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 Aug. 5, 2015
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
Based on observation , staff interview, and review of documents, the hospital, in one of three records reviewed, did not comply with its procedures for the implementation of one to one observation and monitoring of a suicidal patient in the Emergency Department (ED).

Findings include:

During tour of the Emergency Department (ED) on 8/4/2015 at approximately 11:00 AM, a nursing staff member was observed monitoring three patients in the medical emergency room . At interview, this staff reported that she was assigned to monitor the three patients who were all at risk for elopement. The surveyor then examined the documents for close observation
(Fifteen (15) Check Sheets) for all three patients at which time it was noted that the record for Patient #1 was assigned for one to one observation for both elopement and suicide risk.
Review of the monitoring forms for PT# 2 and PT# 3 indicated these patients were assigned to observation for elopement risk.

Review of the medical record for PT #1 determined this patient had a physician order for one to one monitoring for suicidal attempt on 8/2/15 at 11:12 PM.

The hospital policy and procedure titled, "Patient Observation" last revised 5/5/15, stated the following: "One to One observation: The patient is under constant observation by a specific staff member at all times, typically for safety reason. One to One observation is assigned by the registered nurse to a specific staff member who is not assigned concurrently with additional unit coverage activities."

Therefore, the facility did not provide one to one staff monitoring for this suicidal patient as required by the hospital policy.


This observation was discussed with Staff #1 and Staff #2.