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.

BROOKLYN HOSPITAL CENTER - DOWNTOWN CAMPUS 121 DEKALB AVENUE BROOKLYN, NY 11201 Jan. 17, 2019
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0207
Based on document review and interview, the facility failed to ensure that the individual responsible for training staff in restraint and seclusion possess qualification as a trainer.

Findings include:

Review of personnel file for Staff Cc, Nursing Educator, revealed no documented evidence of training, education and experience to qualify her to train staff or personnel in the application of restraints or monitoring of restraints or seclusion.

At interview on 1/14/19 at approximately 3:30 PM, Staff Dd, Human Resource Director, was asked what qualifies Staff Cc as a trainer. Staff Dd stated that Staff Cc was a Masters prepared nurse.

Surveyor requested and did not receive documentation showing the facility's requirement for qualification of the trainer.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, medical record review and interview, the facility failed to ensure that the patient's rights to personal privacy was maintained. This was identified for Patient #27.

This practice does not protect patient's right to privacy and dignity while receiving care.

Finding include:

During a tour of MICU (Medical Intensive Care Unit), on 1/11/19 at approximately 2:50 PM, the surveyor entered the nursing station and observed the video monitor, showing a patient full screen. The monitor was visible to anyone entering the nursing station, including non medical staff. The monitor showed two staff members performing a procedure on the lower extremity of the patient's body, which was exposed (Patient #17). After the procedure was completed, the camera was still on, and the patient was seen pulling up the bed sheet. The patient's lower extremity was exposed including her private area.

It was noted that the video monitor in the nursing station, was focused solely on one patient (Patient #17) for approximately 45 minutes. Later, the monitor began to capture all patients in the unit.

During interview with Staff E, Attending Physician, at the time of the observation at approximately 2:55 PM, this physician stated that the procedure observed was staff inserting a dialysis catheter in the patient. Staff E stated that the monitor was necessary for the safety of all patients on the unit.

During interview with Staff F, Chief of Medicine and Critical Care Specialist on 1/11/19 at approximately 3:30 PM, he acknowledged the findings. Staff F stated that this is a teaching hospital.

Review of the Medical Record for Patient # 27: identified a 62 year old, with history of End Stage Renal Disease on peritoneal (PD) dialysis, admitted to the facility on [DATE]. The physician decided to treat the patient with Hemodialysis (HD) and there are consent forms for Surgical/Diagnostic and other procedure and treatment for HD catheter placement, dated 1/11/19.
There was no documentation on the consent form indicating that the patient/patient's representative consented for the HD procedure to be viewed, by other staff members, via video monitoring.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**






Based on observation, interview, and document review, the facility failed (a) to have a mechanism for patients in the ED to call for assistance and (b) ensure a safe and secure environment for newborns and children.

There is the potential for harm to patients and families.

Findings include:

During a tour of the emergency room on [DATE] at approximately 11:40AM, it was observed that there was no call bells or devices for patients to use to call for help.

Staff U, Nurse Manager and Staff V, RN, were present during the tour. Both staff acknowledged that there are no call bells in the ED. When asked how patients would call if help is needed, they both stated that when the nurses walked by, the patients would called out to them if they need help. Staff U stated that the nurses do hourly rounds.

A patient in Bed 36 in the Green Acuity area was interviewed. When asked what he would do if he needed assistance, the patient stated he would call out for help. This patient was noted to be short of breath when answering the question.

These findings were acknowledged by Staff U and Staff V.



During a tour of the Mother Baby unit on 1/9/19 at approximately 10:30AM, it was observed that visitors to the unit are buzzed in without having a visitor's pass or wearing an ID band.

Staff X, the Clerical Assistant, was asked how visitors gained access to the unit. She stated that it's a locked unit and that visitors are buzzed in. She explained that after buzzed in, visitors must then stop at the nursing station. At the nursing station, they are asked which patient they are here to visit. When the patient is identified to be on the unit, the visitor is then given the patient's room number. Staff X was asked if visitors needed a pass to enter the mother/baby unit. She stated that they do not get a pass to come up to the unit.

It was observed that two patient rooms are located very close to the entrance door; one room on the left, and one on the right. Visitors were observed entering the room after they were buzzed into the unit. Mothers and babies are housed in these rooms.

While on the unit, a housekeeping staff was observed to let a person on the unit without obtaining identification.

The facility policy and procedure titled "Staff, Visitors and Vendor identification," last revised May 15, 2015, states: "All patient visitors will be issued passes at the information desk. The information clerk will verify the patients hospital room assignment; if there are no restrictions on visiting, visitors will be issued a day visitor pass with date and destination".

