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.

MAIMONIDES MEDICAL CENTER 4802 TENTH AVENUE BROOKLYN, NY 11219 April 27, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and document review, the facility failed to ensure that care is provided to patients in a safe environment. Specifically, the facility failed to ensure:
1. A safe and protective environment for patients at risk for elopement;
2. The development and implementation of policies to protect patients from abuse and harassment by staff, other patients, or visitors;
3. That patients are free from staff use of physical restraints and involuntary confinement or seclusion when managing agitated patient behavior;
4. Prior to the use of patient restraints, that staff documented the implementation of less restrictive interventions;
5. Security officers who assist in restraints and perform manual hold are trained in the following: Safe application of restraints; non physical intervention skills; and First Aid and Cardiopulmonary Resuscitation.

This placed patients at risk for potential harm.

See Tag A144, 145, 162, 186, 200, 202 and 206.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0186
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on medical record review and document review, in two (2) of nine (9) medicals record reviewed, the facility did not ensure that prior to the use of restraints, alternative or other less restrictive interventions implemented were documented (Patient #s 3, & 5).

Findings include:

Review of medical record for Patient #3 identified a [AGE]-year-old patient who was brought to the ED by ambulance on 3/4/17 at 1:33 AM. The triage nurse noted that the patient was found on the street.

On 3/4/18 at 2:00 AM, the nurse noted the patient was agitated and combative. Patient was put in 4 points restraints, and medicated as per physician order.

The physician documented in the progress note, "I assisted in the preliminary evaluation of this patient. If I placed orders, I did so to expedite care and treat any acute condition and and/or pain. Any medical care will be delivered by a subsequent team of physicians"

There was no documentation of alternative measures attempted prior to the use of restraints or the rationale for not implementing alternative measures.

Review of medical record for Patient #5: This 37- year-old patient with significant psychiatric history, was brought to the facility's Emergency Department (ED) by ambulance on 11/7/17 at 7:59 PM. The chief complaint was abnormal behavior. On 11/7/17 at 8:05 PM, the triage nurse noted "patient was under the impression someone stole her purse and was throwing chairs around, attempting to leave".

On 11/7/17 at 8:19 PM, the primary nurse noted "As per triage nurse, the patient was aggressive and agitated. The patient was medicated by the triage nurse and placed in 4 points restraints, as per physician orders.

The physician's progress noted dated 11/07/17 at 8:39 AM indicated "I assisted in the preliminary evaluation of this patient. If I placed orders, I did so to expedite care and treat any acute condition and/or pain. Any medical care will be delivered by a subsequent team of physician. Patient agitated here in triage and was trying to get out of bed. Patient was chemically sedated".

There was no documentation of alternative measures attempted prior to placing the patient on physical and chemical restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0200
Based on document review and staff interview, in 6 of 6, personnel files reviewed, the facility failed to ensure that security officers who are called to assist in the management of disruptive patients, received training in the use of nonphysical intervention skills (Staff A through C, Staff T, U and Staff Aa).

Findings include:

Review of six personnel files for Security Officers, Staff A through C and T, U, and Aa identified that these staff members have not received training on nonphysical intervention skills/de-escalation techniques for the safe management of disruptive patients.

During interviews with Security Staffs A, B, C, T, U, and Aa on 4/25/18 at 2 PM, they acknowledged that they have not been trained on nonphysical intervention skills/de-escalation techniques.

During interview with Staff A, Director of Security, on 4/25/18 at 1:35 PM, he acknowledged that none of the 39 Security Officers working at the facility has training on nonphysical intervention skills-de-escalation techniques in the management of aggressive patients.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0202
Based on document review and interview, in six (6) of six (6) personnel files reviewed, the facility failed to ensure that the security officers, who assist with restraints and perform manual holds, are trained in the safe application of restraints (Staff A, B, C, T, U, and Aa).

Findings include:

Review of Job Description for Security Guards last revised 10/03/2002, noted that part of their responsibility is to "Assist in restraining emotional disturbed patients."

Review of personnel file for Staff A revealed there was no documented evidence of restraint training.

Similar findings were noted for Staff B, C, T, U, and Aa whose personnel files did not contain evidence of restraint training.

During interview on 4/25/18 at 1:35 PM with staff A, the Director of Security, he stated that security officers did not receive restraint training.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and documents reviewed, in six (6) of fourteen complaint files reviewed, the facility failed to effectively identify patient complaints that met the criteria for the definition of grievances, which would require the investigation of these complaints.(Files: #s 1, 2, 3, 4, 5 and 6).

Findings include:

Review of file #1: The facility's Patient Relation Department received a grievance from the parent of an infant on 10/17/17. The complainant alleged that "the baby was given adult size Oxygen mask". The parent showed pictures of bruises on the baby's face because of the mask used. This parent also complained about the lack of communication by hospital staff regarding the patient's health status.

