Niagara Falls Memorial 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: 48506 Based on observation, policy review, medical record review, video review, document review, and interview, in four of 18 medical records reviewed, the hospital failed to protect and promote the rights of all patients. Specifically, the hospital failed to provide staff to conduct one-to-one observation (a designated staff member will be assigned solely to watch one patient and cannot attend to other duties) per physician order and to ensure patients in the psychiatric emergency department (ED) area had ligature risks stretchers and door handles that were identified as a ligature risk (any item, object, or fixture in a healthcare setting that can be used to create a sustainable point of attachment for self-harm such as hanging or strangulation) (Patient #1, Patient #2, Patient #4, and Patient #5). Reference: 482.13(c)(2): The patient has the right to receive care in a safe setting.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 48506 Based on medical record review, policy review, document review, and interview, the hospital failed to ensure the quality assurance program conducted a data driven quality assessment and identified opportunities for improvement and changes that would lead to improved quality of care. (Patient #1 and Patient #2) Reference: 482.21(b)(2)(ii), 482.21(c)(1) & 482.21 (c)(3): Quality Improvement Activities”

“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: 48506 Based on policy review, medical record review, video review, document review, and interview, in four of 18 medical records reviewed, the hospital failed to provide care in a safe setting. Specifically: 1. Nursing staff failed to provide one-to-one observation (a designated staff member assigned to watch one patient only with no other duties) for Patient #1 per physician order, which resulted in an attempted suicide. 2. Nursing staff failed to provide one-to-one observation, adequate monitoring, and a safe environment for Patient #2, which resulted in self-harming and two suicide attempts. 3. Nursing staff do not provide oversight of one-to-one staffing to ensure coverage. Nursing staff do not review or schedule one-to-one assignments. Staff are assigned to provide one-to-one observation for multiple patients at the same time (Patient #1, Patient #2, Patient #4, and Patient #5). Findings #1: Review of the policy “Patient Belongings,” dated February 2025, revealed patient belongings, including clothing, wallets, and purses, will be carefully removed if the patient is assessed as a potential threat to self or others. All items will be securely bagged and clearly labeled with two patient identifiers to ensure they are not misplaced or mixed with other’s belongings. (This policy does not address visitor belongings). Review of the policy “Assessment and Monitoring of Psychiatric Patients in the Emergency Department (ED),” dated February 2025, revealed rooms designated for psychiatric patients must be inspected and cleared of potentially harmful items while maintaining balance between psychiatric and medical needs. Review of the policy “Assessment and Monitoring of Psychiatric Patients in the Emergency Department,” dated February 2025, revealed for patients housed in the medical ED, one-to-one observation means that a patient is observed by a designated staff member assigned solely to watch the patient, cannot attend to other duties, is housed within the same room, and keeps eyes on the patient at all times. Another provider may temporarily relieve the assigned staff member, ensuring continuous observation, and a rounding note must be documented every 15 minutes in the patient’s electronic medical record (EMR). Rooms designated for psychiatric patients must be inspected and cleared of potentially harmful items while maintaining balance between psychiatric and medical needs. Review of the policy “Behavioral Health Assessment Procedure for Patients Who Present to the Emergency Department for Services,” dated May 2025, revealed upon arrival, all behavioral health patients will be triaged by the ED triage nurse. Children and adolescents will be placed in a private room in the medical ED and placed on continuous one-to-one observation status unless otherwise specified by the ED provider or psychiatrist. Parents and guardians are not permitted to substitute for staff in providing one-to-one observation. Review of medical record and video review for Patient #1 (pediatric patient) revealed on 08/20/25 at 10:45 PM, Patient #1 presented to the ED via ambulance with the police department for a 9.41 psychiatric evaluation (New York Mental Health Law authorizes peace or police officers to take a person into custody and have evaluated if they appear to be mentally ill and are acting in a manner likely to cause serious harm to themselves or others) after threatening their parent with a knife. Patient #1 was assessed as high risk for suicide and placed on a constant order for suicide precautions that includes one-to-one constant observation and required a psychiatric consult. From 08/20/25 at 10:50 PM to 08/22/25 at 06:30 PM, 15-minute checks were documented on Behavioral Health Psychiatric Emergency Department 24-hour Observation Flowsheet for one-to-one observation. On 08/21/25 at 06:41 PM, Staff (H), Psychiatrist, evaluated Patient #1 who indicated a referral was made to other hospitals for inpatient admission because the hospital does not admit children. Until Patient #1 is transferred, they will be closely observed in the hospital. On 08/22/25 from 06:30 PM to 09:30 PM, no 15-minute checks were documented on Behavioral Health Psychiatric Emergency Department 24-hour Observation Flowsheet for one-to-one observation. (This was confirmed by video review). The log was blank. On 08/22/25 At 08:00 PM, Patient #1’s parent walked out of room #1 in the medical ED. Patient #1 got up out of bed, walked to over to a purse located on the floor, took out a pill bottle (clonazepam-anti-anxiety medication), emptied the contents into their hand (approximately 55 tablets per parent), and put the contents in their mouth. Patient #1’s parent returned to the room. At 08:24 PM, Patient #1’s parent notified nursing staff that Patient #1 took their medication when they were in the bathroom. Patient #1 was lethargic. Activated charcoal (used treat certain oral poisonings and drug overdoses) was administered via a nasogastric tube (hollow tube inserted through the mouth into the stomach to provide medications and suction out stomach contents) without any complications. Poison control center was contacted and recommended close observation and monitoring of vital signs. Interview on 09/03/25 at 10:40 AM with Staff (F), Registered Nurse (RN), revealed pediatric psychiatric patients always have a one-to-one constant observation sitter. One-to-on observations of pediatric patients are documented on the observation sheet (Behavioral Health Psychiatric Emergency Department 24-hour Observation Flowsheet), and it is not just a visual observation. Interview on 09/03/25 at 11:25 AM and 04:39 PM with Staff (G), Hospital Administrator, revealed after review of the record and the video evidence, Patient #1 was placed on 1:1 observation upon arrival due to the 9.41 status. Patient #1 had a one-to-one constant observation ordered during the time of their overdose event. The nurse-to-nurse handoff report would include one-to-one observation information and were surprised at the change of shift, the outgoing RN and the incoming RN did not notice there was no staff posted to sit as the one-to-one observation at Patient #1’s room. There was at least a one-hour lapse in one-to-one observer coverage at the time of the event. Interview on 09/03/25 at 01:52 PM with Staff (H), Psychiatrist, revealed one-to-one constant observation will be ordered for pediatric patients. Patient #1 was housed in the medical ED and seen by psychiatry. Patient #1’s parent left their belongings in the room when they left, and Patient #1 ingested an entire bottle of medication. There was no one-to-one sitter watching them. Interview on 09/03/25 at 02:07 PM with Staff (A) and Staff (G), Hospital Administrators, revealed all pediatric psychiatric patients are a one-to-one observation in the medical ED. Phone interview on 09/04/25 at 09:56 AM with Staff (Z), Physician, revealed Patient #1 required a one-to-one constant observation sitter. Interview on 09/04/25 at 10:22 AM with Staff (J), Patient Care Assistant (PCA), revealed they were assigned to provide the one-to-one observation for two rooms that shift: Room #1 for Patient #1 and Room #2 for Patient #2. At 06:30 PM, Staff (J) told Staff (GG), PCA, they needed to take a break and asked them to cover Patient #1 and Patient #2. Patient #1’s parent had their belongings in the room the entire ED stay and would leave it in the room when they left. Staff (J) came back from break prior to their shift ending at 07:00 PM. Staff (J) did not tell the registered nurse they were leaving, and assumed their assignment was covered by Staff (GG), PCA who was already covering their break. Phone interview on 09/04/25 at 12:57 PM with Staff (BB), Registered Nurse, revealed Patient #1 had a one-to-one observation order in place and had a sitter the “majority of the time,” the day of the incident. The one-to-one sitter and Patient #1’s parent both stepped away leaving Patient #1 alone during the event occurrence. Staff (BB) was unaware that there was no one-to-one sitter from 06:30 PM to 9:15 PM. Staff (BB) was alerted by Patient #1’s who told them a bottle of medication was missing from their bag. Staff (BB) immediately told the provider who went to check on Patient #1 and ordered charcoal (used to induce vomiting after an overdose) to be administered. Patient #1 was refusing the charcoal orally, so Staff (Z), Physician, placed a nasogastric tube to administer the charcoal. Findings #2: Review of the policy “Patient Belongings,” dated February 2025, revealed patient belongings, including clothing, wallets, and purses, will be carefully removed if the patient is assessed as a potential threat to self or others. All items will be securely bagged and clearly labeled with two patient identifiers to ensure they are not misplaced or mixed with other’s belongings. This does not address visitor belongings. Review of the policy “Assessment and Monitoring of Psychiatric Patients in the ED,” dated February 2025, revealed rooms designated for psychiatric patients must be inspected and cleared of potentially harmful items while maintaining balance between psychiatric and medical needs. Review of the policy “Assessment and Monitoring of Psychiatric Patients in the Emergency Department,” dated February 2025, revealed for patients housed in the medical ED, one-to-one observation means that a patient is observed by a designated staff member assigned solely to watch the patient, cannot attend to other duties, is housed within the same room, and keeps eyes on the patient at all times. Rooms designated for psychiatric patients must be inspected and cleared of potentially harmful items while maintaining balance between psychiatric and medical needs. Review of the policy “Use of Emergency Assistance Call System/Environmental Safety Checks (Psychiatric ED),” dated May 2025, revealed environmental safety checks are conducted and documented every hour to ensure that the physical care environment remains safe for all patients, staff, and visitors. Twice per shift, designated staff will conduct safety inspections of all patient rooms, group rooms, and common areas. Inspections must be documented on the environmental round sheet. Items to be checked include but are not limited to: beds for structural integrity or contraband, door handles and hinges for hanging risks, window/screen frames to confirm security, bathrooms for water on floors and functioning faucets, lighting, plumbing, thermostats, and fixture conditions, damage to walls, furniture, and ceilings, light covers present and intact, removal of contraband (glass items, wires, hangers, sharp objects), and confirmation that smoke barrier and fire doors are closed and unobstructed. Common areas, halls, and exits must be checked for safety, damage, or unauthorized propping open of doors. Completed environmental round sheets will be stored in a designated binder, filed monthly, and reviewed by the Director of Emergency Services for completeness and trending. Review of the policy “Adult and Child/Adolescent/Observation Rounds in the Psychiatric Emergency Room,” dated May 2025, revealed this policy applies to all staff responsible for the care of any patient