The facility policy and procedure titled "Visiting Hours," last revised 1/14, states the following "All visitors must stop at the information desk in the lobby before proceeding to the nursing unit or another department in the hospital. A visitor's pass will be given to each patient before they can visit a patient on an inpatient unit."

Staff Z, DON Mother/Baby Unit was present during these observations.



Review of the hospital Security Department Incident Report, dated 10/21/18 at 8: 20 PM, indicated "the officer responded to Neonatal Intensive Care (NICU) unit regarding a safety issue. RN informed the security staff of a unsecured room that connects to the waiting area and Room B 502. The room holds both medical equipment and supplies. The nurse reported that she found open catheter wrappers and equipment in the room. In the waiting area there were three (3) unsupervised children waiting for their mom. The staff was unsure if the children opened the medical supplies. The area was searched, and nothing found. The nurse manager was notified. There was no available key in the security department for Room B 502 door".

During a tour of the NICU on 1/11/19 at approximately 3:20 PM, it was observed that Treatment Room B-502 is located next to the waiting room (Both rooms are located along a short hallway leading to the NICU). There were two doors to Treatment Room B-502; one door from inside the waiting room and the other door from the hallway. It was observed that the door from the waiting room was locked but the door from the hallway does not have a lock. Upon examining of Room B-502, it was observed that Medical equipment and supplies, including sharps, were stored in this room. Easy entrance to Treatment Room (B-502) can be made through the unsecured door from the hallway.

During interview with Staff Aa, Registered Nurse, Staff Aa acknowledged there was no lock to one of the doors of Room B-502. This staff stated there is always a staff member sitting out in the reception area. (The reception area is located across from Room B-502).
When the surveyor arrived on the unit, there were no staff observed sitting in the reception area.

Staff Aa was present during these 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 interview, in two (2) of two (2) medical records reviewed, the facility (a) failed to implement its policy for "allegation of sexual assault by staff " and (b) failed to address patients allegations of sexual harassment in the Radiology Department, in a thorough manner. This was identified for Patient #1, Patient #2.


Findings include:

The facility policy and procedure titled "Allegation of Physical or Sexual Assault by Staff, Policy # C-184," last revised 12/2016, states::
In cases of alleged patient assault by a staff member, the Hospital Center will:
i. Assure patient safety, and provide appropriate and timely physical and psychological care for the patient who is the alleged victim of assault.
ii. Investigate allegations of assault promptly and thoroughly and in a manner designed to be fair to all concerned; social work, risk management, nursing and security departments may be involved in the investigation.

A. Procedures for Care of the Patient:
2. A physical examination will be performed promptly, and the attending physician will be consulted......
4. The patient will be provided counseling and support as appropriate........

C. Administrative Review Process:
4. An overall report of the investigation, including the Social Work and Human Resources Investigation as well as any other reports, statements, or findings as well as any action taken, shall be prepared promptly. The written report shall include a summary of the investigation process and conclusions, as well as documentation that procedures of this policy have been followed.


Patient #1:
Review of Security Department Incident Report, dated 11/7/18 at 4:35 PM, indicated "a patient's relative contacted the Command Post stating that NYPD officers were on site, on 8B, in Room # 831, regarding an incident that occurred on 11/6/18. The incident involved a patient who alleged that she was sexually harassed by an x-ray technician. The patient alleged that when the technician was taking an x-ray of her foot he took an x-ray of her private area. The police officers spoke with the Director of Radiology and requested the x-ray taken of the patient for review. After investigating the case, the police officers deemed that the x-ray technician performed his duties appropriately."

Review of Grievance file for Patient #1 identified a Patient Report form dated 11/7/18 documentation. The patient alleged she was sexually harassed. Patient stated the tech touched both her thighs and directed her to open her legs. She stated he then said "turn to your left and then to your right" and then he took pictures of her private area. Patient said in her head she wanted help but there was no one else there.

Review of the Medical Record for Patient # 1 identified: [AGE] year old presented to the facility's Emergency Department (ED) by ambulance on 11/1/18 after a fall at home. The patient was admitted for observation. On 11/7/2018 at 5:48 PM, the nurse documented "the patient stated a person took a picture of her private area when she took an x-ray. The patient was very upset and her daughter called 911. Police took a report. MD made aware".

It was noted that the hospital's investigation was based on the police report and there was no evidence the facility did their own investigation.