Review of file #3: The complainant filed a verbal grievance with the facility on 1/3/2018. The patient's relative reported that the patient was admitted from the Emergency Department on 12/26/16 for back pain and he was unable to walk. The complainant alleged that the patient was inappropriately discharged on [DATE]. The patient was home a few hours when he fell and hit his head requiring readmission to the hospital.

Review of file #4: Patient's family filed a grievance with the Patient Relations Department on 1/8/18 alleging that the therapist signed for nebulizer treatments that were never administered to the patient. A Patient Relations Staff documented that the patient received a verbal response, but the complainant requested a written response.


Facility's policy and procedure (P & P) titled: "Grievance Resolution Process" A "patient grievance" is a formal or informal written or verbal complaint that is made to the hospital by a patient or the patient's representative, regarding patient's care (when the complaint is not resolved at the time of the complaint by staff present)

There was no documented evidence that complaints related to patient care in file #s 1, 3, and 4 were identified as grievances and investigated.

Similar findings were noted in file #s 2, 5 and 6, where complaints were filed by patients/representative with no documented evidence of an investigation and resolution to the grievances.

In addition, the facility's policy did not include the requirement for a timely written response after the investigation of grievances.

On 4/19/18 at 11:00 AM, during interview with Staff F, Assistant Vice President of Patient Relations Department, she described grievances as follows: complaints that cannot be resolved in real time; complaints that a formal letter has been requested; and complaints from a State Agency.

During interview with staff M, Risk Management on 4/25/18, this staff member acknowledged the findings.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on interview and documents reviewed, the facility's grievance committee did not review grievances to ensure that the grievance process is effective.

Findings include:


Review of five (5) of fourteen (14) of grievances found that complaints that met the definition of grievances were not investigated and lacked written responses to patients/patient's representative. (grievance file #s 1, 2, 3, 4 & 6).
Review of nine (9) of fourteen (14) complaints that were identified as grievance lacked timely written responses (Grievance file #s 5, 7, 8, 9, 10, 11, 12, 13, 14).

Review of Grievance Committee Meeting Minutes dated 1/12/2018 and 4/12/2018 noted, these minutes failed to identify and discuss issues related to grievances, including timely responses, and content of responses. Furthermore, there was no quality improvement intervention to investigate cause of delay responses to complainants. The committee did not discuss how complaints regarding clinical issues can be managed in a more efficient manner when interviews with providers and expert review of records are indicated.

During interview on 4/19/18 at approximately 11:00 AM, Staff M Stated Grievance Committee members meets quarterly to meet and discuss patient grievances, but confirmed that grievance activities have not included review of adherence to the grievance process.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on document review and interview, in nine (9) of fourteen (14) grievances, the facility failed to provide patients with timely written notice of the results of the grievance investigation.(Grievance file #s 5, 7, 8, 9, 10, 11, 12, 13, 14).

Findings include:

Review of grievance file #9: The facility received this grievance on 10/29/17. The patient's family member alleged that the patient had a CT-scan done in April and the doctor and staff did not inform the family that the CT- scan revealed a tumor. The final response was dated 1/24/18, over three months after it was received.

Review of grievance file #12: The facility received the grievance on 1/15/18 regarding language access. The patient's family member was upset that the patient was spoken to in English even though the patient spoke Russia. The final letter to the complainant was dated 2/15/18, thirty days from day the complaint was received.

Similar finding regarding delay in responses to grievances were noted in file #s 5, 7, 8, 10, 11, 13 & 14.

Facility's policy and procedure (P & P) titled: "Grievance Resolution Process" did not include the requirement for a timely written response after the investigation of grievances.

During interview with staff M, Risk Management on 4/25/18, this staff member acknowledged the findings.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review and staff interview, in two (2) of nine (9) medical records reviewed, the facility failed to maintain a safe and protective environment for patents who are at risk for elopement (Patient #s 2 and 6).

Findings include:

Review of medical record for Patient #2: This [AGE]-year-old female was brought to the Emergency Department (ED) by ambulance on 3/12/18 for Opioid overdose. The patient's medical history included mental illness, substance abuse and non-compliance with psychiatric treatment. The patient was admitted .

On 3/16/18 at 9:43 AM, the physician documented that this patient was identified as an elopement risk and placed on one to one (1:1) monitoring.

On 3/18/18 at around 9:30 AM, nurse noted that the Patient Care Technician (PCT) conducting the 1:1 monitoring reported the patient missing. The PCT stated that the patient stepped away to speak to a Physician Assistant (PA) and he assumed the patient was with the PA.

