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.

CROUSE HOSPITAL 736 IRVING AVENUE SYRACUSE, NY 13210 March 28, 2019
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review, medical record (MR) review, and interview, the facility failed to ensure compliance with the Condition of Participation (CoP) of Patient Rights as evidenced by deficient practices identified during the survey. These findings place all patients at risk for potential harm.

Findings include:

The facility failed to ensure that:

-- A policy and procedure (P&P) was in place that instructed staff on how to address complaints of abuse and neglect within the hospital. See Tag A 0145

-- Staff were not educated on how to address patient complaints of abuse or neglect. See Tag A 0145

-- A complaint of abuse and neglect was not promptly addressed. See Tag A 0145
VIOLATION: PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION Tag No: A0133
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record (MR) review, document review and interview the facility did not ensure in: 1) 8 of 9 MRs (Patients #1 - #8) reviewed the MR lacked documentation indicating, that the patient was asked whether they wanted a family member or representative notified of their admission to the hospital. 2) 3 of 8 MRs (Patients #6, #7 and #8) reviewed lacked documentation indicating the patient was asked whether they wanted their own physician notified of their admission to the hospital. Also, the hospital does not have a policy and procedure (P&P) that addresses this process. This could impact a patients continuity of care.

Findings include:

-- Review of Patient #1's MR revealed, she was admitted on [DATE] with acute respiratory failure. There is no documentation that hospital staff inquired as to whether Patient #1 wanted a family member or representative notified of her admission to the hospital.

The same lack of documentation regarding whether patients wanted a family member or representative notified about their admission to the hospital was found in MRs for Patients #2-#8.

-- Review of Patient #6's MR revealed, she was admitted on [DATE] with altered mental status. There is no documentation that hospital staff inquired as to whether Patient #6 wanted her own physician notified of her admission. Documentation in the MR indicated the provider was out of network.

The same lack of documentation regarding whether patients wanted their physician notified about their admission was found in MRs for Patient #7 and Patient #8. Documentation in the MRs indicated the providers were out of network.

-- Review of the facility's P&P's did not provide evidence that the hospital had a process for these above described notifications.

-- During interview of Staff D, Chief Nursing Officer 3/26/18 at 2:30 pm, he/she acknowledged the above findings.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, in 3 of 3 personnel files (Staff A, B, and C) lacked documentation of training regarding abuse and neglect and related requirements, including prevention, intervention and detection. Additionally, the policy and procedure (P&P) did not indicate that the hospital has a system in place to protect patients from abuse and neglect and a allegation of abuse was not promptly addressed. This could place patients at risk for untoward outcomes.

Findings include:

-- Review of Staff A's, Registered Nurse (RN), Staff B's, Nurse Manager, and Staff C's, RN, personnel files all lacked documentation of training in patient abuse and neglect.

-- Review of facility P&P titled Victims of Abuse/Violence: Adult (Including Domestic Violence, Elder Abuse/Neglect)," last revised 8/2018, indicated if during the admitting process to an outpatient or inpatient area, or at any time during a patient's course of treatment at the hospital, it is suspected that a patient may be a victim of abuse/violence/neglect, the RN should contact the Care Coordination Services Department to make a Social Work referral. The P&P does not identify that the facility has an abuse protection program to include staff training, protecting the patient while allegations are investigated, who to notify if incidents occur off hours (e.g., evening or night shift, weekends and holidays). Additionally, the P&P does not address abuse or neglect of a patient while in the hospital by family or staff members.

--During interview of Staff E, Director for Quality Improvement on 3/28/18 at 2:30 pm, he/she indicated there is no formal training provided to staff related to patient abuse and neglect.

-- Per MR review, Patient #1 was admitted on [DATE] with Respiratory Failure (difficulty breathing). On 11/24/18 at 6:00 am Patient #1 attempted to get out of bed unassisted, setting off the bed alarm. Staff A (RN), responded. Patient #1 was unsteady on her feet and Staff A called out for help. Staff C, entered the room and assisted getting Patient #1 to the bedside commode. Patient #1 began falling off the commode, Staff A and Staff C attempted to keep Patient #1 upright on the commode. Patient #1 became agitated, ripped off her telemetry pack and gown, insisted on standing up, pushing the nurses aside, yelling and thrashing and hitting her arms on surrounding objects. Security was called, when they arrived they assisted in getting Patient #1 back to bed safely.

-- Per interview of Staff B on 3/27/19 at 10:30 am, he/she received an e-mail on 11/25/18 from Patient #1's daughter alleging on 11/24/18 the night nurses had hit her mother. Staff B, contacted the unit and spoke with the charge nurse. He/she then contacted the unit director for guidance on how to respond to Patient #1's daughter. Staff B e-mailed Patient #1's daughter and an arrangement was made to meet the next day (Monday). Staff B stated the daughter was pleased with this and no further action was taken.

-- Per interview of Staff D, Chief Nursing Officer (CNO) on 3/27/19 at 11:30 am, he/she was unaware Patient #1's daughter had complained of bruising on her mother. Staff C would expect the nurses in the hospital to provide a nurse managers e-mail address to family if they have concerns, although this is not written in any policy.

An email was sent to the nurse manager alleging abuse. The nursing supervisor or other members of hospital leadership were not notified at the time, to respond to the bedside. The facility did not remove staff from care of the patient while there was an allegation of abuse. An incident report was not done. An investigation was not immediately started.