During interview with Staff Bb, Nurse Manager on 1/14/19 at 1:49 PM, Staff Bb stated that the primary nurse informed her the patient's daughter complained that a person took a picture of her mother's private area when she went for x-ray of her foot. Staff Bb stated that the patient admitted to her that this occurred. Staff Bb stated that the patient was very upset and teary when she spoke to her.

During interview with Staff Gg, Attending, on 1/14/19 approximately 2:15 PM, Staff Gg admitted that he was the attending responsible for the patient's care. He stated that he was informed of the allegation from the house staff during rounds. He admitted not writing a note or discussing the issue with the patient.

There was no documented evidence that the patient was provide appropriate psychological care and assessment.


Patient #2:
Review of facility Grievance File identified: On 11/29/18 the facility received a complaint from a patient (Patient #2) alleging that she felt the technician was too "touchy" when preparing her for the x-ray. Patient stated the technician asked her to lift her leg but when she asked for a sheet he refused to give her one. The patient also stated the technician touched her hip and he did not need to.

The facility's documentation stated the complaint was received on 11/29/18 but the incident took place on 5/25/18. The Patient Relation (PR) Department forward the complaint to the Radiology department for investigation on 11/29/18. The Radiology Department respond on 12/5/18 at 5:22 PM stating that the technician assigned the case could not recall the incident. The Radiology Department planned to discuss the complaint in the next staff meeting.

During interview with Staff R, Assistant Director of Radiology, on 1/11/19 at approximately 2:00 PM, Staff R stated she was aware that the facility received two incidents of alleged sexual abuse in her department. Staff R stated, "Patient Experience" was discussed with the radiology staff. Staff R stated the x-ray of the lower extremity is less invasive than a pelvic examination therefore the facility did not plan to change the protocol or practice when preparing patient's lower extremities.

There was no documentation that procedures of the policy have been followed to complete the investigation.
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, in three (3) of 16 medical records reviewed, the facility failed to ensure (a) all patients are restrained according to the physician's order and (b) there is a physician order for each restraints. (Patient #10, Patient #11, Patient #20).

There was potential that the patient remained in restraint longer than was necessary.

Findings include:

Patient #10:
Review of the Security Department report dated 8/5/2018 at 10:50 AM, documented "security staff reported to blue zone area in the ED, in response to a disorderly patient. Five security staff assisted the registered nurse and medical staff in restraining the patient."

Review of the Medical Record for Patient #10 revealed: [AGE]-year-old patient with history of alcohol and substance abuse was brought to the ED by EMS (emergency service) and police on 8/5/18 at 10:43 AM due to intoxication, and aggressive behavior and assault to patient. The patient had ED medical screening exam at 11:23 AM and the physician noted the patient was aggressive and it took over six security and police officers to restrain the patient. The patient required sedation and medication at the door.

The physician order for restraints was noted on 8/5/18 at 11:55 AM as follows: " restraints-behavioral, both wrists for two (2) hours." The documentation in the medical record indicated the wrist restraint was discontinued via patient discharge on 8/5/2018 at 5:55 PM. This is more than the (2) hours, as ordered by the physician.

Review of the Facility's Policy titled, Physical Restraints of Patients (For Medical Surgical Care Management), Policy #C-433 states: "The amount or duration of patients is to restrained, Not to exceed for 2 hours for adults".


Patient #11:
Review of Security Department Incident Report dated 9/6/18 at 6:55 PM documented that EMS staff brought an emotionally disturbed person (EDP) to the ED. The patient (Patient # 11) became irate and five security staff responded. The security staff assisted the medical staff while they medicated and restrained the patient.

Review of the Medical Record for Patient #11 identified: On 9/6/18 at 7:06 PM, [AGE] year old with unknown history presented to the ED via EMS for evaluation of acute homicidal ideation with suspected alcohol intoxication. On 9/6/18 the physicians documented "no psychiatrist available at this facility. In concern for harm to staff and patient's family, the patient will be chemically sedated and physical restraints applied to assess for medical clearance to transfer to psychiatric facility. Patient placed on 1:1."

There was no written order for the physical restraints in the medical record.

During interview with Staff Hh, Quality Management, on 1/14/19 at 2:50 PM, Staff Hh stated the issue was brought to the attention of the treating physician. The physician stated there was a plan to restrain the patient but the plan was changed and the patient was placed on 1:1 observation.

The physician's documentation in the medical record, however, on 9/6/18 at 10:00 PM, noted "patient wakes intermittently and states that if restraints aren't released he will kill all."

