Albany Medical Center Hospital

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 42925 Based on medical records (MR) review, facility document review and interview, it was determined that 1) the facility failed to ensure there were adequate medical and nursing staff in the emergency department (ED) to meet the written ED policies and procedures and the anticipated needs of presenting patients and 2) In 4 of 11 (Patient #1 - Patient #4) medical records reviewed of patients who presented to the emergency department (ED) via emergency medical services (EMS), the hospital failed to provide a timely medical screening exam to determine if an emergency medical condition existed. Cross Reference: 482.55(b)(2) Qualified Emergency Services Personnel Please see Tag 1104 and 1112.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 42925 Based on observation and interview, the facility failed to ensure that patients received care in a safe and dignified setting while in the emergency department (ED). 1) There was no mechanism in place such as call bells for hallway patients to call for assistance, and a patient was observed having a procedure done in the hallway without privacy. 2) A portable cardiac monitor used on a patient was not connected to the nurse’s station. Findings regarding #1 above include: -- Per observation while in the ED on numerous occasions, multiple patients were noted to be on stretchers in the hallway with no call bells available. -- Per interview of Staff M, Registered Nurse (RN) on 8/29/2024 at 1:55 pm, hallway patients have no call bells. The patients scream or grabs anyone walking by. -- Per interview of Staff N, RN on 8/29/2024 at 1:30 pm, there are no call bells for patients in the ED hallways, they have to grab people walking by. There are no curtains for patient privacy. -- Per interview of Staff F, RN on 9/3/2024 at 11:30 am, there are no cameras in the back hallway. Staff F relies on other staff members to notify the assigned nurse if patient needs are identified. -- Per interview of Staff O, RN on 9/4/2024 at 9:40 am, beds in the back hall are overflow beds, there are no call bells. If the patients need help, they could flag someone down when they walk by. -- Per interview of Patient #9, on 9/3/2024 at 11:10 am, (Patient #9 was observed in the back hallway on a stretcher against the wall with no call light or means to call for help) they stated having vital signs done this morning and seeing a physician assistant and a resident. The patient had been in the hallway since 10:00 pm on 9/1/2024 and was waiting for a computed tomography (CT) scan to be completed. -- Per interview of Staff D, RN on 9/11/2024 at 10:15 am, patients in the hallway (near the D zone) have no call bells and would yell out to staff for help. -- Per observation in the ED on 9/4/2024 at 9:50 am, multiple patients were in the ED hallways. Two staff members were standing next to a patient’s stretcher flushing their Foley catheter to remove blood clots. The patient was yelling out in pain and had no privacy. Findings regarding #2 include: -- Per observation on 9/11/2024 at 11:15 am, a patient was on a stretcher in the ED hallway connected to a portable monitor. Staff P, RN acknowledged this finding at the time of observation and stated the monitor is not connected to the nurse’s station in the ED. Staff P also stated if the monitor alarm came on, they would not be able to hear it. -- During the exit conference on 9/13/2024 at 2:00 pm, Staff BB, Hospital General Director acknowledged the above findings.”

“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: 42925 Based on document review, medical record review, and interview, 1) In 4 of 11 (Patient #1 - Patient #4) medical records reviewed of patients who presented to the emergency department (ED) via emergency medical services (EMS), the hospital failed to provide a timely medical screening exam to determine if an emergency medical condition existed. Findings include: -- Review of the facility’s policy and procedure titled, “Quick Check-in: Emergency Department,” revised 10/2023, indicated under “Procedure: EMS patients waiting on the EMS ramp, while on Albany Med’s property are considered Albany Med’s patients once directed to wait on the ramp.” Findings specific to Patient #1: -- Review of Patient #1’s medical record revealed, Patient #1 (identified as Jane Doe) was a transfer from Hospital B for a higher level of care. At Hospital B Patient #1 was found to have an intracranial bleed with additional concerns for sepsis. (Patient #1 had a