New York-Presbyterian Hospital

“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: 48001 . Based on document review, policy review, and staff interviews, the hospital failed to ensure that proposed corrective actions identified through its incident/adverse event review process were timely implemented and monitored in accordance with the hospital’s Quality and Patient Safety (QPS) Program. This failure was identified in one of sixteen (16) medical records reviewed (Patient #2). Findings include: Review of the hospital’s 2024 QPS Program revealed that the program is responsible for overseeing activities of all hospital and patient services to enhance the quality and safety of patient care. The scope of the QPS Program includes but is not limited to: identifying actual and potential problems related to patient care and clinical performance; assessing the cause and scope of identified problems; developing and recommending corrective actions; implementing corrective actions through established mechanisms; and monitoring and evaluating actions taken to confirm effectiveness. Review of the facility’s Mortality Review Log from January 2025 through March 2025 identified an incident involving the management of Patient #1 classified as American Society of Anesthesiologists (ASA) Physical Status Classification Levels 4 (ASA 4: a patient with severe systemic disease that is a constant threat to life. As a result of this incident, the facility proposed corrective actions, which included education of Certified Registered Nurse Anesthetists (CRNAs) on the use of multiple anesthetic agents and the implementation of a pre-anesthesia huddle involving the anesthesiologist, CRNA, and surgeon to discuss the anesthesia plan and management of patients classified as ASA levels 4 and 5 (ASA 5: a moribund patient who is not expected to survive without the operation). Review of quality meeting minutes dated 01/24/2025 confirmed that concerns related to this event were discussed. However, there was no documented evidence that indicates the proposed corrective actions were implemented or monitored for effectiveness. During an interview conducted on 12/11/2025 at 10:32 AM, Staff I, Anesthesiology Administrator, stated that a preoperative procedure meeting/huddle involving the anesthesiologist, surgeon, and CRNA had been implemented. However, Staff I was unable to provide documentation in the medical record or quality files to support that the corrective actions were implemented. During an interview conducted on 12/12/2025 at 10:58 AM, Staff D, hospital leadership, acknowledged the findings and confirmed that the corrective actions were not documented. Staff D further stated that, after assessing the event as a quality improvement issue, it was determined that a preoperative huddle with the surgeon and anesthesiologist would be held to determine whether a CRNA or anesthesiologist would be assigned to patients classified as ASA levels 4 or 5. Staff D was unable to provide documentation supporting implementation of this process. During an interview conducted on 12/11/2025 at 5:00 PM, Staff DD, CRNA leadership, stated that meetings with CRNAs were held every other month to review problematic medications and cases. However, review of CRNA meeting minutes for 2025 revealed no documented evidence that corrective actions related to Patient #2 were discussed, implemented, or monitored. During interview conducted on 12/11/2025 10:30 AM, Staff I, Anesthesia Administration, confirmed that there are no documentation to support the completion of staff education or preoperative huddles.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 48939 . Based on medical record (MR) review, document review, and interview, facility staff failed to document a discharge safety plan for a patient who presented to the Comprehensive Psychiatric Emergency Program (CPEP) after a suicide attempt in one (1) of six (6) CPEP discharges reviewed (Patient #1). Findings: The Policy and Procedure (P&P), “Safety Planning,” (Revised 04/2023), revealed, “A. Safety Plans are completed for patients who are being discharged to the community from either the ED or Extended Observation Bed Unit (EOB), and who score moderate risk on the SAFE-T rating tool, which is completed by the psychiatrist. B. After discussion with the patient, the clinician (social worker, resident, or attending psychiatrist) enters the plan in the safety plan note in the electronic medical record. C. The psychiatrist will comment on the completion of the Safety Plan in their discharge documentation. D. The patient will be provided with a copy of the Safety Plan with their After-Visit Summary.” MR review of Patient #1 revealed they presented to the facility on 04/21/2025 at 11:17 AM as a transfer from another facility for a psychiatric evaluation after a suicide attempt. At 11:51 AM, Staff B (Physician) documented that the patient scored “High Risk” on the C-SSRS [Columbia Suicide Severity Rating Scale] and SAFE-T [Suicide Assessment Five-Step Evaluation and Triage] Assessment tools. They documented, “I have determined based on clinical information that the patient is at risk for suicide.” At 9:26 PM, Staff B documented that the patient no longer had suicidal ideation. At 9:41 PM, the patient was discharged. There was no documentation in Patient #1’s MR that a Safety Plan was attempted or completed. During an interview with Staff B (Physician), on 11/25/2025 at 2:00 PM, they stated they remembered offering to create a safety plan for the patient, but the patient declined. They were unsure if it was documented. During an interview with Staff J (Administrator), on 11/26/2025 at 10:18 AM, they acknowledged that a Safety Plan should have been documented.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 10686 . Based on medical record (MR) review, document review, and interview, the Governing Body failed to effectively carry out its responsibilities for conducting hospital operations. Findings include: A. The Patient Safety Committee, through its Quality Assurance and Performance Improvement Program, failed to identify that a Nurse Practitioner (NP) who performed circumcision (a surgical procedure where the foreskin covering the penis is removed) for Patient #1 was credentialed and privileged to perform the procedure. (See Tag A - 0286) B. The Medical Staff did not ensure all providers who perform circumcision are credentialed and privileged. (See Tag A-0338 and A-0339) .”

