Olean General Hospital

“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: 48608 Based on policy review, document review, medical record review, and interview, emergency department (ED) staff failed to follow established policies and procedures related patient discharge from the ED for Patient #1. Specifically: 1. ED staff did not call the family or rehabilitation/nursing home facility to discuss discharge and to give report on Patient #1’s condition. There was no evidence Patient #1 received/signed off receiving discharge instructions. 2. There were no discharge orders entered in the medical record for nine of 20 patients (Patient #1, #2, #5, #6, #7, #13, #14, #15, and #16). Findings #1: Review of the policy “Care of the Adult Patient in the ED”, revised 05/2024, revealed the primary registered nurse (RN) is responsible for ensuring completion and documentation of all tasks related to patient care. All assessments and reassessments must be documented in the medical record. Discharge instructions will be reviewed with the patient by the RN who will provide opportunity for the patient to discuss questions and concerns. A copy of the discharge instructions will be signed by the patient and retained in the medical record. A second copy of the instructions will be sent home with the patient. If the patient resides in a nursing home, the primary RN will call the facility to review the instructions with facility personnel. Review of the policy “Discharge Instructions,” revised 06/2024, revealed all patients will receive discharge instructions in written and verbal form. For patients discharged back to a skilled care facility or adult care facility, a copy of the patient’s medical record will be sent with the patient. The facility will be notified of the patient’s return and report will include the following information: new findings, changes in medications and/or treatment, and the time the patient left the hospital ED. Review of the medical record for Patient #1, dated 07/25/25, revealed at 02:43 PM, Patient #1 arrived by ambulance to the ED for a “blood pressure problem from a rehabilitation/nursing home.” At 04:17 PM, Staff (K), RN, documented Patient #1 was discharged ambulatory to home and demonstrated understanding of discharge instructions. At 04:18 PM, the medical record indicated Patient #1 “departed,” or left the facility. (There is no documentation to indicate ED staff contacted the rehabilitation/nursing home for notification of discharge and to give report on Patient #1. There is no evidence Patient #1 received/signed off on the discharge instructions and/or a copy of the signed discharge instructions was included in the medical record). Interview on 08/27/25 at 08:55 AM with Staff (N), Unit Secretary, revealed it is their responsibility to set up transportation for patients who are discharged. The registered nurse will alert them that the patient is ready to go and where the patient is going. It is common for ambulance transportation to be utilized, and the provider completes a certificate of medical necessity (CMN) form to have a patient transported by ambulance back to a facility. The unit clerk will document in the medical record the means of transportation and the estimated time of arrival. Skilled nursing facilities do not provide transportation. Interview on 08/27/25 at 10:14 AM with Staff (B), Hospital Administrator, revealed Patient #1 did not qualify for transportation by ambulance because they could walk. Staff (B) was aware Patient #1 resided at a skilled nursing facility for rehabilitation. Interview on 08/27/25 at 10:14 AM with Staff (B), Hospital Administrator, confirmed these findings. Findings #2: Review of the “Medical Staff Rules and Regulations,” revised 04/30/25, indicated patients will be discharged/transferred upon the order of the attending physician or designee, who shall provide/assist in providing written discharge instruction in a form that can be understood by all individuals or organizations responsible for the patient’s care. Review of the medical records for Patient # 1, #2, #5, #6, #7, #13, #14, #15, and #16 revealed no evidence of a provider discharge order. On 08/27/25 at 11:00 AM Staff (D), Registered Nurse, confirmed these findings.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 32261 Based on observation, medical record review, policy review, document review, and interview, in two of 13 medical records reviewed, it was determined the facility failed to protect and promote the rights of all patients related to the use of restraints as evidence by the facility’s use of spit hoods (a mesh hood or spit guard is a restraint device intended to prevent a person from spitting or biting) on patients in the emergency department, lack of facility policy for the use of spit hoods, and the lack of staff training, education, and competency in the use of spit hoods (Patient #21 and Patient #22). Reference: 482.13(e): Use of Restraint or Seclusion.