Montefiore Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 17636 . Based on medical record review, document review, review of video surveillance, and interview, in one (1) of 10 medical records reviewed, it was determined the facility failed to (a) investigate all grievances and (b) protect a patient’s right to receive care in a safe environment. This resulted in implementation of restrictive measures without authorization from a provider and failure to investigate an allegation of abuse for patient #1. Findings include: The facility failed to investigate a patient’s allegation of abuse in a timely manner per its Complaint and Grievance policy. See detailed findings at A 0119. The facility failed to provide a written response to a patient’s allegation of abuse. See detailed findings at A 0123. The facility failed to afford patient #1 the right to be free from restraint. See detailed findings at A 0154. Staff implemented a manual hold on a patient without authorization from a provider. See detailed findings at A 0168. Staff failed to utilize the least restrictive measures before implementing a manual hold (restraint). See detailed findings at A 0186. Staff failed to document the patient’s symptoms and behavior to justify using a manual hold. See detailed findings at A 0187. .”

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 49610 . Based on document review and interview, in one (1) of eight (8) grievances reviewed, the facility failed to investigate a patient’s allegation of abuse in a timely manner per its Complaint and Grievance policy. This finding was evident for patient #1. Findings include: The policy titled “Patient Complaint and Grievance Policy,” last revised 4/2024, states, “ A complaint or grievance may be received by mail, phone, fax, email, and survey in person or referral. If a grievance is received by email, an email response, including all the required elements, will be sent to the griever. Grievances about situations that may endanger a patient, such as abuse or neglect, will receive immediate review. Grievance investigations will conclude within five (5) calendar days.” During an interview with Staff C, Manager, Security Department, on 8/12/24 at 2:25 PM, Staff C stated that the New York Police Department (NYPD) reported that on 6/26/24, patient #1 alleged two (2) security officers had punched him in the face in the Emergency Department (ED). Staff C stated that the investigation of patient #1’s allegation of assault was not complete. On 8/15/24, at approximately 12:00 PM, Staff A, Assistant Director of Regulatory Affairs, submitted a document titled “Summary of Investigation,” which indicated that the Human Resources Department investigation of the complaint was completed as of 8/14/24, 50 days after the patient made the complaint. This finding was shared with Staff D, Director of Security, and Staff A, Assistant Director of Regulatory Affairs, on 8/15/24 at approximately 2:35 PM. .”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 49610 . Based on document review, video surveillance review, and interview, in one (1) of eight (8) grievances reviewed, the facility failed to respond to the complainant’s grievance in writing in a timely manner. This finding was evident for patient #1. Findings include: The policy titled “Patient Complaint and Grievance Policy,” last revised 4/2024, states, “Grievances are acknowledged by writing or personal contact, and the grievance process and timeline are explained to the griever in the acknowledgment. Grievance investigations will conclude within five (5) calendar days, and the results of the investigation will be communicated to the griever by telephone, email, or letter by seven (7) calendar days.” A review of the list of all grievances for June 2024 revealed no documentation of a grievance related to patient #1. During an interview on 8/12/24 at 2:25 PM, Staff C, Manager, Security Department, stated, “After receiving a call from the New York Police Department (NYPD) officer, who reported that on 6/26/24, patient #1 alleged two (2) security officers punched him in the face in the Emergency Department (ED), they interviewed patient #1 about their allegations and documented the patient’s allegations. There was no documented evidence that the patient received a written response in seven (7) calendar days as per policy. The facility has not responded to the complainant fifty (50) days after the patient complained of physical abuse by security staff. These findings were shared with Staff D, Director of Security, and Staff A, Assistant Director of Regulatory Affairs, on 8/15/24 at approximately 3:35 PM, who acknowledged the findings. .”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 17636 . Based on medical record review, video surveillance review, document review, and interview, in one (1) of 10 medical records reviewed, it was determined that hospital staff failed to ensure that the patient had the right to be free from physical restraint. This finding was evident for Patient #1. Findings include: The policy titled “Restraint or Seclusion, Care of the Patient Requiring,” last revised 4/2024, states, “All patients have the right to be free from restraint or seclusion, of any form, imposed or as a means of coercion, discipline, convenience, or retaliation by staff.” Review of Medical Record #1 identified a triage nurse documented a 46-year-old patient who was brought to the Emergency Department (ED) at 9:35 PM on 6/25/24 accompanied by the New York Police Department and Emergency Medical Service (EMS) “from his home for aggressive behavior and ETOH (ethanol abuse). Per Emergency Medical Services (EMS) personnel, the patient attempted to stab his mom with scissors.” The nurse documented the patient was placed in the Enhanced Observation Area for safety at 9:46 PM. The resident documented at 11:20 PM that the patient has a previous history of Polysubstance Abuse and an extensive psychiatric history. The patient was calm, alert, oriented, and not distressed. Review of video surveillance revealed the following while the patient was in the Enhanced Observation Area of the Emergency Department (ED) on 6/26/24: 2:57:48 - The patient was seen pacing in the ED with a bag of intravenous fluid in their left hand elevated above their head. 2:57:53 - The patient attempted to leave the ED. A Security Officer escorts the patient back to the Enhanced Observation Area. 2:58:59 - The patient walked towards another exit of the Enhanced Observation Area in the ED. Staff V, the Security Officer, extended their right arm toward the patient, and the patient retreated. 2:59:15 -Patient #1 stood before two (2) Security Officers and gesticulated towards them. 2:59:18 - Staff G and V, Security Officers, each held the patient’s upper arm and escorted the patient to a stretcher. 02:59:43 - Security staff firmly placed the patient on the bed. The Security Officers manually held the patient down on the bed. 3:00:13 - The Security Officers released their grip on the patient, who immediately stood at the foot of the stretcher. The patient was in manual restraint for fifty-five seconds. The video surveillance review and the medical record did not indicate the patient’s behavior, which justifies using a manual hold. During an interview on 8/14/24 at 10:35 AM, Staff X, Patient Care Coordinator, RN, stated that a manual hold is a restraint and that the security staff members were not instructed to perform a manual hold on the patient. During an interview on 8/14/24 at approximately 2:35 PM, Staff A, Assistant Director of Regulatory Affairs, acknowledged the finding. .”