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 16362 Based on document review, medical record (MR) review, and interview, the Medical Staff failed to ensure a non-physician practitioner was eligible for appointment by the governing body. Findings include: The Medical Staff failed to appropriately credential and privilege a Nurse Practitioner (NP) to perform circumcisions in the Cardiac Neonatal Intensive Care Unit (NICU). (See Tag A-0339)”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 16362 . Based on document review and interview, the Patient Safety Committee, in its review of adverse events, failed to identify that a Nurse Practitioner (NP) who performed circumcision was credentialed and privileged for the procedure. Findings include: A review of Patient #1’s medical record identified Patient #1 was admitted to the Cardiac Neonatal Intensive Care Unit (NICU) on 4/8/2025. The patient underwent a cardiac procedure and was placed on Aspirin (medication known to thin the blood and increase the risk of bleeding). On 04/14/2025 at 10:28 PM, Staff A (NP) noted that the patient underwent circumcision. Post-procedure, the patient experienced bleeding, and their hematocrit (red blood cells in a person’s total blood volume) dropped, requiring blood transfusion and fluid resuscitation. A review of Staff A’s personnel file on 05/05/2025 revealed they were not credentialed to perform circumcisions in the cardiac NICU. There was no documented evidence that the Patient Safety review identified that Staff A was not privileged or credentialled to perform circumcision. In an interview with Staff B (Attending Director) on 05/02/2025 at 11:44 AM, Staff B stated they knew the NP was privileged and credentialed but did not see the documentation to verify the credentials. During the interview of Staff H (Executive Administrator) on 05/05/2025 at 12:05 PM, Staff H stated that Staff A was privileged for care in the Pediatric ICU but not in the Cardiac Neonatal ICU. Staff P (Executive Administrator) confirmed and acknowledged the findings during an interview on 05/09/2025 at 11:10 AM. .”

“ELIGIBILITY & PROCESS FOR APPT TO MED STAFF CFR(s): 482.22(a) The medical staff must be composed of doctors of medicine or osteopathy. In accordance with State law, including scope of practice laws, the medical staff may also include other categories of physicians (as listed at §482.12(c)(1)) and non-physician practitioners who are determined to be eligible for appointment by the governing body. This Standard is not met as evidenced by: 16362 . Based on document review, medical record (MR) review, and interview, in one (1) of five (5) credentialing/privileging files, the Medical Staff failed to appropriately credential and privilege a Nurse Practitioner (NP) to perform circumcision. Findings include: The Medical Staff Bylaws, dated 12/12/2024, stated, “Clinical privileges for each member of the medical staff shall be specific to each site delineated in writing at the time of appointment, and each reappointment, in accordance with the method recommended by the medical board and approved by the board of trustees for the clinical service concerned, and shall be based on consideration of the practitioner’s education, training, experience, demonstrated current competence, references, the objectives, plans and programs of the hospital and other relevant information and may be obtained.” A review of medical record for Patient #1 identified that the patient was admitted to Cardiac Neonatal Intensive Care Unit) NICU) on 4/8/2025 and underwent a cardiac procedure and was placed on Aspirin (medication known to thin the blood and may increase the risk of bleeding). On 04/14/25 at 10:28 PM, Staff A (Nurse Practitioner) noted that the patient underwent circumcision with no complications and minimal blood loss. On 04/15/25 at 2:30 AM, the patient’s vital signs were within normal range. Bleeding was identified, and the patient’s Hematocrit (Hct, a blood test that measures the percentage of red blood cells in blood) dropped from 33% (pre-procedure) to 22% post-circumcision (normal range for newborns = 45-61%). A review of Staff A’s personnel file on 05/05/25 revealed that Staff A was not credentialed to perform circumcision. During the interview with Staff A on 05/07/25 at 4:00 PM, Staff A stated that they had a break in service from the hospital, having left in 2022 and returned in October 2023. “When I came back, I don’t remember what privileges I asked for. I assumed I had all the same privileges.” Staff A stated, “They were unaware that they were not privileged for circumcision.” According to the interview with Staff B (Director and Attending) on 05/02/2025 at 11:44 AM, Staff B stated that they were aware the NP was privileged/credentialed but had no access to the documentation to verify their credentials. During the interview of Staff H (Executive Administrator) on 05/05/2025 at 12:05 PM, Staff H confirmed and verified that the Medical Staff did not credential Staff A to perform circumcision. Per the interview with Staff P (Executive Administrator) on 05/09/2025 at 11:10 AM, Staff P confirmed and acknowledged the findings.”