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 32261 Based on observation, medical record review, policy review, document review, and interview, in two of 13 medical records reviewed, it was determined the facility used spit hoods/socks (a mesh hood or spit guard is a restraint device intended to prevent a person from spitting or biting) for emergency department patients. There is no clinical policy and/or training curriculum for the use of spit hoods/socks; there is lack of documentation for the initiation and discontinuation of spit hoods/socks; and there is lack of monitoring documentation. Findings include: Observation on 11/14/25 at 03:05 PM with Staff (O), Registered Nurse, revealed two single packaged spit hoods in a supply drawer under a desk in the nursing station. Review on 11/15/24 of Patient # 21’s emergency department medical record dated 10/30/24 revealed the following: -At 12:38 AM, Patient #21 arrived at the emergency department on 9.41 papers (New York State Office of Mental Health Law that allows law enforcement to arrest an individual who appears mentally ill and transport them to a hospital for examination) with law enforcement. -At 01:15 AM, Staff (G), Registered Nurse, documented Patient #21 was placed in four-point restraints for assaulting nurse and a law enforcement officer while in the emergency department. -At 01:20 AM, Staff (F), Physician, ordered four-point leather behavioral restraints. -At 01:25 AM, Staff (G), Registered Nurse, documented that a spit mask was applied to Patient #21’s head. -At 01:50 AM, the triage assessment by Staff (G), Registered Nurse, revealed Patient #21 was brought in by police for a mental health exam after getting into an altercation with the owner of a business next door to their house. -At 05:20 AM, Staff (F), Physician, re-ordered four-point restraints due to Patient #21’s continued display of violent behaviors. -At 07:20 AM, Staff (M), Registered Nurse, documented all restraints were removed. (There is no documentation of a provider order for a spit mask, assessment of spit mask placement, and/or when the spit hood was removed). Review on 11/15/24 of Patient #22’s emergency department medical record dated from 08/31/24 to 09/01/24 revealed the following: -On 08/31/24 at 07:10 PM, Patient #22 was brought to the emergency department on 9.45 papers (New York State Office of Mental Health Law that allows law enforcement to arrest an individual who appears mentally ill and transport them to a hospital for examination) with law enforcement for acute psychosis. -On 08/31/24 at 07:30 PM, triage note by Staff (T), Registered Nurse, revealed Patient #22 was brought in by law enforcement under 9.45 due to Patient #22 being inappropriate at an appointment and taking off their clothes. Patient #22 was uncooperative, spitting, and kicking. -On 08/31/24 at 07:30 PM, Staff (T), Registered Nurse, documented a spit mask was placed on Patient #22. Patient #22 was placed in room #10 with a one-to-one monitor. -On 08/31/24 at 07:30 PM, Patient #22 was placed in four-point restraints due to being hostile and harming self and others. Staff (U), Advanced Practice Practitioner, ordered behavioral restraints. There is no evidence of an order for a spit hood. -On 08/31/24 at 07:34 PM, Staff (U), Advanced Practice Practitioner, documented Patient #22 was placed in restraints for their safety and the safety of others. -On 09/01/24 at 12:00 AM, restraints were discontinued. At 12:25 AM, Patient #22 was admitted to the Behavioral Health in-patient unit. (There is no documentation of a provider order for a spit mask, assessment of spit mask placement, and/or when the spit hood was removed). Review of the product insert for the “The Hood TRANZPORT Protective Hood,” (spit hood/mask) dated 2019, revealed on the front of the document has the following “WARNING: IMPROPER USE OF THE TRANSPORT HOOD MAY CAUSE INJURY OR DEATH.” Improper use may result in serious injury or death due to asphyxiation, suffocation or drowning in one ’ s own fluids. The wearer must be under constant visual supervision and should never be left unattended. Review of the policy “Restraint-Use Of,” last revised 08/2023, revealed a violent/self-destructive restraint is defined as “used for violent or self -destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others.” Examples of violent restraints are four-point, chemical, and seclusion. Clinical