Review of facility's policy titled, Inpatient Observation, last revised 1/25/18 noted, "One to One (1:1) Observation- means one competent observer to one patient within line of sight, within 3 feet of patient with no physical barriers in the same room/area. The patient will be observed constantly by the assigned observer".

There was no indication that this patient on 1:1 observation was within the PCA's line of sight, and was constantly observed.

Review of medical record for patient (Patient # 6) revealed a [AGE]-year-old female who was brought to the facility's Emergency Department by ambulance on 1/30/18 from a homeless shelter for evaluation of aggressive behavior. The patient's medical history was significant for psychiatric conditions. Psychiatrist evaluation on 1/30/18 determined the patient required immediate observation, care and treatment.

The elopement risk assessment conducted upon arrival of the patient to the Emergency Department on 1/30/18 identified the patient at a high risk for elopement evident by her cognitive impairment and a recent elopement from another hospital.

On 2/16/18 at 10:00 AM, while in the Psychiatric Unit, the patient was transported to the Radiology Department for a chest x-ray where she eloped.

There was no documented evidence that this patient, who was still a high risk for elopement, had been assigned a level of monitoring.

Review of Security Department Incident Report dated 2/16/18 at 10:37 AM revealed that Security Department received a call on 2/16/18 at 10:37 AM from a Mental Health Worker that a "female psych patient" escaped from the bathroom on the third floor (Radiology Department). The security report indicated that security officers locked down the hospital and searched the building but were unable to locate the patient.

The patient returned to the hospital on [DATE] at 2:00 PM via ambulance when the homeless shelter called 911.

During interview with Staff M, Risk Manager on 4/26/18 at approximately 10:00 AM, staff acknowledged findings.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review and staff interview, in one (1) of nine (9) medical records reviewed, the facility failed to ensure that all patients are free from all forms of abuse and harassment. Specifically, the facility failed to:
(a) develop and implement a written protocol to address patients' allegation(s) of abuse and neglect, including methods to protect patients from abuse by staff, other patients, and visitors;
(b) investigate a patient allegation of abuse by staff member (Patient #1).


Findings include:

(a) Review of medical record for Patient #1 noted: This was a [AGE]-year-old patient, with medical history of [DIAGNOSES REDACTED].

Security Department Incident Report, dated 3/3/18 at 8:20 AM, indicated that the patient was missing from her room and security was called to locate her. Staff B, Security Officer, documented that the patient was housed on the 6th floor (K 616) and was located on the 7th floor Family Room. Upon approaching the patient, she tried to leave and he and Staff C, security officer, stopped her from leaving. They told her "she was not going anywhere until the doctor come". "You are not going to do today what you did last night." The patient rode the elevator with Staff B, and she was escorted to her room. While in the room, the patient attempted to barricade herself. Staff B pushed into the room, the patient got off the bed and attempted to hit Staff B, who then pushed the patient back onto the bed. The patient got up again and was assisted back to her bed by Staff B with the assistance of Staff C.

During interview with Staff B on 4/25/18 at approximately 2:00 PM, he stated that he was briefed about the patient's behavior on the previous shift. Therefore, he came prepared for her behavior.

During interview with Staff C on 4/25/18 at approximately 3:00 PM, he stated he was on the 7th floor with Staff B where the patient was found. However, he did not ride with them on the elevator to the 6th floor. He stated he took the stairs. When he got to the patient's room, Staff B was struggling with the patient. (Staff B physically held the patient to the bed and the patient resisted)

During interview with staff M, Risk Manager, on 4/23/18 at 11:05 AM, she stated the facility did not have a policy on how to handle patients' allegations of abuse/neglect and harassment from other patients, staff or visitors. It also does not have a policy on how the facility plans to protect patient during the investigation of abuse/neglect and harassment.

Reviewed of Patient Case Sheet- Patient Representative form noted the patient filed a complaint with the facility's Patient Relations Department alleging that a security officer grabbed her very hard and she sustained bruises.

During interview with staff M, Risk Manager, on 4/23/18 at 11:05 AM, she stated the facility did not have a policy on how to handle patients' allegations of abuse/neglect and harassment from other patients, staff or visitors.

The facility also does not have a policy on how the facility plans to protect patient during the investigation of abuse/neglect and harassment.

(b) Review of Patient Case Sheet- Patient Representative form for Patient #1 noted that she filed a complaint with the facility's Patient Relations Department alleging that a security officer grabbed her very hard and she sustained bruises.

There was no documented evidence that the patient received a physical examination after the encounter with Security Staff on 3/3/18.

There was no documented evidence that the facility investigated this allegation of physical abuse by Security Officers.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0162
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review and staff interview, in one (1) of nine (9) medical records reviewed, the facility did not effectively ensure that all patients were free from restraint or seclusion. Specifically, Patient #1 was placed in seclusion by Security officers after she became aggressive and combative when she was not given a pain medication of choice (Patient #1).

