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.

ST JOHN'S EPISCOPAL HOSPITAL AT SOUTH SHORE 327 BEACH 19TH STREET FAR ROCKAWAY, NY 11691 Jan. 13, 2017
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0194
Based on interview, viewing of the video tape and document review, the facility failed to ensure that staff applying restraints were properly trained. (Patient #1)

Findings include:
On 1/11/17 at 2:10 PM, a video dated 11/27/16 of the ED psych holding area was viewed. The video revealed Patient #1 being hoisted up via all four extremities by security and Patient Care Attendant (PCA) staff and placed in the Seclusion Room.
This finding was acknowledged by Staff A, RN Administrator, Staff B and Staff C, Quality Administrators and Staff D, Director, who were present during the viewing of the video.

During interview on 1/12/17 at 10:44 AM of Staff K, Director Security, he acknowledged that there was no restraint training for hospital security staff who assist with restraint and seclusion.
The personnel files reviewed for four (4) of four (4) Hospital Security officers, Staff L, Staff M, Staff N and Staff O lacked evidence of training in restraints.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, medical record review and viewing of the video of the ED psych holding area dated 11/27/16, it was determined that the facility failed to ensure the patient's rights to privacy. (Patient #1)

Findings include:

Review of medical record for Patient #1, triage documentation indicated that the patient a [AGE] year old was brought from home via EMS-FDNY to the emergency department (ED) on 11/27/16 at approximately 6:17 PM for psych evaluation.
On 1/11/17 at 2:10 PM a video dated 11/27/16, of the ED psych holding area was viewed. It showed Patient #1 being undressed by male security staff and the male PCA (patient care assistant) staff in the common area, in front of the nursing station. The patient was surrounded by the staff and the patient's clothes was thrown to the floor.

This finding was acknowledged by Staff A, RN, administrator, Staff B and Staff C, Quality administrators, and Staff D, Patients Relations who were present during viewing of the video.
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review, interview and viewing of facility video tape, it was determined that the facility failed to meet the Condition of Participation for Patient's Rights as evidenced by:

(a) Failure to ensure that staff implemented the facility's policy and procedure for seclusion.

(b) Failure to ensure that less restrictive interventions were determined to be ineffective
before ordering medications and placing a patient in seclusion.

(c) Failure to ensure the safe implementation of restraint or seclusion by trained staff.

(d) Failure to ensure that staff who apply and monitor restraints are trained in the use of first aid techniques and certification in the use of cardiopulmonary resuscitation (CPR).

(e) Failure to provide personal privacy for a patient.

These failures place patients at risk for potential harm.


Findings include:
(a) Review of the medical record for Patient #1 noted: nursing documentation on 11/27/16 at 5:01 PM that "the patient was alert/hostile/screaming, hitting, kicking, threatening staff, unable to redirect, stat intramuscular (IM) meds ordered and administered, placed in quiet room for meds to take effect."
Upon viewing of the video tape of the emergency department psych holding area, dated 11/27/16, it revealed that the patient was placed in the Seclusion Room and not in the Quiet
Room. This finding was confirmed by hospital Staff A, Staff B, Staff C and Staff D, who
were present during the viewing of the video.

There was no physician order for seclusion documented in the medical record.

On interview of Staff J, RN in the ED psych holding area, on 1/10/17 at approximately 11:30 AM, the staff member stated that a physician's order is needed for seclusion.


Review of the MR for Patient # 2 noted: A [AGE] year old with history of schizophrenia, was brought to the Emergency Department (ED) on 12/26/16 at 1:18 PM, for a psych evaluation.
The Restraint/Seclusion Assessment Monitoring form, dated 12/26/16 from 3:00 PM to 6:00 PM indicated that the patient was authorized to be in seclusion for three hours and the patient was placed in seclusion at 3:00 PM and removed from seclusion at 6:00 PM. The physician's order for seclusion for 3 hours was dated 12/26/16, 3:11 PM.

