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.

GOOD SAMARITAN HOSPITAL MEDICAL CENTER 1000 MONTAUK HIGHWAY WEST ISLIP, NY 11795 July 25, 2016
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
.
Based on record review, document review, and interview in one (1) of three (3) Medical Records reviewed, the facility did not ensure that the Physician's Violent Restraint Order was accurate.

This places patients at risk for potential harm.

Findings:

Review of Patient #6's Medical Record identified that on 07/10/16 at 6:13PM the patient was placed in Four (4) Point Restraints. At the same date and time the Physician incorrectly ordered side rails instead of Four (4) Point Restraints.

During an interview with Staff C (Administrator Emergency Department) on 07/11/16 at 2:33PM the staff member confirmed this finding.

The Facility's Policy and Procedure titled "Restraints" last revised 11/27/13, contained the following statement: Violent / Self Destructive Restraint Orders "..... must include: ...... type of restraint....".
.
VIOLATION: PATIENT RIGHTS Tag No: A0115
.
Based on document review, Policy review, and interview, the facility failed to ensure that all staff who assist with the application of restraints received training in the use of First Aid Techniques and certification in Cardiopulmonary Resuscitation (CPR).

These failures place all patients at risk for potential harm.

Findings include:

See Tag A 206
.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

.
Based on record review and interview in two (2) of three (3) Medical Records, the facility did not ensure that an "Important Message" (IM) Form CMS-R-193, was provided to the patient / patient representative in the required timeframe or documented as being mailed to the patient's representative as required by the facility's Policy.

By not providing the Important Message Form in a timely manner, there is a potential that the patient would not have sufficient time to appeal a discharge.

Findings:

Review of Patient #9's Medical Record identified no evidence of an Important Message from Medicare (IM) Form on admission and the data entered into the STAR Navigator System (computer program) for this patient was left blank for the Medicaid IM Form. This patient is a [AGE]-year-old who was admitted on [DATE] and was still an inpatient as of 07/12/16.

Review of Patient #8's Medical Record revealed that the Admitting Clerk documented on the Important Message from Medicare (IM) Form dated 07/02/16 that the patient was "unable to sign". There was no documented evidence in the Medical Record that another attempt was made to deliver the IM Form or that the form was mailed to the patient's representative as required by the facility's Policy. This patient is an [AGE]-year-old who was admitted on [DATE] and was still an inpatient as of 07/12/16.

The facility's Policy and Procedure titled "Patient Access: Important Message from Medicare Procedure", last revised June 2016, states that Admitting Clerks should present the Important Message from Medicare (IM) at the time of inpatient admission.

This Policy also stated that "The IM Form should be signed by the patient, dated, and placed directly in the Chart by the Admitting Clerk."

In the event the patient is unable to sign and the next day a second attempt is made (if no signature obtained) the Admitting Clerk should document on the form "Second Attempt - No Patient Representative available". Then mail a copy of the form to the patient's home address or their representative placing the original in the Chart.

An interview during the afternoon on 07/12/16 with Staff G (Director of Patient Access) and Staff E (Supervisor of Utilization Review) confirmed the findings.
.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
.
Based on record review, document review, and interview in two (2) of three (3) Medical Records reviewed, the facility staff did not perform an immediate assessment after the application of Four (4) Point Restraints to ensure that restraints were properly and safely applied as per Regulation and facility Policy.

This places patients at risk for potential harm.

Findings:

Review of Patient #5's Medical Record identified that on 07/10/16 at 10:34PM the patient was placed in Four (4) Point Restraints. There was no documented evidence that the Registered Nurse performed an assessment of the patient immediately following the application of restraints.

During an interview with Staff C (Administrator Emergency Department) on 07/10/16 at 11:50AM the staff member confirmed this finding.

Review of Patient #6's Medical Record identified that on 07/10/16 at 6:13PM the patient was placed in Four (4) Point Restraints. At 7:00PM vital signs were performed, forty-five (45) minutes after the restraints were applied. The Nursing Assessment was completed at 7:30PM, one (1) hour and fifteen (15) minutes after the restraints were applied.

During an interview with Staff C (Administrator Emergency Department) on 07/11/16 at 2:33PM the staff member confirmed this finding.