“SURGICAL PRIVILEGES CFR(s): 482.51(a)(4) Surgical privileges must be delineated for all practitioners performing surgery in accordance with the competencies of each practitioner. The surgical service must maintain a roster of practitioners specifying the surgical privileges of each practitioner. This Standard is not met as evidenced by: 10686 . Based on document review and staff interview, the hospital did not ensure the surgical privileges of all practitioners, including a Nurse Practitioner (NP) who performed circumcision, were delineated. Findings include: Review of the Medical Staff Bylaws dated 12/12/2024, under the section titled Clinical Privileges, states, “Clinical privileges for each member of the medical staff shall be specific to each site delineated in writing at the time of appointment and each reappointment in accordance with the method recommended by the medical board and approved by the board of trustees for the clinical service concerned, and shall be based on consideration of the practitioner’s education, training, experience, demonstrated current competence, references, the objectives, plans and programs of the hospital and other relevant information and may be obtained.” A review of Staff A’s personnel file on 05/05/25 revealed they were not credentialed and privileged to perform the circumcision. During an interview on 05/09/2025 at 12:25 PM, Staff Q (Quality and Safety) confirmed that the surgical department does the credentialing and privileging of surgeons, and the NICU and PICU department/service is responsible for NICU and PICU providers.”

“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: 33919 Based on medical record review, document review, and staff interview, the facility failed to fully implement and maintain an effective, ongoing, data-driven Quality Assessment and Performance Improvement (QAPI) program. Findings: -The facility failed to ensure all patient events were reviewed, analyzed, and preventive actions were implemented. (See Tag 286)”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 33919 Based on medical record (MR) review, document review and interview, in two (2) of six (6) adverse events reviewed, the facility failed to ensure all patient events are reviewed, analyzed, and preventive actions are implemented. (Patient #8 and Patient #10). Findings: The Policy and Procedure (P&P), “Adverse Event Reporting,” (Revised October 2024), states, “staff should report events that occur on hospital premises which are not consistent with routine operations or care of patients. These events may involve actual harm or no harm...Types of events to report are: 1) Unsafe Conditions: Circumstances or dangerous situations that increase the probability of an event occurring.” Review of Patient #10’s MR revealed the patient was well known to the facility ED and presented on 2/23/2024 with agitation and assessed by the ED physician to be at “baseline” and not in need of a psych eval at that time. Patient #10 was discharged from the Emergency Department (ED) but refused to leave the facility and was escorted out of the ED by Security Officers (SO). Review of the ED Security Log for February 2024 noted while still on the facility grounds near the ambulance bay, Patient #10 became aggressive and threatened SOs with a broken bottle. Per the security report “security notified operations that [Patient #10] grabbed and broke a glass bottle and became menacing towards security and [themselves].” NYPD / 911 was called, and the patient was transported to another facility by Emergency Medical Services (EMS). There was no documented evidence the ED physician or staff were notified by the SOs of Patient #10’s escalating behavior. Per interview with Staff B, Regulatory Manager, on 1/7/2025 at 2:11 PM, SOs would have to put security incidents in the Keepsafe (adverse event reporting) system. The head of security reviews the cases to determine if further investigation is needed. There is no automatic clinical review of security incidents unless the SO notifies the quality or risk department. Per interview with Staff S, Vice Chief of the ED, on 1/8/2025 at 12:57 PM, Staff S acknowledged the ED physician, and staff were not