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.

NYACK HOSPITAL 160 NORTH MIDLAND AVENUE NYACK, NY 10960 March 27, 2019
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0202
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Based on document review and interview, in eight (8) of eight (8) personnel files reviewed, the facility failed to ensure that Security Officers who assist with restraints and perform manual holds, are trained in the safe application of restraints (Staff D, R, S, T, U, V, W and X).

Findings include:

Review of "Incident Report" revealed that security officers applied manual holds during restraint management of disruptive patients. Incident reports dated 4/15/18 at 7:18 PM, and 8/25/18 at 2:46 PM, documented that security officers assisted clinical staff in manual hold and in restraining patients.

Review of personnel file for Staff D, Security Officer, revealed that the staff did not have any documented evidence of training in the safe application of restraints.

Similar findings were noted for Security Officers, Staff R, S, T, U, V, W and X whose personnel files lacked documented evidence of training in the safe application of restraints.

On 3/27/19 at 3:30PM PM, Staff N, Director of Security acknowledged findings.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0206
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Based on document review and interview, in six (6) of eight (8) 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 R, S, T, U, V, W and X).

Findings include:

Review of "Incident Report" revealed that security officers applied manual holds during restraint management of disruptive patients. An incident report dated 4/15/18 at 7:18 PM, indicated that security officers assisted licensed personnel in the Emergency Department to restrain Patient #16. Another incident report dated 8/25/18 at 2:46 PM, documented that security officers helped clinical staff to restrain Patient #20.

Review of the personnel file for Staff R, Security Officer, revealed that the staff did not have any documented evidence of training in the use of First Aid techniques, and certification in CPR.

Similar findings were noted for Security Officers, Staff S, T, U, V, W and X whose personnel files lacked documented evidence of First Aid training and certification in CPR.

On 3/27/19 at 3:30PM PM, Staff N, Director of Security acknowledged findings.
VIOLATION: PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION Tag No: A0133
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Based on medical record review and staff interview, in 13 of 13 applicable medical records reviewed, the hospital did not ensure that patients were afforded the right to have their family/representative and physician notified of their admission to the hospital (Patient #s 4 through 14).

Findings include:

During interview with Patient #10 on 3/25/19 at 12:40 PM, she stated that no hospital staff asked if she wanted her family or physician notified of her admission.

Review of medical record for Patient #10, noted that that there was no documented evidence that the patient was asked if she wanted her family or representative and physician informed of her admission.

Similar findings were noted in medical records for patient #s 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 16 and 17, whose medical records lacked documented evidence that they were asked if their family or representative and physician should be notified of their admission.

On 3/25/2019 at approximately 10:30 AM, Staff N, Nurse Manager, and Staff L, Compliance Officer, acknowledged findings and reported that the facility had no written policy and procedure for such notification.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
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Based on medical record review, document review and interview, in one (1) of 19 records reviewed, the facility did not implement its policies and procedures to ensure that patients are free from all forms of abuse. Specifically, a patient who complained of physical abuse did not received a physician evaluation, and the complaint was not thoroughly investigated. (Patient #1).

Findings include:

Review of the facility policy and procedure titled: "Abuse or Neglect, Suspected Victims of " last revised 12/18, stated: "The nurse caring for the patient or the immediate supervisor should notify the physician and report the abuse..."

Review of medical record for Patient #1 revealed that on 11/1/18 at 2:30PM, a nurse documented bruising to the patient's upper extremities. The patient complained that a security guard was unnecessarily rough with her bruising her back, chest and arms.

There was no documented evidence that a physician was notified of the incident and the injury sustained by the patient.

Review of "Grievance Communication Form" dated 11/1/2018, revealed that Patient #1 alleges that security staff was unnecessarily rough with her, bruising her back, chest, and arm areas.

There was no documented evidence of a thorough investigation of the complaint. The investigative steps and the result of the investigation were not documented in the grievance report.

On 3/27/19 at 11:05 AM, Staff M, Chief Nursing Officer acknowledged findings.

During interview with Staff E, Security Manager on 3/21/19 at 12:50 PM, staff was unable to provide documentation of the investigative process, including interviews he conducted with his staff.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on medical record review and interview, in one (1) of four (4) medical records, the hospital failed to ensure that a restraint order for the management of a patient with violent behavior was renewed in accordance with specified limits, and as indicated in the facility's policy and procedure (Patient #20).

Findings include:

Review of hospitals policy and procedure titled "Restraint and Seclusion Policy" last revised 11/18, indicates that for Violent/Self-Destructive restraints or seclusion in the ED or Inpatient areas, the maximum duration of time for restraint and seclusion may not exceed 4 hours for adults (17 years and above). "Continued use or restraint and/or seclusion beyond the authorized time frame requires a new order."

Review of the medical record for Patient #20 revealed a [AGE]-year-old who was evaluated in the Emergency Department on 6/20/18 for psychotic disorder. On 6/20/18 at 3PM, a physician ordered a 2-point wrist restraint to be applied for up to 4 hours.
The "Restraint Flow Sheet", for 6/20/18, showed that a 2-point restraint was initiated at 3PM and ended on 6/21/18 at 6:45AM. The patient was in restraints for approximately 15 hours and 45 minutes.

There was no documented evidence that a new order was written for the continued use of restraints beyond the authorized time frame.

During interview on 3/26/19 at 11:41 AM, Staff L, Compliance Officer confirmed findings.