history of substance abuse and was found on the street unresponsive with suspected drug overdose.) Patient #1 arrived at the facility via EMS 8/24/2024 at 5:42 pm. The patient was not triaged until 7:57 pm. The patient was given an emergency severity index (ESI) level of 2 (Level 1-life threatening, Level 5 - non-urgent). The patient was seen by a provider at 8:06 pm Review of the EMS Patient Care Record (PCR), dated 8/24/2024, “pt arrived at hospital A, at 5:38 and transfer of care occurred at 8:05 pm. -- Per interview of Staff A, provider on 9/4/24 at 11:35 am , Patient #1 appeared very ill and septic, with questionable endocarditis, spinal abscess, and brain bleed. The patient was clearly very sick and waited too long. Staff A stated in their opinion, the patient should have been brought in sooner. Staff A expressed concerns about the long EMS wait times. -- Per interview of Staff B, provider on 9/4/2024 at 3:20 pm, they recalled Patient #1. Staff B wasn’t aware the patient had been in the ED vestibule for 2 hours and opined that this is not appropriate. Patient #1’s medical screening exam did not start for 2.5 hours after their arrival. Findings specific to Patient #2: -- Review of the facility’s protocol titled, “Aneurysmal Subarachnoid Hemorrhage AMC Protocol: Emergent management of a SAH,” dated 1/2021, indicated the “Emergency Department provider will evaluate the patient at bedside within 10 minutes of the patient’s arrival.” -- Review of Patient #2’s medical record revealed, Patient #2 was a transfer from from another hospital (Hospital C). The patient had fallen from a curb, with head strike. There was no loss of consciousness and the patient was not on blood thinners. The patient had a computerized tomography (CT) at the transferring facility (Hospital C), with findings of a subarachnoid hemorrhage (brain bleed) and a skull fracture. Patient #2 presented to the ED (from Hospital B) on 7/28/2024 at 8:07pm pm via EMS. Patient #2 remained on the ED ramp until a room became available on 7/29/2024 at 12:13 am. 12:26 am - Provider documentation indicated, “Unfortunately patient had a prolonged wait for room and EMS reports that she declined while waiting. Unclear how she has changed however family states that she appears more confused than normal. An immediate neurosurgery consult was order.” 2:54 am - Computed Tomography (CT) revealed questionable thrombosis (clot) and brain contusion. Neurosurgery believes the subarachnoid (bleed) has worsened. At 2:55 am Patient admitted to the trauma team. Patient #2’s medical screening exam did not start for 4 hours after their arrival. Findings regarding Patient #3: -- Review of Patient #3’s medical record revealed, Patient #3 presented to the ED via EMS on 8/30/2024 at 3:33 pm, with a chief complaint of right hip pain. Past medical history of bone metastasis (cancer). Patient #3 “was recently admitted to Albany Medical Center after pathological left femoral shaft fracture and underwent an open reduction and internal fixation (ORIF) on 8/18/2024 without any complications. Today at rehabilitation center while undergoing physical therapy the patient felt a snap in the right leg. Concern for right femoral shaft fracture and orthopedic surgery plans for ORIF in the morning.” Patient #3 remaind on the EMS ramp until 7:20pm. (4 hours). 12:17 am - First provider evaluation done. Multiple orders written for example, CT of right leg, laboratory studies, orthopedic consult, etc. Patient #3’s medical screening exam did not start for 4 hours after their arrival. Findings regarding Patient #4: -- Review of Patient #4’s medical record revealed, Patient #4 was a transfer from another Hospital (Hospital D). At Hospital D Patient #4 had electrocardiogram changes and chest pain. Patient #4 presented to the ED via EMS on 8/30/2024 at 3:05 pm, (from Hospital D). 6:58 pm - First provider evaluation, indicated patient sent for further workup and possible catheterization. Patient complained of some left medial thigh discomfort that has been present for over a week following an episode of left lower leg erythema and swelling. “Patient denies hemoptysis, hematemesis, fevers/chills, nausea/vomiting, abdominal pain, numbness/tingling of unilateral swelling and erythema of extremity and increased dyspnea raises suspicion for deep vein thrombosis/possible pulmonary embolism as another potential etiology of presenting symptoms.” Per ED provider notes, dated 8/30/24 at 7:04 PM, The ED at Hospital A contacted AMC cardiology who recommended patient be transferred to AMC for