notified of the incident. Staff S also stated that no one from the ED reviews the Security Logs regarding patient interactions. There was no documented evidence the event involving Patient #10 was documented and investigated as an adverse event. Review of the Emergency Department Quality Assurance meeting, Security Department meetings, or hospital-wide quality assurance meetings from 1/2024 to 1/2025 revealed there was no evidence that Security Log incidents involving patients are reviewed and discussed. Per interview with Staff R, (Senior Director of Quality and Patient Services), on 1/9/2025 at 1:45P, Staff R acknowledged this finding and confirmed the security log events involving patients are not reviewed by any clinical staff to ensure patient care and safety are met. The facility failed to identify room for improvement in the adverse event review for Patient #8, who experienced a delay in seizure diagnosis while admitted to the intensive care unit (ICU). Medical record review for Patient #8 revealed that they were admitted to the ICU on 12/12/2024 for blood pressure monitoring and frequent neuro checks following a stroke. On 12/13/2024 at 9:40 PM, the RN documented they notified the physician of new symptoms of upper extremity twitching and intermittent unresponsiveness. They stated, “EEG (electroencephalogram, a test to measure seizure activity in the brain) tech is out for the night. EEG still pending ...nursing supervisor contacted encouraged to notify 3rd year resident ...3rd year resident at bedside. 1 mg Ativan (a medication that can be used to rapidly treat seizures short-term) given.” On 12/13/2024 at 11:23 PM, Staff H, Resident, ordered a routine EEG and documented, “Given that patient possibly had focal seizures in the setting of intracranial bleed, neurology was contacted. Case was discussed and a plan was made: Give Ativan 1 mg IV stat; Ativan PRN (as needed) IV; EEG first and consider vEEG (video EEG) if confirmed abnormal activity; Load with keppra (anticonvulsant seizure medication) 3,000 mg IV if seizure doesn’t respond to Ativan.” During interview with Staff J, ICU RN, on 1/15/2025 at 9:52 AM, they stated, “The patient had multiple episodes of twitching and desaturation, so a few nurses were in the room. We notified the doctor, and there was a big gap in them responding. It took at least 30 minutes. We notified the nursing supervisor and then went up the chain of command.” During interview with Staff M, EEG Technician, on 01/15/2025 at 1:11 PM, they stated, “When I got there at 8:00 AM, I saw the order for an over one-hour EEG and called to confirm the order ...I spoke to [Staff G, Neurology Attending], who said the order could be changed to continuous monitoring once the head CT was completed. I asked the resident to change the order at 8:42 AM and again at 9:52 AM ...At one point I went down to the ICU and saw the CT scan was being done. Shortly after, I contacted the resident asking if it was done. It took them a while to respond, and I had already moved on to another patient ...The order was changed at 11:32 AM ...I had to finish what I was doing before I could go back to the ICU.” The patient’s head CT was completed with results read on 12/14/2024 at 10:39 AM. The EEG began at 2:47 PM. During interview with Staff N, Critical Care Attending, on 01/16/2025 at 11:33 AM, they stated, “In the ICU, the resident is expected to respond within minutes” During interview with Staff I, Critical Care Fellow on 01/14/2025 at 2:16 PM, they stated, “During the case review in QA [Quality Assurance], we inquired why we can’t have an EEG tech at night.” Staff I did not know the outcome of the QA review. Review of the document, “Current Summary Treatment/Coordination of Care Event” revealed that QA was completed with Critical Care Medicine, Nursing, and Neurology departments for a potential delay in care. The document indicated that there were no gaps in care identified, no room for improvement, and therefore no corrective implemented. The facility failed to identify delays in physician response to nursing and the EEG technologist and availability of EEG staff as room for improvement in their Quality Review of this adverse event.”

