Garden City Hospital

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to document an order for placing a patient in four-point restraints for 1 (P-1) of 4 patients reviewed in restraints resulting in the increased likelihood of negative consequences for the patient. Findings include: P-1’s medical record was reviewed with Director of Quality Staff B and Charge Nurse Staff J. P-1’s nursing flowsheet documentation revealed that P-1 was in behavioral restraints starting from 3/26/2025 at 2200 to discontinuation on 3/27/2025 at 0000. P-1’s only restraint order on 3/26/2025 at 2200 was “Siderail x 4” for one day. According to the facility’s policy “Restraints: Violent Behavior or Seclusion,” dated 6/2024 for “Initiation of Restraints or Seclusion, the order includes: The type of restraint, The number of limbs to be restrained: 4 points, For locked Velcro restraints - the order must specify 4-point restraints* (Any deviation from this must include the documented rationale for < 4-point restraint.), Duration, If a verbal order was given to initiate restraints, the physician must sign the verbal order and complete a written order, which must take place within 1 hour. According to the facility’s policy “Restraints: Violent Behavior or Seclusion,” dated 6/2024, “The use of restraint follows the orders of a physician or other LP responsible for the patient’s care.” The policy also revealed “If an LP is not available to issue an order, a Registered Nurse (LICENSED COMPETENT NURSE) may initiate using restraints based on an appropriate patient assessment. If the LICENSED COMPETENT NURSE initiates restraints, the attending physician is consulted as soon as possible and within one hour as specified in this policy.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(vi) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (vi) Monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy associated with the 1-hour face-to-face evaluation. This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to document a face-to-face evaluation after placing a patient in four-point restraints for 1 (P-1) of 4 patients reviewed in restraints resulting in the increased likelihood of negative consequences for the patient. Findings include: On 3/26/2025 at 2200, P-1 was placed in four-point locking restraints and the medical record revealed no documentation that a face-to-face was completed following the restraint application. When queried whether a face-to-face evaluation was present, Charge RN Staff J confirmed the missing evaluation documentation at the time of discovery. According to the facility’s policy “Restraints: Violent Behavior or Seclusion,” dated 6/2024, “2. The patient for whom restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, is seen face-to-face as soon as possible, but no later than one (1) hour after the initiation of the intervention by the attending physician, another LP, or an RN.” The policy also revealed “3. The face-to-face is to evaluate: 3.1 The patient’s immediate situation; 3.2 The patient’s reaction to the intervention; 3.3 The patient’s medical and behavioral condition; and 3.4 The need to continue or terminate the restraint or seclusion.” “4. If the face-to-face evaluation is conducted by a competent RN, LP, or a physician who is not the attending, that person consults the attending physician or other physician who is responsible for the care of the patient as soon as possible and no later than one (1) hour after the initiation of the restraint or seclusion to: 4.1 Obtain a telephone order for restraints or seclusion 4.2 Consult with the physician about the patient’s status 4.3 The physician reviews the information and determines if the restraint or seclusion should continue 4.4 Supplies guidance to staff in identifying ways to help patient regain control””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(4) Training documentation. The hospital must document in the staff personnel records that the training and demonstration of competency were successfully completed. This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to ensure a staff member completed the required annual competencies in a timely manner for 1 (Staff O) of 4 staff members reviewed resulting in the increased likelihood of negative findings for the patients in the behavioral health unit. Findings include: On 4/29/2025 at 1400, Mental Health Technician Staff O’s personnel file was reviewed with Director of Quality Staff B. Staff O has been working for the facility for three years. Staff B revealed Staff O did not have any documentation that annual competencies for the calendar year 2024 were completed. When queried, Staff B confirmed that Staff O was expected to complete competencies in 2024. Staff B revealed the facility did not have a policy for completing annual competencies. Staff B provided a presentation packet titled, “Corporate Education & Competency Plan,” dated 2025 edition, that revealed “Non-Licensed/Patient Facing Curriculum included “Patient Rights, Restraints, Abuse and Neglect, Informed Consent, and Advance Directives” were to be completed annually.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 45245 Based on interview and record review, the facility failed to verify, evaluate and update policies and procedures for emergency medical services on an ongoing basis for all patients presenting to the emergecy department (ED). Findings include: During tour of the facility on 05/08/24 at 0920, Staff C was questioned which triage acuity system was used in the ED. Staff C reported, “ESI” (Emergency Severity Index). On 05/08/24 at 1300, review of policy titled “Triage”, (no policy #), reviewed 2017, demonstrated that the triage acuity rating system was not “ESI”. The policy demonstrated a system of Priority 1 through Priority 5. Each priority level is defined as “Immediate” (1); “Emergent” (2); “Urgent” (3); “Non-Urgent” (4); and no definition is provided for Priority 5. Each Priority level lists approximately a dozen examples of patient complaints that fit that level. Unique to the ESI Triage system, is that “resources needed” and “vital signs” are used to establish the acuity rating. The triage policy does not state that the facility uses ESI for Triage acuity rating. A single reference to ESI is found in the policy ‘Reference’ footnote, “ESI- A Triage Tool for Emergency Department Care Version 4 (2012) AHRQ Agency For Healthcare Research and Quality.” An interview was conducted with Chief Nursing Officer Staff B on 05/09/24 at approximately 1010. Staff B was questioned why the Triage policy does not reflect current Triage practice in the EC. Staff B stated, “We will need to update that policy. All policy is updated at the corporate level.””

