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 JOSEPH'S MEDICAL CENTER 127 SOUTH BROADWAY YONKERS, NY 10701 Jan. 18, 2019
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on document review and interview, it was determined vulnerable patients were placed at risk for harm.

Finding include:

Review of the hospital's occurrence reports for 1/2/18 to 12/30/18 documented:

On 5/26/18, an incident report showed that the pediatric security system "Wander Guard" (to prevent the risk of infant and child abduction) located on the 5th floor was not working. The hospital's written response to the incidence was; "Everyone is aware that the system is not working for some time."

The policy titled "Pediatric Security" effective on 4/17/18, states "upon sensing a patient with a Wander Guard sensor, the doors will automatically lock and a visible red alarm will be present over the door."

During a tour of the 5th floor on 1/16/19 at approximately 11:00 AM, the state surveyors tested the system seven (7) times. The system did not alarm when the Wander Guard tag was taken through the main entrance/exit doors and the doors did not automatically lock during these tests.

This finding was shared with Staff A, the Vice President of Quality and Risk during an interview conducted on 1/18/19 at 3:15 PM.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on document review, interview and in of one (1) of six (6) medical records reviewed, it was determined there was no documented evidence that a patient consented to an infectious disease test and was provided information required by Public Health Law. (Patient #5).

Findings include:

Review of the hospital grievance log for 1/7/18 to 12/28/18 documented on 7/2/18 that a patient (Patient #5) alleged he was administered an infectious disease test without being informed of his right to refuse this test.

Review of the Medical Record for Patient #5 revealed that on 7/2/18, the physician ordered an infectious disease test. There was no evidence that the physician documented pre-counseling for the test or informed the patient of the seven (7) points of information required by Public Health Law and as stated in the facility's policy.

The hospital policy for this testing, which was last reviewed 12/2013, states: "prior to being asked to consent to this test, a patient or person must be provided with the seven (7) points of information required by the Public Health Law. The policy also states: "All counseling and referrals must be documented in the patient's medical record."

During an interview on 1/17/19 at 12:02 PM, Staff C, Vice President of Patient Care, stated the physician spoke to the patient, that he had a rationale for conducting the test and that it was New York State policy to administer the test without a written consent.

During an interview with the Staff B, Chief Medical Officer on 1/18/19 at 11:25 AM, he stated that the staff should have discussed the testing and that they should have documented, "something in the medical record" indicating that they explained the process to the patient.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on medical record review, interview and in of one (1) of six (6) medical records reviewed, it was determined the hospital failed to ensure a patient's right to privacy in the disclosure of health related information. (Patient #5).

Findings include:

Review of the hospital grievance log for 1/7/18 to 12/28/18 documented that (Patient #5) alleged that on 7/2/18, his test result was disclosed in the presence of his wife and other people within hearing proximity in the Emergency Department and that he was not asked if his test result could be disclosed to his spouse.

Review of the Medical Record for Patient #5 revealed that on 7/2/18, the physician ordered an infectious disease test.

During an interview with Staff C, VP of Patient Care on 1/17/19 at 12:05 PM, she stated the doctor asked the patient several times if they could discuss his medical information in front of his wife but this was not documented in the medical record.

During an interview with the Staff B, Chief Medical Officer on 1/18/19 at 11:25 AM, he confirmed the finding.

Review of the hospital's policy and procedure for ...Test Counseling, which was last revised 12/2013, states: "test results are given to the patient or person authorized to consent to health care for that person, by the ordering Provider along with an explanation of the test results."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0187
Based on medical record review and interview, in four (4) of 13 medical records reviewed, the facility did not ensure that physicians are documenting the indication and reason for application of restraints as is required by the facility's policy and Federal Regulations. This finding was evident for Patients #1, #2, #3 and #4.

Findings include:

Review of the medical record for Patient # 1 revealed application of wrist restraints to the patient on 01/01/2018 at 09:28 AM.

There were no documented evidence of indications and reasons for the application of restraints as required by the facility's policy.

Similar findings were noted in medical records for Patients #2, #3, and #4 where restraints were applied and there was no physician documentation for the restraints.

Review of the policy titled "Restraint and Seclusion (Violent/Self Destructive and Non-Violent/Medical Management "(No.:005-649; Revised March 23, 2018), states: "The order for restraint will include:

*Type of restraint
*Starting and ending times.
*Indications and reasons for use."

The facility did not implement its policy.

On 01/18/2019 at 11:00 AM, these findings were confirmed with Staff D, the Assistant Vice President of Nursing.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on document review and interview, the hospital failed to ensure that the Quality Assessment and Performance Improvement Program used all data collected from the incident reports to assess and improve the delivery of care and services provided to its patients.

Finding include:

Review of the hospital's occurrence reports for 1/2/18 to 12/30/18, showed evidence of incidents relating to self harm, suicide attempts, medication errors, deaths, discharges and equipment failure.

The hospital Performance Improvement Minutes from 1/12/18 to 1/9/19 showed no evidence that these incidence were reviewed, trended or analyzed to identify and address significant issues.

During interview on 1/17/19 at 2:35 PM, Staff A, Vice President of Quality and Risk acknowledged that not all incidents were discussed or analyzed in the quality improvement meetings.

The hospital "Quality Assessment and Performance Improvement Plan" (QAPI) did not address incident reporting and implementation of corrective actions.

It was noted that the QAPI Plan did not have any revision dates.