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 33919 Based on medical record review, document review, and interview, the facility failed to ensure an attending physician signed a first year (PGY1) Resident’s note in a timely manner in one (1) of ten (10) patients reviewed (Patient #7). The policy, “Supervision Policy” (Revised October 2022), states, “The Medical Board, on behalf of the Medical Staff, shall ...institute written policies and procedures governing medical practice by graduate staff.” In the section, “Supervision in Specific Settings,” the policy states that oversight and supervision of graduate staff by an Attending physician must be documented within 24 hours on inpatient units. There is no timeframe for Attending physician oversight of graduate staff in the Emergency Department (ED). Medical Record review revealed that Patient #7 presented to the ED on 01/02/2025 at 12:30 PM with a chief complaint of unsteady gait and fall. On 01/02/2025 at 8:22 PM, Staff L, PGY1 ED Resident, documented a note that included History of Present Illness, Physician Examination, Review of Laboratory and Imaging Results, ED Course, and plan for admission. On 01/10/2025 at 5:28 PM Staff K, ED Attending, signed an Attestation stating, “I was the Supervising Physician. I have seen face to face and examined the patient; reviewed history and physician and discussed the medical decision making with the Medical Student, Resident, Fellow, PA, and/or NP. I agree with the assessment and plan as presented unless otherwise documented.” During interview with Staff K, ED Attending on 1/17/2025 at 10:40 AM, they stated, “The expectation is to sign off on notes within 48 hours. I understand that didn’t happen with this case.” During interview with Staff B, Regulatory Manager, on 1/17/2025 at 2:22 PM, they stated, “there is no written timeframe for Attending sign offs on Resident notes in the ED. The timeline is department specific ...inpatient units have 24 hours. The ED has 48 hours.””

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 33919 Based on medical record (MR) review, document review and interview, the facility failed to provide a Medical Screening Exam (MSE) prior to discharge, in two (2) of forty-four (44) MRs reviewed. Findings: Review of the facility’s policy, “Emergency Medical Treatment and Labor Act (EMTALA), revised 05/2023, stated, “...If it determines that an Emergency Medical Condition (EMC) exists, the Hospital will provide further medical care and treatment intended to stabilize such EMC.” Review of Patient #23’s medical record revealed this patient was a hemodialysis (a treatment for kidney failure that removes waste and extra fluids from the blood) patient who presented to the Emergency Department (ED) on 1/1/2025 with shortness of breath (SOB) and chest pain, after missing 3-4 dialysis treatment sessions. Review of the ED’s Security Logs for January 2025 noted that after Patient #23’s triage and medical screen, Patient #23 walked through a metal detector while entering the treatment area and was found with a firearm. The patient was calm and cooperative and willingly handed over the firearm to the facility Security Officers without incident. The New York Police Department (NYPD) was notified, and the patient was arrested by NYPD and removed from the hospital. There was no documented evidence an ED physician or other medical staff were notified by the Security Officers (SO) during the event. Review of Patient #23’s medical record lacked documented evidence that a Medical Screen Exam (MSE) for an EMC was conducted prior to Patient #23’s removal from the hospital. During interview of Staff S (Vice Chief of the ED) on 1/8/2025 at 12:57 PM, Staff S stated, “The patient shouldn’t have left the property without treatment.” Staff S acknowledged the patient was not examined by a physician or medical provider. Review of Patient #36’s medical record revealed this patient was well known to the facility and presented to the ED on 2/23/2024 with agitation. Patient #36 was assessed by the ED physician to be at “baseline” and not in need of a psychiatric evaluation at the time. Patient #36 was discharged from the Emergency Department (ED) but refused to leave the facility and was escorted out of the ED by Security Officers (SO). Review of the ED’s Security Log for February 2024 noted that while on the facility grounds near the ambulance bay, Patient #36 became aggressive and threatened SOs with a broken bottle. Per the Security Report dated 2/23/2024, “security notified operations that [Patient #36] grabbed and broke a glass bottle and became menacing towards security and himself.” NYPD/ 911 was called, and Patient #36 was transported to another facility by Emergency Medical Services (EMS). During interview of Staff S (Vice Chief of the ED) on 1/8/2025 at 12:57 PM, Staff S stated that when a patient is refusing to leave, the physician should be called to evaluate. During interview of Staff W (Security Officer) on 1/9/2025 at 10:05 AM, Staff W stated, “if a patient is discharged, we would try verbal de-escalation, ask if they need help, and notify clinical staff. If it gets beyond our control, we will notify our supervisor who could notify the doctor or send more officers. They could also call the police if necessary.” There was no documented evidence that an ED physician or staff were notified by the SOs of Patient #36’s escalating behavior. In addition, the patient’s medical record lacked documented evidence that the patient received a MSE for the sudden change in condition prior to Patient #36’s transport to another facility. During interview of Staff R (Senior Director of Quality and Patient Services) on 01/9/2025 at 1:45P, Staff R acknowledged these findings.”

