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 four (4) of four (4) medical records reviewed, the facility did not ensure all patients who had non- emergency/outpatient procedures, were provided with informed consent for the type of procedures performed. (Patients #1, 9 10 & 11)

Findings include:
Review of medical record for Patient #1 identified: On 6/7/19, the patient had a Venous Duplex (test shows how blood flow through the veins) of both legs, in the facility's Vascular Outpatient Department. The patient consent form titled "Consent And Authorization," is similar to the General Consent For Treatment form given to admitted patients. This form which was signed by the patient, did not specify the diagnostic test which was performed. There was no documented evidence of the information given to the patient about the procedure.

Similar findings were identified for patients # 9, 10 & 11, who were seen in the Vascular Lab for venous tests. The consent forms lacked the specific procedure information and there was no documented evidence that the patients were given information about the procedure.

During interview with Staff B, Technical Director of Vascular Lab, on 9/12/19 at approximately 11:58 AM, Staff B acknowledged the findings. When asked about patient education, Staff B admitted the patients were not provide with any education information. Staff B stated the facility has no written information for venous procedures.

Review of the facility policy titled "Consents," reviewed 9/25/15, noted the policy did not include Outpatient Department procedures or non-emergency diagnostic testing.

Review of the policy "Lower Extremity Venous Duplex Evaluation with Color Flow Imaging," reviewed 8/5/2019, states for: Patient Preparation: (1) Explain the procedure to the patient"

The facility was unable to provide information on how patients are educated on the procedure.
Based on document review and interview, in one (1) of four (4) medical records reviewed, the facility (a) did not address patient's allegation of sexual molestation, in the Vascular Department, in a timely manner, (b) did not implement its policy for reporting and investigating complaint of patient sexual molestation. (Patient #1).

Findings include:
The facility policy and procedure titled "Reporting Patient Abuse," effective 3/16/2011, states: "any instance of patient abuse must be reported to the Director of the Patient Advocate Department. In the absence of the Director of Patient Advocate, the Nursing/Department Supervisor shall be notified."

The facility policy and procedure titled "Patient Complaint of Sexual Molestation," reviewed 2/17/2010, states: "If the allegation involves an employee, the Director of Patient Advocate Services (or in his/her absence, the Patient Care Manger/designee) will inform the employee's supervisor, who will place the employee on immediate administrative leave, for a period not to exceeded three business days, pending the outcome of the investigation."
The policy also states: "The Director of Patient Advocate Service will coordinate the investigation with the Director of Labor Relations, if the allegation involves an employee of Wyckoff Heights Medical Center ...."

Review of the document titled, "Weekly Audits on Pending Grievances for September 6, 2019," noted, on 7/19/19 a grievance was documented for the patient (Patient #1): "Patient alleges he was fondled by a technician during an examination. Status: Pending 7/19/19 awaiting response from Vascular Dept."
As of date, during the survey 09/06/2019, there was no written response from the Vascular Department.

During interview on 9/11/19 at approximately 10:33 AM, Staff H, (who is both Director Risk Manager & Director of Patient Advocate), stated the incident took place in June. However, Risk Management became aware on 7/9/2019, when the police came to the facility unannounced and went to the Vascular Department and spoke to the director. The director informed the facility's lawyer and the facility's lawyer informed Risk Management.
Staff H stated it's the hospital's Grievance policy that department head investigates the grievance. When the investigation is completed, a copy of the finding is forward to the Patient Advocate Department. Staff H stated the Advocate Department is still waiting for the Vascular Departments' investigation.

During interview on 9/12/19 at approximately 11:58 AM, Staff B, Technical Director Vascular Lab, stated the police came to the Vascular Department, on 6/20/19. Staff B stated the police did not provide the complainant's name just that they were investigating a staff in the unit. Upon inquiring, the police stated they were investigating Staff A. Staff B stated after the police left the unit, "I told my boss, Staff L, Vice Present of Nursing, and I told legal. I assumed the issue was dealt with."

Staff B stated the police returned to the Vascular Department on 7/10/19. The police did not give the patient's name, but the nature of the allegation was provided. The patient alleged that he was fondled by Staff A. Staff B stated the police attempted to speak to Staff A, but the police was escorted to the Legal Department. Staff B stated he did not believe the allegation against Staff A. Staff B stated hospital's policy on patient' allegation against staff member, was for the supervisor to complete an incident report, notify Legal and Risk Management. According to staff B, "I followed the hospital's policy."

When asked by the surveyor, Staff B did not know the facility's policy on reporting patient incident involving a staff member.

On 9/13/19, Staff B provided the surveyor a copy of an Incident report. The report was dated 6/20/19, Unknown Patient, with a description of the incident. The report was otherwise incomplete.

During interview with Staff L, Vice President of Nursing, on 9/13/19 at approximately 10:09 AM, Staff L stated she was aware two detectives went to the Vascular Department. She stated Staff B informed her the detectives were very vague on the allegation. She stated she checked her emails and calendar. She spoke to Patient Advocate Department, to see if they received a complaint regarding the Vascular Department. Staff L stated, since there was no patient complaint, she told Staff B that there was nothing. Staff L stated the detectives returned two weeks later. The second time, more details were provided. Staff B was informed that patient #1 alleged he was fondled during a Vascular examination. Staff L stated the facility did not receive a patient complaint.

During interview on 9/13/19 at approximately 12:43 PM, Staff C, Administrative Assistant,
Vascular Department, stated two detectives came to the department and spoke to her. Staff C was unable to provide the date and time the detective came to the unit. She stated they asked her how the tests were performed. She informed them to speak to her supervisor. After the detectives left the unit, the first time, her supervisor asked her "did any patient complain about Staff A." Staff C stated she told her supervisor "one patient called, and he asked the name of the tech who did his test." Staff C stated the patient identified himself and gave the date and time of the test. Staff C stated she told her supervisor the patient's name.

When asked by the surveyor, Staff C did not know the facility's policy on Reporting Patient's Abuse against a staff member.

During interview with Staff M, Labor Relation Manger, on 9/16/19 at approximately 2:00 PM, Staff M stated Labor Relation Department was not aware that there was a patient complaint against Staff A.