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.

STATEN ISLAND UNIVERSITY HOSPITAL 475 SEAVIEW AVENUE STATEN ISLAND, NY 10305 April 22, 2016
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on record review, document review, and interview, the facility did not implement its policy and procedure to ensure that for each emergency application of restraint, a physician order was obtained immediately.
This finding was noted in four (4) of 10 medical records reviewed (Patient #s 1, 2, 3, and 4).

Findings include:

Review of medical record for Patient #1 noted there was no restraint order by a physician/LIP (Licensed Independent Practitioner), after the patient was restrained by a registered nurse on 3/5/16 at 3:48 AM for agitated, combative, verbally abusive, and verbally threatening behavior.

Review of medical record for Patient #2 identified that a physician order was not obtained for the emergency application of restraint of the patient on 3/6/15 at 6:06 AM, for agitated and combative behavior.

The same finding regarding lack of a restraint order by a physician/LIP (Licensed Independent Practitioner), was found in medical record for Patient #3, who was placed in restraint while in the Emergency Department on 3/7/16 at 1:18 AM; and Patient #4 who was placed in 4-point leather restraint on 3/5/2016 at 6:03 AM.


The facility did not implement its policy and procedure titled, "Restraints," last reviewed June 2014. The policy notes, "The use of physical restraints requires written authorization of the physician/Licensed Independent Practitioner (LIP) or their designee ...as soon as possible." As soon as possible was defined in the policy as "one (1) hour from when restraints are applied for violent/self-destructive behavior.


During interview of Staff A, Administrator of the Emergency Department on 4/22/16 at 11:30 AM, he acknowledged that a physician order for restraint was not written after the emergency application of restraints for Patient #s 1, 2, 3, and 4.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, document review, and interview, the facility did not implement its policy and procedure to ensure that patients who are restrained for violent and self-destructive behavior, receive a timely face-to-face assessment by a physician or other Licensed Independent Practitioner (LIP).
This finding was noted in one (1) of 10 medical records reviewed (Patient # 1).


Findings include:

Review of medical record for Patient #1 identified the following information: This [AGE]-year-old was triaged in the Emergency Department on 3/5/16 at 12:51 AM, after he was found in the hospital ambulance bay, wandering, and intoxicated. The restraint flow sheet dated 3/5/16 noted; the patient was "agitated, combative, verbally abusive, and verbally threatening," and was placed in 4-point leather restraints on 3/5/16, from 3:48 AM to 6:52 AM.

There was no documented evidence of a face-to-face assessment by a physician or other Licensed Independent Practitioner.

The facility policy and procedure titled, "Restraints," last reviewed June 2014 notes, "In an emergency situation, when the patient is engaging in activities that presents an immediate danger to the patient and others ... a qualified registered nurse (RN) present may direct that the patient be restrained. The patient will have a face to face assessment within thirty minutes by the physician."

During interview of Staff A, Administrator of the Emergency Department, on 4/22/16 at 11:30 AM, he acknowledged there was no documentation of a face-to-face assessment of the patient after restraint application.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and interview, nursing staff did not ensure that a care plan was developed to meet the care needs of a patient. Specifically, physician orders for the medical management of the patient were not implemented.
This finding was evident in one (1) of five (5) medical records reviewed (Patient #5).

Findings include:

Review of medical record for Patient #5 identified: This [AGE]-year-old male was evaluated in the Emergency Department on 1/27/16 for complaint of chest pain, shortness of breath and cough. The patient was admitted on [DATE] at 6:20 AM, with a diagnosis of CHF exacerbation, secondary to Respiratory Tract Infection. The patient, however, remained in the Emergency Department awaiting Telemetry bed until 1/30/16 at 2:14 PM, when he was transferred to the Hospital South campus for admission.

Review of admission orders written on 1/27/16 at 10:47 AM, noted that physician orders for daily weight, and strict intake/output indicated for fluid management of the patient, were not implemented by nursing staff on 1/27, 1/28 and 1/30/16. In addition, the physician order written on 1/27/16 at 10:47 AM for "Out of bed to chair" was not implemented.

At interview with Staff B, Registered Nurse, on 4/21/16 at 2:30 PM, she acknowledged the patient was not weighed daily and his intake and output were not measured until he was transferred to an inpatient unit on 1/30/16. Staff B confirmed the patient was maintained on bed rest until 1/31/16.