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Based on observations, interviews, review of medical records and other documents, it was determined that the facility failed to ensure that patients' rights requirement are met.


Findings include:


1. The facility failed to ensure the development and implementation of an effective process for prompt resolution of grievances; see tags A0119 and A0122.

2. The facility failed to ensure the psychiatric inpatient unit is safe and free of hazards for individual with self-injurious behavior; see tag A0144.

3. The facility failed to ensure that each patient who is restrained receives a written order by a licensed independent practitioner and is monitored in accordance with regulatory requirements for the use of restraints; see tags A0168 and A0175.

5. The facility failed to ensure appropriate staff members are trained in the safe implementation of restraints and the use of first aid techniques; see tags A0194 and A0206.

Based on staff interviews, and review of the Complaint Log, and Patient Relations Department 2013 Annual Report, it was determined that the facility's Governing Body failed to ensure that the facility had an effective grievance process for the prompt resolution of all grievances that the facility received. This was evident in twelve of fifteen grievance files reviewed (Files #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, & #12).

Findings include:

Fifteen (15) Grievance files and twenty (20) Complaint files were reviewed on 4/1/2015. It was noted that twelve (12) of the fifteen (15) files that were classified as grievances did not have timely responses to complainants for the outcome of the facility's investigation. In addition, out of the twenty (20) files classified as complaints, only seven (7) were complaints; the remaining thirteen (13) of these files met CMS requirements for definition of grievances.

Staff #8 and staff #9 were interviewed on 4/1/2015. Staff #8 stated that files classified as complaints do not require written responses. Therefore, there were no written responses in complaint files. Staff # 8 & Staff #9 stated that Patient Relations Department is responsible for the implementation of the grievance process. The Director of Patient Relations Department reports to the Quality Compliance Committee and the Quality Compliance Committee reports to the Board of Trustees annually.

Patient Relation's Report was reviewed on 4/1/2015. It was noted that the 2013 Annual Patient Relation's Report was dated August 4, 2014. During interview with staff (#8 & #9), it was stated that this information was reported to the Board of Trustees on August 4, 2014. Staff #8 stated that 2014 Complaints/Grievance issues would be reported to the Governing Body during the August 2015 meeting.

The Patient Relation's Data for Complaints and Grievances was submitted for review by Staff #8 and this was reviewed on 4/1/2015. It was noted that this material was data for 2013. This staff stated that this information was presented to the Board of Trustees in August 2014. Therefore, it could not be determined if the Governing Body was aware that the facility was not providing written and timely responses to all grievances, and that grievances were not classified appropriately.

Based on review of patients' Grievance Files and the facility's policy, it was determined that the facility failed to assure that: 1) the timeframe specified in the facility's grievance process for resolving each patient's grievance meets the Federal Requirements within a reasonable timeframe, and 2) a written response is provided for all grievances. This was evident in twelve (12) of fifteen (15) Grievance Files reviewed (Files #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 & #12 ).

Findings include:

Grievance file #1 was reviewed on 4/1/2015. It was noted that the patient's daughter filed a complaint to the facility on 11/5/2014. The complainant alleged that her father was inappropriately discharged as her father was admitted for eighteen (18)days , went home for one day, and returned to the Medical ICU on 11/5/2014. It was noted that the written response to the complainant on the outcome of the investigation was dated 12/31/14. The response letter to the complainant was sent over 30 days after receipt of the grievance.

Grievance file #2 was reviewed on 4/1/2015. It was noted that the facility received a complaint from the husband of a patient on 11/24/14. The complainant alleged that his wife almost died after a C-section. It was noted that the written response to the complainant was dated 12/31/2014.

Grievance file # 3 was reviewed on 4/1/2015. The patient' s husband filed a complaint with the facility on 12/18/2014, alleging that the patient was not properly monitored; consequently, the patient expired. It was noted that the written response to the complainant on the outcome of the investigation was dated 3/5/2015. It was noted that the complainant was not provided with an interim letter regarding the facility plan and date for completion of this investigation.

Grievance File # 4 was reviewed on 4/1/2015. It was noted that the facility received a written complaint from the patient' s daughter on 2/26/2015. It was noted, as of the date of this review on 4/2/2015, the complainant was not yet provided with a written response on the outcome of the investigation.