This documentation was also discussed with Staff Hh, Quality Management, on 1/14/19 at 2:50 PM. The facility provided a written response from the physician on 1/17/19, but this issue was not addressed in the response.


Patent #20:
Review of Security Department Incident Report dated 12/20/18 at 8:50 PM documented, MD informed security staff that a patient with dementia was attempting to walk out. The patient became irate and physical so security staff called for back- up. Four security staff responded. MD ordered chemical and physical restraints for the patient. RN administered the medications and put on the restraints.

Review of MR for patient #20 revealed this [AGE]-year-old patient with history of Dementia was sent from a nursing facility for an evaluation on 12/20/18 at 4:14 PM and received initial medical screening at 5:31 PM. On 12/20/2018 at 8:44 PM, the patient became combative with staff and began to be violent. The physician notes documented that multiple attempts to deescalate patient were unsuccessful and security mobilized and assisted with sedation with antipsychotic medications.

There was no documented physician order for staff physically (manual) holding the patient to administer the medication.

The findings were brought to the attention of Staff Hh, Quality Management.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, document review, medical record review and interview, the facility failed to ensure compliance with the Condition of Participation (CoP) of Patient Rights as evidenced by the systemic deficient practices identified during the survey.

These findings place all patients at risk for potential harm.


Findings include:

The facility failed to ensure that:

Each patient exercised his/her rights to receive care in a comfortable environment.
See Tag A 0129.

A patient's rights to personal privacy was maintained while receiving care and treatment in the Medical Intensive Care Unit.
See Tag A 0143.

A mechanism is in place for ED patients to call for assistance; and that a safe environment for care and treatment is provided for patients on the Mother/Baby Unit.
See Tag A 0144.


Staff followed the facility's policy for allegation of "Sexual Assault" by staff and provide the care and thoroughly investigate allegations of sexual harassment by staff, in the Radiology Department.
See Tag A 0145.


All patients are restrained according to physician's orders and an order is written for each episode of restraints.
See Tag A 0168.


Patients' response to the administration of medication for aggressive behavior and to the application of wrist restraints were documented.
See Tag A 0188.


Security officers who are called to assist in the management of disruptive patients receive training in the use of nonphysical intervention skills.
See Tag A 200.


All security staff who assist with restraints and perform manual holds, are trained in the safe application of restraints.
See Tag A 0202.


All security officers who assist in restraints and perform manual holds, are trained in the use of First Aid Techniques, and certified in the use of cardiopulmonary resuscitation (CPR).
See Tag A 0206.


Individual(s) responsible for training staff/personnel in restraint and seclusion, possess trainer qualification.
See Tag A 0207.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and interview, it was determined the facility failed to provide the Medicare beneficiary standardized notice to each Medicare beneficiary inpatient within 2 days of admission and prior to the patient's discharge. This finding was noted in one (1) of three (3) applicable records reviewed.

This failure denies patients and/or their representatives information about their rights.

Findings include:
Review of Medical Record for Patient #6 identified: this [AGE]-year-old was admitted from a nursing home to the facility on [DATE]. The patient's medical history included dementia.

The documentation on the notice "Important Message from Medicare (IM),"dated 9/2/18, noted that the "patient is unable to sign" and "family not at bedside."

There is no documentation why the patient was unable to sign or why there was no follow up with the patient's family or representative.

Upon discharge on 9/12/18, the follow-up IM was not signed by patient/representative. The facility staff noted "DC 9/12/18" on the IM form.

The facility policy and procedure titled "CMS Beneficiary Notices," last revised 3/2015 States:..."When the patient discharge/transfer services are coordinated by the CRM department, the HCM department staff member will have the patient or their representative sign the follow-up IM within two days of discharge/transfer and not routinely on the day of discharge/transfer."

During interview on 1/14/19 at approximately 2:00 PM, Staff A, Case Manager, acknowledged the hospital did not provide the follow up IM to the patient or his representative
VIOLATION: PATIENT RIGHTS: EXERCISE OF RIGHTS Tag No: A0129
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review, interview and in one (1) of 16 medical records reviewed, the facility did not ensure each patient exercise his/her rights to receive care in a comfortable environment (Patient #17).

This placed patient at risk for potential negative health outcomes.

Findings include:

Security Department Incident Report, dated 10/31/18 at 1:48 AM, documented the following: A patient in Bed #11 expired and patient in Bed #12 (Patient #17) became irate because she was in the bed beside the deceased patient. The patient demanded to be moved. Two security staff approached the patient. The patient spat and scratched one security staff. Both security staff restrained the patient. MD gave security staff permission to escort the patient off the premises. This event took place in the facility's adult emergency room .

