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.

CROUSE HOSPITAL 736 IRVING AVENUE SYRACUSE, NY 13210 Aug. 7, 2015
VIOLATION: PATIENT RIGHTS: GRIEVANCE PROCEDURES Tag No: A0121
Based on findings from interview, on 2 of 9 inpatient units, 5 South and 4 North, the hospital did not inform patients or patient's representatives of its internal grievance process.

Findings include:

-- During interview of Patient A's legal guardian on 8/5/15 at 10:15 am on unit 5 South, when asked, he acknowledged not being provided information regarding the hospital's grievance process.

-- During interview of Staff #1, Nurse Manager of 5 South on 8/5/15 at 10:30 am, he/she acknowledged that patients on 5 South are not provided information regarding the hospital's grievance process.

-- Per interview of Staff #2, Discharge Nurse of 4 North on 8/5/15 at 2:30 pm, he/she indicated that grievance information is not provided to patients unless there is a problem. At that time staff will provide a patient or a patient representative the phone number of the Patient Relations department to register a grievance.
VIOLATION: PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION Tag No: A0133
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on findings from medical record (MR) review, document review, and interview, in 12 of 12 MRs reviewed, Patients A through L, there was no documentation indicating, that at the time of a patient's admission to the hospital, the patient was asked whether he/she wanted a family member or representative and his/her own physician notified of their admission to the hospital. Also, the hospital does not have a policy and procedure (P&P) that addresses this process.

Findings include:

-- Per review of Patient A's MR, he was admitted on [DATE] with small bowel obstruction. There is no documentation that hospital staff inquired as to whether Patient A wanted his own physician notified of his admission.

-- Per review of Patient I's MR, he was admitted on [DATE] with a cerebral vascular accident (CVA). There is no documentation that hospital staff inquired as to whether Patient I wanted his own physician and family or 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 Patient B - H, J, K and L.

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

-- During interview of Staff #1 on 8/5/15 at 10:30 am, he/she acknowledged the above findings.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on findings from document review and interview, the hospital did not have a policy and procedure (P&P) that specifically addressed the investigation of allegations of patient abuse and neglect. Also, the hospital did not provide staff education specific to the handling of complaints of patient abuse and neglect.

Findings include:

-- Per review of the facility P&P titled, "Patient Complaint Management" last revised, 3/2012, it indicated a patient has the right to complain and have the hospital respond to their complaint. The policy also indicated if the patient is not satisfied with the response the patient can complain to the Department of Health. The P&P did not specifically address complaints of abuse and neglect.

-- Per interview of Staff #3, Director for Quality Improvement on 8/6/15 at 12:15 pm, staff are educated in child abuse, domestic violence, elder abuse and complaint investigations, but not specifically educated in the investigation of complaints related to patient abuse and neglect. During this interview, Staff #3 acknowledged the above finding.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0170
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on findings from medical record (MR) review, document review and interview, in 4 of 4 MRs reviewed for restraint application, (Patients C, I, J, K) there is no documentation that the patient's attending physician was notified regarding the application of restraints. Additionally, the facility policy and procedure (P&P) regarding restraints did not require that the attending physician be notified of restraint application.

Findings include:

-- Per MR review, Patient K, was admitted on [DATE] with an intercranial hemorrhage. On 8/4/15 at 7:45 pm, Staff #4, Medicine Hospital Resident, ordered application of a restraint for protection of a medical device (ENT tube). There is no documentation that the patient's attending physician was notified at the time of the restraint application.

The same lack of documentation of attending physician notification was found in MRs for Patients C, I, J.

-- Per review of facility P&P titled "Restraints: Definitions and Ordering, Care of the Patient Requiring Medical/Surgical or Behavioral Restraint and/or Seclusion," last revised 4/2014, it lacked direction to staff to notify the attending physician of restraint application as soon as possible and to document the notification.

-- During interview of Staff #5, Nurse Manager Intensive Care Unit (ICU) on 8/6/15 at 11:30 am, he/she acknowledged staff on the unit do not notify or document notification of the attending physician when a patient has restraints applied.