being treated under the psychiatric emergency protocols, regardless of physical location (medical ED or psychiatric ED). Observation must be recorded on the designated observation flow sheet every 15 minutes, including both the location and the method of observation period all patients will be observed and documented at a minimum of every 15 minutes. Observations must be staggered and not performed in exact 15-minute intervals. Observation include direct visual observation in the patient rooms, hallway, and common areas; and camera monitoring from the nurse’ s station; In person direct visualization observation must occur at least every 30 minutes for all patients, regardless of camera monitoring. Patients placed on a one-to-one observation require continuous visual monitoring by an assigned staff member who remains within arm’s length at all times, including during sleep periods. Review of medical record and video review for Patient #2 revealed on 08/22/25 at 09:00 AM, Patient #2 presented to the ED via ambulance after an intentional overdose (took 30 Entresto pills (medication to treat chronic heart failure) and 30 Prazosin pills (medication to treat high blood pressure) at home). At 09:06 AM, Patient #2 was triaged and assessed as high risk for suicide and constant order for suicide precautions (including one-to-one constant observation) was implemented. Between 09:06 AM and 09:11 AM, a rapid response was called as Patient #2 was threatening to leave the hospital and ingested an unknown amount of nitroglycerin (medication used to lower blood pressure) while changing into hospital clothing (on one-to-monitoring). Patient #2 developed decreased responsiveness for a short period of time with associated nausea, vomiting, and low blood pressure that improved with the administration of IV fluids. The administration of charcoal was attempted; however, Patient #2 could not tolerate it. Poison control recommended six to twelve hours of observation depending on stability. At 03:30 PM, Patient #2 was awake but was trying to cut their wrist with a hair clip. This was stopped but Patient #2 became combative, and a rapid response was called. From 01:15 PM AM to 06:45 PM, 15-minute checks were documented on Behavioral Health Psychiatric Emergency Department 24-hour Observation Flowsheet for one-to-one observation. Patient #2 was assigned the same staff member that was assigned to Patient #1 to provide one-to-one observation. At 03:30 PM, Patient #2 was awake but was trying to cut their wrist with a hair clip. This was stopped but Patient #2 became combative, and a rapid response was called. From 06:45 PM to 07:46 PM, no one-to-one documentation was found. At 07:05 PM, Patient #2 was transferred from the medical ED to the psychiatric ED area in room #2. From 07:40 PM to 07:46 PM, there were no staff present in the patient area (milieu or rooms per video). During this time, Patient #2 tied the bed sheet on the stretcher (used as a bed, not ligature free) and around their neck in an attempt to asphyxiate self. At 07:46 PM, the registered nurse walked out of the nursing station and looked into the window of room #2 where Patient #2 was on the floor. The registered nurse immediately removed the sheet from Patient #2’s neck and lowered the bed to release the tension on the sheet. Staff remained with Patient #2 except at 07:51 PM for 30 seconds, until 11:01 PM, when they were transferred to the inpatient psychiatric unit. Interview on 09/04/25 at 10:22 AM with Staff (J), PCA, revealed on 08/22/25, they were in the room when Patient #2 was being changed into a hospital gown. Patient #2 grabbed a pill bottle from under their bra and quickly put the pills in their mouth before staff could grab them. Staff (J) found the nitroglycerin pill bottle in the bed and given to nursing staff. Patient #2 was initially housed into room #3 of the medical ED. After the attempted overdose with the nitroglycerin pills by Patient #2, nursing staff told Staff (J) that they needed to watch both Patient #1 and Patient #2, but to focus more on Patient #2. Patient #2 was moved to room #2, to have Patient #1 and Patient #2 housed in side-by-side rooms. Interview on 09/03/25 at 10:12 AM with Staff (E), Registered Nurse, revealed psychiatric ED considers all patients a one-to-one observation and patients are monitored during 15-minute rounds and on video monitoring that can be seen in the nurse ’ s station. The psychiatric ED rooms have an ED cart bed, a pillow with pillowcase, a flat sheet, a bath blanket, and a bench attached to the floor. The psychiatric ED nurse’s station has three TV monitors with multiple views of the unit, that can also be seen by security. Interview on 09/05/25 at 12:05 PM with Staff (SS), Registered Nurse, revealed each bed in the psychiatric ED has one flat sheet, one blanket, and one pillow with pillowcase, extra linens are allowed, and patients are provided snap closure linen gowns, due to paper scrubs are not available. Psychiatric ED patients are monitored by the staff with 15-minute rounding and via camera monitor. Interview on 09/05/25 at 12:09 PM with Staff (R), Program Aide, revealed all beds located in the psychiatric ED have looping hazards which Staff (R) has identified on the hourly environmental check sheets. When sitting at the nursing station, patient rooms cannot be visualized unless staff is watching the cameras, which is why rounding is very important. Interview on 09/05/25 at 01:45 PM and 02:06 PM with Staff (S), Hospital Administrator, revealed the ligature risks within the psychiatric ED include all beds, the benches that are bolted down to the floor in rooms #1-5, and the door handles on the hallway side of the doors. Rooms #1 and #5 cannot be directly visualized from the nursing station. Room #4 can only be partially visualized from the nursing station. The only way to directly visualize the hallway bed is by standing up, leaning over the nursing station desk, and looking out the side window. The bathroom only has direct visualization when the door is open. When staff are not performing rounds in the unit, they are stationed in the nursing station. Interview on 09/05/25 at 02:25 PM with Staff (T), RN, revealed when a patient is on a one-to-one sitter in the medical ED, the need for a sitter does not transfer to the psychiatric ED. A one-to-one would be put in place if a patient was actively trying to harm themselves. Otherwise, the psychiatric ED does every 15-minute observation rounds and is able to constantly visualize the patients on camera. Phone interview on 09/08/25 with Staff (NN), Behavioral Health Technician (BHT), revealed they were there during the event when Patient #2 attempted to asphyxiate themselves with a bed sheet attached to the ED cart bed. Phone interview on 09/09/25 at 09:02 AM with Staff (MM), RN, revealed Patent #2 arrived at the psychiatric ED at approximately 06:30 PM from the medical ED and the incident occurred approximately 30 minutes after their arrival. Staff (MM) found Patient #2 during their rounds and remained one-to-one with Patient #2 after the suicide attempt. Patient #2 was transferred to the inpatient unit on a one-to-one sitter. When a patient has a moderate or high CSSRS (suicide) score, the patient would require a one-to-one observation in the medical ED. When this patient is transferred to the psychiatric ED area, they are automatically downgraded to a Level 3 observation (every 15-minute observations) via camera monitoring and rounding every 15 minutes. There is no physician order for the downgrade of monitoring. Staff were informed a couple of months ago not to have ED cart beds on their unit due to the ligature risk. Phone interview on 09/09/25 at 12:47 PM with Staff (LL), RN, revealed Patient #2 was a one-to-one observation in the medical ED. Patient #2 was cleared medically and transferred to the psychiatric ED, where Patient #2 was a regular level three (every 15-minute observation) observation level. The environmental safety rounds identified the beds as a ligature risks, but administration did not notify staff that they were a concern for safety. On 08/22/25, Staff (A), Hospital Administrator, spoke to Staff (LL) regarding the incident. Staff (LL) notified them that there was a lag on the camera monitors. Because of that, the cameras are not a good indicator of patient safety. Findings #3: Review of the policy “Assessment and Monitoring of Psychiatric Patients in the Emergency Department,” dated February 2025, revealed for patients housed in the medical ED, one-to-one observation means that a patient is observed by a designated staff member assigned solely to watch the patient, cannot attend to other duties, is housed within the same room, and keeps eyes on the patient at all times. Another provider may temporarily relieve the assigned staff member, ensuring continuous observation, and a rounding note must be documented every 15 minutes in the patient’ s electronic medical record (EMR). Review of the policy “Behavioral Health Assessment Procedure for Patients who Present to the Emergency Department for Services,” dated May 2025, revealed children and adolescents will be placed in a private room in the medical ED and placed on continuous one-to-one observation status unless otherwise specified by the ED provider or psychiatrist. Review of the policy “Adult and Child/Adolescent/Observation Rounds in the Psychiatric Emergency Room,” dated May 2025, revealed this policy applies to all staff responsible for the care of any patient being treated under the psychiatric emergency protocols, regardless of physical location (medical or psychiatric ED). Patients placed on a one-to-one observation require continuous visual monitoring by an assigned staff member who remains within arm ’ s length at all times, including during sleep periods. Medical record review revealed one-to-one observation (one designated staff member assigned to watch one patient only with no other duties) per physician order was not provided to the following patients according to the “Behavioral Health Psychiatric Emergency Department 24-hour Observation Flowsheet,” for one-to-one observation: -Patient #1 and Patient #2: On 08/22/25 from 01:15 PM to 06:15 PM, the same staff member was assigned to Patient #1 and Patient #2 at the same time to provide one-to-one observation in the medical ED. -Patient #4 and Patient #5: On 08/02/25 from 06:45 AM to 08:45 AM and 09:00 AM to 11:15 AM, the same staff member was assigned to Patient #4 and Patient #5 at the same time to provide one-to-one observation in the medical ED. Interview on 09/03/25 at 03:53 PM with Staff (I), Psychiatrist, revealed they are aware at times the one-to-one sitter will watch more than one patient due to a staffing shortage. Staff (I) has re-educated staff that a one-to-one patient requires one direct staff who cannot have more than one patient. Interview on 09/03/25 at 04:40 PM with Staff (G), Hospital Administrator, revealed the nurse-to-nurse handoff report would include one-to-one observation information and were surprised at the change of shift (on 08/22/25), the outgoing RN and the incoming RN did not notice there was no staff posted to sit as the one-to-one observation at Patient #1 ’ s room. A staffing shortage that day contributed to not having enough staff available to provide coverage. Phone interview on 09/04/25 at 09:56 AM with Staff (Z), Physician, revealed it is common in the medical ED that the one-to-one sitter observes up to three patients. On 08/22/25, Patient #2 located in the room next to Patient #1, was a higher acuity and risk for suicide, so attention may have been on them. Staffing shortages are a concern with one-to-one observations patients. Most patients that have a one-to-one observation ordered are provided safe care at the facility when the facility is not busy. Interview on 09/04/25 at 10:22 AM with Staff (J), PCA, revealed they were assigned to be the one-to-one observer for Patient #1 and Patient #2’s on 08/22/25. After the attempted overdose by Patient #2 with the nitroglycerin pills, nursing staff told Staff (J) that they needed to watch both Patient #1 and Patient #2, but to focus more on Patient #2. Patient #2 was moved to Room #2, to have Patient #1 and Patient #2 housed in side-by-side rooms. It was common for the PCA’s to tell one another when they were taking a break and cover each other’s assignment. There was no assignment sheet for one-to-one coverage. Staff (J) came back from break prior to their shift ending at 07:00 PM but did not tell the RN they were leaving, and assumed their assignment was covered by Staff (GG), PCA who was already covering their break. When they arrive