The Policy titled "Care of Patients/Patient Rights Subject: Complaint Reporting Investigation Policy No. C-50" was reviewed on 3/31/2015. This Policy indicated, " During the investigative process, any other department as being involved in the issue (s) must submit all additional information needed to respond to the grievance, in writing to patient Relations, within 10 business days of receipt. All grievances will be responded to in writing by a designated senior managerial staff member with the involvement of Patient Relations within 30 days of receipt " .

Based on interview and observation, it was determined the facility failed to ensure the psychiatric unit is safe and free of hazards for individuals with suicidal, psychotic, and self-injurious behavior. Specifically, bathrooms in the psychiatric unit are fitted with Paper Towel Dispensers that are a looping hazard. This finding was noted in twenty patients' rooms in the psychiatric unit.

Findings include:

During tour of the Behavioral Unit on 4/2/15 at about 12:30 PM, it was observed that each room's bathroom has a Paper Towel Dispenser (11 ½ inches length x 9 ¼ inches width x 8 ¾ depth) that is fitted to the wall approximately 60 inches from the floor. The Paper Towel Dispenser is made of a metal frame and a see through plastic case that projects 8 ¾ inches from the wall.

At interview with staff #7, he stated "the Behavioral Unit had passed several inspections conducted by the Office of Mental Health and the use of the Paper Towel Dispensers had never been an issue of concern".

16790



Based on staff interview and review of patient record, restraint policy and procedures, and Security incident reports, the facility failed to ensure that patients are restrained in accordance with orders of a physician or other licensed independent practitioner. This finding was noted in one of five applicable medical records reviewed for patients where restraints were applied.


Findings Include:


Review of MR # 1 on 4/2/2015 noted that this patient, a 49 year old female, with history of COPD (chronic pulmonary disease (COPD), Asthma, HTN (hypertension), DM (diabetes), anxiety, and borderline personality disorder, went to the facility' s Emergency Department on 2/11/2015 with presenting problem of atypical chest pain. The patient was admitted on 2/12/2015 and she was transferred to a medical unit.


There were two episodes of restraint application for patient #1, on 2/15/15 and again on 2/26/15.


The first episode of restraint, on 2/15/15, found the lack of timely and accurate physician orders immediately following restraint application for patient #1. It was documented in the record that on 2/15/2015 at 11:30 PM, the patient became very agitated and combative, requiring physical restraint. The justification for the restraint was "to prevent harm to self and others". It was noted that the restraint order was written on 2/16/2015 at 04:27 AM, fours after the patient was restrained. In addition, this late order obtained for patient's restraints was inaccurate. Review on 4/2/15 of a Security Incident Report, dated 2/16/15, indicated that security was called for assistance on 2/15/15 at 2345 (11:45 PM). This document indicated that the patient was placed on "four point restraints". However, review of the physician's order , dated 02/16/2015 at 04:27 (4:27 AM), indicated the written order was for "soft limb both arms". It was noted that there was no written order for four point restraints.

The second episode of restraint cited, on 2/26/15, found no evidence of any physician orders for the application of a restraint for patient# 1. Review of the Security Incident Report, dated 2/26/15, indicated that the security officers responded to assist nursing staff with the patient in MR #1. This document indicated that patient was "physically taken back to her bed and she was restrained as per MD order". Review of the medical record (MR#1) on 4/2/15, found there was no physician's order for the restraints applied on 2/26/2015. The nursing staff did not document the application of the restraints in the medical record.

Staff # 4 was interviewed on 4/2/2015. This staff stated that security applied bilateral restraints to the patient in MR#1 on 2/26/2015. This staff stated that the patient was in restraints for only two or three minutes and the patient broke free from the restraint. It was also stated the restraint was not reapplied because the patient became calmer following the arrival of her family.

The procedure titled, "Use of Restraint and Seclusion" reviewed on 4/2/15, notes "in the emergency department and in other areas of the hospital covered by psychiatric consultation, liaison service, licensed by NYSDOH (New York State Department of Health), restraint is ordered by a licensed physician or licensed independent practitioner." It further notes that in an emergency situation, the nurse may apply the restraints, but the RN shall notify the licensed physician or licensed independent practitioner (LIP) within 30 minutes of application. This policy also requires that "if based on the results of the physician or LIP examination, the physician or LIP determines that continued use of restraint or seclusion is indicated, the physician/LIP shall write an order."