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 45245 Based on interview and record review, the facility failed to maintain a central log for all 20 of 20 patients reviewed for documentation in the Central Log for the Emergency Department (ED), resulting in inaccurate documentation of patient arrivals to the ED. Findings include: On 05/08/24 at 0900, the required ED Central Log was requested from Director of ED (Staff C) for additional documentation of patients’ arrival times. Staff C explained that the Central Log was moved from a previous electronic medical record platform to our new electronic medical record platform and we have incorporated portions of the ED Central Log into it. On 05/08/24 at 1137, Staff C provided a copy of the facility’s “Daily ED Summary Log” in lieu of the required ED Central Log requested. Staff C stated that “(The new electronic medical record platform) was able to duplicate the Central Log and the report is pending.” Staff C returned a short time later and presented a spreadsheet titled “ED Daily Log” displayed on his computer screen. A comparison and review of facility’s policy “EMTALA- Compliance with the Emergency Medical Treatment and Active Labor Act”, (no policy #) revised 03/2016, demonstrated, “Central Log: Each department of the hospital that provides medical screening examination shall maintain a central log recording the following: Patient’s name DOB Sex Chief complaint Arrival time Triage time Registration time MSE time Medical record/ Account number Mode of arrival Name of LIP (Licensed Independant Practicioner) who provided MSE (Medical Screening Exam) If admitted Name of admitting LIP Disposition of patient including refusal of treatments, transfers, admitted, stabilized and transferred or discharged.” The facility’s report “Daily Summary” reviewed on 05/08/24 at 1137 demonstrated that the log did not include registration time, mode of arrival, or name of LIP who provided MSE, as stated in the policy above. Further review of the “Daily Summary” on 05/10/24 at 1440 failed to demonstrate documentation of P-1 as presenting to the facility ED on 02/15/24 at 1600. The “Daily Summary” demonstrated a time gap with no patients logged between 02/15/24 at 1408 until 02/15/24 at 1744. A review of the facility’s “ED Registrations” report provided by the facility’s Director of Registrations (Staff O) on 05/10/24 at 1445, did not match the “Daily Summary Log.” It demonstrated the registration of 37 patients between 1408 and 1744, on 02/15/24. An interview was conducted on 05/08/24 with Registration Manager Staff N. Staff N was questioned about the many discrepancies with the data. Staff N stated, “The registration history report pulls data from another emergency center, which is under the same CCN (facility registration number).” Staff N stated that a second attempt at the report would be made the following morning. No other report was provided.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 45245 Based on interview and record review the facility failed to ensure a medical screening exam (MSE) was performed for 1 of 20 patients (P-1) requesting services of the Emergency Department (ED) resulting in P-1 not receiving an MSE. Findings include: During review of P-1’s medical record with ED Director Staff C, on 05/07/24 at 1300, Staff C was questioned if P-1 received a triage evaluation and Medical Screening Exam (MSE). Staff C replied “No, he left before being seen.” Staff C was next asked why he thought P-1 left the facility after seeking treatment. Staff C replied, “The triage nurse chose a chest pain over him first.” During chart review for P-1 it was noted that the medical record contained “depart” information showing “Discharged at 1602.” Staff C was requested to provide the “Discharge Instructions” that were provided to P-1. Staff C stated that “P-1 was not provided discharge instructions because he left before being seen.” Review of facility’s document “Facesheet”, dated 02/15/24 demonstrated P-1’s “Arrival Date/Time” as 1658, and “Admit Date/Time” as 1707 (P-1 was not admitted). Review of document, “Registration History for the Patient Encounter,” dated 02/15/24 from 1602 through 1616 demonstrated that P-1 was registered at the facility approximately one hour prior to the documented “arrival time” indicated on the “Facesheet”. Review of documents “Registration History for the Patient Encounter” dated 02/15/24, revealed the following information in timeline format: Date/Time: 02/15/24 at 1602: P-1 arrived at ED (registration) and “Patient Encounter” created. 02/15/24 at 1616: Hospital account verified, and Confirmation Error was recorded. 02/15/25 at 1625: Patient Disposition documented as “Dismissed.” Documentation of P-1’s presenting to Facility A was not located in either the “ED Summary Log” nor the “ED Registrations” file. The “Registration History for the Patient Encounter” was the only documentation of P-1’s arrival or registration on 02/16/24 at 1604.”