The facility policy and procedure titled "Psychiatry Policy and Procedure Manual," last reviewed 4/21/15, stated: each order for restraint or seclusion shall not exceed two hours. If the continued use of restraint or seclusion is deemed necessary based on an individualized patient assessment, another order is required and a physician must evaluate the patient.
The physician order for seclusion for 3 hours was not in compliance with the seclusion policy that limits seclusion to two hours only.
(See Tag A 168)


(b) Review of the Seclusion/Restraint Log for the ED psych holding area, noted that Patient #2 was placed in the Seclusion room on 12/26/16 at 3:00 PM.
Review of the medical record (MR) for Patient #2 identified a [AGE] year old with history of schizophrenia, was brought to the Emergency Department (ED), on 12/26/16 at 1:18 PM for a psychiatric evaluation. The patient arrived in the psych holding area, on 12/26/16 at 2:49 PM, accompanied by EMS/police, ambulatory with handcuffs. The nurse noted that the patient was agitated, uncooperative, refusing to change into hospital garb.
The medical provider ordered antipsychotic and antianxiety medications, on 12/26/16 2:37 PM and the medications were administered at 2:50 PM. At 3:11 PM, on 12/26/16, the physician ordered "seclusion 3 hours." The reason noted for the seclusion was "agitation, violent/aggressive behavior."
There was no documented evidence that less restrictive method of treatment was initiated before administration of medications and the implementation of seclusion, approximately 20 minutes after the patient's arrival to the psych holding area.

Review of a video tape of the ED psychiatric holding area, dated 12/26/16, showed that at 2:37 PM, Patient #2 entered the psych holding area accompanied by security staff at each side. The security staff took the patient directly to the Seclusion Room. It was observed that, at the time the patient was placed in the Seclusion Room, the patient did not appear to be acting out or was she acting aggressively.

Staff I, physician who also viewed the video, concurred that the patient did not need to be restrained or placed in seclusion at that time and suggested that the patient had been medicated in the main ED.
(See Tag A 164)

(c) Review of a video tape of the psych holding area, dated 11/27/16, revealed that Patient #1 was hoisted up by both lower and upper extremities by the security and PCA staff and placed in the Seclusion Room. This finding was acknowledged by Staff A, Staff B, and Staff C who were present during the viewing of the video.

During interview on 1/12/17 at approximately 10:44 AM, Staff K, Security Director
acknowledged that there was a lack of restraint training for hospital security staff.

Review of four (4) of four (4) personnel files for Hospital Security Officers, Staff L, Staff M, Staff N and Staff O, lacked evidence of training in restraints.

(See A 194)

(d) During interview on 1/12/17 at approximately 10:44 AM, Staff K, Security Director acknowledged that there was a lack of first aid training and certification in cardiopulmonary resuscitation for hospital security staff.

The personnel files reviewed for Hospital Security Officers, Staff L, Staff M, Staff N and Staff O, lacked evidence of training in the use of first aid and cardiopulmonary resuscitation
(CPR).


(e) Review of a video tape of the ED psych holding area, dated 11/27/16, showed Patient #1
being undressed by security and Patient Care Assistant (PCA) staff in the common area, in front of the nursing station and the patient's clothing was thrown on the floor.
(See Tag A143)
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record (MR) review, document review, viewing of video tape and interview, in 1 (one ) of 5 (five) medical records reviewed, the facility failed to use less restrictive intervention before administration of medications and implementation of seclusion.
(Patient #2).