The facility's Policy and Procedure titled "Restraints" last revised 11/27/13 contained the following statement: "An Registered Nurse performs an assessment of the patient immediately following the application of restraints, including signs of any injury associated with the application of restraints, blood pressure, pulse, respirations, temperature, patient's condition, hygiene, skin integrity, circulation, range of motion in extremities, hydration / nutrition needs, elimination needs, mental status and readiness for discontinuation of restraints."
.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

.
Based on record review, document review, and interview in one (1) of one (1) Medical Records reviewed, the facility did not ensure that Violent Restraints Orders were renewed timely.

This places patients at risk for potential harm.

Findings:

Review of Patient #6's Medical Record identified that on 07/10/16 at 6:13PM the patient was placed in Four (4) Point Restraints. On 07/11/16 at 7:00AM the restraints were removed.

The Violent Restraint Order was not renewed on 07/10/16 at 10:13PM, and 07/11/16 at 2:13AM and 6:13AM, during the eleven (11) hours and forty-five (45) minutes the patient was restrained and as required by Regulation and facility Policy.

During an interview with Staff C (Administrator Emergency Department) on 07/11/16 at 2:33PM the staff member confirmed this finding.

The facility's Policy and Procedure titled "Restraints" last revised 11/27/13 contained the following statement: "A Restraint Order for violent, self-destructive behavior cannot exceed four (4) hours for patients [AGE] (eighteen) and older."
.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
.
Based on record review, document review, and interview in two (2) of three (3) Medical Records reviewed, the facility did not ensure that patients in Violent Restraints were monitored and assessed as per facility Policy and Physician Orders.

This places patients in Violent Restraints at risk for potential harm.

Findings:

The facility's Policy and Procedure titled "Restraints" last revised 11/27/13, contained the following statement: "A Registered Nurse performs an assessment of the patient immediately following the application of restraints, including signs of any injury associated with the application of restraints, blood pressure, pulse, respirations, temperature, patient's condition, hygiene, skin integrity, circulation, range of motion in extremities, hydration / nutrition needs, elimination needs, mental status and readiness for discontinuation of restraints. Assessments occur every 15 (fifteen) minutes thereafter, based on type of restraint patient's condition and patient needs. The staff shall keep the patient under constant observation for the duration of the restraint. If appropriate, the Registered Nurse will release the restraint one (1) limb at a time and provide range of motion, pulse check, skin integrity assessment at least every 2 (two) hours."

The facility's Restraint and Monitoring Checklist directed staff that "the following observations or actions must be documented every 15 (fifteen) minutes" and that vital signs will be done "every 4 (four) hours or as directed by the Registered Nurse."

Review of Patient #6's Medical Record identified that on 07/10/16 at 6:13PM the patient was placed in Four (4) Point Restraints. At the same date and time the Physician ordered 1:1 observation and restraint checks every fifteen (15) minutes for four (4) hours. On 07/11/16 at 7:00AM the restraints were removed.

Between 07/10/16 at 6:13PM and 07/11/16 at 7:00AM, eleven (11) hours and forty-five (45) minutes, there was no documented evidence that the Nurse released the restraints every two (2) hours. The "Violent Restraint Intervention" Release Section was blank.

Between 07/10/16 at 8:00PM and 07/11/16 at 6:30AM, ten and one-half (10) hours, there was no documented evidence that the Nurse provided range of motion, performed a pulse check, and a skin integrity assessment of each limb every two (2) hours.

Between 07/10/16 at 6:13PM and 11:45PM, approximately five and one half (5) hours, two (2) of twenty-two (22) every fifteen (15) minutes patient assessment and monitoring were documented.

Between 07/10/16 at 6:13PM and 7:30PM, approximately one (1) hour and fifteen (15) minutes, there was no documented evidence that the patient was placed on 1:1 observation as required by facility Policy and Physician Order.

During an interview with Staff C (Administrator Emergency Department) on 07/11/16 at 2:33PM the staff member confirmed this finding.

Review of Patient #5's Medical Record identified that on 07/10/16 at 10:34PM the patient was placed in Four (4) Point Restraints. The Physician ordered Violent Restraints for one (1) hour, 1:1 observation and restraint checks every fifteen (15) minutes.

Between 10:34PM and 11:45PM there was no documented evidence of restraint checks every fifteen (15) minutes and that the patient was placed on 1:1 observation.

During an interview with Staff C (Administrator Emergency Department) on 07/10/16 at 11:50AM the staff member confirmed this finding.
.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0176
.
Based on document review and interview, the facility did not ensure that thirteen (13) of sixty-one (61) Physicians who order restraints, had received the Annual Education on the Restraint Policy.