Consequently, the facility failed to follow the restraint procedures, because during the 2/15/15 restraint episode, there was no evidence of timely physician notification and orders and in the 2/26/15 restraint event, there was no evidence of a written physician restraint order.

16790




Based on staff interview, and review of medical record and other hospital procedures/documents, it was determined that the facility failed to ensure: 1) the immediate assessment by a physician or the licensed independent practitioner (LIP) following restraint application; and 2) the ongoing assessment and monitoring of a patient in restraints. These findings were evident in one of five applicable medical records reviewed (MR #1).

Findings include:

Review of MR # 1 on 4/2/2015 noted that this patient, a 49 year old female, with history of COPD (chronic pulmonary disease (COPD), Asthma, HTN (hypertension), DM (diabetes), anxiety and borderline personality disorder, went to the facility' s Emergency Department on 2/11/2015 with presenting problem of atypical chest pain. The patient was admitted on 2/12/2015 and she was transferred to a medical unit.

There were two incidents of restraint application for patient #1, on 2/15/15 and again on 2/26/15.

The first episode of restraint, on 2/15/15, found a lack of immediate assessment following restraint application by a physician. It was documented in the medical record that on 2/15/2015 at 11:30 PM, the patient became very agitated and combative, requiring physical restraint. The justification for the restraint was "to prevent harm to self and others". A Security report dated 2/16/2015 at 0030 (12:30AM) was reviewed on 4/2/2015. This report indicated that security was called for assistance on 2/15/2015 at 2345 (11:45 PM) and the patient (MR#1) was placed on "four point restraints " . However, the "restraint care plan" form, which includes a restraint monitoring checklist, noted the use of "both arms" in restraint. Therefore, the nursing staff responsible for the care of the patient did not document in the patient ' s medical record that the patient was placed in a four-point restraint.

The procedure titled, "Use of Restraint and Seclusion" reviewed on 4/2/15, notes "in the emergency department and in other areas of the hospital covered by psychiatric consultation, liaison service, licensed by NYSDOH (New York State Department of Health), restraint is ordered by a licensed physician or licensed independent practitioner." It further notes that in an emergency situation, the nurse may apply the restraints, but the RN shall notify the licensed physician or licensed independent practitioner (LIP) within 30 minutes of application.

The assessment by medical staff was not documented within 30 minutes of the restraint application.

The second episode of restraint cited, on 2/26/15, found no evidence of ongoing monitoring by clinical nursing staff of this patient following application of restraints. The medical record for Patient #1 found that, on 2/25/2015 at 10:00 PM, the nurse noted, "Informed by staff that patient had the bed all the way up. Assessed patient agitated informed patient that bed has to be in the lowest position to prevent fall & injury. Patient refused. Security called, patient still very agitated; MD at bedside".

Review of a Security Incident Report, dated 2/26/15, described that at 19:50 Hours (7:50PM) that the security officers responded to assist nursing staff with patient #1, who was aggressive and uncooperative; the patient pulled out the IV lock and was sprinkling her blood on the face and uniform of security staff. This document indicated that patient was "physically taken back to her bed and she was restrained as per MD order".

Staff #4 was interviewed on 4/2/2015. This staff stated that the patient referenced in MR #1 was placed in bilateral restraints as per MD order and in the presence of nursing staff. This staff also stated that security applied bilateral restraints to the patient in MR#1. It was added the patient had been in restraints for only two or three minutes and the patient broke free from the restraint. The restraint was not reapplied because the patient became calmer following the arrival of the family.

The nursing staff assigned to the patient did not document that the patient was placed on restraints. The patient's medical record lacked documentation of the restraint care plan (including monitoring flow sheet) for this restraint episode on 2/26/15. Therefore, there was no written nursing assessment or monitoring after security staff had restrained the patient.

