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.

GOOD SAMARITAN HOSPITAL MEDICAL CENTER 1000 MONTAUK HIGHWAY WEST ISLIP, NY 11795 Feb. 27, 2017
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
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Based on document review and interview, the Governing Body did not ensure the effective operation of the grievance process, which resulted in the facility not conducting a recent grievance investigation.

Findings:

An anonymous grievance letter from "Past and Present emergency room Staff" to the Human Resource Department, dated 01/04/17, alleged that Staff D was previously reported on multiple occasions [since 2010] as having a substance abuse addiction and working under the influence. This letter was postmarked on 01/09/17. Electronic mail correspondence from Staff W to Staff Members S, X, Y and C, dated 01/12/17 at 11:06AM, confirmed receipt of the above grievance letter.

An electronic mail correspondence reply from Staff C to Staff Members W, S, X and Y revealed that in the past, when similar letters regarding Staff D had been received, Staff C had reported Staff D to Employee Health. Staff C inquired if she should have Staff D return to Employee Health.

An electronic mail correspondence reply from Staff Y to Staff Members C, W, S and X, dated 01/14/17 at 10:02AM, indicated this was the third letter that had been received regarding Staff D, and acknowledged that, "we need to address this once and for all". No documented evidence of an investigation or review of this grievance was available. No additional correspondence or evidence was provided of a final determination as to how this, nor any other future related grievances of this nature would be handled.

During an interview with Staff S on 02/27/16 at 12:45PM, when asked if policies for the review of related grievances that had been previously investigated and unfounded were available, Staff S replied, "we do not have written policies for this".

This was discussed with Staff E on 02/27/16 at 1:30PM. Staff E stated that this particular situation of continuously receiving multiple related anonymous grievances against a specific employee (that had previously been investigated, unsubstantiated and closed), is an unusual situation. Even so, Staff E confirmed that the January grievance that had not been reviewed or investigated should not be ignored based on previous unfounded investigations. Staff E acknowledged that the facility is responsible for providing evidence of having reviewed this and any future related grievances they may continue to receive.
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VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on observation, interview, and document review, in five (5) of five (5) random observations, the facility failed to protect the patients' right to physical privacy during examination and treatment in the Emergency Department (ED).

This failure infringes on the patient's basic right to respect, dignity and comfort while in the ED.

Findings:

Observations during the initial tour of the ED on 02/23/17 at 10:15AM revealed that the beds surrounding the Nurses' Station did not have any separation. These stretchers were placed head to toe with no visible privacy screen available. Similar observations were made during additional tours of the emergency room on [DATE] and 02/27/17.

During another tour of the ED on 02/24/17 at 2:30PM, Staff V was observed examining Patient #5 housed in Hall Bed #19 W, while wearing a hospital gown, without privacy curtains or screens.

On interview during the initial tour, Staff C stated that privacy screens were not available in the Department and that there was no Policy and Procedure for the protection of patient physical privacy in an ED Hallway Bed.
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VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
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Based on document review, observation, and interview, in one (1) of five (5) random observations, the Emergency Department (ED) staff did not ensure that patient safety was maintained. This was evident in the unsecured storage of medication in Patient Treatment Rooms.

These lapses in environmental safety places patients and visitors at increased safety risk.

Findings:

Observation in the Pediatric Trauma Room, during a tour on 02/23/17 at 10:30AM identified a 20cc bottle of unopened Lidocaine solution stored in an unsecured storage cabinet in the Patient Treatment Room. The storage cabinet doors did not contain locking devices to prevent unauthorized (patient or visitors) access.

Additional observations in Adult Trauma Room #1, during the same tour, identified another 20cc bottle of unopened Lidocaine solution stored in an unsecured storage cabinet in the Patient Treatment Room. These storage cabinet doors also did not contain locking devices to prevent unauthorized (patient or visitors) access.

Interviews with Staff Members B and C on 02/23/17 at 10:30AM confirmed that medications are kept in locked areas and did not belong in an unsecured storage cabinet. Staff B stated "this doesn't belong here" and promptly removed the medications.

The facility's Policy and Procedure titled "Security of Medication" lasted revised July 2016, states the following: "Medications must be placed in approved storage areas" and "Medications are stored in lockable medication carts, locked cabinets, locked medication rooms or in automated dispensing machines." The Policy also states: "all medication removed from storage must remain secure with the individual" and "if a medication is not administered after removal it must be returned ... within 60 minutes."
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VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on Medical Record review, document review, and interview, in two (2) of five (5) Medical Records reviewed, the emergency room Nursing Staff did not implement the Triage Policies and Procedures to ensure that each patient presenting to the Emergency Department with a complaint of abdominal pain had a documented Pain Assessment.

The lack of a Pain Assessment makes it difficult to assure that patients have an appropriate Triage Level.

Findings:

Review of Patient #4's Medical Record, identified a [AGE]-year-old female who (MDS) dated [DATE] at 12:09PM with a chief complaint of abdominal pain (lower abdomen with blood in urine that radiates into the back). The patient had stable vital signs and was assigned a ESI (Emergency Severity Index) Level of 3, but there was no documented Pain Assessment by the Triage Nurse.

The Physician Assistant documented at 2:09PM, that the patient presented with three (3) days of progressively worsening lower abdominal pain associated with frequency and hematuria. The Review of Symptoms documented Gastrointestinal: positive for abdominal pain and the Physical Exam documents tenderness at Mc Burney's Point. After medical evaluation, the patient was diagnosed with Pyelonephritis and discharged with outpatient follow-up.

The same lack of a documented Pain Assessment at Triage was found in the Medical Record for Patient #9.

These findings were confirmed during review of the Patient #4's Medical Record by Staff B on 02/23/17 at 11:00AM and again for Patient #9's Medical Record on 02/24/17 at 10:45AM.

The current Emergency Department Orientation Manual reviewed on 02/24/17 states the following under "Triage Review": "the triage interview is the basis for gathering data and making clinical decisions regarding the patient triage level" and "all patients receive vital signs, including a pain scale assessment".

The facility's Policy and Procedure titled "Triage Policy: Emergency Severity Index and Direct Bedding", last revised on 09/01/16, states the following: "Level II Presentation: examples include (to) consider severe pain / distress 8-10 together with clinical presentation and VS in the danger zone".