“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: 10686 Based on medical record (MR) review, document review, and interview, in one (1) of twenty-three (23) MRs reviewed, the facility failed to maintain an effective, ongoing, hospital-wide quality assurance and performance improvement (QAPI) program. Findings: - The facility failed to identify opportunities that would lead to improvement. (See Tag A-0283)”

“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: 37527 Based on medical record review (MR), document review, and interview, the facility failed to identify opportunities that would lead to improvement. (Patient # 2) Findings: Review of Patient #2’s medical record (MR) identified that this patient was admitted to the cardiology stepdown unit on 05/07/2024 at 6:01 PM. At 8:54 PM, the Morse Fall Risk Assessment (a tool used to assess a patient’s likelihood of falling) score was 40 (moderate risk for falls). The Activities of Daily Living Flowsheet at 9:24 PM noted the use of an ambulatory aid and weakness in both legs. On 05/08/2024 at 8:00 PM, the patient’s Morse Fall Risk score was changed to 60 (high risk for falls) due to an IV (intravenous) placement. On 05/09/2024 at 9:24 PM, the patient’s ambulatory aid was upgraded to a walker rather than the cane. On 05/30/2024 at 4:17 PM, a Nursing Note stated that Patient #2 suffered an unwitnessed fall and was unable to describe or remember falling. There was evidence of head trauma to the left side of Patient #2’s head and left elbow. A CT Scan (computed tomography: a medical imaging scan used to create pictures inside the body) was ordered. The CT Scan performed on 5/31/2024 at 4:00 AM revealed intracranial hemorrhage (a brain bleed). The patient was transferred to the Neurology Intensive Care Unit. Review of the facility’s policy and procedure titled: “Falls Risk Assessment Tools & Risk Reduction Measures,” reviewed 06/2023, stated: “ ...The Registered Nurse (RN) will determine a patient’s level of fall risk by using the appropriate population-based risk assessment tool and any patient specific risk factor (s). Based on level of risk and RN’s clinical judgement, the appropriate risk reduction measures are implemented as outlined in this procedure ...Supervised Toileting: Patients at High Risk For Falls will be directly supervised during toileting and returned to bed or chair upon completion. The RN will determine the type of supervision warranted, e.g. whether to stay in the bathroom during toileting or to stand outside with door ajar to allow for visualization all times”. The facility’s Nursing and Medicine departments reviewed Patient #2’s fall on 06/05/2024 and concluded the standard of care was met. The nursing review concluded there was room for improvement: “ ...In addition to visualization, delegate another RN or Support Staff to remain at patient’s side ...” No revisions were made to the existing fall policy dated 06/2023. Review of the facility’s Staff Re-Education Attendance Records, dated 05/31/2024 to 06/30/2024, identified that staff re-education on the existing fall policy was conducted on the patient care unit where Patient #2’s fall occurred. There was no documented evidence that staff re-education was implemented in other patient care areas with fall-risk patients. During interview of Staff K (Director of Nursing Quality) on 09/06/2024 at 11:14 AM, Staff K confirmed no policy revisions or changes were implemented since Patient #2’s fall. During interview of Staff O (Senior Director of Professional Nursing Practice) and Staff P (Program Director for Nursing Practice and Patient Education) on 09/09/2024 at 11:30 AM, Staff O Staff stated: “The policy was really to make sure the nurse is with patients who are toileting so the nurse can directly visualize when the patient gets up and assist. It [the fall policy] did say visualization at all times ...The policy says the nurse will use their critical thinking to decide if visualization is through the window or inside [the room]. We leave critical thinking and judgment to the nurse ...” During interview of Staff U (Registered Nurse/RN) on 09/11/2024 at 11:11 AM, Staff U confirmed they worked on patient care Unit 4S and that they had not received recent training specific to fall prevention. During interview of Staff V (Patient Care Support Staff) on 09/11/2024 at 11:37 AM, Staff V confirmed they worked on patient care Unit 4C and that they completed the facility’s mandatory annual competency module titled, “Safe Patient Handling,” last Thursday [09/05/2024], but had not received training specific to fall prevention for patients while toileting. During interview of Staff Y (RN) on 09/11/2024 at 11:59 AM, Staff Y confirmed they received the facility’s mandatory annual competency training on safe patient handling approximately two (2) weeks prior, but had not received training specific to the supervision of fall risk patients during toileting. During interview of Staff B-1 (Nurse Educator) on 09/12/2024 at 3:26 PM, Staff B-1 confirmed that all clinical staff receive annual hospital training which includes fall prevention and management. Staff B-1 stated that the next module is not due until 12/2024. These findings were shared with Staff Z-1 (Chief Nursing Officer), Staff F-1 (Senior Director Quality and Patient Safety), and Staff D-1 (Manager, Quality and Patient Safety) during the Exit Conference on 09/12/2024 at 5:15 PM.