Based on interviews, review of incident report and other documents, it was determined that the facility failed to ensure appropriate staff is trained in the safe implementation of restraints. Specifically, the facility failed to ensure security staff members received restraint training and are able to demonstrate competency in the application of restraints. This finding is noted in 5 of 5 security staff credential files reviewed (Staff #1, #2, #3, #4 and #5).

Findings include:

Facility's policy titled "Restraint Use In Non-Violent Patient", last revised in 1/2014, and the policy titled "Restraint and Seclusion" for Psychiatric Acute Care, last revised in 6/2014, notes that staff members are trained during orientation and annually, including demonstrating competency in the application of restraints/seclusion, monitoring, assessment and providing care for a patient in restraint/seclusion. The restraint policies do not describe the role of security staff in the utilization of restraints/seclusion for non-violent and psychiatric patients.

At interview with Staff #3, Security Supervisor on 4/2/15 at 1:30 PM, she stated, security guards may assist staff in holding patient for intervention and may apply soft wrist restraint if ordered by a physician. Staff #3 stated she had received training in the use of restraint once or twice since hired four years ago.

The review of the document titled "Job description for security guards", last revised on 4/30/14, notes a list of job responsibility that includes "Assist in patient restraint". However, the review of personnel files for security staff #1, #2, #3, #4, and #5 revealed a lack restraint training and annual competencies in the application of restraints.

Staff #4, a security guard was interviewed on 4/2/15 at 1:36 PM and was asked about an incident involving the use of restraint on 2/26/15. Staff #4 stated he responded to a call for help on inpatient unit 4A. Patient #1 was found in her room agitated, combative, and threatening staff members. He stated the physician ordered the application of soft wrist restraints, which he applied with the help of two other security guards.

At interview with Staff #6, Security Director on 4/2/15 at 1:40 PM, he stated all security guards have annual certification in Crisis Prevention Intervention (CPI). He acknowledged that security staff files have no documentation of restraint training during orientation and annually, including demonstration of competencies in the application of restraint as prescribed by the facility policy for staff members who apply, monitor, and provide care for patients in restraints.

The review of the CPI course description on 4/2/15 revealed the training did not include the use of restraints.

Based on interviews, and the review of personnel files, it was determined the facility failed to ensure all staff who apply restraints receive education and training in the use of first aid techniques as well as training and certification in the use of cardiopulmonary resuscitation. This finding was noted in 5 of 5 security staff credential files reviewed.

Findings include:

Personnel files for Staff #1, #2, #3, #4 and #5 lacked education and training in the use of first aid technique and certification in the use of cardiopulmonary resuscitation. All staff members are security personnel.

At interview with Staff #3, Security Supervisor on 4/2/15 at 1:30 PM, she stated, security guards may assist staff in holding patient for intervention and may apply soft wrist restraint if ordered by a physician.

At interview Staff #6, Director of Security on 4/2/15 at 1:45 PM, he stated it was not a requirement for security staff to have first aid training and maintain certification in cardiopulmonary resuscitation.

Based on staff interview and medical record review, It was determined that the facility failed to provide a complete discharge planning assessment prior to discharge. This finding was evident in one of one medical records reviewed (Patient #1).

Findings include:

Review of MR #1 on 4/2/2015, noted this patient, a 49-year-old female with history of borderline personality disorder, was admitted on 2/12/2015 and managed in a medical unit.

It was noted that on 2/26/2015 at around 9:30 PM, the patient became violent and aggressive warranting security staff intervention. It was documented in the medical record that patient's family member arrived on the unit and the patient became calm. The treating physician made a determination to discharge the patient on the same day on 2/26/2015 with an appointment to follow up with her outpatient psychiatrist. The discharge planning assessment did not include if this was a safe and appropriate discharge plan for this patient. The patient ' s household composition was not included in the assessment. It was documented that the patient's sister, who resides close to the patient, would help with post discharge needs. The discharge assessment did not include if a contract was obtained from the family member responsible for providing care, or the reason why this was not necessary.

Staff # 10 was interviewed on 4/2/2015. This staff reported that the patient was a danger to self and others, and she would manage better at home. It was noted that there was no discharge evaluation form the psychiatrist clearing the patient for discharge. The patient did not have a discharge planning reassessment before the patient was discharged.