Review of medical record for Patient #17 identified: [AGE]-year-old presented in the ED on 10/30/18. On 10/30/18 at 8:42 PM, the nurse noted that the patient was admitted to CSCU (Critical Care Unit) for CVA (cerebrovascular accident) and was awaiting a bed. On 10/31/18 at 3:24 AM, the physician noted that the patient became very violent and aggressive towards emergency staff at about 1:00 AM in the morning. "Security was called, and patient insisted she wanted to leave. Patient left against medical advice and was provided with a letter to allow her to return to her shelter."

There was no documentation in the medical record regarding the reasons the patient became irate. There was no documented evidence that steps were taken to address the patient's request to be moved from next to a deceased patient.

The Facility's Policy, Patient Elopement and Discharge Against Medical Advice (AMA), last revised 10/8/14 states: "If the patient persists in wanting to leave against medical advice, the nurse, physician or other person responsible for the patient's care shall: request that the patient sign the Discharge Against Medical Advice (AMA) form. If the patient refuses to sign the form, this should be noted on the form the patient's signature line."

There was no documented evidence in the medical record that the patient signed/refused to sign the Discharge Against Medical Advice (AMA) form.
A copy of the form was not in the record nor was one presented for review.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0188
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review and interview, in two (2) of 16 medical records reviewed the facility failed to document patients' response to chemical restraints. (Patient #10, Patient #22)

This may have placed patients at risk of not receiving the appropriate intervention.

Finding include:

Patient #10:
Review of the Medical Record for Patient #10 revealed, on 8/5/18 at 10:43 AM, [AGE]-year-old patient was brought to the ED by EMS and police on 8/5/18 at 10:43 AM due to intoxication, aggressive behavior after having been physically assaulted. On 8/5/18 at 11:55 AM the physician ordered : restraints-behavioral, both wrists for two (2) hours.

There was no documentation of the patient's response to restraint used.

Patient #22:
Review of Security Department Incident Report, dated 10/20/18 at 6:55 PM, noted nursing staff informed security staff that the RN needed assistance in restraining a patient. (Patient #22).

Review of Medical Record for Patient #22 revealed [AGE] year old patient brought to the ED (Emergency Department) by EMS (Emergency Medical Services) on 10/20/18 at 6:03 PM for possible drug overdose. While in the ED, the patient awoke and became aggressive and combative swinging at the EMS and ED staff. Midazolam (a sedative) IM was ordered and given on 10/20/18 at 6:56 PM.

There was no documentation of a nursing assessment or patient's response/behavior after the medication was given .

The findings were discussed with Staff G, Quality Management on 1/14/19 at approximately 10:30 AM.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0200
Based on document review and interview, 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 H through N)

Findings include:

During interview with Staff N, Security Officer, on 1/11/19 at approximately 10:30 AM, he stated he was trained in de-escalation techniques.
There was no documented evidence that this staff member was trained in nonphysical intervention/de-escalation techniques.

Review of seven (7) personnel files for Security Officers, Staff H through N identified that these staff members have not received training on nonphysical intervention skills/de-escalation techniques for the safe management of disruptive patients.
.
During interview with Staff C, Director of Security, on 1/14/2019 at appropriately 4:30 PM, he stated that de-escalation techniques were included in the "8 hour Unarmed Security Guard training."

Review of the "8 Hour Unarmed Security Guard Training" syllabus, noted that nonphysical intervention-de-escalation techniques was not included in this training.

The facility had no evidence that these security officers were trained in nonphysical intervention skills/de-escalation techniques.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0202
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review and interview, the facility failed to ensure that security officers who are assisting in restraining patients and performing physical (manual) holds, are trained in the safe application of all restraints used in the hospital. (Staff H to Staff N).

Findings include:

Review of Security Department Incident Report from July 2018 through January 2019 identified the following:

(a) Incident report dated 11/29/2018 at 6:20 PM, indicated that security was called by nursing staff to assist in restraining a patient. (Patient #23).

Review of the Medical Record for Patient #23 identified: [AGE]-year-old was admitted to the facility on [DATE]. At 4:20 PM, the physician noted "patient is verbally and physically abusive toward nursing staff and demanding to leave. Security at beside. Will give Haldol (antipsychotic medication) and Versed (to induce sleepiness) because he is still clinically drunk and exhibiting symptoms of significant left sided weakness."