“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: 17636 . Based on medical record review, video surveillance review, document review, and interview, one (1) of 10 medical records reviewed, it was determined that the use of manual restraints was not authorized by a provider. This finding was evident for Patient #1. Findings include: The policy titled “Restraint or Seclusion, Care of the Patient Requiring,” last revised 4/2024, states, “Each discrete episode that calls for the use of manual restraint requires a unique face-to-face assessment and order by the physician within 30 minutes.” Review of Medical Record #1 identified a triage nurse documented that the patient was brought to the Emergency Department (ED) at 9:35 PM on 6/25/24 accompanied by New York Police Department officers and Emergency Medical Services (EMS) personnel from his home for aggressive behavior and ETOH (ethanol abuse). Per EMS personnel, the patient was attempting to stab their mom with scissors. The nurse documented that the patient was calm, alert, oriented, and not in distress. The patient was placed on enhanced observation for safety at 9:46 PM. Review of video surveillance revealed the following while the patient was in the Enhanced Observation Area of the Emergency Department (ED) on 6/26/24: 2:57:48 - The patient was seen pacing in the ED with a bag of intravenous fluid in their left hand elevated above their head. 2:57:53 - The patient attempted to leave the ED. A Security Officer escorts the patient back to the Enhanced Observation Area. 2:58:59 - The patient walked towards another exit of the Enhanced Observation Area in the ED. Staff V, the Security Officer, extended their right arm toward the patient, and the patient retreated. 2:59:15 - Patient #1 stood before two (2) Security Officers and gesticulated towards them. 2:59:18 - Staff G and V, Security Officers, each held the patient’s upper arm and escorted the patient to a stretcher. 02:59:43 - Security staff firmly placed the patient on the bed. The Security Officers manually held the patient down on the bed. 3:00:13 - The Security Officers released their grip on the patient, who immediately stood at the foot of the stretcher. During an interview on 8/14/24 at 10:35 AM, Staff Aa, Patient Care Coordinator, RN, stated that a manual hold is a restraint and requires a physician’s order. There was no documentation in the medical record that a provider authorized the manual restraint. Staff A, Assistant Director of Regulatory Affairs, acknowledged the finding on 8/15/24 at approximately 3:35 PM. .”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(iii) [there must be documentation in the patient’s medical record of] Alternatives or other less restrictive interventions attempted (as applicable); This Standard is not met as evidenced by: 17636 . Based on medical record review, video surveillance review, document review, and interview, in one (1) of 10 medical records reviewed, it was determined that the staff failed to utilize the least restrictive measures for an agitated patient before implementing manual holds (restraints). This finding was evident for Patient #1. Findings include: The policy titled “Restraint or Seclusion, Care of the Patient Requiring,” last revised 4/2024, states that the hospital “is committed to limiting the use of restraint by using alternatives and nonphysical interventions first, as well as the least restrictive methods or restraint or seclusion as needed.” Review of Medical Record #1 identified the triage nurse documented on 6/25/24 that the patient was brought to the Emergency Department (ED) at 9:35 PM accompanied by the New York Police Department officers from his home for aggressive behavior and ethanol abuse. Per the Emergency Medical Services attendant, the patient was attempting to stab mom with scissors.” The patient was calm, alert, and oriented and was not distressed upon arrival. A nurse documented the patient was placed on enhanced observation for safety at 9:46 PM. During an interview with Staff Z, Certified Nurse Attendant, conducted on 8/14/24 at 9:35 AM, Staff Z stated they were assigned to monitor Patient #1 at 9:46 PM on 6/25/24, and “initially the patient wasn’t aggressive. At midnight, the patient was not threatening, not trying to leave the ED, and was calm.” Review of video surveillance revealed the following while the patient was in the Enhanced Observation Area of the Emergency Department (ED) on 6/26/24: 2:57:48 - The patient was seen pacing in the ED with a bag of intravenous fluid in their left hand elevated above their head. 2:57:53 - The patient attempted to leave the ED. A Security Officer escorts the patient back to the Enhanced Observation Area. 2:58:59 - The patient walked towards another exit of the Enhanced Observation Area in the ED. Staff V, the Security Officer, extended their right arm toward the patient, and the patient retreated. 2:59:15 -Patient #1 stood before two (2) Security Officers and gesticulated towards them. 2:59:18 - Staff G and V, Security Officers, each held the patient’s upper arm and escorted the patient to a stretcher. 