acute coronary syndrome workup and possible cardiac catheterization. The patient had complaints of chest pain, shortness of breath and the transfer documents from Hospital A indicated the patient had a t-wave abnormality on EKG (abnormal t-waves may indicate the presence of cardiovascular disease). The patient was sent to the waiting room and not triaged until 6:19 PM, over three hours later. Patient #4’s medical screening exam did not start for 3 hours after their arrival. Additional Findings: -- Per interview of Staff C, RN on 9/4/2024 at 3:40 pm, they have concerns about EMS patients. Staff C stated “I have never seen anything like this. Emergency medical services watches the patients in the bay and on the ramp. This is a safety concern. Someone is going to get hurt.” -- Per interview of Staff D, RN on 9/3/2024 at 12:15 pm, if a patient is waiting for a room/bed, the patient is the responsibility of EMS until they give report. -- Per interview of Staff E, RN on 9/3/2024 at 11:15 am and 9/4/2024 at 2:30 pm, in regard to the patients in the vestibule, “it is their understanding that until EMS gives report the patient is still in EMS’s care. The nurse assumes care of the patient when the patient is off the EMS stretcher and the patient is in a room and report is given.” -- Per interview of Staff F, RN, on 9/3/2024 at 11:30 am and 9/5/2024 at 11:45, EMS remains responsible for the patient until they have been triaged and EMS continues to monitor and document on the patient in the patient care report (PCR). Staff G, Director of Hospital Regulatory Affairs on 9/5/2024 at 2:42 pm, during presentation of the IJ template, acknowledged the above findings.”

“QUALIFIED EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b)(2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This Standard is not met as evidenced by: 42925 Based on facility document review, interview, and medical record review, the hospital failed to ensure there were adequate nursing staff in the emergency department (ED) to meet the written ED policies and procedures and the anticipated needs of presenting patients. Findings include: -- Review of the Clinical Staffing Plan submitted by the hospital for 2024 revealed the average ratio of patients to registered nurses (RN) is 2.58 patients on day, evening, and night shift. -- Review of posted staffing matrix in the ED on 8/28/2024 revealed there should be 21 RNs on day shift, 24 RNs on evening shift. and 20 RNs on night shift. The daily staffing schedules showed staffing should be 20 RNs on day shift, 24 RNs on evening shift and 21 RNs on night shift. -- Review of the hospital’s policy and procedure titled, “Triage Process Guidelines” reviewed 7/2024, showed “the goal is to triage all patients within 30 minutes of arrival. If this goal cannot be met the triage nurse will communicate this to the ED triage nurse, who will then mobilize other triage staff”. -- Review of the hospital’s policy and procedure titled, “Emergency Department,” reviewed 4/2024, revealed under Quality Management, “Under the supervision of administration, department management is responsible for setting standards and assuring the provision of quality, safe and appropriate care within their scope of service. This is achieved by establishing regular and ongoing processes to identify and monitor at a minimum high risk and high volume activities and regulatory requirements. If this monitoring identifies an opportunity for improvement, department management is responsible for developing and implementing an action plan for goal achievement.” -- Review of the hospital’s policy and procedure titled, “Quick Check-in: Emergency Department,” revised 10/2023, indicated under “Procedure: EMS patients waiting on the EMS ramp, while on Albany Med’s property are considered Albany Med’s patients once directed to wait on the ramp.” -- Per interview of Staff N, Registered Nurse (RN), on 8/29/2024 at 1:30 pm, they feel the ED environment is unsafe and they do not really want to work in ED. -- Per interview of Staff R, Chief Nursing Officer on 9/4/2024 at 11:05 am, the hospital has been seeing an increased number of visits to the ED and an increased number of patient boarding (awaiting admission) in the ED. There is also a 30 percent vacancy rate for RNs. A Tier Plan for the adult ED, that addresses staffing needs during times of increased volume of patients, has been developed but has not been implemented. -- Per interview of Staff F, RN on 8/28/2024 at 9:30 am, 9/3/2024 at 11:30 am and on 9/5/2024 at 11:45 am, current staffing