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.

STATEN ISLAND UNIVERSITY HOSPITAL 475 SEAVIEW AVENUE STATEN ISLAND, NY 10305 April 15, 2019
VIOLATION: CONTRACTED SERVICES Tag No: A0084
Based on document review and staff interview, the facility failed to (a) provide training in hospital policies to the New York Police Department (NYPD) Paid Detail Officers, contracted to provide services at the facility, and (b) develop a plan to evaluate this contracted service.

Findings include:

Review of the undated New York Police Department (NYPD) Paid Detail Agreement with the Facility, documented, "Police Officers assigned to the Paid Detail Program are bound by the rules and procedures (i.e., Patrol Guide) of NYPD as well as laws of the United States, State of New York, and the City of New York."

During interview on 4/15/19 at 12:28 PM, Staff M, Senior Director of Support Services, stated that the contract with NYPD for Paid Detail services started in October of 2018. The NYPD Precinct provides the facility one (1) Paid Detail NYPD Officer every shift. The Paid Detail Officer is given verbal directives upon arrival to their assigned post. Staff M stated the Hospital Security staff are trained to call the NYPD Paid Detail Officers on-site to respond for assistance when there is a crime or assault within the hospital premises; they are also called to lead in the management of active shooter incidents.

Staff M acknowledged that the facility has not provided any orientation and training to the NYPD Paid Detail Officers working in the facility.

Staff M acknowledged that the facility has not developed a plan to evaluate the services provided by the NYPD Paid Detail Officers.
VIOLATION: CONTRACTED SERVICES Tag No: A0085
Based on document review and staff interview, the facility did not ensure that the contract with the New York Police Department (NYPD) Paid Detail officers, included a delineation of the duties and responsibilities of the NYPD Paid Detail Officers.

Findings include:

During a tour of the Emergency Department (ED) on 4/11/15 at 12:12 PM, a NYPD Officer was observed standing by the door in the Walk-In, ED. The officer, Staff Q, stated he was a Paid Detail NYPD Officer, and explained that the roles of the NYPD Officers are to mitigate active shooter events and to serve as a deterrent to hostile individuals in the hospital.

Staff R, Senior Administrative Director who was present at the time, acknowledged the role.

Review of the undated Agreement between the facility and the New York Police Department (NYPD) Paid Detail Officers documented, "Police Officers assigned to the Paid Detail Program are bound by the rules and procedures (i.e., Patrol Guide) of the Department as well as laws of the United States, State of New York, and City of New York.

The Agreement did not delineate the duties and responsibilities of the NYPD Paid Detail Officers assigned to the facility.

During interview on 4/12/15 at 2:44 PM, Staff M, Senior Director of Patient Services explained that the roles of the NYPD Officers are to enhance security; to serve as a deterrent to hostile individuals; and armed response in the event of active shooter or terror in the hospital.

Staff M acknowledged that the facility does not have written delineation of duties and responsibilities for the NYPD Paid Detail Officers.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review and interview, in one (1) of three (3) medical records reviewed, the facility failed to ensure that: (a) staff in the Emergency Department (ED) implement an individualized Fall Prevention plan of care for patients at risk for falls, (b) revise their fall prevention policy to reflect current changes in fall management that were identified by the facility, and (c) provide training to staff on the current changes. (Patient #1).


Findings include:
Review of the medical record for Patient #1 identified: a 90 year/old female brought to the hospital emergency room on [DATE] via ambulance at approximately 8:51 PM after a syncopal event at home. Patient has past medical history of: Diabetes, Coronary Artery Disease, Brain Aneurysm. The Nursing triage assessment signed at approximately 8:57 PM, assessed the patient as potential for falls and high risk for injury. The nursing assessment categorized patient as "Fall with harm risk" with indicators: patient needing assistance with walking/toileting, fallen in the past 6 months, mental confusion/attempting to get out of bed unassisted, [AGE] years and older, coagulopathy, bone disease, surgical intervention, disease process.

The Fall Risk Plan of Care initiated on 1/9/19 at 11:17 PM by Staff E, patient's primary nurse stated "fall risk: progress to goal. Absence of falls, making progress towards outcome. Plan of care ongoing interventions implemented as appropriate."

The plan of care did not document the fall risk interventions that were implemented and the monitoring provided.

On 1/10/19, nursing plan of care note signed at 02:05 AM, stated "call bell going off again. Spoke with patient via interpreter phone and reassured her daughter will be here at 7:00 AM."

On 1/10/19, progress nursing note documentation timed 5:15 AM, stated "patient agitated and ripped out I.V. (intravenous line), took off bracelet, ripping off 02 sat (oxygen saturation). Called interpreter, discussed situation with patient, patient states she wants to go home, told patient daughter will be coming at 7:00 AM. Instructed how a new I.V. (intravenous line) will be placed. Will continue to monitor."
There was no evidence of nursing reassessment for changes in mental status and no update in the plan of care.

On 1/10/19, nursing documentation signed at 8:17 AM, stated "patient had an unwitnessed fall at 6:58 AM." The Physician Assistant note dated 1/10/19 at 8:40 AM, stated "[AGE]-year-old female s/p unwitnessed fall from stretcher at the bottom of the bed, per medical /ED team, patient is confused now, was not confused prior to fall." Patient had Cat-scan of the head, spine and neck angiogram and was diagnosed with C2 vertebrae fracture without need for surgical intervention.


Review of the policy titled: "Fall Prevention-Inpatient/Resident," dated 1/25/17, states:
Plan of Care:
- All patients/residents who are assessed as being at risk for falls should be an individualize fall prevention plan of care to prevent the occurrence of falls and harm from falls, and to promote safety.

- The plan will be an interdisciplinary approach and should be documented in the appropriate areas in the medical record.

- The plan will include input from the inpatient/resident/caregiver/family and should include:
(a) Identified risks.
(b) Interventions appropriate to the inpatient's/resident's needs based on Fall/Harm Risk Assessment.
Documentation of the Assessment Category and Interventions on the Fall/Harm Risk Assessment and Intervention Form.

The documentation in the medical record did not show evidence of the assessment, interventions and monitoring to prevent falls.


During interview on 4/12/19 at approximately 11:32 AM, on the injurious fall of patient #1, Staff D, Emergency Department Manager responded "it was a devastating fall and we had done extensive review of the case. Patients were previously assessed once per shift since our nurses work the 12-hour shift, but now the assessment is on an ongoing basis during each shift with hourly rounding documentation. We also hold daily huddle and look at each high-risk patients' criteria like the confused patients that cannot be easily directed or is at risk for self-harm. We categorize them as possible 1:1 care."

There was no documented evidence that the policy "Fall Prevention-Inpatient/Resident," dated 1/25/17 has been revised to reflect these changes. There is no documented evidence that staff training has been provided.