) (antipsychotic) and Ativan 1 mg (sedative/hypnotic), intramuscular (IM). The medication was ordered STAT (to be given immediately). At 8:13 pm nursing entered a physician telephone order to apply restraints. The physician order did not contain the type of restraint (physical, 4 point), reason for restraint, duration of restraint, monitoring of patient in restraint or under what circumstances the restraint could be removed. Nursing staff documented in a note that Patient #3 was placed in 4 point restraints and medicated with a chemical restraints.

-- Review of Patient #12's MR revealed, on 11/14/17 at 4:19 am nursing staff entered a physician telephone order for Ativan 2 mg, Benadryl 50 mg (sedative), and Haldol 10 mg IM STAT. The order did not indicate the reason for the restraint or the time frame for monitoring of the patient. Nursing documented a physician's telephone order for "Restraints" at 4:45 am for aggressive behavior. There was no documentation of the type of restraint, duration of restraint or length of time the patient should be monitored and under what conditions the restraints could be removed.

-- Review of Patient #11's MR revealed, on 12/11/17 at 11:11 am, nursing staff entered a physician order for Haldol 5 mg, Ativan 2 mg and Benadryl 50 mg by mouth STAT. The order lacked the reason for the chemical restraint and the required monitoring.

-- During interview of Staff M (Nurse Manager) on 12/13/17 at 9:45 am, he/she confirmed the above findings.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on findings from document review, medical record (MR) review and interview, the facility did not ensure patients placed in mechanical and chemical restraints were monitored or had ongoing assessments in 2 of 4 MRs (Patient #1 and Patient #11) reviewed for restraints. This lack of monitoring may lead to untoward patient outcomes.

Findings include:

-- Review of the hospital policy and procedure (P&P) titled "Restraint and Seclusion," last revised 4/2017, indicated the decision to use restraints is decided not by diagnosis but by a comprehensive individual assessment, including a physical assessment to identify medical problems that may be causing behavioral changes. The use of restraints is documented in the patient's MR. The Registered Nurse (RN) documents date and time of application of restraints and/or administration of a chemical restraints, date and time of removal of restraints, any in-person evaluation to manage violent or self destructive behavior. The physician should document findings of the face to face assessment on the Restraint and Seclusion For Physician Order form. Responsibilities of the RN during a restraint are to perform an assessment of patient, collaborate with the physician, and monitor patient status during the restraints, document assessment and reassessment data in the MR. Immediately following an initiation of restraint for the violent patient the RN will assess the patients immediate situation, and the recurring assessment of the restraint will be documented every 30 minutes. When chemical restraints are implemented, assessments should continue every 30 minutes for 2 hours. The RN may discontinue the restraint when select criteria are met (the patient is no longer at risk of harm to self). After the restraint has concluded a physician should document a final note on the restraint and seclusion flow sheet including the outcome of the restraint and the effectiveness of the restraint.

-- Review of Patient #1's MR revealed he was brought to the behavioral health unit (BHU) in the emergency department (ED) on 10/9/17 after attempting suicide. Patient #1 physically attacked a staff member. The patient was placed in 4 point restraints. At 9:30 pm, a licensed practical nurse (LPN) documented that 4-point mechanical and chemical restraints were applied at 9:30 pm and initiated by the RN. Patient #1 was medicated with Haldol (antipsychotic) 5 milligrams (mg) intramuscular (IM) and Benadryl (sedative) 50 mg IM to right thigh, and Ativan (sedative/hyponotic) 2 mg IM to left thigh. At 11:15 pm, the LPN documented the physician gave a verbal order to discontinue restraints, the arm restraints were released, and safety was maintained.

There was no documented time, date, assessment or reassessment noted by the RN in the MR after 4- point restraints and chemical restraints were initiated and no documentation by the physician of a face to face assessment or a final note documented to remove the restraints.

-- During interview of Staff I (ED Assistant Nurse Manager) on 12/11/17 at 2:35 pm, he/she acknowledged that Patient #1's MR lacked the required RN documentation and physician face to face assessment.

