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.

MOUNT SINAI SOUTH NASSAU ONE HEALTHY WAY OCEANSIDE, NY 11572 Jan. 9, 2013
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
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1. Based on record reviews and staff interviews during a Federal Allegation Survey the facility failed to fully implement its policy for patients leaving Against Medical Advice who refused to wait for the physician and did not complete an "Occurrence Form" required by hospital policy (Patients #16 and #19).

Findings:

Review of the medical records for Patients #16 and #19 revealed that both patients left Against Medical Advice prior to the physician's arrival but there were no occurrence reports completed.

The policy titled "Discharge Against Medical Advice" dated August 2011 states if the patient wants to leave before conferring with a physician the Registered Nurse (RN) should inform the physician of the patient's departure and document the situation in the medical record. An "Occurrence Form" should then be completed by the RN and the physician.

An interview with the Assistant Vice President (AVP) of Quality / Risk Management revealed the nursing staff did not complete occurrence reports for either patient.


2. Based on record review and staff interviews during a Federal Allegation Survey there was no evidence of consent for treatment on admission for two (2) out of thirty (30) medical records reviewed (Patients #24 and #29).

Findings:

Review of the medical records for Patients #24 and #29 revealed neither the patient nor the health care agent signed the "Emergency Department / Inpatient Authorization for Treatment" Form on admission.

Review of the facility's policy titled "Informed Consent" dated April 2012 states that all patients or the patient's health care agent, after discussion with the physician, must sign, date and time a consent form prior to the initiation of any surgery, diagnostic procedure or treatment.

This was confirmed on interview with the Assistant VP of Quality Assurance / Risk Management and Assistant Director of Performance Improvement / Quality Assurance.
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VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
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Based on document review and interviews the facility failed to develop a Behavioral Health Escalation Policy for procedures when a Code Grey failed to resolve a crisis situation.(Patient #1)

Findings:

Medical record review revealed on 11/27/12 at 7:15PM a Code Grey intervention failed to de-escalate a physically aggressive and verbally threatening patient (Patient #1). The decision was made by the onsite hospital Administrators and Director of Security to call for Police assistance.

The Behavioral Health Staff confirmed on interview on 01/09/13 that "this had never happened before and we don't have a policy for this type of situation".

There is no documented evidence that the facility developed a policy delineating notifying the chain of command for Behavioral Health Services.
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VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on observations, documentation review, and interviews, the hospital failed to implement their policy for administering medication against a patient's will to a patient in an emergency situation who presented as an immediate danger to himself and others (Patient #1).

Findings:

Medical record review for Patient #1 revealed a [AGE]-year-old male taken to the hospital on [DATE] at 3:15PM via ambulance precipitated by a suicide attempt. The patient was admitted on an involuntary status into the Acute Inpatient Behavioral Health Unit where he was placed on constant observation for safety.

On 11/27/12 at 7:00PM during patient visiting hours the patient exhibited violent behaviors. The patient went into the bathroom was slamming doors, banging his fist against the wall, kicking the walls, and started banging his head against the wall. The patient maintained an enraged threatening posture and verbal attempts to calm the patient were unsuccessful. The patient was offered oral medications and refused.

The patient's staff nurse telephoned the on-call physician who prescribed Geodon 20mg IM and Ativan 2mg IM Stat. The patient refused the medication. The staff did not carry out the physician's order to medicate the patient over objection and did not restrain or seclude the patient.

Review of the hospital policy titled "Administration of Medications against Patients Will" effective date May 2012, stated "Clinical situations that warrant administration of medications against patients' will are: (a) When verbal and all other interventions fail to reduce dangerousness, (b) When oral medication is refused by the patient who is imminently endangering himself or others."

The Psychiatric Medical Director stated during interview on 01/07/13 at 11:45AM "Patients who become severely agitated and pose an immediate threat to others or a danger to self would be medicated over objection if the situation needed and required a physician one time only order."
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VIOLATION: DISCHARGE PLANNING Tag No: A0812
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on record review and staff interviews it was determined that the nursing staff failed to consistently complete the "Discharge Planning" section of the "Patient Admission Assessment" and the "Multidisciplinary Clinical Pathways / Plan of Care" for discharge planning as required by hospital policy in four (4) out of thirty (30) medical records reviewed (Patients #9, #10, #12 and #23).

Findings:

Review of the "Patient Admission Assessment" Form on 01/07/13 for Patient #10, admitted [DATE], revealed the discharge plan section was blank and the "Multidisciplinary Clinical Pathways / Plan of Care" for the discharge plan was also blank.

The "Multidisciplinary Plan of Care Addendum" form for the discharge plan of Patient #9 was blank from 01/04/13 to 01/07/13.

The "Multidisciplinary Clinical Pathways / Plan of Care" Form for the discharge plan of Patient #12 was blank from 12/14/12 to 12/20/12 and the form for Patient #23 was blank on 10/05/12 and 10/06/12.

Review of the "Assessment of Patient" Policy dated June 2011 states that the "Patient Admission Assessment" will be completed within twenty-four (24) hours. A collaborative Interdisciplinary Plan of Care is formulated and documented in the medical record which is reviewed and updated daily.

Review of the facility's policy titled "Discharge Planning Policy" dated March 2011 revealed that representatives from all disciplines attend regular scheduled inpatient "Plan of Care Meetings" and discuss patient goals as well as impediments to discharge. Documentation is then maintained on the "Multidisciplinary Clinical Pathways / Plan of Care" Form in the Discharge Plan section within the medical record.

The "Plan of Care / Clinical Pathway - Multidisciplinary" Policy dated July 2011 states the Plan of Care will include the discharge planning needs documented on the second page of the "Multidisciplinary Clinical Pathways / Plan of Care" Form.

This was confirmed during the three (3) day survey by interview with the Assistant VP of Quality Assurance / Risk Management and Assistant Director of Performance Improvement / Quality Assurance.
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VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on medical record review and interviews the hospital failed to ensure necessary medical information for treatment and follow up was provided for a patient at the time of disposition from the Inpatient Psychiatric Care Unit (Patient #1).

Findings:

Medical record review revealed Patient #1 was removed from the Inpatient Behavioral Health Unit on 11/27/12 at 8:45PM by the Police Department and there was no documented evidence that medical information accompanied the patient.

On 11/27/12 at 9:00PM, the nurse documented "The patient was noted to be visibly upset after a visit with his wife and started kicking walls and banging doors. The patient broke a chair and had the arm of the chair in his hand and it was able to be confiscated. The patient was offered medication. The patient was transferred to Nassau University Medical Center at 8:45PM via Police custody. "

Review of the Code Grey Response Team Data dated 11/27/12 at 7:15PM stated "Reason for code: verbally abusive toward staff. Patient punching holes in wall also broke chair. Actions taken: show of force only, Nassau County Police Department notified and responded with Emergency Service Unit, patient taken to NUMC."

Hospital Administration stated in interviews on 01/07/13 in the morning "We believed he was being arrested when he left here with the Police."

The Medical Director of the receiving hospital on [DATE] at 11:30AM stated on interview "We did not receive any written documentation from the sending hospital, including legal papers."