02:59:43 - Security staff firmly placed the patient on the bed. The Security Officers manually held the patient down on the bed. 3:00:13 - The Security Officers released their grip on the patient, who immediately stood at the foot of the stretcher. The nurse documented that the patient was placed in seclusion at 3:21 AM on 6/26/24, constant observation at 3:26 AM on 6/26/24, and security watch at 5:40 AM that morning. The nurse also documented that the patient was transferred to a psychiatric hospital at 8:45 PM on 6/26/24. There is no evidence in the video that staff attempted less restrictive measures to de-escalate the patient’s agitation during their attempts to leave the ED on 6/26/24 at 2:59:18 prior to using the manual hold. Staff A, Assistant Director of Regulatory Affairs, acknowledged the finding on 8/15/24 at approximately 3:35 PM. .”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(iv) [there must be documentation in the patient’s medical record of the following: ] The patient’s condition or symptom(s) that warranted the use of the restraint or seclusion. This Standard is not met as evidenced by: 17636 . Based on medical record review, video surveillance review, document review, and interview, one (1) of 10 medical records reviewed, it was determined that staff failed to document the patient’s symptoms and behavior to justify using manual restraints. This finding was evident for Patient #1. Findings include: The policy titled “Restraint or Seclusion, Care of the Patient Requiring,” last revised 4/2024, states, “ Each episode of manual restraint requires documentation for the reasons for use of manual restraint in a PROVIDER Manual Restraint Progress Note.” Review of Medical Record #1 identified a 46-year-old patient who was brought to the Emergency Department (ED) at 9:35 PM on 6/25/24 accompanied by an officer from the New York Police Department and Emergency Medical Service (EMS) “from his home for aggressive behavior and ETOH (ethanol abuse). Per Emergency Medical Services (EMS), the patient was attempting to stab mom with scissors.” The patient, upon arrival, was calm, alert, and oriented and was not in distress. The nurse documented that the patient was placed in the Enhanced Observation Area for safety at 9:46 PM that night. Review of video surveillance revealed the following while the patient was in the Enhanced Observation Area of the Emergency Department (ED) on 6/26/24: 2:57:48 - The patient was seen pacing in the ED with a bag of intravenous fluid in their left hand elevated above their head. 2:57:53 - The patient attempted to leave the ED. A Security Officer escorts the patient back to the Enhanced Observation Area. 2:58:59 - The patient walked towards another exit of the Enhanced Observation Area in the ED. Staff V, the Security Officer, extended their right arm toward the patient, and the patient retreated. 2:59:15 -Patient #1 stood before two (2) Security Officers and gesticulated towards them. 2:59:18 - Staff G and V, Security Officers, each held the patient’s upper arm and escorted the patient to a stretcher. 02:59:43 - Security staff firmly placed the patient on the bed. The Security Officers manually held the patient down on the bed. 3:00:13 - The Security Officers released their grip on the patient, who immediately stood at the foot of the stretcher. There was no documentation in the medical record that indicated the patient’s symptoms or behavior that required the implementation of a manual hold by the two security staff members. Staff A, Assistant Director of Regulatory Affairs, acknowledged these findings on 8/15/24 at approximately 3:35 PM. .”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: 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 ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 17636 . Based on document review and interview, it was determined that the facility, in its review of incidents, failed to identify clinical staff failure to provide appropriate oversight and management of an agitated patient. This finding was evident in one (1) of eight (8) incidents reviewed. Findings include: The facility’s document, “Quality Assessment And Performance Improvement (QAPI) Plan 2024,” states that the roles and responsibilities of all Montefiore Associates are to “identify areas of opportunity for improvement and report unsafe conditions to their supervisor.” On 8/13/24, the surveyor requested a copy of the facility’s investigation of a patient’s allegation of an assault on 6/26/24. Staff A, Assistant Director of Regulatory Affairs, provided a copy of the investigation on 8/14/24, which was completed on 8/13/24. The investigation concluded that the allegation was not substantiated, and no deficiencies were identified. A review of the incident identified that two security officers manually held the patient to restrict the patient’s movement. They did not implement the least restrictive measures to de-escalate the patient before utilizing a manual hold. The clinical staff did not immediately supervise the care of an agitated patient. No provider had authorized the use of the manual hold, and there was no documentation of the patient’s symptoms that justified the use of a manual hold (restraint). No documentation was found that indicated that the facility effectively implemented its 2024 QAPI Plan to identify areas for improvement and implement measures to prevent the recurrence of such failures. See detailed findings at A0115. This finding was shared with Staff A, Assistant Director of Regulatory Affairs, on 8/13/24 at approximately 11:35 AM, who acknowledged the findings.”