(b) Security officers were called to assist, and applied manual hold during the management of disruptive behavior patients. (Patient #9, #10, #11, #12, #13, #20, #22, #23)


During interview with Staff C, Director of Security, on 1/9/19 at approximately 3:00 PM, Staff C stated that security staff do not restrain patients as they are not trained in the application of restraints. Staff C acknowledged that security staff do manual holds to assist medical staff who are administering medication and do take downs with aggressive patients.

During interview with Staff N, security officer on 1/11/19 at approximately 10:30 AM, this staff acknowledged physically restraining aggressive patients.

On 1/14/19, the Director of Security submitted a document from the "8 Hour Unarmed Security Guard" training school, which indicated that security officers may restrain patients if they are told to do so or ordered by a doctor or registered nurse. This document also stated Security Officers will utilize the 4 point restraint method. This will require a minimum of four officers, one officer for each limb.

Review of the "8 Hour Unarmed Security Guard Training" syllabus, noted that restraining patients was not included in this training. There was no documented evidence of any training provided.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0206
Based on document review and interview, and in seven (7) of seven (7) personnel files reviewed, the facility failed to ensure that Security Officers, who assist in restraints and perform manual hold, are trained in the use of First Aid Techniques, and certified in the use of cardiopulmonary resuscitation (CPR). (Staff H thought N).

Findings include:

Review of eight (8) documents titled "Security Department Incident Reports" dated 7/2018 through 1/2019, revealed that security officers applied manual hold during the management of disruptive behavior patients. (Patient #9, #10, #11, #12, #13, #20, #22 & #23).

On 1/14/19, the Director of Security submitted a document from the "8 Hour Unarmed Security Guard" training school, which indicated that security officers may restrain patients if they are told to do so or ordered by a doctor or registered nurse. This document also stated Security Officers will utilize the 4 point restraint method. This will require a minimum of four officers, one officer for each limb.

There is no documented evidence of training for the Security Officers in first aid techniques or certifications in CPR.

During the interview with Staff C, Director of Security, on 1/14/19 at approximately 4:30 PM, this staff stated the security officers are not trained in the use of First Aid Techniques and in the use of CPR.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**







Based on medical record review, document review, interview and in one (1) of 16 medical records reviewed, the facility failed to implement its infection control policies to protect Emergency Department (ED) patient population from the transmission of infections and communicable diseases.

This may have placed patients at increased risk for hospital-acquired infection.

Findings include:

During a tour of the ED on 1/11/19 at 10:30AM, a patient (Patient #14) was observed laying on Bed #7 and a green "Contact Precautions" sign was observed at the foot of the patient's bed, partially covered with sheets.

Review of Patient #14 medical record identified this [AGE]-year-old male was brought into the hospital by ambulance on 1/10/19 from nursing home. Patient was placed on contact precautions for rule out Clostridium difficile ([DIAGNOSES REDACTED]) (bacteria which causes serious infection)

Staff P, ED RN, when interviewed stated that when the patient was placed on contact precautions for [DIAGNOSES REDACTED], the one isolation room in the adult ED was occupied with an airborne isolation patient.

The surveyor observed at 11:50 AM, that a patient housed in the isolation room was not on isolation precautions. When asked why the patient on [DIAGNOSES REDACTED]. precautions was not relocated to the isolation room when it became available, Staff P acknowledged that they should have done that. She stated they were waiting on terminal cleaning of the room and respiratory department to move the patient.

The Infection Control Nurse, Staff Q, when interviewed on 1/11/19 at approximately 11:50AM, stated that patient was placed on contact precautions the night of 1/10/19 for rule out [DIAGNOSES REDACTED]. Staff Q stated that it's the hospital practice to place patients with [DIAGNOSES REDACTED] or rule out [DIAGNOSES REDACTED]. in a single room. When a single room is not available, the patient should be isolated in a corner. She stated that the [DIAGNOSES REDACTED] patient should have had first preference to the isolation room.

The facility policy and procedure titled: "Infection Prevention and Control Isolation Precautions," last revised August 2016, states:

Contact Precautions: Patient Placement:
Place the patient in a private room. When a private room is not available, place the patient in a room with a patient(s) who has active infection with the same microorganism but with no other infection (cohorting). When a private room is not available and cohorting is not achievable, consider the epidemiology of the microorganism and the patient population when determining patient placement. Consultation with infection and control professionals is advised before placement.

Clostridium difficile Precautions: A patient diagnosed or suspected of [DIAGNOSES REDACTED]icle is also placed on contact precautions with the special sign posted outside the door along with contact precaution sign.