-- Review of Patient #11's MR revealed, on 12/11/17 at 11:33 am, nursing documented Patient #11 received Haldol 5 mg by mouth (po), Ativan 2 mg po and Benadryl 50 mg po as a chemical restraint for agitation at 11:17 am. The next documentation of an assessment by an RN was at 2:09 pm (2.5 hours later). Additionally, there was no face to face assessment documented by the physician.

-- During interview of Staff M (Nurse Manager of Inpatient Behavioral Health Unit) on 12/12/17 at 9:45 am, he/she confirmed the above findings.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0188
Based on medical record (MR) review and interview, in 1 of 1 behavioral health patients in the emergency department (ED) MR reviewed regarding restraint use, the documentation describing results of a restraint intervention was lacking. This could lead to an inaccurate description of care provided to patient.

Findings include:

-- Per MR review, Patient #1 presented to the emergency department (ED) on 10/9/17 at 6:14 pm with suicidal ideations. While in the ED the patient became agitated and physically attacked a nurse. The patient was placed in 4- point restraints and medicated with Haldol (antipsychotic) 5 milligrams (mg) intramuscular (IM) and Benadryl (sedative) 50 mg IM to right thigh, and Ativan (sedative/hypnotic) 2 mg IM to left thigh at 9:30 pm.

At 9:30 pm, a licensed practical nurse (LPN) documented 4-point and chemical restraints were initiated by the RN.

The MR lacked documentation by the RN and the physician of the patient's response to the 4- point physical and chemical restraint used.

-- During interview of Staff I (Assistant Nurse Manager of ED) on 12/11/17 at 2:35 pm, he/she acknowledged the above findings.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review, medical record (MR) review and interview, the hospital failed to protect each patient's right to safe care.

See Tag 145- The hospital failed to thoroughly investigate an allegation of patient abuse. The hospital did not have a policy and procedure for investigating allegations of abuse and neglect.

See Tag 164- The hospital did not ensure that physician orders for restraints were complete.

See Tag 175- The hospital did not ensure patients placed in mechanical and chemical restraints had ongoing assessment and monitoring.









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VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record (MR) review and interview, 2 of 6 MRs reviewed (for patients whose hospital stay was longer than 2 calendar days) lacked documentation that patients were provided a second follow up Important Message from Medicare (IM) notice by the hospital prior to their discharge. Also, the hospital lacked a policy and procedure (P&P) that addressed the process of providing the notice to patients. This could place patients at risk for being unaware of the right to appeal discharge.

Findings include:

-- Per MR review Patient #7 was admitted on [DATE]. Initial IM was signed by the patient on 12/2/17. Patient #7 was discharged from the hospital on [DATE]. The MR contained an unsigned IM notice for the patient with documentation that stated "patient transferred to SSV (Samaritan Summit Village) rehab."

-- Per MR review Patient #15 was admitted on [DATE]. Initial IM notice was signed by the patient on 11/20/17. Patient #15 was discharged from the hospital on [DATE]. The MR contained an unsigned IM notice for the patient with documentation that stated "patient transferred to SKH (Samaritan Keep Home) for STR (short term rehabilitation)."

-- During interview of Staff A (Patient Care Coordinator) on 12/12/17 at 9:45 am, he/she acknowledged understanding that if a patient was going to short term rehabilitation or to a skilled nursing facility, the IM did not need to be signed by the patient.

-- During interview of Staff B (Director of Case Management and Discharge Planning) on 12/12/17 at 8:30 am, he/she acknowledged that the hospital did not have a written P&P describing the provision of the IM notice to patients and that an IM needs to be signed within 48 hours of discharge regardless of whether the patient is going for rehabilitation.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review, medical record (MR) review, and interview, in 3 of 3 MRs reviewed, the hospital's informed consent form for anesthesia did not contain the name of the practitioner administering the anesthesia. Additionally, the hospital's informed consent forms did not provide the option to refuse various aspects of care and the hospital's informed consent policy and procedure (P&P) did not describe a process to refuse various aspects of care. This may affect a patients right to make informed decisions regarding their care.