for a shift in the medical ED, it is common to be assigned as a one-to-one constant observation sitter where two or more patients are watched at the same time. Up to four patients are observed at one time in the ED fast track area. Phone interview on 09/04/25 at 12:35 PM with Staff (JJ), Registered Nurse, revealed they check on the one-to-one observation staff frequently but do not check the observation logs. PCA’s will cover each other’s break with discussions among themselves. If more than one patient needs to be watched, the PCA would be assigned more than one patient to monitor because of staffing constraints. It is common to have psychiatric patients in the medical ED. If they are agitated, the one-to-one sitter will watch them from the hallway. PCA’s are not allowed to leave without coverage. Patient #1 had a lapse in coverage due to miscommunication between the PCA’s. PCT’s are assigned zones of the medical ED at the beginning of their shift. Zone One is Room #1 to #4, Zone Two is Room #5 to #8, and Zone Three is Room #9 to #2. The nursing staff allow the PCA’s to choose their own assignment when they come on shift. There is no assignment sheet for one-to-one observation. The PCA’s cover their own breaks and handoff report at change of shift amongst themselves. Phone interview on 09/04/25 at 12:57 PM with Staff (BB), Registered Nurse, revealed on 08/22/25 from 06:30 PM until 07:00 AM, they were assigned to Patient #1. Patient #1 had a one-to-one observation order in place and had a sitter the “majority of the time.” The one-to-one sitter and Patient #1’s parent both stepped away which left Patient #1 alone during the event occurrence. Staff (BB) was unaware that there was no one-to-one sitter from 06:30 PM to 09:15 PM and did not receive one-to-one information in report. The one-to-one sitter reports are conducted directly between the PCA’s. Staff (BB) will sometimes help take items out of the room when a one-to-one sitter is ordered, but the PCA’s do the room checks regularly. Interview on 09/04/25 at 12:34 PM with Staff (GG), PCA, revealed when assigned to a one-to-one patient, they are unable to leave without relief and would let the registered nurse know when they are leaving. They will fill out the observation logs for all one-to-one patients they are assigned to. PCA’s will switch the one-to-one observation sitting responsibilities every two hours with another PCA that is available. Occasionally the RN will assign a PCA to sit with a one-to-one patient. Typically, the PCA’s decide amongst themselves who will be assigned to the one-to-ones. Interview on 09/04/25 at 02:24 PM with Staff (Y), PCA, revealed when they are assigned to a one-to-one patient, it is common to watch more than one patient and they will fill out each observation log (Behavioral Health Psychiatric Emergency Department 24-hour Observation Flowsheet), as there is not enough staff to provide direct one-to-one observation. They must wait for relief before they can leave their assignment.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 48506 Based on medical record review, policy review, document review, and interview, the hospital failed to use collected data to identify opportunities and make changes for improvement. Specifically: 1.The hospital failed to ensure identified staffing shortages were addressed and implement corrective actions to provide adequate staffing for high-risk patients that require 1:1 observation. This resulted in an adverse event for Patient #1 and Patient #2 on 08/22/25. 2.The hospital failed to ensure environmental rounding documentation was reviewed at the unit level and quality assurance level to identify and implement corrective actions to remove identified ligature and other safety risks in the psychiatric Emergency Department (ED). This resulted in an adverse event for Patient #2 on 08/22/25. 3.The hospital failed to ensure documentation and/or analyze adverse events for Patient #2 and implement all corrective actions needed to minimize/prevent future occurrences. Findings include: Review of the 2025 “Niagara Falls Memorial Medical Center Quality Assurance and Performance Improvement Plan (QAPI),” revealed the goal is to set priorities, define objectives, and advance overall performance improvement strategies to reduce medical errors, improve health outcomes, and protect the safety of patients, visitors, and employees. Each department in the hospital will identify actual or potential problems concerning patient care and clinical performance; monitor activities taken to strengthen performance improvement; review adverse outcomes as they relate to departmental activities; participate in Root Cause Analysis (RCA) and implement corrective action plans as required. Review of the policy “Standards of Care: Standard V: Systemic Review and Evaluation of Nursing Practice- Important Aspects of Performance Improvement Activity,” dated February 2025, indicated ongoing performance improvement (PI) activities are used to determine compliance to standards (structure, process, and outcome). Nursing practice standards related to important aspects of care associated with high volume, high-risk conditions are monitored and evaluated. Staffing standards are monitored and evaluated to determine if they are consistent with current workload (patient acuity, staffing for certain populations, staffing allocations/assignments). Methods for monitoring and evaluating include concurrent and retrospective chart reviews, data collection for volume indicators, and focused reviews to closely monitor specific problems. Nursing participates with multidisciplinary staff to plan, evaluate, and discuss results. Action plans may be coordinated with multidiscipline input and action plans reported to hospital leadership. Performance improvement monitoring and evaluation activity reports are completed for each indicator; managers document results and action plans; and trends are identified for evaluation of improvement at all levels. Findings #1: Review of the policy “Assessment and Monitoring of Psychiatric Patients in the Emergency Department,” dated February 2025, revealed for patients housed in the medical ED, one-to-one observation means that a patient is observed by a designated staff member assigned solely to watch the patient, cannot attend to other duties, is housed within the same room, and keeps eyes on the patient at all times. When the number of psychiatric patients in the medical ED exceeds the staffing capacity for observation or if a one-to-one observation exceeds a one-to-four staff to patient ratio, staff will be reassigned from other hospital units if possible. Review of the document “ ....Clinical Staffing Plan,” dated 07/16/25, revealed the ED is a twenty-bed unit with a 75-patient volume in a 24-hour period. There is a medical ED and a psychiatric ED area. For the medical ED, planned staffing includes: six Registered Nurses (RN) per day shift (07:00 AM-03:00 PM), evening shift (03:00 PM-11:00 PM), and the overnight shift (11:00 PM-07:00 AM) for an average of 21 patients per day. Four patients to one RN; two PCTs (patient care technicians) on the day and overnight shift, and three on the evening shift. Additional resources include: a charge nurse on the day shift and calling in more staff if needed. To support the evening and overnight shift, RN staffing ratios will vary based on acuity, surge volume, observation, admission holds, social service placements, and one-to-one needs. RN volunteers will be called in and the charge RN takes an assignment. For the psychiatric ED, planned staffing includes: two RNs on the day shift, evening shift, and overnight shift. The three patients to one RN; one PCT or BHT (behavioral health therapy aide) on the day and evening shift and two on the overnight shift. Additional resources include: one charge nurse taking an assignment on the day and evening shift. To support the overnight shift, the float pool and a call in system will be utilized for additional RNs, PCAs, and BHTs not already on call. Review of the “Clinical Staffing Meeting Minutes,” dated 05/15/25, 07/17/25, and 08/21/25, revealed there were discussions of RN staffing vacancies, but ancillary staff (PCA’s or BHT’s) were not discussed. Interview on 09/08/25 at 01:09 PM with Staff (A), Administrator, revealed during the clinical staffing meetings, PCA’s and BHT’s positions are discussed, however the vacancy numbers are not placed in the meeting minutes. There is no discussion of staffing call ins affecting the staffing within the hospital or the staffing needs for one-to-one observation needs. There is no float pool to pull staff from. There is no one-to-one schedule. Review of document “Dates Psychiatric ED was Closed,” dated from June 2025 to September 2025, revealed the psychiatric ED unit was closed on the following days: 06/04/25, 06/07/25, 06/08/25, 06/16/25, 06/18/25, 06/24/25, 06/27/25, 07/03/25, 07/14/25, 07/15/25, 07/26/25, 07/27/25, 07/28/25, 08/03/25, 08/05/25, 08/13/25, 08/15/25, 08/16/25, 08/27/25, and 08/28/25. Interview on 09/08/25 at 01:00 PM with Staff (G), Hospital Administrator, revealed the psychiatric ED will close on the overnight shifts due to a lack of staff. All psychiatric patients would be cared for in the main ED, during these times. Review of the “Medical ED Staffing Schedule and Psychiatric ED Staff Schedules,” dated 08/17/25 to 08/25/25, revealed consistent short staffing in both areas for RNs and PCA/BHT. Specifically: -On 08/22/25 in the medical ED, there were seven RNs scheduled from 06:30 AM to 07:00 PM. There were five RNs scheduled for 06:30 PM to 07:00 AM, one called in sick and one scheduled for 11:00 PM to 07:00 AM. There was one PCA scheduled from 07:00 AM to 03:00 PM, one from 08:00 AM to 07:00 PM, and one from 03:00 PM to 07:00 AM. -On 08/22/25 in the psychiatric ED, there was one RN scheduled from 06:30 AM to 02:00 PM, one from 09:30 AM to 11:00 PM, and one from 06:30 PM to 07:00 AM. There was one BHT scheduled from 07:00 AM to 03:00 PM, one from 03:00 PM to 11:00 PM, and one from 11:00 PM to 07:00 AM. Review of multiple quality assurance documents from May 2025 to September 2025 revealed no evidence hospital administration discussed and addressed staffing issues including the implementation of corrective actions/strategies to improve staffing issues. Interview on 09/03/25 at 10:40 AM with Staff (F), Registered Nurse, revealed sitters commonly watched two patients at one time based on staffing levels being low. Interview on 09/03/25 at 11:25 AM and 04:39 PM with Staff (G), Hospital Administrator, revealed Patient #1 was made one-to-one constant observation based upon their admission status of a 9.41 mental health examination (authorizes peace or police officers to take a person into custody and have evaluated if they appear to be mentally ill and are acting in a manner likely to cause serious harm to themselves or others). Patient #1 had a one-to-one constant observation ordered during the time of their overdose event. There was at least a one-hour lapse in one-to-one observer coverage at the time of the event. Staffing constraints contributed to not having the appropriate one-to-one observation coverage. A PCA frequently watches more than one patient on one-to-one observation due to lack of staff. Interview on 09/03/25 at 02:07 PM with Staff (A), Hospital Administrator, revealed they can “see the hole” in their system regarding one-to-one constant observation. There has been a root cause analysis investigation regarding the incident with Patient #1 scheduled based upon staff availability. The initial findings indicate the lapse of coverage of the one-to-one sitter due to staffing shortages. Interview on 09/03/25 at 03:53 PM with Staff (I), Psychiatrist, indicated they were aware the one-to-one sitter will watch more than one patient due to a staffing shortage. Staff (I) has re-educated staff that a one-to-one patient requires one direct staff who cannot have more than one patient. Interview on 09/03/25 at 04:40 PM with Staff (G), Hospital Administrator, a staffing shortage on 08/22/25 contributed to not having enough staff available to provide coverage for Patient #1. Phone interview on 09/04/25 at 09:56 AM with Staff (Z), Physician, revealed Patient #1 required a one-to-one constant observation sitter. It is common in the medical ED that the one-to-one sitter observes up to three patients. Staffing shortages are a concern with one-to-one observations patients. Staff (Z) has expressed concerns to the nursing supervisor at night multiple times and have been told staffing is out of their control as well as the ED director’s control. Most patients that have a one-to-one