is as follows: 7:00 am - 3:00 pm = 20 RNs, 3:00 pm - 11:00 pm = 24 RNs, 11:00 pm - 7:00 am = 21 RNs. These are the staffing levels regardless of the number of ED patients, patient acuity and boarders. There are 55 ED beds, and 30 hallway beds. Staff F said they cannot staff intensive care unit (ICU) patients residing in the ED with 2 patients to 1 RN ratio. There is also an observation unit with 12 beds that is staffed by ED staff and float pool nurses. Staff F said ’’they will get a float nurse if there is one available. There is not always one available.” If an emergency medical services (EMS) patient is offloaded in the vestibule (of the ED) the flow nurse doesn’t go out and get report or assess the patient unless there is a change in the patient’s condition. Emergency Medical Services remains responsible for the patient until triage and they continue to document on the patient in the patient care report (PCR). Sometimes patients stay in the ambulance. -- Per interview of Staff D, RN on 9/3/2024 at 12:15 pm, nursing assignments are 5-6 patients and not based on patient acuity. Staff D said the facility no longer goes on diversion. There are traveler nurses that are precepting new staff. Recently, for example, Staff D’s assignment included a medical intensive care patient (MICU) (ICU level patient residing in the ED), a surgical intensive care unit (SICU) patient (ICU level patient residing in the ED), a patient with 1 hour neuro checks, 3 medical/surgical patients, and was involved in a code (a patient in cardiac arrest). -- Per interview of Staff S, EMS Coordinator on 9/4/2024 at 10:00 am, regarding EMS offloading process to the ED, if a room is available the patient should go straight to the room. The flow nurse may say to hold the patient in the rig or ED vestibule, the hospital is responsible to monitor the patient, however, nursing says it’s not their responsibility as they haven’t taken report yet. -- Per interview of Staff O, RN on 9/4/2024 at 9:40 am, staffing is not as good as it should be due to workload. Staff O stated having a 6:1 patient to nurse ratio that included 2 ICU (ICU level patient residing in the ED) patients and other patients with high acuity. There are lots of hall beds with the addition of new hall beds. The beds in the back hall are overflow beds, there are no call bells. If the patients need help, they could flag someone down when they walk by. Assignments make Staff O “scared and anxious.” -- Per interview of Staff C, RN on 9/4/2024 at 3:35 pm, Staff C has concerns about EMS patients. “It is a safety concern.” Staff C works with the charge nurse and throughput nurse and still struggles to provide care. Staff C has never seen anything like this. Emergency medical services watches the patients in the bay and on the ramp. -- Per interview of Staff T, Registered Nurse on 9/5/2024 at 8:30 am, sometimes patients are put in the E hall which is considered part of the waiting room. These patients can be out of vision. -- Per interview of Staff P, RN on 9/6/2024 at 10:40 am, Staff P indicated having an assignment on that day (9/6/2024 from 7:00 am to 11:00 am) included 2 ICU patients (ICU level residing in the ED) plus 4 additional patients. Review of the medical records of the patients assigned to Staff P revealed the following: 1. Patient presented with seizures diagnosed with septic shock, admitted to MICU. 2. Patient transferred from another facility concerns for sepsis 3. Patient with left arm paralysis, stroke code called. 4. Patient with chest pain and shortness of breath 5. Patient for trauma services multiple fractures, liver and kidney lacerations from a motorcycle accident 6. Patient with flank pain and hematuria (blood in urine), kidney stones -- Per interview of Staff V, RN on 9/9/2024 at 3:10 pm, they indicated from 7:00 am - 11:00 am being assigned 5 patients, one stepdown ICU patient (ICU level patient residing in the ED), 4 medical patients (3 patients ESI level 2 and 2 patients ESI level 3[Emergency Severity Index - five level triage algorithm that categorizes emergency department patients by evaluating both patient acuity and resource needs. ESI 1 is critical up to ESI 5 non-acute condition]). Acuity is not taken into account and staffing is usually 1:6 and can include any kind of patients including ICU patients. -- Per interview of Staff W, RN on 9/9/2024 at 3:30 pm. Staff W indicated having 6 patients assigned until 11:00 am which included: 2 patients with ESI level 2, 3 patients with ESI level 3, and 1 which was an ICU patient (ICU level patient