Findings include:

-- Review of the hospital's P&P titled "Informed Consent," dated 9/2017, indicated that the informed consent form for anesthesia should contain the name of the practitioner that will administer the anesthesia and the name of the anesthesia and/or performing practitioner who explained the anesthesia to the patient or legal representative.

-- Per review of Patient #8's MR, he was admitted on [DATE] with a fractured right ankle. A "Consent for Anesthesia" signed by the patient and anesthesiologist lacked the name of the practitioner who would be administering anesthesia.

-- Per review of Patient #5's MR, she was admitted on [DATE] with anemia. A "Consent for Anesthesia " signed by the patient and anesthesiologist lacked the name of the practitioner who would be administering anesthesia.

-- Per review of Patient #13's MR, she was admitted on [DATE] for a caesarean section. A "Consent for Anesthesia" signed by the patient and anesthesiologist lacked the name of the practitioner who would be administering anesthesia.

-- During interview of Staff D, (Director of Surgical Services) on 12/13/17 at 10:00 am, he/she acknowledged that the name of the practitioner that would be administering the anesthesia is not specifically documented on the consent form.

-- Review of the hospital's consent forms titled "Consent for Surgery or Other Procedure," last revised 7/2008, "Consent for Surgery or Other Procedure - Aortagram /Angiogram," last revised 8/2015, "Consent for Surgery or Other Procedure- Samaritan Gastroenterology," last revised 7/2017 revealed that these consent forms allowed manufacturers representatives to be present during a patients operation or procedure. Additionally, "Consent for Anesthesia," last revised 9/2015, allowed students or emergency medical technicians to participate in care under the direct supervision of an anesthesiologists or certified registered nurse anesthetist (CRNA).

These consent forms did not contain instructions or provisions that allowed a patient (representative) the option of refusing to consent to the presence manufacturers representatives, students, or EMTs during a procedure or operation. Additionally the hospital's P&P titled "Informed Consent," dated 9/2017, did not describe a process for patient's to refuse the presence of manufacturers representatives, students, or EMTs.

-- During interview of Staff P (Chair of Department of Anesthesiology) on 12/20/18 at 2:45 pm, he/she acknowledged the of lack of instruction or provision on the form or in the P&P that allowed a patient or their representative the option of refusing to consent to the presence of students.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
Based on interview, the Inpatient Mental Health Unit (IMHU) did not have a policy and procedure (P&P) pertaining to patient's Advance Directives and do not resuscitate (DNR) status. (The hospital had an Advance Directives P&P but it did not pertain to IMHU.) This could put patients at risk of their advance health directives not being honored.

Findings include:

-- During interview of Staff M, (Nurse Manager, IMHU) on 12/12/17 at 9:30 am, he/she acknowledged the IMHU does not have a P&P for patient Advance Directives or DNR.
VIOLATION: PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION Tag No: A0133
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record (MR) review and interview, in 11 of 11 MRs (#1, #3 - #7, #9 - #13) reviewed, there was no documentation indicating, that at the time of the patient's admission to the hospital, the patient was asked whether he/she wanted a family member (representative) and his/her own physician notified of admission to the hospital. Also, the hospital does not have a policy and procedure (P&P) that addresses this process. This could impact continuity of care.

Findings include:

-- Per review of Patient #1's MR, he was admitted on [DATE] with fractured right ankle. There is no documentation that hospital staff inquired as to whether Patient #1 wanted his own physician and family (representative) notified of his admission.

-- Per review of Patient #7's MR, she was admitted on [DATE] with cellulitis. There is no documentation that hospital staff inquired as to whether Patient #7 wanted his own physician and family (representative) notified of his admission.

The same lack of documentation regarding whether patients wanted their family or representative and physician notified about their admission was found in MRs for Patients #3, #4, #5, #6, #9, #10, #11, #12, #13.

-- Review of hospital's P&P did not provide evidence that the hospital had a process for these above described notifications.

-- During interview of Staff E (Quality Improvement Practitioner) on 12/11/17 at 10:30 am, he/she acknowledged that hospital staff do not ask patients whether they want their own practioner or family (representative) notified of admission.