This failure may have placed the patient at risk for harm.

Findings include:

Review of medical record for Patient #1 noted: This [AGE]-year-old patient, with medical history of [DIAGNOSES REDACTED].

On 3/2/18 at 11:00 PM, the nurse documented that, on 3/2/18 at 7:40 PM, the patient's score was 9/10 (Pain scale is a numerical measurement of pain, ranging from 0 to 10, with 0 being no pain, and 10 being the worst pain). The patient requested a stronger medication. The physician was notified. The physician informed the patient that she could not receive any narcotic. The patient became agitated and extremely aggressive in her behavior. Security and NYPD (New York Police Department) were called to manage the situation.

Security Department Incident Report, dated 3/3/18 at 8:20 AM, indicated that the patient was missing from her room and security was called to locate her. Staff B, Security Officer, documented that the patient was housed on the 6th floor (K 616) and the patient was found on the 7th floor Family Room. Upon approaching the patient, the patient tried to leave and he and another Staff C stopped her from leaving.

During interview with Staff B on 4/25/18 at approximately 2:00 PM, he stated that he prevented Patient #1 from leaving the 7th Floor where she was found. Staff B acknowledged that there was no physician's order to seclude the patient. This staff stated he was not aware that restricting the patient's movement was a form of seclusion/restraint and stated that he was also not aware that manual hold was a form of physical restraint.

During interview with Staff A, Directory of Security on 4/25/18 at 1:35 PM, he stated that after the behavior displayed by the patient on 3/3/18, security staff was placed outside the patient's door to prevent her from leaving the unit.

A Memo dated 3/3/18 was submitted for review. This document indicated that there was a huddle to evaluate the safe management of the situation. The patient was informed that she could remain on the unit if she did not become disruptive and combative. A male Patient Care Technician (PCT) was assigned to monitor the patient one on one (1:1).
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0206
Based on document review and interview, in six (6) of six (6) personnel files reviewed, the facility failed to ensure that Security Officers, who assist with restraints and perform manual holds, are trained in the use of First Aid techniques, and are certified in the use of cardiopulmonary resuscitation (CPR), including periodic recertification (Staff A, B, C, T, U, and Aa).

Findings include:

Review of six (6) security reports titled "Security Department Incident Report" revealed that security officers applied manual holds during restraint management of disruptive patients.

Security report on 3/30/18 at 8:20 AM documented that security officers assisted licensed personnel by manually holding down Patient #1 for therapeutic treatment.

Security report on 6/21/17 at 12:30 PM documented that in the Emergency Department, security officers assisted licensed personnel to restrain Patient #25.

Review of facility document titled "Restraint and Seclusion Policy" dated March 23, 2017 stated that "security guards that have been trained may assist under the supervision of the physician, Licensed Independent Practitioner, or trained registered nurse or Physician Assistant with the application of restraint."

Review of six (6) security personnel files on 4/27/18 at 2 PM revealed that none of these staff members have been trained in First Aid and CPR.

On 4/27/18 at 2:50 PM Staff Bb, Vice President of Risk Management and Regulatory Affairs, acknowledged that security officers did not receive the training.

At interview with Staff A, Director of Security, on 4/25/18 at 1:35 PM, he stated that the facility does not offer First Aid and CPR training to security officers.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on medical record, document review and interview, the facility failed to implement its policy and procedure to ensure that occurrences that have a potential for negative outcome are tracked and analyzed for improvement in hospital processes.

Findings Include:

The facility's Policy and Procedure titled "Patient Occurrence Reporting and Disclosure", last revised 07/2017, states that, any staff member who becomes aware of an occurrence is required to complete an Occurrence Report Form and submit to the Nurse Manager who will forward to the Hospital Risk Management." All errors are monitored and trended by the Organizational Performance Department.

Review of medical record for Patient #2 noted that on 03/02/18 at 6:51 PM, the Physician wrote an order to transfuse an emergency plasmapheresis (Plasma exchange) treatment overnight because Patient #2's platelet count dropped from 35,000 to 16,000.

On 03/03/18 at 4:37 AM, the physician documented the patient did not receive the emergency plasmapheresis treatment because the New York Blood Center was unable to provide a nurse overnight.

On 04/19/18, there was no evidence that the incident was documented and reported to the Hospital Risk Management. There was no documented investigation of the incident, and plan for improvement measures.

During interview on 04/26/18 at 3:00 pm Staff M (Director of Regulatory Affairs) confirmed that an occurrence report was not generated for the incident.

During interview on 04/27/18 at 11:33 AM, Staff K, (Registered Nurse Hematology/ Oncology Care Unit) she confirmed the findings.