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 48940 Based on medical record (MR) review, document review and interview, in one (1) of 14 medical records (MR) reviewed, it was determined that the facility failed to report and investigate an incident related to a patient who sustained injuries after being restrained and perform an assessment or analysis to identify potential issues to prevent future occurrences. Findings include: The document titled “2024 Quality and Patient Safety Plan” states, “The QPS Program oversees activities of all hospital and patient services to enhance the quality and safety of patient care, to identify actual and potential problems concerning patient care and clinical performance and develop and implement strategies to prevent harm. The program measures, analyzes, and tracks quality indicators, including adverse events and other aspects of performance that assess processes of care, hospital services, and operations.” The policy titled “Adverse Event Reporting,” last revised 8/2022 states: “1. Events to report ... staff should report events that occur on hospital premises which are not consistent with routine operations or care of patients. The events may involve actual harm or no harm ... A. Types of events to report are: 1) Events that cause harm, 2) Events that occur but do not cause harm ... B. Events are categorized in the system within general event types such as: ... medication ... patient fall event ... safety/security ... 3. Event report submission ... Complete appropriate notifications (e.g., Supervisor, Provider, Attending) and enter the event into the Adverse Event Reporting System as soon as possible after the event has occurred.” Review of the MR of Patient #1 identified: a 49-year-old patient who presented to the emergency department (ED) on 2/21/24 at 2:58 PM for a manic episode. At 3:12 PM, the patient was triaged by ED Registered Nurse (RN) and was placed in the room at 3:22 PM. At 3:45 PM, the ED Attending evaluation documentation included: patient presented manic with anxiety and pressured speech and was requesting a psychiatric admission. The patient’s past medical history was significant for Bipolar Disorder, Post-Traumatic Stress Disorder (PTSD), and two (2) previous suicidal attempts. The ED Attending placed an order for a psychiatric consultation and medication at 3:45 PM. The patient was administered Ativan (medication to treat anxiety) 2 milligrams intravenously at 3:59 PM. At 7:57 PM, Staff I, Psychiatric Attending, documented in the Tele consult Note that during her evaluation, the patient attempted to leave, security was called, and further assessment was terminated due to escalating behaviors. At 8:00 PM, ED Staff RN documented, the patient became agitated, needed to be put into four-point restraints and medicated. Restraints were removed on 2/22/24 at 6:29 AM. At 8:55 PM, ED Attending, documented an updated ED Provider Note, that the patient had abrasions under his left eye and above the left ear, so he ordered a CT scan of the head. CT scan of the head was performed on 2/22/24 at 6:50 AM, which showed no abnormal findings. Review of the facility Keepsafe (Adverse Event Reporting System) from 10/2023 to 05/2024, revealed there was no entry related to an incident with Patient #1. During an interview conducted on 5/16/24 at 2:02 PM, Staff F, Security Officer, stated that security was called to the patient’s room due to the patient being verbally aggressive with staff. Upon arrival, the patient was making verbal threats to harm staff. An attempt to verbally deescalate the patient was made, but the patient eventually attempted to rush at security in attempt to escape. Security officers needed to restrain the patient and hold his limbs so that the RNs could safely place the four-point restraints. During an interview conducted on 5/16/24 at 3:15 PM with Staff N, Assistant Director of Quality and Safety, confirmed that there was no incident report filed or investigation done regarding the patient’s injuries. During an interview conducted on 5/17/24 at 10:00 AM, Staff E, ED Attending, stated that he was informed that the patient was becoming increasingly agitated and verbally threatening towards staff, so he went to the bedside to reassess the patient and attempted to verbally deescalate the patient. Staff E determined the patient would require medication for his agitation and in the process of staff preparing the medication, the patient attempted to rush at security officers and had to be restrained. Staff E stated, in fear of the RNs getting injured, administered the medications while the patient was being restrained by security officers and the four-point restraints were being applied. After the patient had been put into four-point restraints, Staff E, noticed a superficial abrasion under the patient’s left eye and above the left ear, so he ordered a CT scan of the head. Staff E stated that no treatment was necessary for the abrasions and that the patient had no physical complaints at that time. When asked by the surveyor if he filed an incident report, Staff E, ED Attending stated that he did not but verbalized understanding that the injuries should have been reported.”