Based on review of patient record and staff interview, it was determined the facility failed to develop and implement an appropriate discharge planning evaluation, which addressed safety of the home care discharge plan of a patient with complex medical needs. This finding was identified in one of twelve medical records reviewed (Patient #2).


Findings include:


Review of the medical record of Patient #2 on 4/2/2015 at approximately 10 AM revealed this 50 year old patient with multiple medical medical needs, including neurofibromatosis type 2 (a disorder characterized by the growth of noncancerous tumors in the nervous system), laryngeal tumor, multiple meningiomas, toxic encephalopathy, past cerebrovascular accident (CVA), with residual weakness and slurred speech, was admitted to the facility from a nursing home for treatment of respiratory failure, sepsis, and pneumonia on 11/16/2014. It was the noted the patient had a ventriculoperitoneal shunt (VP), Percutaneous endoscopic gastrostomy (PEG) feeding tube, and was confused and bedridden.

The discharge planning initial assessment of 11/19/2014 noted the patient resided at a nursing home prior to arrival and the plan at that time was to return to the nursing home. On 12/2/2014, the case manager noted the plan as reviewed with the interdisciplinary team and noted the "family plan is home with home care and extensive DME (durable medical equipment) scripts". The equipment prescriptions were faxed to the pharmacy on that same date.

A family meeting was noted on 12/8/2014, which indicated the family was instructed on aspects of care, including PEG feedings, medication administration, foley catheter care, and suctioning. The family reported they had been instructed on hoyer lift at the prior facility. Discussion was held with the Visiting Nurse Services liaison about the plan to discharge home with home care once the supplies and equipment were in the home.

On 12/12/2014, the Case manager noted the family was adamant about taking the patient home and they would follow up with the pharmacy to obtain the best prices for DME. The Case manager also noted on 12/16/2014 that the VNS home care is ready to start services and that the patient "is high risk for readmission, as she has extensive needs at home." On 12/18/2014, the patient had also been referred to a house calls program.

On 12/20/2014, the Case Manager noted following discussion with a VNS supervisor, a letter of responsibility was needed from the patient's family and that follow up with the VNS coordinator would occur Monday (12/22/2014).

On 12/22/2014, Case management noted all equipment, including hoyer lift, and suction was delivered to the patient's home and that she was scheduled for ambulance pick up that same day at 5 PM.

The discharge planning evaluation was incomplete and failed to sufficiently address the caretaker's ability to safely meet the patient's continuous post hospital care needs, including the availability of the identified caretaker to provide complete assistance with all activities of daily living, oxygen care, and suctioning at all times. The availability of a designated family caretaker to provide care in the absence of agency home care staff was not explored. The assessment also did not address if the caretaker was capable of assuming responsibility for this patient with total care needs and did not reflect return demonstration of competency for tasks related to suctioning and oxygen care. The medical record lacked documentation of follow up by hospital staff to ensure the family had provided a letter of responsibility as requested by the Visiting Nurse Services. There was no documentation that discharge planning staff confirmed arrangements for home care services prior to release of the patient and failed to document the type, home care hours approved, and frequency of specific home care services to be provided, along with the date these services would begin. Without validation of the home care hours to be provided, the assessment could not address whether the discharge plan was sufficient to meet the continuous patient care needs. The safety of the plan to discharge the patient to home without validated home care services in place was therefore not addressed.

At interview with staff # 11 on 4/2/15 at approximately noon , it was stated there was no proof that the letter of family responsibility had been obtained from the responsible family member prior to the patient's discharge.

Based on staff interview and review of medical records and policy, it was determined the hospital did not document and inform the patient or the patient's family of the freedom to choose among participating Medicare providers of post-hospital home health agency services. This finding was identified in one of twelve medical records reviewed.


Findings include:


Review of the medical record of patient #2 on 4/2/15 found this patient was referred to a home health agency care provider, the Visiting Nurse Services of New York (VNS). There was no documentation the patient or the family member acting as the patient's representative was informed of the option to select a post hospital home care agency provider, nor evidence that a written list of home health agency options was provided.


At interview with staff # 11 on 4/2/15 at approximately noon, it was confirmed that there was no documentation the family was provided with a list of home health agency provider options as required by the facility's practice and this regulation.