residing in the ED). Sometimes due to lack of staffing, Staff W doesn’t feel safe. -- Per interview of Staff X, RN on 9/4/2024 at 2:15 pm, when assigned as the flow nurse the responsibilities include moving all patient through the department. From 7:00 am - 11:00 am Staff X triages all patients who present to the ED which includes walk-ins and patients who arrive via EMS. Today a patient waited 2.5 hours before care was turned over from the EMS to the hospital -- Per interview of Staff Y, RN on 9/4/2024 at 2:30 pm and 9/9/2024 at 10:15 am, Staff Y works as a flow nurse and nurse 1 (triage nurse) usually from 7:00 am - 11:00 am, depending on staff who call in. Staff Y also has contact with the Logistics Center and stated there is tension between staff. Medics are covering the EMS patients. Staff Y said she is concerned with the care patients are getting due to the poor staffing. Staff Y said the acuity and number of patients are difficult to manage. -- Per observation on 9/3/2024 at 11:20 am, Patient #9, was in the back hallway (of the ED) on a stretcher against the wall with no call light or means to call for help. Per interview of Patient #9, they had their vital signs done this morning and saw a physician assistant and a resident. Patient #9 stated they had been in the hallway since 10:00 pm on 9/2/2024 and was waiting for a computed tomography (CT) scan to be completed. -- Review of medical record revealed Patient #1 presented to the ED on 8/24/2024 at 5:42 pm via EMS as a transfer from Hospital B as a Jane Doe for a higher level of care. Transfer diagnosis was noted as intracranial bleed with additional concerns for sepsis. Patient #1 remained in the hospital’s vestibule (ramp where EMS patients enter) attended by EMS personnel. At 7:57 pm, Patient #1 was triaged by nursing staff. Per review of the hospital’s policy and procedure, titled “Triage Process Guidelines,” approved 7/29/2024, “Triage level 2 is assigned to patients who are in a high risk situation/confused/lethargic/disoriented or severe pain or distress.” Per interview of Staff A, Provider, on 9/4/24 at 11:35 am, they recalled Patient #1, stated the patient appeared very ill and septic with questionable endocarditis, spinal abscess, and brain bleed. The radiologist at Hospital B suggested a brain bleed. The patient was clearly very sick and waited too long. Staff A was not aware of how long the patient had waited. Staff A stated they rarely see patients in the vestibule. If asked by EMS or the flow nurse, they will see the patient. Staff A expressed concerns about the long EMS wait times and stated in their opinion the patient should have been brought in sooner. Per interview of Staff B, Provider, on 9/4/2024 at 3:20 pm, they recalled Patient #1. Staff B wasn’t aware the patient had been in the ED vestibule for 2 hours and opined this was not appropriate. Patient #1 was not assessed by nursing staff until 2 hours after arrival and assigned triage level 2. -- Review of medical record revealed, Patient # 11 presented to the ED on 7/28/2024 at 11:02 pm via EMS as a transfer from Hospital C for a higher level of care. Diagnosis included MRSA (methicillin-resistant staphylococcus aureus) and bacteremia (bacteria present in the blood stream), and a change in mental status. A CT scan done at Hospital C showed a spontaneous hemorrhagic stroke. Emergency Medical Service’s Patient Care Record showed Patient #11 arrived at the receiving hospital at 10:52 pm, transfer of care was on 7/29/2024 at 3:40 am. Per review of the hospital’s policy and procedure, titled “Triage Process Guidelines,” approved 7/29/2024, “Triage level 2 is assigned to patients who are in a high risk situation/confused/lethargic/disoriented or severe pain or distress.” Patient # 11 was not assessed by nursing staff until 4.5 hours after arrival and assigned triage level 2. . -- Review of medical record revealed, Patient #4, transferred via EMS on 8/30/2024 for further evaluation of 1 week of episodic chest pain and left lower extremity pain and swelling. No past medical or surgical history. Patient arrived at the ED at 3:05 pm and was placed on the EMS ramp. Transfer of care was on 8/30/2024 at 6:19 pm. Per review of the hospital’s policy and procedure titled “Triage Process Guidelines,” approved 7/29/2024, “Triage level 3 is assigned to hemodynamically stable patients and in no acute distress. A patient will need two or more resources for his/her care.” Patient #4 was not assessed by nursing staff until 3 hours after arrival and assigned triage level 3. -- Review