Findings include:
During the tour of the facility's ED psych holding area on 1/10/17 at approximately 11:45 AM, the Seclusion/Restraint log was reviewed. The Seclusion/Restraint log indicated that Patient #2 was placed in the Seclusion Room on 12/26/16 at 3:00 PM.
Review of MR for Patient #2 noted: A [AGE] year old with history of schizophrenia, was brought to the Emergency Department (ED), on 12/26/16 at 1:18 PM, for a psych evaluation. The patient arrived in the ED psych holding area in handcuffs, accompanied by Emergency Medical Services (EMS) personnel and police, on 12/26/16 at 2:49 PM. The nurse noted the patient was agitated, shouting she wants to be discharged back to the residential treatment facility where the patient resided. Patient is uncooperative, refusing to change into hospital garb, coat and shoes removed to prevent elopement.
The documentation in the MR noted that antipsychotic and anti-anxiety medications were ordered and administered at 2:50 PM, and at 3:11 PM on 12/26/16, the physician ordered seclusion for 3 hours. The reason for the seclusion was agitation, violent/aggressive behavior

There was no documentation that the facility staff used a less restrictive intervention prior to medication and implementation of seclusion.

Review of the video tape dated 12/26/16, showed that, on 12/26/16 at 2:37 PM, the patient entered the psych holding area accompanied with security staff at each side. The security staff took the patient directly to the Seclusion Room. It was observed that, at the time the patient was placed in the Seclusion Room, the patient did not appear to be acting out nor was she acting aggressively.

Staff I, Administrator-MD, who also viewed the video, concurred that the patient did not need to be restrained or placed in seclusion at that time and suggested that the patient had been medicated in the main ED.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0206
Based on interview and document review, it was determined that the facility failed to ensure that hospital security staff who assist in take downs, application and monitoring of patients in restraints, are trained in the use of first aid techniques and cardiopulmonary resuscitation.

Findings include:
During interview on 1/12/17 at 10:44 AM Staff K, Director Security, he acknowledged that hospital security staff have not received any training in first aid and certification in cardiopulmonary resuscitation .
The personnel files reviewed for four (4) of four (4) Hospital Security officers, Staff L, Staff M, Staff N and Staff O lacked evidence of training in the use of first aid and cardiopulmonary resuscitation (CPR).
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on medical record (MR) review, document review, interview and viewing of the video, in four (4) of five (5) medical records reviewed, staff failed to implement the facility's policy for seclusion. (Patient #1, #2, #3 & #4).

Findings include:
Review of the medical record for Patient #1, noted that the nursing documentation on 11/27/16 at 5:01 PM indicated that "the patient was alert/hostile/screaming, hitting, kicking, threatening staff, unable to redirect, stat intramuscular (IM) meds ordered and administered, placed in quiet room for meds to take effect. Physician's documentation on 11/27/16 at 7:57 PM indicated that the plan was for the patient to be admitted , medication management and monitored every 15 minutes.

Upon viewing the video of the emergency department psych holding area, dated 11/27/16, it revealed that the patient was placed in the Seclusion Room and not in the Quiet Room.
This finding was acknowledged by Staff A, RN Administrator, Staff B and Staff C, Quality Administrators, and Staff D, Director, who were present during the viewing of the video.

There was no physician's order for seclusion documented in the medical record.

On interview of Staff J, RN, on 1/10/17 approximately 11:45 AM, this staff member stated that a physician's order is needed for seclusion.


Review of the MR for Patient #2 noted: A [AGE] year old with history of schizophrenia, was brought to the Emergency Department (ED) on 12/26/16 at 1:18 PM, for a psych evaluation.
The Restraint/Seclusion Assessment Monitoring form, dated 12/26/16 from 3:00 PM to 6:00 PM indicated that the patient was authorized to be in seclusion for three hours. The form indicated that the patient was placed in seclusion at 3:00 PM and removed from seclusion at 6:00 PM. The physician's order for seclusion for 3 hours was dated 12/26/16, 3:11 PM.

