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 Dec. 6, 2019
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on document review and interview, the facility failed to conduct complete investigations of patients' grievances. This was found in two (2) of six (6) grievance files reviewed. (Patients #10 and #11).

Findings:

Review of the Grievance Log for August 2019 to December 2019 showed;

Patient #10: The Grievance Log showed an email dated September 25, 2019. The complainant stated that she was her mother's health care proxy and that the hospital failed to advise her that her mother (Patient #10) was in the emergency room , and of her mother's death. She complained about the process she encountered when she went to the emergency room to inquire about her mother's death. She alleged that the emergency room staff failed to provide information and was disrespectful, unprofessional, insensitive, lacked compassion, education and training to handle this type of situation. She also wrote that "this was not her first bad experience" as her mother was not treated well during a prior visit.

There was no documented evidence these allegations were investigated or addressed.


Patient #11 wrote a letter on 10/28/19, complaining that she did not receive appropriate care during an emergency room visit and a short admittance to the hospital. She described a series of events and concluded that the care was "lacking in every way, staff was inattention and did not seem to care." She also expressed concern about not seeing a nurse and a physician for several hours.

There was no documented evidence these allegations were investigated or addressed.


During an interview on 12/6/19 at 11:10 AM, Staff F, Director of Patient experience, stated that all grievances are forwarded to the applicable department for investigation. She believed that both grievances were investigated, however she was unable to provide any additional supporting documents that the issues were addressed.

The facility's policy and procedure titled "Patient Complaint-Grievance Process," last revised 12/18, does not describe the investigative process.
VIOLATION: PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION Tag No: A0133
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and staff interview, in six (6) of eight (8) medical records reviewed, the hospital failed to ensure that patients were afforded the right to have their family/representative and physician notified of their admission to the hospital (Patient #s 9, 11, 12, 13, 14 and 15).

Findings include:

Review of the medical record for Patient #11 identified: the patient was admitted on [DATE]. There was no documented evidence that the hospital asked the patient if she wanted her family or representative and physician informed of her admission.

Patient #12 was admitted on [DATE]. There was no documented evidence that the patient was asked if she wanted her family or representative and physician informed of her admission.

Patient #13 was admitted on [DATE]. Review of the medical record showed no evidence that the patient was asked if she wanted her family or representative and physician informed of her admission.

Similar findings were noted for Patients # 9, 14 and 15, whose medical records lacked documented evidence that they were asked if their family or representative and physician should be notified of their admission.

During an interview on 12/3/2019 at approximately 2:45 PM, Staff B, Director of Medical/Surgical Units acknowledged the findings.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on document review and staff interview, it was determined that incidents are not investigated, reviewed and addressed in the Quality Assessment and Performance Improvement Program. Specifically, incidents involving patient care and safety were not investigated and analyzed to identify opportunities for improvement and develop corrective actions.

Findings include:

Review of the Performance Improvement Committee meetings from 5/8/19 to 10/23/19 and the Occurrence Reports from March 2019 to November 2019, showed:

The facility's incident report dated 4/15/19 documented the following. A Registered Nurse in the Emergency Department:
*Administered medications without a physician's order.
*Administered IV fluid without consulting with the MD.
*Instructed staff to insert a Foley catheter without an MD order.
*Instructed other staff to order a lab test with a physician's name without his knowledge.
*Transported the patient to an in-patient unit without communicating with the physician.
*Bypassed the primary RN and began titrating Nitroglycerine and failed to inform the primary nurse that she changed the dose.
*Called a MICU Nurse to the emergency room to begin a drip without a physician's order (Cardene).

There was no documented evidence that this incident was investigated or discussed in the Performance Improvement Committee meetings.

During an interview on 12/6/19 at 10:10 AM, Staff E, Director of Quality acknowledged the findings.


Review of the Occurrence Reports showed 24 incidents of security officers who were involved in patient's care.

Examples:
On 3/10/19 a Security Officer was involved in an altercation with a female patient. The incident report stated that while the patient was being escorted to her bed she sustained a "small mark" on her right arm.

On 4/7/19, a patient who was under security watch tried to elope. During the incident she "tripped and fell to the ground causing abrasion to the forehead."

On 4/7/19 Security Officers were called to assist with a highly agitated and intoxicated patient. The patient was medicated and restrained for safety purposes.

There was no documentation that these incidents were reviewed, addressed or discussed in the Performance Improvement Committee meetings.

During an interview conducted on 12/6/19 at 3:00 PM, Staff D, Director of Security acknowledged the findings.