observation ordered are provided safe care at the facility when the facility is not busy. Interview on 09/04/25 at 10:22 AM with Staff (J), PCA, revealed on 08/22/25, Patient #2 was moved to room #2 so they could provide observation for both patients (Patient #1 and Patient #2) at the same time. When they arrive for a shift in the medical ED, it is common to be assigned as a one-to-one constant observation sitter where two or more patients are watched at the same time. There are several instances when the psychiatric ED will close due to low staffing and the patients are housed in the medical ED. Up to four patients are observed at one time in the ED fast track area. Staff (J) has expressed safety and staffing concerns to Staff (G), ED Director, and other administration. Their understanding is nothing can be done as there is no staff to cover. It is well known that the second shift from 03:00 PM to 11:00 PM is the toughest shifts to staff. Phone interview on 09/04/25 at 12:35 PM with Staff (JJ), Registered Nurse, revealed if more than one patient needs to be watched, the PCA would be assigned more than one patient to monitor because of staffing constraints It is common to have psychiatric patients in the medical ED. If they are agitated, the one-to-one sitter will watch them from the hallway. The ED would benefit from more staff as there is no float pool. Phone interview on 09/04/25 at 12:57 PM with Staff (BB), Registered Nurse, revealed PCA’s are regularly pulled off the floor to sit with psychiatric patients leaving them short staffed with not enough help. It is well known by administration that staffing shortages are a concern, and they are trying to help. Interview on 09/04/25 at 12:34 PM with Staff (GG), PCA, revealed they have had concerns when watching more than one patient at a time and stated that they need more staff to ensure that “this does not happen (Patient #1).” Interview on 09/04/25 at 02:24 PM with Staff (Y), PCA, revealed when assigned to a one-to-one patient, it is common to watch more than one patient. Staff (Y) has concerns with short staffing. Interview on 09/05/25 at 12:05 PM with Staff (SS), RN, revealed the psychiatric ED is supposed to be staffed with two RNs and two PCA’s however this varies and sometimes there is one of each. Psychiatric ED patients are monitored by the staff with 15-minute rounding and via camera monitor. There is a daily concern with staffing, and they have verbalized concerns to Staff (G), Hospital Administrator, daily as well as submitting an electronic staffing complaint where they have not heard anything. There is no float pool available to assist with staffing shortages. The psychiatric ED will close often due to short staffing unless a registered nurse from the medical ED is mandated to cover in the psychiatric area. There are concerns with the medical ED staff floating to the psychiatric ED. Phone interview on 09/08/25 with Staff (NN), Behavioral Health Technician (BHT), revealed short staffing is a huge concern. Many times, there is one RN and one BHT for a 6-patient census, which is difficult. Staff (NN) had made daily verbal complaints about staffing to management but were not sure what was being done to address it. There are concerns on the unit with low staffing when the RNs need to perform assessments on their patients, which is a lengthy interview process. Phone interview on 09/09/25 at 09:02 AM with Staff (MM), RN, revealed The psychiatric ED generally has one RN and one BHT for staffing on in the overnight shift. They regularly fill out online complaints for short staffing and receive e-mail confirmation which they think it’s copied to the ED director and then the union representative. They have made approximately two complaints over the last month. Phone interview on 09/09/25 at 12:47 PM with Staff (LL), RN, revealed staffing is an issue, there are not a lot of jobs posted. The day of Patient #2’s incident had a high patient acuity in the unit. The psych ED is often closed because there is not enough staffing. In order to keep the unit, medical ED nurses are floated over without adequate training. Some staff fill out short staffing forms. Staff (LL) and their coworkers do not because of the fear of retaliation. It is not widely done because it is not a confidential process. Finding #2: Review of the policy “Environment of Care Inspections for Patient Care Areas,” revised 03/31/25, revealed during the environment of care inspections, an assessment checklist is used to record real-time findings and actions. The inspector must note the specific deficiencies and the exact location where the deficiency was identified to assure timely, follow-up corrective action. At the conclusion of the environmental tour of a patient care unit, a copy of the completed environment of care assessment checklist form is given to the head nurse of the unit, the Vice President of Quality, corporate compliance, and the Chair of the Joint Emergency Safety Committee. The original form is given to the safety officer who reviews the findings and enters work orders to fix the noted deficiencies. The findings of the environment of care inspections are presented at the Joint Emergency Management Safety Committee. The inspection team conducts a follow-up tour to ensure correction or mediation of previous findings, they should have the previous inspection findings in hand. The Vice President of Quality and corporate compliance will review the results of each environment of care inspection and enter the findings into the event reporting system as well as log findings for inclusion in the annual QAPI report. Review of the document “Physical Environment Risk Assessment Tool (PRT) for the Emergency Department (ED),” dated 04/03/25, revealed ligature risks were identified with cords, wires, curtains, and other non-named items. Staff were educated on ligature risks and observation policies. In the psychiatric ED, it was noted cupboards were not locked where linen, cleaning supplies, rags, cat food, and miscellaneous items were being stored. Review of the document “Environmental Rounds Worksheet For Infection Prevention,” dated 08/01/25, revealed ligature risks were not assessed during the inspection and there were no comments on the form regarding ligature risks. Review of “Use of Emergency Assistance Call System/Environmental Safety Checks (Psychiatric ED),” dated May 2025, revealed environmental safety checks are conducted and documented every hour to ensure that the physical care environment remains safe for all patients, staff, and visitors. Twice per shift, designated staff will conduct safety inspections of all patient rooms, group rooms, and common areas. Inspections must be documented on the environmental round sheet. Items to be checked include but are not limited to: beds for structural integrity or contraband, door handles and hinges for hanging risks, window/screen frames to confirm security, bathrooms for water on floors and functioning faucets, lighting, plumbing, thermostats, and fixture conditions, damage to walls, furniture, and ceilings, light covers present and intact, removal of contraband (glass items, wires, hangers, sharp objects), and confirmation that smoke barrier and fire doors are closed and unobstructed. Common areas, halls, and exits must be checked for safety, damage, or unauthorized propping open of doors. Completed environmental round sheets will be stored in a designated binder, filed monthly, and reviewed by the Director of Emergency Services for completeness and trending. Observation on 09/05/25 at 01:30 PM in the psychiatric ED with Staff (S), Hospital Administrator, revealed there are five private patient rooms with doors. The inside of room #1, #4, and #5 cannot be seen from the nursing desk. Patient observation rounding is documented every 15 minutes and conducted either in-person or by camera monitoring from the nursing station. In-person rounding is only required every 30 minutes per policy. ED stretchers (multiple ligature risks) were used as beds and located in all five rooms and one in the main patient milieu area as beds. Looking hazards were found in room’s #1, #2, #3, and #4, and the patient bathroom (door handles pointing upward). Looking hazards were found on the outside of the staff bathroom (horizontal handle), the decontamination room, and the door next to the hallway bed (knob handles). Staff (S) confirmed these findings. Review of document “NFMMC Psychiatric ED Environmental Safety Checks,” dated 06/01/25 to 09/05/25, revealed the following: In June 2025: -On 06/01/25, 06/04/25, 06/05/25, 06/07/25, 06/10/25, 06/11/25, 06/12/25, 06/13/25, 06/16/25, 06/17/25, 06/19/25, 06/21/25, 06/22/25, 06/24/25, 06/26/26, from 07:00 AM to 02:00 PM, and on 06/06/25, 06/08/25, 06/25/25, from 07:00 AM to 06:00 PM, looping hazards were identified on the beds. -On 06/03/25, from 07:00 AM to 03:00 PM, Staff (R), Program Aide, documented there were looping hazards. -On 06/13/25 from 06:00 PM to 10:00 PM, 06/14/25 from 07:00 AM to 08:00 AM, 06/18/25 from 07:00 AM to 02:00 PM, 06/19/25 from 07:00 PM to 10:00 PM, 06/21/25 from 03:00 PM to 10:00 PM, 06/23/25 from 10:00 AM to 06:00 PM, 06/25/25 from 11:00 PM to 06/26/25 06:00 AM, from 06/27/25 at 06:00 PM to 06/28/25 at 06:00 AM, and 06/30/25 from 11:00 AM to 02:00 PM, no hourly environmental checks and/or safety checks were performed twice a shift per hospital policy. In July 2025: -On 07/01/25, 07/02/25, 07/04/25, 07/07/25, 07/09/25, 07/11/25, 07/14/25 to 07/16/25, 07/18/25 to 07/20/25, 07/22/25, 07/23/25, 07/25/25, 07/28/25 to 07/30/25, from 07:00 AM to 02:00 PM, 07/06/25 from 10:00 AM to 02:00 PM, 07/07/25 from 08:00 AM to 02:00 PM, and on 07/11/25 from 07:00 AM to 11:00 AM, looping hazards were identified on the beds. -On 07/01/25 at 10:00 PM, 07/05/25 from 07:00 AM to 02:00 PM, From 07/06/25 at 11:00 PM to 07/07/25 at 06:00 AM, 07/13/25 from 07:00 AM to 02:00 PM and 11:00 PM to 07/14/25 at 06:00 AM, 07/15/25 from 01:00 AM to 04:00 AM, 07/16/25 at 02:00 PM, 07/20/25 from 06:00 PM to 07/21/25 at 06:00 AM, 07/25/25 from 08:00 PM to 10:00 PM, 07/27/25 from 06:00 PM to 07/28/25 at 06:00 AM, and 07/28/25 from 09:00 PM to 07/29/25 at 05:00 AM, no hourly environmental checks and/or safety checks were performed twice a shift per hospital policy. August 2025: -On 08/01/25, 08/02/25, 08/05/25, 08/06/25, 08/11/25, 08/15/25, 08/19/25, 08/25/25, 08/27/25, 08/30/25, 08/31/25 from 07:00 AM to 02:00 PM, looping hazards on the beds were identified. -On 08/07/25, 08/15/25, 08/20/25, Staff (R), Program Aide, documented there were looping hazards. -On 08/08/25, 08/12/25, 08/16/25, 08/17/25, 08/22/25, 08/25/25, 08/26/25, Staff (R), Program Aide, documented all beds have looping hazards. -On 08/07/25 and 08/08/25, Staff (R), Program Aide, documented the cameras were not functioning. -On 08/15/25, it was documented that there was a looping hazard in Room #5. -On 08/21/25, there was documentation that beds had looping hazards. -On 08/05/25 at 01:00 PM to 02:00 PM, 08/08/25 from 02:00 PM to 05:00 PM, 08/22/25 from 06:00 PM to 10:00 PM, 08/23/25 from 11:00 PM to 08/24/25 at 06:00 AM, 08/27/25 from 06:00 PM to 08/28/25 at 05:00 AM and 06:00 PM to 08/29/25 at 06:00 AM, no hourly environmental checks and/or safety checks were performed twice a shift per hospital policy. In September 2025: -On 09/02/25, 09/04/25, 09/05/25, there were looping hazards identified on the unit. -On 09/03/25 from 07:00 AM to 02:00 PM, looping hazards were identified on the beds. -On 09/02/25 from 08:00 PM to 10:00 PM, no hourly environmental checks and/or safety checks were performed twice a shift per hospital policy. Review of the meeting minutes for QAPI, Psychiatric, and ED Quality Assurance, dated May 2025 to August 2025, revealed no documentation of identified ligature risks within the psychiatric ED or that psychiatric ED environmental safety checks were reviewed by the quality assurance program and/or administration. Review of the medical record and video review for Patient #2, dated 08/22/25, revealed from 07:40 PM to 07:46 PM, no staff were present in the patient area. During this time, Patient #2 tied the bed sheet on the stretcher (used as a bed, not ligature free) and around their neck in an attempt to asphyxiate self. Interview on 09/05/25 at 01:45 PM and 02:06 PM with Staff (S), Hospital Administrator, revealed the ligature risks within the psychiatric ED include all beds, the benches that are bolted down to the floor in Rooms #1- 5, and the door handles on the hallway side of the doors. Rooms #1 and #5 cannot be directly visualized from the nursing station. Room #4 can only be partially visualized from the nursing station. The