of medical record reaveled, Patient # 3 was transported via EMS to the ED on 8/30/2024 at 3:33 pm with chief complaints of pain to the right hip. Patient # 3 was placed on the EMS ramp and monitored by EMS. Transfer of care was on 8/30/2024 at 7:20 pm. Per review of the hospital’s policy and procedure titled “Triage Process Guidelines,” approved 7/29/2024, “Triage level 3 is assigned to hemodynamically stable patients and in no acute distress. A patient will need two or more resources for his/her care.” Patient #3 was not assessed by nursing staff until 4 hours after arrival and assigned triage level 3. -- During the exit conference on 9/13/2024 at 2:00 pm, Staff BB, Hospital General Director acknowledged the above findings.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 35159 Based on document review, medical record review and interview, the hospital did not comply with the requirements at 489.24 and 489.20, Specifically, in 3 of 3 (Patient #5 - Patient #7) medical records reviewed of patients who required a transfer to another facility, each lacked documentation of “signed physician certification containing the summary of risks and benefits of transfer “ Please reference findings at Tag 2409.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 35159 Based on medical record review, document review and interview, in 3 of 3 (Patient #5 - Patient #7) medical records reviewed of patients who were transferred to another facility, each lacked documentation of the required transfer certification form. Findings include: -- Review of Patient #5’s medical record revealed, Patient #5 presented to the emergency department (ED) on 6/9/24 at 10:46 am with a chief complaint of difficulty breathing. The patient’s oxygen saturation dropped to 60% necessitating epinephrine nebulizer treatment. Patient #5 had a history of severe burns, on over 30 of their body (occurred a month ago). The patient was discharged from another Hospital (B) the previous week. The patient was being followed at Hospital B by outpatient thoracic surgery for tracheal dilatation. The provider contacted Hospital B and the patient was accepted as a transfer. The patient was transferred on 6/10/24 at 9:47am via ambulance. “There was no documentation of a signed physician certification containing the summary of risks and benefits of transfer “ -- Review of Patient #6’s medical record revealed, Patient #6 presented to the ED on 3/15/24 at 9:46 am via emergency medical services (EMS) with suspected overdose and possible opiate withdrawal. It was determined the patient intentionally overdosed on Tylenol and Advil. Acetaminophen level was 89.5 - critical (normal 10.0 - 30.0) Liver studies were elevated. The patient was transferred to a transplant center due to the overdose, elevated liver studies and fulminant liver failure. Patient was transferred on 3/16/24 at 4:00am via ambulance. “There was no documentation of a signed physician certification containing the summary of risks and benefits of transfer “. -- Review of Patient #7’s medical record revealed, Patient #7 presented to the ED via EMS on 3/9/24 at 8:04 am with a chief complaint of chest pain. The patient was transferred from another hospital with a diagnosis of a type A Dissection of the Ascending Aortic Aneurysm. Multiple laboratory studies were done as well as an electrocardiogram and chest x-ray. The decision was made to transfer the patient to the hospital where the patient had a transcatheter aortic valve replacement (TAVR) done. The patient was transferred on 3/9/24 at 12:11 pm via ambulance. “There was no documentation of a signed physician certification containing the summary of risks and benefits of transfer “. -- Review of the policy and procedure titled, “Emergency Medical Treatment & Labor Act” reviewed 11/2023, in section V1-Transfer from Albany Medical Center Hospital (AMCH) indicated the transfer certification form is required and should be completed. -- Review of the document titled “Transfer Certification,” revised 5/2016 contained space to document risks and benefits, physician recommended transfer for patients who specialty care is not available at AMCH, and patient requested transfer for unstabilized patients whose medical condition can be treated at AMCH. The form required physician and patient signature. During interview of Staff G, Director of Hospital Regulatory Affairs, on 9/13/2024 at 2:00 pm, the above findings were acknowledged.