The lack of physician education has the potential to result in the increased use of restraints.

Findings:

Review of the "Restraints" Policy and Procedure effective 11/27/13 documented that staff involved in the use / application of restraints will receive Initial and Annual Education in the use of restraints.

The facility could not provide documented evidence that six (6) Hospitalists, three (3) Intensivists, and four (4) Mid-Level Practitioners (Physician Assistants, Nurse Practitioners) who order restraints received the required Annual Restraint Education as required per the facility's Policy.

The Personnel File of Staff BB (Hospitalist) lacked the required Annual Education which included the Restraint Policy for 2015.

The Personnel File of Staff HH (Intensivist) lacked the required Annual Education which included the Restraint Policy for 2015.

The Personnel File of Staff KK (Physician Assistant) lacked the required Annual Education which included the Restraint Policy for 2015.

Similar finds were identified in the Personnel Files of Staff CC, DD, EE, FF, GG, II, JJ, LL, MM and NN.

During an interview on 07/25/16 at 12:15PM with Staff A (Vice President of Risk Management) the staff member stated that all Physicians are required to complete the online inservice annually. This inservice includes the Restraint Training.
.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
.
Based on record review and interview in two (2) of three (3) Medical Records reviewed, the facility did not ensure that when patients are placed in Four (4) Point Violent Restraints, that the Physician documented a comprehensive (physical and behavioral) assessment of the patient's condition.

This failure has the potential for patients being inappropriately placed in restraints.

Findings:

Review of Patient #6's Medical Record identified that on 07/10/16 at 6:13PM the patient was placed in Four (4) Point Restraints. The Physician ordered the Violent Restraint and attested to performing a face to face evaluation of the patient. However, there was no documented evidence of a comprehensive (physical and behavioral) assessment of the patient's condition.

Review of Patient #7's Medical Record identified that on 07/12/16 at 8:57PM the patient was placed in Four (4) Point Restraints. The Physician ordered the Violent Restraint and attested to performing a face to face evaluation of the patient. However, there was no documented evidence of a comprehensive (physical and behavioral) assessment of the patient's condition.

The facility's Policy and Procedure titled "Restraints" last reviewed 11/27/13 described the following: when restraints are used for violent behavior a Physician must perform the face to face assessment of the patient within one (1) hour. However, the Policy and Procedure does not define the elements of the face to face assessment.

Per interview of Staff C (Emergency Department Administration) on 07/11/16 at 2:13PM, the staff member stated that when the Physician orders Violent Restraints the Physician can attest to performing a face to face evaluation of the patient. She agreed that the "Restraint" Policy does not define the elements of the face to face assessment.
.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0206
.
Based on document review and interview, the facility did not ensure that staff who participate in non-violent crisis intervention, and/or place patients in restraints, had the required training in the use of First Aid Techniques and certification in the use of Cardiopulmonary Resuscitation (CPR).

This places restrained patients at risk for potential harm.

Findings:

The facility's Policy and Procedure titled "Restraints" last revised 11/27/13 stated the following: "to minimize restraint use, all Direct Care Nursing Staff, as well as other staff involved in the use / application of restraints will receive initial and annual education in the use of restraints and demonstrate an understanding of the following: ....BLS (Basic Life Support)."

The facility could not provide documented evidence that the fifty-one (51) Security Officers who participate in non-violent crisis intervention, and/or place patients in restraints, had the required training in the use of First Aid Techniques and certification in the use of Cardiopulmonary Resuscitation (CPR).

The Personnel File for Staff J (Security Officer) hired on 02/17/04 lacked evidence that the staff member received training in the use of First Aid Techniques and certification in the use of Cardiopulmonary Resuscitation.

The Personnel File for Staff S (Security Officer) hired on 02/04/08 lacked evidence that the staff member received training in the use of First Aid Techniques and certification in the use of Cardiopulmonary Resuscitation.

The Personnel File for Staff V (Security Officer) hired on 04/18/09 lacked evidence that the staff member received training in the use of First Aid Techniques and certification in the use of Cardiopulmonary Resuscitation.

During interview of Staff K (Director of Safety) on 07/12/16 at 2:00PM the staff member stated "I have fifty-one (51) Officers. Under the direction of a Nurse the Officers place Four (4) Point Restraints on patients. The Officers are not mandated to take training in CPR or First Aid.

An interview with Staff A on 07/25/16 at 11:35AM confirmed that evidence of First Aid training and CPR certification was not found in the Security Officers' Personnel Files.