“DISCHARGE PLANNING - MD REQUEST FOR PLAN CFR(s): Upon the request of a patient’s physician, the hospital must arrange for the development and initial implementation of a discharge plan for the patient. This Standard is not met as evidenced by: 17636 Based on medical record review, document review and interview, in one (1) of 14 medical records (MR) reviewed, it was the determined the facility failed to provide a prescription for care of a patient’s unstageable pressure ulcer when the patient was discharged from the hospital. (Patient #2) Findings include: The policy titled “Discharge Planning and the Continuum of Care,” last revised 5/2023 states, “patients will have their post-acute care needs assessed and as applicable, will be provided with a discharge plan to support their continued recovery and well-being after leaving the in-patient care setting. Identification and implementation of the discharge plan is the responsibility of the interdisciplinary team.” Review of the MR for Patient #2 identified a 79-year-old patient who was admitted to the facility on 6/28/23 at 1:35 PM for Aspiration Pneumonitis. The patient’s previous medical history was significant for Coronary Atherosclerotic Disease, Cognitive Impairment, Advanced Frontal Lobe Dementia, Hypertension, Hyperlipidemia, Hyperthyroidism, Thyroid Nodule, and Coronary Artery Bypass Graft. The admitting diagnoses were Acute Hypoxic Respiratory Failure secondary to Aspiration, Aspiration Pneumonitis and Dysphagia/Choking. On 6/29/23 at 10:20 AM, the wound care nurse documented the patient’s wound assessment; patient had an “unstageable pressure injury to the sacrum/sacrococcygeal area with an open area which measured 6 x 6 x 0.3 cm, bilateral calcanei with deep tissue pressure injuries each with maroon non-blanchable hue over boggy area, measures 1 x 1 cm. No fluctuance, induration or exudate present.” Daily nursing assessment and wound care was documented twice daily from 6/28/23 until discharge on 7/3/23. The wound care nurse documented the patient’s discharge instructions on 7/3/23 included instructions for wound care with the application of collagenase (Santyl) ointment daily to wound. (Medication used for removing damaged or burned skin to allow for wound healing...) There was no documentation in the medical record that the interdisciplinary team provided a prescription to the patient/family for the collagenase ointment when the patient was discharged home on 7/3/23. Documentation in the medical record revealed the prescription was sent to the pharmacy on 7/5/23, two (2) days after the patient was discharged from the facility. During interview on 5/16/24 at 11:00 AM, Staff B, Manager Wound and Ostomy Care stated, in this case the patient was discharged with instructions for application of two (2) ointments for wound debridement of the sacrum. During interview on 5/17/24 at 10:45AM, Staff A, physician, stated he did not recall the patient having a wound. He states he remembers receiving a call for the Santyl ointment a couple days after patient #2 was discharged from the hospital and he ordered the prescription for the wound care treatment on 7/5/23. .”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 33919 Based on medical record (MR) review, document review, and interview, in 1 (one) of 1 (one) MRs, the facility staff did not fully implement their de-escalation protocol, as per facility policy. This failure placed all patients at risk for harm. Findings: The facility policy and procedure (P&P) titled, “Patient and Visitor Abusive / Discriminatory Behavior Policy,” last dated 2/2024, instructed staff to “Contact Patient Services Administration (PSA) and/or Administrator On Call (AOC) [as] resources who may assess and attempt to employ various additional dispute resolution and service recovery de-escalation techniques,” when attempts to de-escalate are ineffective. Review of Patient #2’s MR identified that this patient presented to the Emergency Department (ED) on 2/21/2024 at 11:16PM. After examination by the physician, the patient refused medication or additional treatment. Patient #2 remained sleeping in the ED for approximately 6 hours, until they were discharged at 05:47AM. Upon notification of discharge, Patient #2 became angry and belligerent, yelled and screamed at staff, and urinated on the floor. During interview of Staff K (physician provider) on 3/19/2024 at 3:50PM, Staff K stated that Patient #2 had no psychiatric history, was not exhibiting signs or symptoms of psychosis, but that the patient was very angry about being discharged because he wanted to continue to sleep in the ED. Security staff were called, and the patient was escorted out of the facility. Upon request, the facility could not furnish documented evidence that facility staff had notified the PSA or AOD as per facility policy. During interview of Staff J (Senior Director of Quality and Patient Safety) on 3/20/2024 at 11:25AM, Staff J confirmed there was no notification to the PSA or AOD as required by the facility policy.”