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 09785 Based upon medical record review, review of restraint policies, observations and staff interview, it was determined that the facility failed to meet the Condition of Participation for Patient Rights as evidenced by: The facility failed to ensure that in-person assessments were performed for patients within twenty-four hours of restraint initiation of “non-violent/non-destructive restraints”. (See findings at A167) The facility failed to ensure that staff conducted restraint monitoring every thirty minutes for patients in “violent/self- destructive restraints”. (See findings at A175) The facility failed to ensure that practitioners authorized to order restraints complete yearly restraint training. (See findings at A176) The facility failed to ensure that face to face assessments were conducted within one hour on all patients who were placed in “violent/self destructive restraints.” (See findings at A178) Failure to comply with minimum standards for restraint use can result in physical and/or psychological harm to patients.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 09785 Based on record review and interview, physician staff failed to document an in-person assessment within twenty-four (24) hours of restraint initiation to verify that the restraint is needed, and that less restrictive measures are not appropriate. This finding was observed in one (1) of fourteen (14) patients in the sample (Patient #7). Review of medical record for Patient #7 on 4/30/2024 revealed that physician orders were written for non-violent/non self destructive behavior on 4/21/2024 at 1024, 4/22/2024 at 1855 and 4/23/2024 at 2033. The physician failed to document an in person assessment of Patient #7 within 24 hours of each restraint order to verify that restraint is needed. Facility policy entitled “Restraint use for Non-Violent/Non-Destructive Behavior 2/16/98, revision 6/24/22” and reviewed by the SA survey staff on 5/1/2024 indicates that “The prescriber will perform an in-person assessment of the restrained patient within 24 hours of initiation to verify that the restraint is needed, and that less restrictive measures are not appropriate.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 09785 Based on record review, staff failed to monitor, per hospital policy, the conditions of patients who were restrained for violent/self-destructive behavior and non violent/non self destructive behavior. This finding was identified in 2 of 14 patients in the sample (patients #5, #7). Findings: Medical record for patient #5 was reviewed on 4/30/2024. Survey staff noted that on 4/29/2024 from 1200 to 1305 in the Emergency Department patient #5 was restrained in five point restraints. “Restraint Monitoring Every 30 Minutes” flowsheet was not documented by nursing for that time period. -Medical record for Patient # 5; during stay on Medical Intensive Care Stepdown unit, for application of violent restraints that began on 4/29/2024 at 1546, “Restraint Monitoring Every 30 Minutes” flowsheet was not documented between 1646-1923 and 2154-0035. There is no date or time when these restraints were removed. -Facility policy entitled “Restraint use for Violent/Self Destructive Behavior Management 3/23/07, revised 2/20/24” and reviewed by the SA survey staff on 5/1/2024 indicates that “the physical and emotional wellbeing of the restrained/secluded patient are continually assessed, monitored, reevaluated every thirty (30) minutes by an RPN.” (Registered Professional Nurse) -Medical record for Patient #7 reviewed on 4/30/2024: patient was restrained for non-violent/non-self-destructive behavior from 4/21/2024 at 1424 to 4/22/2024 at 0738. “Restraint Monitoring Every 30 minutes” flowsheet was not documented by nursing between 1024-1200, 2100-2234 and 2254-0738. -Facility policy entitled “Restraint use for Non-Violent/Non Destructive Behavior 2/16/98, revised 6/24/22” and reviewed by the SA survey staff on survey on 5/1/2024 indicates that “An assessment of the patient’s condition shall be made at least every 30 minutes or at more frequent intervals if directed by a prescriber.