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.

CATSKILL REGIONAL MEDICAL CENTER 68 HARRIS BUSHVILLE ROAD HARRIS, NY 12742 Nov. 1, 2017
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review and interview, it was determined the physician did not complete a face-to-face evaluation after the physical restraint was applied on an agitated patient. This was evident in one (1) of
six (6) medical records reviewed (Patient #2).

Findings include:

Review of Patient #2's medical record revealed a nurse applied physical restraint on this [AGE] year old child on 3/27/17. The patient was aggressive, combative and uncooperative with care in the ED.

There was no documentation that a physician examined or evaluated the patient, after the physical restraint was applied.

The policy titled "Restraints," which was last reviewed 7/16 states, "the physician will complete a face-to-face evaluation within 1 hour after the initiation of restraints" and document what warranted the restraint use, patient response to interventions used and the MD will assess the physical condition of the patient.

This finding was shared with Staff A, the Director of Quality on November 1, 2017 at approximately 4:00 PM.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review and interview, it was determined the staff failed to use the least restrictive measures for an agitated patient before applying physical restraints. This was evident in one (1) of six (6)medical records reviewed (Patient #2).

Findings include:

Review of Patient #2's medical record identified the following: the triage nurse documented the police brought this [AGE] year old patient to the emergency department (ED) on 3/27/17 at 4:43 PM, after he had allegedly punched a teacher and a nurse at school that day, then he tried to run away from home after school. The patient was aggressive, combative and uncooperative with care upon arrival in the ED. The patient's previous medical history included Oppositional Defiant Disorder, Attention Deficit Hyperactivity Disorder and Bipolar 1 Disorder.

Nursing documentation at 8:32 PM revealed the patient was physically restrained. These notes revealed "the patient continues to verbally abuse, thrash around, kick, hit, bite staff and police."

Nursing documentation at 8:35 PM revealed the patient's vital signs were stable, safety measures were in place and the patient was asleep in bed.

The patient was discharged from the facility on 3/27/17 at 9:08 PM.

The record does not indicate when the physical restraint was applied and when it was removed.

There was no documentation in the medical record that the least restrictive measures were used before applying physical restraints.

The policy titled "Restraints," last reviewed 7/16 states, "behavioral management restraints are used only in emergency and all least restrictive interventions must be attempted and documented first."

This finding was shared with Staff A, the Director of Quality on November 1, 2017 at approximately 4:00 PM.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review and interview, it was determined the staff applied physical restraint for an agitated patient without a written physician's order. This was evident in one (1) of six (6) medical records reviewed (Patient #2).

Findings include:

Review of Patient #2's medical record identified the following: the triage nurse documented the police brought this [AGE] year old child to the emergency department (ED) on 3/27/17 at 4:43 PM, after he had allegedly punched a teacher and a nurse at school then he tried to run away from home. The patient was aggressive, combative and uncooperative with care upon arrival to the ED.

Nursing documentation at 8:35 PM revealed the patient was physically restrained.

The record does not contain a physician's order for the application and use of a physical restraint.

The policy titled "Restraints," which was last reviewed 7/16 states, "upon notification of need for patient restraint, physician will provide a written or telephone order for restraint. The MD must be called each time for order for restraint."

This finding was shared with Staff A, the Director of Quality, on November 1, 2017 at approximately 4:00 PM.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review and interview, it was determined the facility failed to ensure that staff conducted a suicide assessment for a patient who presented to the emergency room (ED) with suicidality. This was evident in one (1) of four (4) medical records reviewed (Patient #3).

Findings include:

Review of the Facility Policy titled "Suicide Risk Assessment," which was last revised 4/17 states: "The suicidality/lethality of patients will be assessed and reassessed to address the treatment needs and safety of our patients."

Review of patient #3's medical record identified a twenty three year old male who was brought into the emergency room on [DATE] at 6:11 PM by EMS, with a complaint of "suicide". He was triaged by the emergency room nurse who wrote that the patient had "Mental Health Problems."

The medical record indicated that he had a history of a Behavior Problem, Bipolar disorder, Depression, Outburst of Explosive Behavior and Schizophrenia.

On 9/10/17 at 6:45 PM, the patient was seen by the Physician Assistant (PA) who documented that the patient was "agitated."
On 9/10/17 at 7:11PM the patient was discharged home.

There was no documentation of a suicide risk assessment.

During interview on 10/31/17 at 2:45 PM, Staff B, Clinical Director of the emergency room acknowledged the findings.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review and interview, it was determined the staff failed to monitor an agitated patient who was placed in restraint. This was evident in one (1) of six (6) medical records reviewed (Patient #2).

Findings include:

Review of Patient #2's medical record revealed: the triage nurse documented this [AGE] year old child arrived in the emergency department (ED) on 3/27/17 at 4:43 PM, after he had allegedly punched a teacher and a nurse at school then he tried to run away from home after school that day. The patient was aggressive, combative and uncooperative with care upon arrival in the ED.

Nursing documentation at 8:32 PM revealed the patient was physically restrained and that the patient continues to verbally abuse, thrash around, kick, hit and bite staff and police.

Nursing documentation at 8:35 PM revealed the patient was on constant awareness monitoring, the vital signs were stable and that the patient was asleep.
There was no documentation in the medical record of the constant awareness monitoring.

The policy titled "Restraints," which was last reviewed in 7/16 states, documentation of observation as follows: "patients deemed to be at high risk for injury to themselves or others should be placed on constant awareness one-to-one with 15 minute monitoring documentation completed."

This finding was shared with Staff A, the Director of Quality on November 1, 2017 at approximately 4:00 PM.