The facility Quality and Safety Plan for 2018 - 2019, states that the "team will be organized to collect and analyze data to formalize action plans to effect positive change and improvement."

Facility documents showed no evidence that this plan was implemented.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review and interview, in one (1) of 10 medical records reviewed, it was determined the nursing staff failed to follow the facility's policy to reassess a patient's pain level, despite her increasing pain and deteriorating condition. (Patient #1).

Findings include:

The facility's policy titled "Pain Management, Assessment, and Reassessment," which was last revised in 3/19 states, "the patient is reassessed within one hour of each pain management intervention (pharmacological and non-pharmacological). Progress toward the pain management goal is assessed by the pain score."

Review of medical record #1 identified the following: this thirty-seven year old patient (MDS) dated [DATE] with a complaint of acute abdominal/chest pain. She was diagnosed with Cholelithiasis and on 5/12/19 at 10:42 AM, the patient had her gallbladder removed under general anesthesia. At noon the patient's pain was noted as 4/10 on a scale of 0 - no pain, to 7-10 severe pain. The patient was given 1 tablet of Percocet at 12:11 PM but at 1:36 PM, the patient reported her pain had increased to 8/10. A physician was contacted at that time who ordered an additional 2 tablets of Percocet which was given at 1:36 PM.

There was no documented evidence that the patient's pain was reevaluated an hour after the medication was administered at 12:11 PM.

At 3:41 PM, the doctor documented that the patient was "having increased pain and dizziness. Vitals checked, B/P 90's/40's for hypotension that is symptomatic. Will bolus 500ccs Normal Saline solution."

A nurse documented that a rapid response was activated at 4:04 PM and that the patient's "husband shouted for assistance. Upon arrival the patient appeared to be sitting at the edge of the bed in a frozen like manner. She appeared pale and was unable to respond to her name or to stimulation. Eyes are rolling back in the back of head. After a few minutes patient is able to respond to name and nod her head. She recalled people around her and where she was. Patient still seems lethargic but responds to voices. Patient bolused 1 liter."

The physician documented at 5:17 PM that the patient's B/P was 50/30 and that Narcan was given for hypotension. A blood sample drawn at 4:15 PM, revealed the hemoglobin was 7.8 (normal range 12.0 -16.0).

The CT-Scan of the abdomen completed at 5:13 PM showed the patient had a large area of complex fluid posterior to the liver. She was diagnosed with hemorrhagic shock.

The nurse's notes documented another rapid response activation was called at 6:22 PM for the patient's deteriorating and unstable condition. The patient returned to the operating room at 7:20 PM that night with a diagnosis of Uncontrolled Bleeding.

The patient's pain was reassessed at 6:42 PM, when it was noted to be 8/10 and in the epigastric region.

There was no evidence that the patient's pain was reassessed when the patient received pain medication at 1:36 PM, until 6:42 PM, more than five (5) hours after the medication was given.

During interview on 12/6/19 at approximately 2:35 PM, Staff A, the Compliance Officer, acknowledged the findings.
VIOLATION: WRITTEN MEDICAL ODERS FOR DRUGS Tag No: A0406
Based on medical record review, document review and staff interview, in five (5) of five (5) medical records reviewed, it was determined the facility failed to ensure that verbal orders (telephone orders) were authenticated by the prescribing physician within 24 hours, as per the facility's policy (Patients #4, 5, 6, 7 and 8).

Findings Include:

Review of medical record for Patient #5 identified the following: a nurse documented a physician's verbal order on 8/8/19 at 2:54 AM, to administer to the patient Ativan 2 mg by mouth stat for agitation. The psychiatrist authenticated the medication order on 10/15/19 at 8:22 PM, more than two (2) months after the verbal order was given to the nurse.

Review of medical record for Patient #4 identified the following: a nurse documented a psychiatrist's verbal order on 9/18/19 at 11:07 AM to administer to the patient Haldol 7 mg intramuscular stat (immediately) for agitation. The psychiatrist authenticated the order on 10/2/19 at 5:34 PM.

Similar findings of physicians' failure to authenticate verbal orders in 24 hours were noted in medical records #s 6, 7, and 8.

Review of the policy titled "Verbal Orders and Telephone Orders Policy," last revised 12/18 states, "verbal/telephone orders must be cosigned or verified within 24 hours by the ordering Licensed Independent Practitioner."

During an Interview with Staff G, Behavioral Unit Nurse Manager on 12/5/19 at 12:30 PM, she confirmed these findings.