support staff involved in caring for patient in restraints must complete restraint training during orientation and maintain annual competency thereafter. The provider is responsible for the patient’s ongoing care must order the restraint after an initial evaluation is completed. Safety checks are done every 15 minutes and include restraints are applied by manufacturer’s instructions, skin examination at restraint site, patient safe from injury, two fingers can be placed under restraint, skin under restraint is monitored for decreased sensation/color/mobility/warmth/integrity, and nutrition/hydration/hygiene/elimination needs are met. Every hour, restraints are assessed/reassessed for release, and to reposition patient. (The policy does not include the use of a spit mask/hood on patients, if a provider order is required for the use of a spit mask/hood, and what monitoring/safety check documentation are to be documented). Review of the education for “Restraints,” and “Restraint Competency,” no date, revealed education and demonstrated competency for the use of restraints (soft limb, mitts, four-point in the emergency department only). The use of restraints requires a provider order, assessment of a patient while in restraints, provider face to face assessment requirements, documentation of restraint use, risks of restraint use, and indication for restraint use. (The education does not include use of spit masks/hoods). Interview on 11/14/24 at 11:31 AM with Staff (L), Physician Assistant, at 11:35 AM with Staff (K), Emergency department Manager, and at 01:15 PM with Staff (D), Chief Nursing Officer, revealed that spit hoods are used on patient in the emergency department. Interview on 11/14/24 at 02:00 PM with Staff (J), Nurse Educator and at 02:50 PM with Staff (A), Director of Quality and Risk, revealed the hospital does not have a policy regarding the use of spit hoods and staff do not have any training or education on the spit hoods. Interview on 11/15/24 at 07:20 AM with Staff (G), Registered Nurse and at 09:30 AM with Staff (T), Registered Nurse, revealed that spit hoods are used in the emergency department when a patient is spitting. An order is not documented in the medical record. Staff (T) did not receive any training on the spit hood.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 48608 Based on policy review, medical record review, and interview, in two of six medical records reviewed, the physician did not complete a patient evaluation when ordering non-violent restraints for Patient #2 and Patient #3. Findings include: Review on 10/04/24 of policy “Restraints-Use of,” last revised 08/2023 revealed “non-violent/non-self-destructive restraints are used when a patient is interfering with medical devices. A provider responsible for the patient’s ongoing care must order the restraint after an initial evaluation is completed. The attending provider must be consulted as soon as possible, not to exceed 24 hours, if he/she did not order the restraint. The provider must then complete a face-to face comprehensive assessment within two hours of restraint placement and document.” Review on 10/04/24 of the medical record for Patient #2 revealed on 07/25/24 at 03:51 AM, they presented to the emergency department with septic shock and multi-organ failure. On 07/29/24 at 12:01 PM, bilateral wrist restraints were ordered by Staff (Z), Physician, for attempts to dislodge the endotracheal tube (flexible tube that is used to assist in breathing) . On 07/29/24 at 04:00 PM the bilateral wrist restraints were discontinued by nursing due to the discontinuation of the endotracheal tube. There was no evidence in the medical record indicating a provider completed an assessment of Patient #2, prior to and/or after the initiation of the bilateral wrist restraints. Review on 10/04/24 of the medical record for Patient #3 revealed on 08/07/24 at 11:15 AM, they presented to the emergency department for a witnessed seizure and has a history of daily alcohol and fentanyl use. On 08/12/24 at 02:48 AM, Staff (AA), Registered Nurse entered a telephone order from Staff (Z), Physician, for bilateral wrist restraints to prevent removal of medical devices. There was no evidence in the medical record indicating a provider completed an assessment of Patient #3, prior to and/or after the initiation of the bilateral wrist restraints. Interview on 10/04/24 at 10:45 AM with Staff (BB), Quality Coordinator, verified these findings. Interview at 02:07 PM with Staff (B), Chief Medical Officer, and Staff (C), Director of Quality, verified that provider evaluations for the use of non-violent restraints are required to be documented in the medical record.”