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.

Based on medical record review, document review and interview, in one (1) of four (4) medical records reviewed, the facility failed to ensure that an allegation of physical abuse was investigated in accordance with its policy to ensure patient safety (Patient #2).

This failure may place patients at potential risk for harm.

Findings include:

Review of the facility's policy and procedure titled "Patient Abuse and Neglect" last revised on 4/19 stated the following:

"Any allegation of abuse or neglect is to be reported immediately to the Risk Manager and the Administrator on Duty (AOD).

All Departments, including Psychiatry, must inform Risk Management, the Administrator on Duty, and the Patient Relations of allegations of abuse.

The Risk Management office and/or AOD will notify a provider if any medical needs have to be addressed.

The patient involved should be informed that the appropriate departments will be notified, a complete investigation will be conducted, and the patient will be notified of the outcome.

A formal investigation will be conducted by the Risk Management Department. The investigation should include interviews with patients, hospital employees, witnesses, video footage and personnel folder reviews.

A meeting of the Patient Abuse Committee will be scheduled to review/discuss the incident investigation conducted by Risk Management and to review/discuss/approve recommended corrective actions."

Review of the facility's Security Command Log, from 4/21/19 to 7/24/19 revealed on 6/26/19 at 9:53 AM, Staff W, Hospital Police responded to a call from the medical Emergency Department (ED) for a patient that was discharged and refused to leave the ED.

At 9:57 AM, Staff W reported an unknown, male patient escorted out of the ED with incident.

At 10:37 AM, Staff W noted the New York Police Department officers responded to a call from an unknown male patient who reported that a hospital police pushed his head into the door.

On 8/8/19 at 10:32 AM, during interview with Staff S, Hospital Police, the staff stated that in order to report a complaint or allegation he would call the Desk Officer/Dispatcher to report and document the incident and then notify his supervisor.

On 8/8/19 at 2:37 PM, during interview with Staff T, Hospital Police Sergeant, she was asked what the expectations and protocol are for reporting a complaint or an allegation. Staff T stated that she would notify her director. Staff T acknowledged that she did not generate a written report for the patient's incident and complaint.

The facility did not investigate a complaint or allegation of physical abuse by a hospital police in accordance with its policy.

On 8/9/19 at 10:01 AM to 11:07 AM, the concern was brought to the attention of Staff U, Associate Risk Management and Staff V, Director of Security who acknowledged the finding.