New York-Presbyterian/Queens

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 33919 . Based on document review and interview, the facility did not ensure that the Surgical Services Quality Assurance Program trended, analyzed, implemented actions and evaluated progress during monthly Quality Assurance Performance Improvement (QAPI) meetings. Findings: The facility’s “Quality and Patient Safety Plan 2025,” indicated that “The Departmental Quality Assurance Subcommittees exist in each clinical department and serve to monitor and evaluate medical care...Each departmental subcommittee provides monthly minutes...” The Plan also indicated that the QAPI department requires, “Identification of actual or potential problems concerning patient care and clinical performance; assessment of the cause and scope of problems identified; development and recommendation of proposed courses of action to address identified problems; use of information gathered regarding problems for reviewing and making revisions to hospital policies and procedures; use of established mechanisms to implement corrective actions to identified problems; monitoring and evaluation of actions taken and implementation of remedial actions to confirm effectiveness...and documentation of the measures outlined...” Upon request, the facility was unable to provide documented evidence of monthly departmental Surgical Services QAPI meeting minutes. Per interview of Staff A (Administrator) on 11/20/2025 at 2:35PM, Staff A confirmed this finding and stated, “There are no monthly surgical services QAPI meeting minutes.””

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 47318 . Based on medical record (MR) review, document review, and interview, the facility failed to ensure that medical staff provided appropriate patient care, adhering to the bylaws approved by the governing body. Findings: The facility failed to: Ensure a physician assesses and reassesses a patient after notification of a potentially serious medical condition. (See Tag A-0347) .”

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 47318 . Based on medical record review, document review, and interview, in one (1) of twelve (12) medical records reviewed, a physician failed to conduct a timely assessment and reassessment of a patient following a medical event and potential change in status (Patient #1). Findings include: Medical Record Review of Patient #1’s Medical Record (MR) identified the following information: The patient was born on 05/11/2025, at 12:42 AM. The Hospital’s Medical Staff Bylaws, effective 07/2022, indicated the physician “ ... must document an examination for any changes in the patient’s condition ...” If the physician “finds no change in the patient’s condition, they may indicate in the patient’s medical record that the history and physical examination was reviewed, the patient examined, and that “no change” has occurred in the patient’s condition.” The Bylaws also specified “ ...an examination for any changes in the patient’s condition since the history and physical examination was performed that might be significant for the planned course of treatment.” Clinical Note on 5/11/2025, written at 2:46 PM, Staff B (RN) wrote the patient’s mother rang their call bell to notify them that the baby’s face and arms had turned blue. Staff B (RN) documented that they assessed the baby’s vital signs: the temperature was 97.8 degrees, the heart rate was 134, the respiratory rate was 44, and the oxygen saturation was 100% [Normal vital signs for newborn: heart rate of 120-160 beats per minute, a respiratory rate of 30-60 breaths per minute, a temperature of 97.7°F to 99.5°F, oxygen saturation of 95 -100]. The nurse did not note any cyanosis (blue color) of the face or arms during this assessment. The nurse called the Pediatrician at their office to notify them of the mother’s observation and received instructions to notify him of any changes. There was no documented evidence of assessment of Patient #1 by the Pediatrician following the mother’s observation that Patient #1’s face and arms turned blue. Per Nursing Flowsheet, the patient’s vital signs were reassessed at 5:10 PM by the day shift nurse, who documented a temperature of 97.7 degrees, a heart rate of 122, and a respiratory rate of 34. Clinical Note on 5/11/2025 at 11:53 PM written by Staff M (RN) indicated during rounds at the start of their shift, 7:15 PM, Staff noted Patient #1 appeared pale while lying on their side against the mother’s chest. Staff indicated they assessed Patient #1 and found the patient not breathing with no heartbeat. Staff M pulled the code lever in the room, and a full code was immediately called; resuscitation efforts were unsuccessful, and the Patient was pronounced deceased at 7:43 PM. Per an interview with Staff D (Patient #1’s doctor) on 06/03/2025, at 11:00 AM, Staff stated they performed the History and Physical (H & P) when the patient was born. Staff D indicated they received a call from Staff B (RN) letting them know that Patient #1’s mother observed the patient’s face and arms turn blue. Staff B (RN) told them that the patient’s vital signs were within normal range. When Staff D was asked if they should have come to assess the patient, Staff D stated, “The nurse didn’t tell me to come in. I told her [the nurse] that if anything changes to let me know.” Per an interview with Staff E (Senior Medical Leadership) on 06/04/2025 at 2:00 PM, they acknowledged these findings and confirmed that a reassessment of the patient should have taken place after the mother reported that the patient’s face and arms became blue on 05/11/2025 at 2:36 PM. .”