only way to directly visualize the hallway bed is by standing up, leaning over the nursing station desk, and looking out the side window. The bathroom only has direct visualization when the door is open. When staff are not performing rounds in the unit, they are stationed in the nursing station. Interview on 09/08/25 at 10:00 AM with Staff (B), Hospital Administrator, revealed the psychiatric ED environmental safety check audits/data was not being reviewed by the quality assurance program. Interview on 09/08/25 at 10:52 AM with Staff (G), Hospital Administrator, revealed the psychiatric ED environmental safety check data was not reviewed as regularly. The only time that the data was reviewed was when issues were brought to Staff (G)’s attention, such as the rounds are not being completed. The data from the environmental safety rounds are not being trended or brough to the quality assurance committee. Phone interview on 09/09/25 at 09:02 AM with Staff (MM), RN, revealed the behavioral health therapy staff complete environmental rounding sheets but Staff (MM) does not review them. Staff were informed a couple of months ago not to have ED cart beds on their unit due to the ligature risk. Phone interview on 09/09/25 at 12:47 PM with Staff (LL), RN, revealed the environmental safety rounds identified the beds as a ligature risks, but administration did not notify staff that they were a concern for safety. When Staff (A), Hospital Administrator, spoke to Staff (LL) on 08/22/25 regarding the incident with Patient #2, Staff (LL) notified them that there was a lag on the camera monitors. Because of that, the cameras are not a good indicator of patient safety. Findings #3: Review of the policy “Event Reporting,” dated October 2018, indicated it is policy to report any unusual events that are out of the ordinary that might have or actually did cause harm to a patient, staff, or visitor; potentially involved negligence or the appearance of negligence; possibility of a complaint or liability; or requires immediate consideration or response. An event is any type of error-actual or potential regardless of harm or not. Event reports are maintained on each nursing unit and should be completed by the staff that observes, involved, or the event is reported to. The report will be forwarded to the appropriate manager. The first and second page will be competed and entered into the database within 24 hours of the occurrence. Completed forms will be maintained in the quality management department for review, tracking, and trending. The Quality Management Director will determine the need for further investigation and/or remediation. Review of the policy “Serious Adverse Events,” revised December 2021, indicated any time a serious adverse event occurs, a complete, thorough, credible root cause analysis (process to identify basic or casual factors that involve variation in performance focusing on systems and processes) will be conducted implementing improvements to reduce risk and monitor the effectiveness of those improvements. This would include but not limited to a patient suicide or attempted suicide resulting in serious disability while being cared for in a healthcare facility. The employee involved in or discovering a serious adverse event is responsible for initiating an Event Report within that work shift. The product of the root cause analysis is an action plan that identifies strategies the hospital intends to implement to reduce the risk of similar events occurring in the future. The plan will address responsibility for implementation, oversight, testing, timelines, and strategies for measuring effectiveness of actions. The Director of Quality will present a written summary of the adverse clinical event to the appropriate committee at the next scheduled meeting. (This policy does not account for trends or multiple occurrences and allows for review of an event(s) only if there was a serious disability or death). Observation on 09/05/25 at 01:30 PM in the psychiatric ED with Staff (S), Hospital Administrator, revealed there are five private patient rooms with doors. The inside of Room #1, #4, and #5 cannot be seen from the nursing desk. Patient observation rounding is documented every 15 minutes and conducted either in-person or by camera monitoring from the nursing station. In-person rounding is only required every 30 minutes per policy. ED stretchers (multiple ligature risks) were used as beds and located in all five rooms and one in the main patient milieu area as beds. Looking hazards were found in Room’s #1, #2, #3, and #4, and the patient bathroom (door handles pointing upward). Looking hazards were found on the outside of the staff bathroom (horizontal handle), the decontamination room, and the door next to the hallway bed (knob handles). Staff (S) confirmed the looping hazards identified. Review of the medical record and video review for Patient #2, dated 08/22/25, revealed at 09:00 AM, Patient #2 arrived at the hospital after attempting suicide in the community ingesting 30 pills to overdose. Between 09:06 AM to 09:11 AM, Patient #2 attempted suicide in the medical ED when changing their clothes by taking nitroglycerin pills hidden in their bra. At 06:00 PM a rapid response was called after Patient #2 was found cutting their wrist with a hair clip. At 07:05 PM, Patient #2 was transferred from the medical ED to a room in the psychiatric ED. No one-to-one observation was assigned. From 07:43 PM to 07:46 PM, Patient #2 attempted suicide using sheet on a ligature risk bed while unobserved by staff. A staff member was walking by, noticed Patient #2 in their room, and intervened per video. Patient #2 was examined and not injured. Patient #2 had a history of multiple attempted suicides. Review of quality assurance documents revealed no adverse event report was found related to Patient #2 ingesting nitroglycerin pills and cutting their wrists in the medical ED on 08/22/25 prior to the suicide attempt in the psychiatric ED area the same day. No RCA was found for these three events that occurred with Patient #2 on 08/22/25. Review of the email between multiple members of Hospital Administration dated 08/22/25 at 11:26 PM, revealed Staff (A) and Staff (G) would meet to implement strategies to prevent future events after the 08/22/25 at 07:45 PM event in the psychiatric ED area. There were no negative outcomes and a NYPORTS (New York Patient Occurrence Reporting and Tracking System - a mandatory reporting system) did not need to be filed. On 08/25/25 at 07:32 PM, Staff (A), Hospital Administrator, met with the staff involved and reviewed video footage. Staff (A) felt there was absolutely nothing they would have asked the staff to change or do better. “We do have some opportunities from a management standpoint which have already been requested.” The staffing was completely adequate. An RCA was not needed for Patient #2’s event and the process problem fixes had been requested. Review of the email between Staff (A), Hospital Administrator, and the staff involved in Patient #2’s event, dated 08/25/25 at 07:46 PM, revealed the following steps toward fixing the process (in the psychiatric ED area): requested a central monitor between the RN s and one for the PCA desk on which all patients will be visible at eye level; patient rooms to be put into sensical order on the screen; a better means of notification in the event something happens; a review of the time lapse reported between the actual patient activity and the visibility on the camera; and paper gowns/sheets to keep stocked for all high acuity one-to-one patients. These are more costly, so they need to reserve them for those patients most in need. (The “process problem fixes” addressed in this email did not include the following: all psychiatric ED staff or medical ED staff that float to the area were notified of the “fixes”; Staffing issues, patient acuity, and patient monitoring based on clinical presentation was not addressed; physical rounding occurs every 30 minutes and is otherwise conducted from the nursing station; patients are left alone in the milieu between 30 minute rounding and staff cannot see into rooms # 1, # 4 and # 5 using the camera; the need to review the psychiatric ED area and remove all ligature risks and contraband to ensure patient safety; and the need to ensure environmental rounding is performed per policy).”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 48506 Based on observations, policy review, medical record review, and interview, the hospital failed to ensure acceptable standards of practice consistent in quality with inpatient care were utilized to ensure the health and safety of patients. Specifically: 1. The hospital failed to ensure Surgeon (Staff K) maintained continuous attendance and responsibility for Patient #2 during a surgical procedure, by allowing the surgeon to leave the hospital building while the patient’s abdomen was open and the procedure was incomplete. 2. The hospital failed to promptly and thoroughly investigate verbal and written complaints, dated May 8th and May 13th, 2025, from a staff member (Staff V) regarding inappropriate, high-risk, and potentially harmful behaviors by surgical staff (Staff L and Staff K) in the operating room (OR). The lack of timely investigation persisted for approximately one month. Findings #1: Observation on 06/12/25 from 10:45 AM to 04:15 PM revealed the surgical OR suites were located on the first floor of the main hospital building. There is a parking ramp across the street from the main hospital building that houses the surgery clinic for Staff (K), Surgeon, on the seventh floor (above the parking ramp). Review of policy “Sponge, Sharp, and Instrument counts in the Operating Room (OR) ...,” dated 01/2022, revealed under no circumstances will the surgeon leave the hospital until the patient is in the recovery room, deemed stable by the anesthesia staff. Review of “Rules and Regulations of the Medical and Dental Staff...” dated 2025, revealed all consults are required to be completed within 24 hours of notification of consult, unless a stat consult is requested. Review of the medical record for Patient #2 revealed on 05/08/25 from 01:48 PM to 05:50 PM, Patient #2 was in the OR, where Staff (K), Surgeon, was listed as present to conduct a hernia (condition where an organ or tissue protrudes through a weak spot in a muscle or connective tissue wall) repair. (The medical record does not indicate that Staff (K), left the building during the surgical procedure). Review of the clinic medical record for Patient #4 revealed on 05/08/25 at 04:33 PM, Staff (K), Surgeon, documented Patient #4 was to be scheduled for a robotic cholecystectomy (surgery to remove the gall bladder). (This consult was conducted while Patient #2 was still in the surgical OR with their abdomen opened). On 05/23/25, Patient #4 had a robotic cholecystectomy (The procedure for the consult was not performed emergently or urgently). Interview on 06/12/25 at 11:47 AM with Staff (H), Registered Nurse, revealed on 05/08/25, Patient #2’s hernia repair was completed, but the abdominal incision was not closed, when Staff (K) needed to leave the OR to consult on Patient #4 at the clinic (across the street above the parking ramp) for a potential surgery. Staff (H) stated that while Staff (K) was gone, they were responsible for monitoring the sterile field, and a certified registered nurse anesthetist, was responsible for monitoring Patient #2. Interview on 06/12/25 at 12:00 PM with Staff (K), Surgeon, revealed they started Patient #2’s hernia surgery. When Patient #2 was stable, Staff (K) stopped the surgery, and alerted Staff (H), Registered Nurse, that they needed to leave the OR to perform an urgent medically necessary consult on Patient #4 (an outpatient surgical clinic patient), to schedule surgery. Staff (K) saw Patient #4 briefly (in office across the street from the main hospital), returned to the OR, rescrubbed into the case, and completed Patient #2’s surgery. Findings #2: Review of the policy “Conflict/Dispute Resolution,” dated 12/2024, revealed upon receipt of a formal complaint, the director/department head must schedule a meeting with the employee to discuss the complaint. Human Resources may call a meeting and gather information with the parties directly involved to facilitate a resolution. Review of the policy “Discrimination and Harassment Policy,” dated 12/2024, revealed all supervisors and managers who receive a complaint or information about suspected discrimination or harassment are required to report to the director of human resources. A prompt and thorough investigation will be conducted whenever