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(11) Physician and other licensed independent practitioner training requirements must be specified in hospital policy. At a minimum, physicians and other licensed practitioners authorized to order restraint or seclusion by hospital policy in accordance with State law must have a working knowledge of hospital policy regarding the use of restraint or seclusion. This Standard is not met as evidenced by: 09785 Based on record review and interview, the facility failed to conduct yearly restraint training for 2 of 5 physicians and licensed independent professionals reviewed during the survey. Findings: -Education files of staff members were reviewed by the State Agency (SA) during the survey on 5/2/2024. Two physicians ( X and BB ) did not complete annual mandatory training as required by the hospital. -This was verified with the Director, Hospital Regulatory Affairs (Staff M) on 5/2/2024 at approximately 1:30 PM -Review of the medical record of Patient # 1 completed on 5/3/2024 revealed that Staff X wrote 18 of the 53 non compliant physician orders for violent restraint.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When 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, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 09785 Based on record review and interview, physician staff failed to document a “face to face” evaluation within one hour of placing patients in violent/self destructive restraints. This finding was observed in three (3) of fourteen (14) patients in the sample. (Patients #1, #5, and #7). Findings include: Patient 1’s medical record was reviewed on 5/3/24 and revealed physician orders placing Patient 1 in restraints for violent/self-destructive behavior fifty (50) times on the following dates and times: · On 4/11/2024 at 1438 (staff MM), 2045(staff OO), and 2341(staff NN) · On 4/12/2024 at 0433 (staff PP), 0949 (staff QQ), 1009 (staff RR), 1546 (staff QQ), and 2055 (staff SS) · On 4/13/2024 at 0105 (staff SS), 0534 (staff SS), 0919 (staff X), 1257 (staff X), and 1755 (staff TT) · On 4/14/2024 at 0150 (staff SS), 0757 (staff X), and 2213 (staff PP) · On 4/15/2024 at 0421 (staff PP), 0800 (staff X), 1240 (staff X), and 2112 (staff PP) · On 4/16/2024 at 0359 (staff PP), 0656 (staff PP), 1041 (staff X), 1520 (staff X), and 1909 (staff X) · On 4/17/2024 at 0011 (staff PP), 0508 (staff PP), 0952 (staff X), 1444 (staff X), and 1859 (staff X) · On 4/18/2024 at 0035 (staff PP), 0531 (staff PP), 0928 (staff X), 1414 (staff X), 1809 (staff X), and 2233 (staff UU) · On 4/19/2024 at 0246 (staff PP) and 2102 (staff PP) · On 4/20/2024 at 0115 (staff PP) · On 4/21/2024 at 0759 (staff X), 1328 (staff X), 1627 (staff XX), 2031 (staff WW) · On 4/22/2024 at 0213 (staff QQ), 0617 (staff XX), 1011(staff YY) , and 2113 (staff QQ) · On 4/23/ 2024 at 0251 (staff QQ) and 2336 (staff XX) · On 4/24/2024 at 0512 (staff XX) Patient 1 was placed in restraints fifty (50) times, however, there were only three (3) documented face to face assessments conducted by a physician as follows: · On 4/20/2024 restraint reorder placed at 0115. At 1045, staff X conducted a face to face assessment 9.5 hours later. · On 4/21/2024 restraint placed 0759. At 1008, staff X conducted a face to face assessment of the patient two (2) hours later. · On 4/22/2024 restraint placed at 0213. At 0617, staff XX conducted a face to face assessment of the patient four (4) hours later. -Staff “X” (physician) stated on interview on 5/1/2024 at 1112 that they have completed training modules on restraints but was not aware of the requirement for “face to face” documentation in the EPIC electronic medical record system until 4/20/2024. He stated he was not aware a note had to be completed when re-ordering restraints. Patient 5’s medical record was reviewed on 5/3/24 and revealed physician orders placing Patient 5 in restraints for violent/self-destructive behavior seven (7) times on the following dates and times: · 4/28/2024 at 2336 (staff A) · 4/29/2024 at 0339 (staff A) and 1218 (staff B) · 4/29/2024 at 1546 (staff A), 1923 (staff C), and 2336 (staff A) · 4/30/2024 at 0305 (staff SS) The physician failed to document “face to face” evaluations within one hour of placing the patient in violent/self destructive restraints on the above dates/times. Patient 7’s medical record was reviewed on 5/3/24 and revealed a physician order placing Patient 7 in restraints for violent/self-destructive behavior one (1) time on the following date and time: · 4/22/2024 at 1558 for restraint order placed by staff D. There was no face to face assessment completed by the prescriber. These findings were verified with Staff M (Director, Hospital Regulatory Affairs) on 5/1/2024 at 1751. -Facility policy entitled “Restraint use for Violent/Self Destructive Behavior Management 3/23/07, rev. 2/20/24” and reviewed by the SA survey staff on 5/1/2024 indicates that the “The prescriber must complete a face to face assessment and evaluate the need for restraint within (1) hour of the initiation of the intervention.””