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 47355 . Based on medical record (MR) review, document review, and interview, in 1 (one) of 12 (twelve) MRs, the nursing staff did not follow the facility’s policies and procedures. Specifically, the nursing staff did not conduct a bedside shift report as per policy. Findings include: The facility policy and procedure titled “Patient Care ‘Hand-off’ Communication,” last reviewed 10/2024, directed nursing staff to conduct bedside shift reports to verify the information received, obtain patient/ family input, and individualize goal-setting for the patient’s plan of care. A review of Patient #1’s MR revealed that the Registered Nurse (RN) entered the patient’s room at 7:15 PM on 05/11/2025, and upon initial assessment, Patient #1 was lying on Patient #2’s chest on their right side. Patient #1 was observed pale, limp, and unresponsive; a code blue was called overhead. Review of the video camera timeline dated 05/11/2025 revealed that Staff B (Registered Nurse) gave Staff M (Registered Nurse) a handoff/shift report at the nurses’ station from 6:50 PM to 6:53 PM. During the interview of Staff B (Registered Nurse) on 06/03/2025 at 9:54 AM, Staff B explained that they recalled caring for Patient #1 on 05/11/2025. Staff B further explained that on the evening of 05/11/2025, they did not do a bedside handoff/shift report with Staff M (Registered Nurse), the incoming nurse. Staff B shared that they were aware of the facility’s policy for bedside handoff reports, but they reported to Staff M at the nurses’ station so that they could complete their charting. During the interview of Staff N (Senior Manager of Regulatory Affairs) on 06/03/2025 at 9:24 AM, Staff N shared that Staff M (Registered Nurse) was out on leave and could not be reached for an interview. During the Interview of Staff N and Staff O (Senior Regulatory Leadership) on 06/04/2025 at 2:00 PM, both Staff N and Staff O confirmed these findings.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 39392 Based on medical record review, document review, interview, and in one (1) of four (4) medical records reviewed, the facility failed to get approval from the appropriate patient representative before discontinuing Cardio-Pulmonary Resuscitation (CPR) (Patient # 1). Findings include: Review of the hospital policy and procedure titled “Patient Verification (P111),” dated 3/23 states. “Purpose: To describe the processes for verifying the correct patient prior to rendering care, treatment or services and matching service or treatment to that patient. The verification process is applicable to all employees and providers i.e., physicians, NP’s (Nurse Practitioner), PAs (Physician Assistant) who interact with patients or deal with patient information. This includes verbal and telephone conversations. Policy: 1.Two unique identifiers must be used to verify that the correct patient has been identified prior to receiving any care, treatment, and services. This includes, but not limited to: Administration of medication Administration of breast milk Administration of blood or blood products. Specimen collection Tests or procedures Venipuncture Transport of patients 2.The two unique identifiers must also be used in situations where patient information is being transmitted over the phone or in person. This includes, but is not limited to, scheduling procedures, requesting patient transport, and reporting test results. 3.Room number or other location is never used to identify a patient.” Review of the medical record for patient #1 revealed: that patient #1 was admitted to the facility on 4/24/2024. The patient was identified as a full code as per the advanced directives. A health care proxy was not completed. The family contact information was documented in the medical record. Patient # 1 was in the Medical Intensive Care Unit (MICU) and was treated for lactic acidosis (a buildup of lactic acid in the blood stream), pleural effusion, and atelectasis (a condition where all or part of the lung collapses), metapneumovirus pneumonia, cancer of the prostate, adenocarcinoma of the left lung, liver metastasis (cancer that spreads from the liver from another part of the body), bleeding from left chest tube drain, decreased blood pressure, and was intubated (insertion of a tube to keep the airway open to help with breathing). On 5/14/2024 at 12:55 AM, Staff D, Medical Resident, documented that a code was called to the bedside as patient #1 had no activity on the monitor. CPR was initiated, and during CPR, a physician called the patient’s family who requested discontinuation of compressions. On 5/14/24 at 2:57 AM, a medical resident