a complaint about discrimination, harassment, or retaliation is received in writing or verbally. Review of the email complaint submitted by Staff (V), Surgical Technician, to Staff (I), Hospital Administration, dated 05/13/25 at 02:05 PM, revealed that on 05/08/25, Staff (L), Surgeon, entered the OR with street clothes on and screamed at Staff (V) to give them a gown. Staff (L) did not perform a surgical scrub or wash their hands at any time. When Staff (L) received a gown, they put it on over their yoga pants and tee-shirt and began to position the patient. Staff (L) put both patient ’ s legs in the stirrups but did not strap them down. Staff (L) did not use sterile drapes during the procedure. Staff (L) did not dilate the cervix and used a size 13 curette as an introducer. Staff (L) had difficulty inserting the curette and Patient #1 started to hemorrhage. Patient #1 was injured. Staff (L) did not provide Patient #1 a sanitary pad. Staff (L) ’ s behavior was erratic, hostile, and their pupils were extremely dilated. Post operatively, Staff (V) spoke to Staff (J), Hospital Administrator, and told them about Staff (L)’s behavior and contamination. Also, on 05/08/25, Staff (K), Surgeon, placed a wet towel on Patient #2 and left the OR. Registered nurses were left monitoring Patient #2 for 25 minutes while Staff (K) went across the street to their office to conduct a consult on another patient. Staff (V) included additional complaints of inappropriate touching, rude language, and inappropriate behaviors between other hospital and non-hospital employees. Staff (V) requested a follow up (via phone/email) after the investigation was conducted to determine if corporate compliance and the New York State Department of Health needed to be notified. Review of email from Staff (V), Surgical Technician to Staff (I), Hospital Administration, dated 06/06/25 at 09:14 AM, revealed Staff (V) had not yet received an update or a resolution for the complaint submitted. On 06/11/25 at 09:50 AM, Staff (V) received an email from Hospital Administration indicating that every issue raised will be fully investigated and if any allegations are found to be valid, necessary steps would be taken. (No documentation of any investigation activities was provided to onsite surveyors). Interview on 06/12/25 at 10:30 AM and at 03:45 PM with Staff (D), Nursing Administrator revealed they were notified by Staff (F), Nursing Administrator, who stated Staff (V) wanted to quit and gave a laundry list of concerns, but did not state anything specific or list any specific date. Staff (D) did not speak to Staff (V), but no concerns brought to them needed to be escalated to Human Resources. Interview on 06/12/25 at 11:26 AM and on 06/13/25 at 11:50 AM with Staff (I), Hospital Administration, Staff (V), Surgical Technician, came to their office on 05/09/25 indicating they told Staff (F), Nursing Administrator, they quit due to concerns related to a surgeon who came into the OR in street clothes, “under the influence,” and another surgeon left the OR while a patient was on the table. Staff (I) informed Staff (V) to fill out the complaint form and follow the process on submission of their complaint. On 05/13/25, Staff (I) received an email from Staff (V), however, they did not read the email and forwarded it to Staff (G), Hospital Administration. Staff (V) continued to call asking about the status of their complaint. Staff (I) informed Staff (V) each time that they would need to contact Staff (G), Hospital Administration. On 06/09/25, Staff (V) re-sent their email complaint to Staff (I), who forwarded the email to Staff (G), Hospital Administration. Interview on 06/13/25 at 12:00 PM with Staff (G), Hospital Administration, never received the original email complaint but did receive an email on 06/09/25 from Staff (V), Surgical Technician, and immediately sent the email to Staff (U), Medical Director. Staff (G) stated they are in the process of interviewing staff but did not provide any documentation of an investigation.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48506 Based on policy review, medical record review, document review, and interview, the hospital failed to protect and promote the rights of all patients. The hospital failed to protect and promote patient rights by not ensuring Crisis Prevention Intervention (CPI) techniques were properly used prior to and during a restraint application for Patient #1; failed to obtain required physician orders for restraints for three paitnets (Patient #1, Patient #5, and Patient #8); failed to conduct mandatory physician face-to-face assessments within one hour of restraint initiation for four patients (Patient #1, Patient #4, Patient #5, and Patient #8); failed to complete and submit an incident report within 24-hour timeframe for Patient #2’s elopement from the Emergency Department (ED); and failed to implement previously identified corrective actions related to Patient #2’s elopement from the Emergency Department (ED) despite the patient being on an involuntary admission physician order. These systematic failures across restraint protocols, documentation requirements, incident reporting, and policy implementation demonstrate the facility’s inability to maintain basic patient rights protections, resulting in an Immediate Jeopardy finding and a determination that the Condition of Participation for Patient Rights was NOT MET. Reference: 482.13(c)(2): The patient has the right to receive care in a safe setting. 482.13(e)(5): Restraint and/or Seclusion: Physician order. 482.13(e)(12): Restraint and/or Seclusion: Face-to-face assessment.”

“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: 48506 Based on policy review, medical record review, document review, and interview, it was determined the hospital failed to protect and promote the rights of all patients by ensuring all patients receive care in a safe setting, specifically: 1. In 1 of 11 medical records reviewed, Emergency Department (ED) staff failed to follow approved Crisis Prevention Intervention (CPI) techniques prior to and during restraint application (Patient #1). 2. In one of two medical records reviewed, the hospital failed to ensure that an incident report was completed and submitted within 24 hours to the quality department (Patient #2). 3. In one of two medical records reviewed, the hospital failed to implement corrective actions related to Patient #2’s eloping from the ED while on an involuntary admission physician order (Patient #2). Findings #1: Review of the policy “Restraints and Seclusion,” dated February 2025, revealed that restraints are used only as a last resort, after all efforts to avoid use have failed, indicating that the treatment of the patient is not effective. Before resorting to the use of restraints, other interventions must be attempted to maintain safety. Safe, effective, and least restrictive interventions are determined by the patient’s assessed needs and effective methods, if previously used for the patient. All behavioral health staff and security will be trained on Crisis Prevention Institute (CPI-an organization providing de-escalation and crisis prevention training programs) with written record of training and use CPI techniques. Review of the document “NCI (Nonviolent Crisis Intervention) With Advanced Physical Skills Training Instructor’s Guide,” from the Crisis Prevention Institute, copyright 2023 indicated the program objectives include: use the philosophy of care, welfare, safety, and security with a person centered approach when responding to a person in distress, the interpret distress behaviors, de-escalate of the situation, assess risk of behavior, and identify preventive strategies to mitigate risk, identify and respond appropriately to various levels of crisis behaviors. Safety intervention strategies include as staff move close to the person in distress, they approach from the side rather than the front or behind. The staff keep their posture nonthreatening, balanced, and relaxed. Staff respect their personal space and only move as close as they need to show support or provide assistance. Advanced physical skills include floor transition of a patient from a standing to seated positions. Staff are to maintain a supportive stance (managing your position, posture, and proximity in relation to the person in distress) and the outside/inside principle (Placing something on the outside and something on the inside of the limbs and/or body) on the person’s arms. With a staff member supporting the arms, as the person moves to the floor, step back with your foot nearest the person, and kneel. Once in a kneeling position, adjust your supportive stance, placing your knee, nearest the person, close to their hip. Adjust the position of your leg, furthest from the person, so you remain balanced and stable. Remain close in the supportive stance and apply the outside/inside principle to maintain your hold. With a staff member supporting the shoulders, begin with the supportive stance, approaching the person from behind. Stand close, adjusting your furthest leg so you remain balanced and stable. Place both hands behind the person’s shoulders. As the person moves to the floor, kneel placing your knee nearest the person on the floor, with your thigh resting against their spine. Once in a kneeling position, remain close, adjusting the position of your leg furthest from the person, so you remain balanced and stable. Once everyone is stable, encourage the person to rest back towards you. Avoid leaning or bending their body forward. Remain close in the supportive stance and apply the outside principle (by placing the palm of your furthest hand at their elbow, limits the outward motion of their arm, thus protecting yourself) to help maintain a seated position. Safety tips include move in a coordinated way, avoid pulling, pushing, or leaning the person forward as this will impair breathing, once the person is seated, consider the option to let go. The goal is to use the safety intervention that is a last resort, reasonable, and proportionate. And most often, this means considering verbal and environmental non-restrictive interventions first. Review of the medical record for Patient #1 revealed that on 04/02/25 at 04:56 PM, Patient #1 presented to the ED via ambulance with complaints of suicidal ideation with a plan. At 06:15 PM, Staff (L), Registered Nurse, documented that Patient #1 arrived voluntarily, was angry, non-compliant with staff requests, and threw objects, yelled, and swore at staff. At 05:12 PM, a rapid response was called. Patient #1 punched a security guard in the face twice and kicked the security guard. Patient #1 was medicated with Haldol 10 mg, Versed 2 mg, and Benadryl 50 mg (medications use to calm behavioral health patients). Patient #1 was placed in 4-point restraints. At 05:49 PM, the restraints were released. Review of the video surveillance of “ED Behavioral Health (BH) Hall 1,” dated 04/02/25, revealed: -At 05:04:21 PM, Patient #1 was escorted into the BH ED by Staff (O), Behavioral Health Technician (BHT), and was seated in a chair in the patient common area (located in front of the glassed in nursing station). -At 05:11:25 PM, Patient #1 removed a plastic water bottle from the right front pocket of the robe they were wearing and tossed it at the wall towards Staff (P), RN. Staff (L), RN, entered the common area. -At 05:11:34 PM, Staff (O), ED BHT, pointed down the hallway (in the direction of the bathroom) and Patient #1 shook their head in a side-to-side motion. Staff (O), Staff (N), RN, Staff (L), RN, and Staff (P), RN, were all in the common area standing approximately six feet from Patient #1. Staff (L) was speaking to Patient #1 who was becoming animated with their response to what Staff (L) was saying. -At 05:12:27 PM, Staff (L), RN, entered the nursing station and picking up a telephone receiver. Staff (P), RN, Staff (N), RN, and Staff (O) ED BHT exited the common area and entered the nursing station. -At 05:12:48 PM, Patient #1 stood up from the chair and began pacing, while talking and make gestures with their arms. -At 05:12:58 PM, Patient #1 approached a table in the common area, picked up clothes on the table, and tossed them in the air. -At 05:13:05 PM, Patient #1 walked up to the table, picked up a specimen collection cup, and stepped away from the table. Staff (K), RN, opened the door from the nurse ’ s station and spoke to Patient #1. -At 05:13:15 PM, Staff (I), Security Officer, Staff (K), RN, and Staff (N), RN, entered the common area from the nursing station. Patient #1 took a few steps back away from the staff members. Staff (I), Security Officer, approached