The facility policy and procedure titled "Psychiatry Policy and Procedure Manual," last reviewed 4/21/15, stated: each order for restraint or seclusion shall not exceed two hours. If the continued use of restraint or seclusion is deemed necessary based on an individualized patient assessment, another order is required and a physician must evaluate the patient.
The policy also stated; if an episode of mechanical restraint or seclusion has exceeded two hours for adults and it is expected that restraint or seclusion will be required beyond such time periods, the facility's clinical medical director or director of psychiatry, or his/her designee, must be notified and consulted. It is preferable that they personally evaluate the situation






Security Department Occurrence Report form, dated 10-30-16, was reviewed. The staff writing this report documented for Patient #3: "On the above date and time assistance was needed in psych holding due to a patient who was not following instructions. Nurse requested patient to be placed into seclusion. At that time patient became combative and snatched my radio. Four other officers assisted the Patient Care Attendant (PCA). The patient was directed into seclusion and was medicated by the RN."
There was no physician's order for seclusion located in the medical record.


Security Department Occurrence Report form, dated 11-1-16, was reviewed. The Security Officer's report documented that Patient #4 was given several instructions by the PCA to sit down and relax before the doctor would communicate with him. The patient did not follow instruction and raised his fist in an aggressive manner at the Security Officer. The Security Officer called for assistance and two other officers responded. The patient was directed into the seclusion area until further instruction by the nurse.
Review of MR for Patient # 4 noted: [AGE] year old male with psychiatric history of anxiety and alcohol use disorder who was brought to the facility's ED by EMS on 11/1/16, 3:04 PM. The ED medical provider saw the patient on 11/1/16, 3:47 PM.
There was no order for seclusion by the medical provider.

The facility's hospital wide restraint policy titled "The Psychiatry Policy and Procedure Manual," last reviewed 4/21/15, stated "the implementation of restraint or seclusion shall only be pursuant to a physician's written order based on the results of a personal examination of the patient by the physician."
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation and staff interview, it was determined that the facility failed to ensure that care was provided in a clean and safe environment.

Findings include:
1. During tour of the Emergency Department Psychiatric holding area on 1/10/17 at 11:30 AM, the following was observed:

(a) The Seclusion Room (T140) was observed to be dirty with brown and red finger prints on the wall, which gave an appearance of finger painting.
The perimeter of the seclusion room floor was observed to have accumulation of encrusted dust and dirt.
Broken walls were observed in the Quiet Room. The bed in the room was broken with wooden panel falling off and protruding nails. The mattress cover was observed to be filthy with white color spots on the entire cover. Encrusted dust and dirt was observed on the perimeter of the floor.

Staff E, Housekeeping, was interviewed on 1/10/17 at approximately 11:45 AM and stated that the rooms are supposed to be cleaned daily.

(b). During tour of the main Emergency Department (ED) on 1/10/17 at 11:00 AM, a red raised mass of material was observed next to a cubicle bed. ED staff was not able to identify what it was. Housekeeping staff was called to clean it up, they were later observed scraping up the red lump. A red spot was observed left on the floor after scraping was done.

The facility Housekeeping policy and procedure titled "ED/Behavioral Health Unit Cleaning," last revised 5-5-2015, stated the following "The housekeeping department personnel will clean all areas of the Emergency Department daily. Seclusion room: Spot wipe stains and spots from wall and other vertical surfaces. Dust mop the room beginning with the corners and edges, moving from the far side of the room toward the door. Maintain one leading edge with the dust mop. Begin damp mopping all the hard floor surfaces including corners, edges and behind doors."

This finding was confirmed with Staff A RN, Administrator and Staff B, Quality Administrator who were present during the tour.

2. The facility's Geriatric Psychiatric unit was toured on 1/13/17 at 10:00 am.
(a) The shower room (room 433) was found to be in disrepair with chipping walls and a broken shower head.
(b) The floors in Room 414 and 412 were found to be dirty and stained.
(c) The tops of the bedside tables in Room 413 and 414 were found partially stripped and in need of repair

These findings were brought to the attention of Staff F, RN, Director, Staff G, Nurse Manager and Staff H, RN.