documented, “After a code, patient’s son was called. However, after further discussion with family and amongst our team, the wrong family was called during the CAT (cardiac arrest team). The family of [Patient #2] was called instead. Patient #1 sons came in the MICU (Medical Intensive Care Unit) to discuss what happened during the code. I explained an error was made and we had called the wrong family during the code and received instructions to stop CPR (cardiopulmonary resuscitation). I apologized on behalf of our team and answered any questions patient #1’s son had. They had no other questions and asked for time with their father.” During the interview on 11/7/2024 at 10:38 AM, Staff F, Medical Director (MICU) was asked, how a staff is instructed to call the family. Staff F stated a physician is instructed verbally to notify the family; it is preference for a physician who knows the patient to make the call to the family. The physician who is given the instruction to make the call to the family, is given the patient’s name and must verify who the patient representative is before making the call. When asked why was the wrong family was called? Staff F responded that all physicians are trained on patient and family identification in the electronic medical record. The length of time to continue a code is determined by several factors such as the patient medical history, diagnosis, comorbidities, cardiac and respiratory response to cardiopulmonary resuscitation. The code stopped after the staff member spoke with the family. During the interview on 11/7/2024 at 11:45 AM, Staff D, Medical Resident, PGY1 (post graduate year1) who was present during the code, stated. “After the first two minutes of compressions, the patient was reassessed, and CPR continued. Their focus was continuing the code and monitoring the patient’s response. They were not aware who made the request for a resident, who responded to the code announcement, to notify the family of the patient’s status. The resident returned and informed the team that they spoke with the patient’s spouse, who requested to cease code operations. The fellow agreed to stop code. The code was in effect for about eight minutes and the patient did not respond, the fellow agreed to stop the code. The length of a code is determined by multiple factors, each case is different. A code can last for minutes to about an hour. Patient # 1 had blood loss, and prognosis was poor. There were discussions with the family about the patient’s general condition, and prognosis. One of the patient’s sons is a doctor and the physicians taking care of the patient had conversations with the son about the patient’s condition. The family did not want to sign a Do not Resuscitate/ Do not intubate (DNR/DNI) document because of religious reasons. The son stated he wanted a “soft code” compressions and airway management.” During the interview on 11/7/2024 at 4:05 PM, with Staff C, Medical Attending stated, ‘it is uncertain if the intern that called the family verified the patient and contact information prior to initiating the call to the wrong family. The intern returned after speaking with the family and informed the team that the patient’s wife requested to stop the code. He was present at the code and stated that the staff had decided to stop CPR. It was a reasonable to stop the code which lasted 8 to 10 minutes. The patient would not have survived with continuing the CPR. The patient’s prognosis was poor.” The intern that called the family is no longer at the facility. The facility provided an IJ removal plan to survey staff 11/13/2024 at 9:15 PM. The plan included: a) An education online module will be developed to educate all attending physicians (i.e. attendings, residents, fellows), and advanced practice providers (i.e. physician assistants and nurse practitioners) who are privileged to practice at New York Presbyterian Queens. The module will emphasize key information available in the below policies as they pertain to patient verification and patient rights: -Patient Rights and Responsibilities Q P120 (Policy and Procedure) -Patient Verification P111 (Policy and Procedure) -Advanced Directives Q A163 (Policy and Procedure) b) The education training to begin on November 13th, 2024. The IJ was removed on 11/14/2024 at 2:30 PM after an onsite verification of the online education module training on the policy and procedures, staff interviews and verification of staff education attendance. 100% (22/22) of staff that were interviewed had received the online training for Patient’s Rights and Responsibilities, Patient Verification, and Advanced Directives. As of 11/14/2024 at 2:30 PM hospital staff were trained were as follows: 11/14/24 Overnight staff trained: Attendings = 16/16 (100%) Residents = 16/16 (100%) Fellows = 1/1 (100%) Physician Assistants = 24/24 (100%) Nurse Practitioners/ CRNAs = 3/3 (100%) Total number of overnight trained 60/60 = 100% 11/14/24 Day Shift trained: Attending = 159/163 (97.5%) Residents = 94/96 (97.9%) Fellows = 10/11 (90.9%) Physician Assistants = 70/70 (100%) Nurse Practitioners/ CRNAs = 18/18 (100%) Total number of day shift trained 351/358 = 98%”