Patient #1. -At 05:13:30 PM, Staff (I), Security Officer, was standing approximately three feet away from Patient #1 while putting on a pair of gloves and talking to Patient #1. Staff (K), RN, and Staff (N), RN were approximately nine feet away from Patient #1, in front of the nursing station door. -At 05:13:35 PM, Patient #1 took a step towards Staff (I), Security Officer, and was within two feet, yelling and pointing their left index finger at Staff (I). Staff (I) took a step towards Patient #1 and stood face-to-face with them, while pointing down the hall and speaking. -At 05:13:38 PM, Staff (I), Security Officer, took their left hand, placed it on Patient #1 ’ s right shoulder, and shoved Patient #1 in the direction Staff (I) had been pointing. Patient #1 took one step in the direction Staff (I) had been pointing. Patient #1 turned back to face Staff (I) and struck out with their right fist, which appeared to contact the left side of Staff (I)’s neck/jaw. Staff (I) stepped into Patient #1, grabbed Patient #1 ’ s right arm with their left hand, and grabbed Patient #1’s robe around the right shoulder with their right hand. Staff (I) took a step away from Patient #1, pulled Patient #1 towards them, and swung Patient #1 around Staff (I) ’ s body to the ground. Patient #1 landed on their right hip and was then in an upright seated position on the floor. Staff (I) advanced to stand over the seated Patient #1. Patient #1 struck out with their right fist hitting Staff (I) in the left upper thigh area. Staff (I) pushed Patient #1 backwards. While lying on their back, Patient #1 kicked out at Staff (I). Staff (I) caught both of Patient #1’s feet as they contacted Staff (I) and threw them to the side. Staff (I) stepped in and laid their weight on Patient #1. Patient #1 was on the ground struggling with Staff (I) on top of them. Patient #1 struck Staff (I) two to three times in the face with their left fist. During the struggle, Staff (L), RN, and Staff (F), RN/Director Of Emergency Department, entered the common area from the nursing station. -At 05:14:00 PM, Staff (I), Security Officer, with the assistance of Staff (L), RN, and Staff (F), RN/Director of the ED, physically restrained Patient #1 to the ground lying in a back down lying position. Staff (F) secured Patient #1 ’ s legs while Staff (L) secured Patient #1 ’ s left upper body. Staff (I) held their forearm across the right side of Patient #1 ’ s neck and chest area, while forcing Patient #1 ’ s face to the left. -At 05:14:32 PM, Staff (N), RN, arrived in the common area with a four-point restraint stretcher. Staff (R), Security Officer, arrived, went to Patient #1 ’ s legs and took over for Staff (F). Staff (I) and Staff (R), Security Officers were physically restraining Patient #1 on the floor. The other nursing staff were preparing the restraint stretcher. -At 05:15:11 PM, Staff (I), Security Officer, grabbed the left upper extremity of Patient #1, Staff (L), RN, grabbed the right upper extremity of Patient #1, Staff (R), Security Officer, grabbed the lower left extremity of Patient #1, and Staff (N), RN, grabbed the right lower extremity of Patient #1. Together the four staff members lifted Patient #1 from the floor to the stretcher. Once on the stretcher, Patient #1 was held in place by Staff (I) and Staff (R), while Staff (F), RN/Director Of Emergency Department, Staff (K), RN, Staff (L), RN, and Staff (O), ED BHT, placed the four-point restraints on Patient #1. -At 05:16:24 PM, Patient #1 was restrained lying with their back down on the stretcher with all four extremities strapped to the stretcher at the ankles and wrists. All staff members removed their hands from Patient #1. Patient #1 was thrashing around on the stretcher. Interview on 05/02/25 at 11:55 AM with Staff (J), Crisis Prevention Intervention (CPI) Instructor, revealed that they were unaware of the incident involving Patient #1. After reviewing video surveillance footage of the ED Behavioral Health unit, dated 04/02/25 from 05:04 PM to 05:17:59 PM, from three different angles, Staff (J) stated that there were multiple instances where CPI techniques were not followed by staff. Staff (I), Security Officer, approached Patient #1 alone, which was inconsistent with CPI training. CPI training teaches that when approaching a potentially threatening patient, there should be a minimum of two staff members, and ideally at least three staff members. Unless there was an immediate safety issue, which was not seen in the video, Staff (I) should have waited until more staff members arrived to approach Patient #1. If only one staff member had to approach a potentially threatening patient for safety reasons, they should approach from the patient’s side, placing their hands on the patient’s upper arms to prevent the patient from striking out, and guide the patient in the direction staff wishes patient to go. In the video footage Staff (I) approached Patient #1 face-to-face, placing their right arm on Patient #1’s right shoulder and left hand on Patient #1’s back, shoving Patient #1 in the direction of the bathroom. This is inconsistent with CPI training. There is no training in the CPI curriculum for a single person to take a patient from a standing position to the ground. At least three staff members should be used, and the take-down should be completed in two steps. There should be a staff member on each side of the patient and one directly behind the patient. The staff members should take patient from a standing position to a seated position, then from a seated position to a laying position with the patient lying flat on their back on the floor. The actions of Staff (I), grabbing Patient #1 by the arms and swinging them around to the ground, was inconsistent with the CPI training. Per CPI training curriculum, when holding a patient in a laying position there should be four staff members utilized, two holding the upper body at the shoulders and one holding each of the patient’s legs. There should never be a staff member holding down a patient by placing an arm across a patient’s neck and chest, as was seen in the surveillance video. Staff (I) placed their arm across Patient #1’s neck and chest area, forcing Patient #1’s face to the left. This action by Staff (I) was inconsistent with CPI training. There were other staff members, seen on the video footage, who had current CPI certification that should have intervened when they witnessed Staff (I)’s inappropriate actions. Interview on 05/02/25 at 12:00 PM with Staff (A), Vice President of Quality and Compliance, verified that ED staff did not follow CPI approved techniques when restraining Patient #1. Findings #2: Review of policy “Pursuit of Patient Leaving Without Permission (Elopement),” dated August 2023, revealed any patient elopement must be reported within 24 hours to the quality management department and an incident report will be completed in its entirety by the department manager. Documentation of the event must be entered in the incident reporting system and should include the time of the elopement, who was notified by whom, that a code grey was performed, areas searched, and the condition of the patient upon return and final patient disposition. The report should also include the names of those notified and time of notification. Review of medical record for Patient #2 revealed on 01/24/25 at 03:57 PM, Patient #2 presented to the Emergency Department (ED) for a mental health exam. On 01/25/25 at 10:44 AM, Staff (G), ED Physician completed a 9.39 Mental Hygiene Law (New York State law allowing for an involuntary emergency admission of an individual who is believed to have a mental illness and are in immediate danger of harming themselves or others.) form and placed an order for an involuntary emergency admission of Patient #2 to the behavioral health inpatient unit for severe postpartum depression, violent behavior, and severe anxiety. On 01/25/25 at 04:44 PM, Staff (AA), Registered Nurse, documented Patient #2 eloped from two staff members during transport to the behavioral health inpatient unit. A code was called. The physician and house supervisor were made aware. On 01/26/25 at 07:10 AM, Patient #2 called the hospital and wanted to come get their belongings. Staff (K), Registered Nurse, called the house supervisor who indicated to release the belongings to Patient #2. Patient #2 was notified that their belongings were at the front desk with the security guard and that they needed to sign that they picked up their stuff. Security was notified that Patient #2 would be arriving in 20 minutes and needed to sign paperwork. The call was ended, and the physician was notified. Review of incident report log, dated 01/01/25 to 04/30/25, revealed no evidence that an incident was found for the elopement of Patient #2. Interview on 05/12/25 at 02:00 PM with Staff (C), Chief Nursing Officer, verified this finding. Findings #3: Review of policy “Pursuit of Patient Leaving Without Permission (Elopement),” dated August 2023, revealed when a patient is discovered missing from an inpatient care unit, a code gray (patient elopement) is called. The hospital operator will contact security, the administrative coordinator on duty, and the police. At least two staff members from the unit will begin the immediate search. Once outside the facility, if the patient returns to the hospital they must be reevaluated and admitted through the emergency department. If applicable, the unit charge nurse will notify the following parties if the patient returns: communications, security, administrative coordinator, the police, quality management, and the case manager. Review of medical record for Patient #2 revealed on 01/24/25 at 03:57 PM, Patient #2 presented to the ED for a mental health exam. On 01/25/25 at 10:44 AM, Staff (G), ED Physician completed a 9.39 Mental Hygiene Law (New York State law allowing for an involuntary emergency admission of an individual who is believed to have a mental illness and are in immediate danger of harming themselves or others.) form and placed an order for an involuntary emergency admission of Patient #2 to the behavioral health inpatient unit for severe postpartum depression, violent behavior, and severe anxiety. On 01/25/25 at 04:44 PM, Staff (AA), Registered Nurse, documented Patient #2 eloped from two staff members during transport to the behavioral health inpatient unit. A code was called. The physician and house supervisor were made aware. On 01/26/25 at 07:10 AM, Patient #2 called the hospital and wanted to come get their belongings. Staff (K), Registered Nurse, called the house supervisor who indicated to release the belongings to Patient #2. Patient #2 was notified that their belongings were at the front desk with the security guard and that they needed to sign that they picked up their stuff. Security was notified that Patient #2 would be arriving in 20 minutes and needed to sign paperwork. The call was ended, and the physician was notified. Review of Quality Assurance documents from February 2025 revealed the facility identified the need to revise elopement policies to include security will be present on all behavioral health transfers and that any patient who elopes and returns the facility will be reassessed by a provider. However, the polices have not been approved by administration and there was no evidence of any formal staff education on the new procedures. Interview on 05/12/25 at 10:39 AM and 02:00 PM with Staff (C), Chief Nursing Officer, revealed they were the house supervisor on 01/26/25. Staff (C) spoke with Staff (K), Registered Nurse from the ED who asked if Patient #2 could come into the hospital to pick up their belongings. Staff (K) updated Staff (C) on what had occurred with Patient #2. Staff (C) asked if Patient #2 was on a hold. Staff (K) stated Patient #2 was not on a hold. Staff (C) gave the okay that Patient #2 could pick up their belongings. If Staff (C) knew Patient #2 was on an involuntary admission hold, Patient #2 would have been re-evaluated by a provider upon arrival to the facility. Interview on 05/12/25 at 11:18 AM with Staff (K), Registered Nurse, revealed on 01/26/25, they told Staff (C), Chief Nursing Officer, that Patient #2 was not on any involuntary emergency admission papers. Patient #2 was a voluntary presentation to the ED. Staff (K) stated the 9.39 involuntary emergency admission paperwork was signed for Patient #2 but indicated it would only go into effect when the patient presented to the inpatient behavioral health unit. 9.39 paperwork is for admission purposes only. Staff (K) stated Patient #2 was an inpatient behavioral health patient at the time of absconding from the ED.”

