Good Samaritan Hospital of Suffern

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 35161 . Based on document review and staff interview, in one (1) of seven (7) medical records reviewed, the facility did not ensure that an investigation of an allegation of sexual abuse was timely completed. This finding was evident in 1 of 7 grievance reports reviewed (Patient #1). Findings include: Review of the grievance report at Hospital A revealed that on 03/27/2024, staff received a report from Hospital B that Patient #1 reported that an ED staff sexually abused her in the Emergency Department at Hospital A. A review of the facility’s investigation report on 04/19/2024 revealed the facility initiated an investigation of the alleged sexual abuse on 03/27/2024. There was no documentation found that indicated the investigation was completed as of 04/19/2024. A review of facility policy and procedure titled “Patient Complaint and Grievance,” effective March 2017, states, “ ... All grievances will be referred to Patient Relations for intake; acknowledgment and appropriate distribution for investigation. A written acknowledgment must be sent within (7) days of receipt of the grievance. 4. All grievances will be investigated by the appropriate Managers and/or Directors of the area(s) involved in the grievance. The results of the investigation and/or follow-up will be communicated to the complainant and/or designee in a timely manner. Written responses will be generated to the complainant within 30 days or less from the time the grievance is received, or an extension letter will be sent if the grievance is more complicated and requires additional investigation ...” The time frame established in the policy for grievance resolution is not timely, and the policy did not address the timely investigation of allegations of abuse, neglect, or mistreatment. As per the interview of Staff I (Chief Nursing Officer) on 04/17/2024 at 1:00 PM, the investigation of sexual assault made by Patient #1 has not been completed. On 04/19/2024, at 12:00 PM, during an interview with Staff B (Behavioral Health Quality Manager), she stated that the investigation was still in progress. Staff B acknowledged that Patient #1’s grievance was not acknowledged within seven days as per the facility’s policy.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 35161 Based on medical record (MR) review, document review, and interview, the facility failed to accept patient transfers for cardiac treatment within their capacity and capability in two (2) of twenty (20) medical records reviewed. The failure to accept patient transfers potentially delayed medical treatment and increased the risk of adverse outcomes. Findings: Review of Patient #1’s medical record identified this 50-year-old with mid-sternal epigastric pain arrived at the sending facility on 9/23/2023 at 10:32PM by private vehicle. Patient #1’s electrocardiogram (EKG) revealed an elevation in the inferior leads, and Patient #1 was placed on a heparin (anticoagulant) drip with nitroglycerin sublingual (medication administered under the tongue to treat chest pain) for Patient #1’s chest pain. As a result of Patient #1’s electrocardiogram results, the sending physician notified this receiving facility of Patient #1’s “borderline elevations in the inferior leads [and] concern for MI [myocardial infarction/heart attack].” The sending physician documented that the case was discussed with [Staff B] the Interventional Cardiologist at the receiving facility on 9/23/2023 at 11:15PM, and that [Staff B] “feels the patient should go to [a closer facility] given that we are closer...” Patient #1, in critical condition, was transferred on 9/24/2023 at approximately 1:30AM via a private ALS (advanced life support) ambulance to another facility with capacity and capability to treat Patient #1 ’ s cardiac condition. The estimated arrival time for Patient #1 to reach the alternate facility was 3:00AM. During interview of Staff A (Chief Medical Officer/CMO) on 11/15/2023 at 11:12AM, Staff A recalled that [Staff B] had been called through the call center by the ED physician from the sending facility. [Staff B] stated that ethically, it was more appropriate if the patient goes to the closest facility. Staff A confirmed that Patient #1’s transfer was not accepted. Per interview of Staff B (receiving Interventional Cardiologist) on 11/15/2023 at 11:32AM, Staff B confirmed that Patient #1 was transferred to another facility as they suggested. Staff B stated that Patient #1 should have been transferred to the closest facility. Staff B explained, “It is well documented that the faster blood supply is restored, the better the patients’ outcome; the longer it takes, the higher the mortality. It is ethically appropriate to transfer the patient to the closest hospital [or] patients’ care is unnecessary delayed.” Staff B revealed that after seeking legal advice and being told that they have to accept these patients, Staff B agrees to accept them, but “will inform the [sending] providers that it is unethical ...[and] will tell the sending MD [physician] that ethically, patients should be sent to [closest facility].” Review of Patient #2’s medical record identified this 53-year-old patient arrived at the sending facility on 8/30/2023 at 8:32AM with chest and arm pain, lightheadedness, and dizziness. At 8:33AM, Patient #2 was evaluated by the physician who documented that Patient #2 became short of breath while on a treadmill and presented with a sudden onset of midsternal chest pain radiating to the left side, arms, and throat. Patient #2 was diagnosed with a STEMI (ST-Elevation Myocardial Infarction/heart attack). At 09:04AM, the sending physician documented that they spoke to [Staff G], the Interventional Cardiologist, at the receiving facility, who “advised patient needs to go to the nearest hospital. Unfortunately, helicopter could not fly [Patient #2] to Good Sam due to weather conditions at this time. Case discussed with [another facility] who accepts patient...” Patient #2 was transferred to [another facility] at 9:40AM. No estimated arrival time was identified. Per interview of Staff A (Chief Medical Officer) on 11/16/2023 at 09:34AM, Staff A confirmed that [Staff G] conditioned Patient #2 ’ s transfer by stipulating a transfer timeframe to the sending physician. Staff A explained, “The transfer helicopter flight was cancelled due to weather conditions. The [receiving physician] told [the sending physician] to transfer [Patient #2] to the closest hospital ...I spoke to [them] ...I told [them] that [they] cannot make contingent acceptances. Once you accept the patient, the patient has to be transferred...” Per interview of Staff G [receiving Interventional Cardiologist] on 11/16/2023 at 09:48AM, Staff G stated, “They said it was a STEMI [ST-Elevation Myocardial Infarction/heart attack] case. They said that there are difficulties of getting an ambulance for transfer. It took a long time for the ambulance to arrive, so I just told them that if they can find a closer facility, to take the patient there....” The Medical Staff’s Rules and Regulations, dated 09/022, stated the following: “Hospitals with specialized capabilities shall not refuse a request to transfer a patient except when the hospital does not have the capacity at the time....The policy ‘Emergency Medical Treatment and Active Labor Act (EMTALA)’ should be followed.” The facility policy and procedure (P&P) titled, “Emergency Medical Treatment and Active Labor Act (EMTALA),” last revised 02/2023, stated the following: “The Hospital will not refuse to accept an appropriate transfer of an individual who requires specialized capabilities or facilities of the Hospital, if the Hospital has the capacity and capability to treat the individual.” During interview of Staff A (Chief Medical Officer) on 11/16/2023 at 09:34AM, Staff A confirmed that Emergency Medical Treatment and Active Labor Act regulations were discussed with physician staff. Surveyors verified, through interview and review of pertinent documents, that the facility had implemented corrective actions prior to the survey. The hospital had no similar cited violations in the past 6 months. These findings were confirmed with Staff A (Chief Medical Officer) on 11/16/2023 at 4:00PM during the exit conference.”