“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: 48506 Based on policy review, medical record review, document review, and interview, in 3 of 11 medical records reviewed, it was determined that a physician order was not obtained for the use of restraints (Patient #1, Patient #5, and Patient #8) Findings include: Review of the policy “Restraints and Seclusion,” dated February 2025, revealed all restraint use is initiated and continued for a specified, limited period pursuant to a written order. Only a licensed physician may order restraints and/or manage patients in restraints. Restraints may be initiated by a physician, or in an emergency by a registered nurse (RN) when the patient presents as an immediate danger to self or others. The RN shall call the physician as soon as it is safe to do so, recording the time of the call, and the physician who was contacted. Review of the policy “Restraints,” dated September 2023, revealed all restraint use is initiated and continued for a specified, limited period of time pursuant to a written order. When the patient is engaging in an activity that presents an immediate danger to the patient or others and a physician is not available on the unit, a restraint may be applied, or under the supervision and direction of, a RN who must document the circumstances requiring the use of a restraint. In such emergencies, the nurse must immediately request an assessment by a physician and obtain a telephone order. A written order must be obtained within one hour. A telephone order must be obtained within five minutes of the application of restraint. The order for restraint will include date and time, type of restraint, specific indications and reasons for use, and a specified limited period of time for use. If a patient who is restrained for aggressiveness or violence quickly recovers and is released before the physician arrives to perform the assessment, the physician must still perform a face-to-face assessment and write an order for the period of time that the patient was restrained. Review of the medical records revealed no evidence a physician order was obtained for the implementation and utilization of restraints for the following patients: Patient #1 was placed in four-point restraints on 04/02/25 from 05:16 PM until 05:49 PM; Patient #5 was placed in 4-point restraints on 01/31/25 from 04:18 AM to 04:48 AM; and Patient #8 was placed in 4-point restraints on 10/26/24 from 06:14 PM to 06:25 PM. Interview on 05/01/25 at 02:00 PM with Staff (F), Director of Emergency Department, verified the finding for Patient #1. Interview on 05/02/25 at 02:00 PM with Staff (V), Emergency Department Clinical Coordinator, verified the finding for Patient #5 and Patient #8.”

“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: 48506 Based on policy review, medical record review, and interview, in 4 of 11 medical records reviewed, it was determined that a physician’s face-to-face assessment was not conducted within one hour of the initiation of restraints. (Patient #1, Patient #4, Patient #5, and Patient #8). Findings include: Review of the policy “Restraints and Seclusion,” dated February 2025, revealed restraints may be initiated by a physician (MD), or by a registered nurse (RN) in an emergency when the patient presents as an immediate danger to self or others. The physician who arrives must be the same as the physician who gave the restraints order. This physician must arrive to the unit within 30 minutes of restraints application, perform a face-to-face evaluation of the patient, and document this encounter using the “MD Face-to-Face Assessment note.” If a physician does not arrive within thirty minutes of being summoned, the senior staff member shall record any such delay in the patient’s clinical record with a written description justifying the emergency restraint, the nature of the restraints, and any conditions for maintaining the restraints until the arrival of a physician. The physician shall place in the clinical record an explanation for any such delay. Review of the policy “Restraints,” dated September 2023, revealed the physician will perform a face-to-face evaluation of the patient and write an order for the restraint within one hour of notification by the nurse. If a patient who is restrained for aggressiveness or violence quickly recovers and is released before the physician arrives to perform the assessment, the physician must still perform a face-to-face assessment and write an order for the period of time that the patient was restrained. The fact that the patient’s behavior warranted the use of a restraint indicated a serious medical or psychological need for prompt assessment of the incident/situation that led to the intervention, as well as the medical and psychological condition of the patient at the time of the assessment. Review of the medical records revealed no evidence a physician face to face assessment was conducted within one hour of the initiation of restraints for the following patients: Patient #1 was placed in four-point restraints on 04/02/25 from 05:16 PM until 05:49 PM; Patient #4 was placed in 4-point restraints on 02/24/24 from 07:00 PM until 07:15 PM; Patient #5 was placed in 4-point restraints on 01/31/25 from 04:18 AM to 04:48 AM; and Patient #8 was placed in 4-point restraints on 10/26/24 from 06:14 PM to 06:25 PM. Interview on 05/01/25 at 02:00 PM with Staff (F), Director of Emergency Department, verified the finding for Patient #1. Interview on 05/02/25 at 02:00 PM with Staff (V), Emergency Department Clinical Coordinator, verified the findings for Patients #4, Patient #5, and Patient #8.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(ii) [there must be documentation in the patient’s medical record of the following:] A description of the patient’s behavior and the intervention used. This Standard is not met as evidenced by: 48506 Based on policy review, medical record review, and interview, in 4 of 11 medical records reviewed, clinical staff failed to complete restraint documentation for Patients #1, Patient #2, Patient #4, and Patient #7. Findings include: Review of the policy “Restraints and Seclusion,” dated February 2025, revealed that upon initiation of restraints, the registered nurse (RN) shall complete the “Behavioral Health Restraint/Seclusion Application using the corresponding nursing note template in the electronic medical record. This documentation must contain the restraint/seclusion start time, name of the provider who was contacted and the time they were contacted, and the time the physician arrived to see the patient face-to-face. The nurse must also document any de-escalation methods attempted and the patient’s response to these interventions. Review of the policy “Restraints,” dated September 2023, revealed the order for restraint will include date and time, type of restraint, specific indications and reasons for use, and a specified limited period of time for use. The nurse must document behaviors of the patient, which required maintaining the restraint until arrival of the practitioner. Review of the medical record for Patient #1 revealed no evidence of the start time of restraint, and the name and time of the contacted provider. Patient #1 was placed in 4-point restraints on 04/02/25. Review of medical record for Patient #2 revealed an order for a side rail restraint but Patient #2 was placed in five-point restraints on 01/24/25 by clinical staff. Review of medical record for Patient #4 revealed no evidence of the start time or the time of discontinuation of the four-point restraints implemented on 04/24/25. Review of medical record for Patient #7 revealed an order for a side rail restraint but Patient #7 was placed in four-point restraints on 12/19/24 by clinical staff. Interview on 05/01/25 at 02:00 PM with Staff (F), Director of Emergency Department, verified the lack of documentation for Patient #1. Interview on 05/02/25 at 02:00 PM with Staff (V), Emergency Department Clinical Coordinator, verified the wrong restraint orders and use for Patients #2 and #7 and the lack of documentation for Patient #4.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2) Training content. 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: (i) Techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion. This Standard is not met as evidenced by: 48506 Based on policy review, document review, and interview, in three of nine credential/personnel files reviewed, the hospital failed to ensure all staff are trained on Crisis Prevention Intervention (Staff (F), Staff (N), and Staff (O). Findings include: Review of the policy “Restraints and Seclusion,” dated February 2025, revealed Crisis Prevention Intervention (CPI) techniques will be used at all times by the behavioral health staff while on duty. All behavioral health staff, security staff, and any staff who responds to behavioral crisis situations will be trained on CPI, with written record of the training. Review of credential/personnel files for Staff (F), Director of Emergency Department, Staff (N), Registered Nurse, and Staff (O), Behavioral Health Technician, revealed no evidence of CPI training. Interview on 05/02/25 at 05:28 PM with Staff (O), Behavioral Health Technician, revealed they were not CPI trained. Interview on 05/02/25 at 08:30 PM with Staff (F), Director of Emergency Department, revealed they were not CPI trained. Interview on 05/12/25 at 12:16 PM with Staff (A), Vice President Quality and Compliance, revealed Staff (N), Registered Nurse, was not CPI trained.”