Canton-Potsdam Hospital

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 49512 Based on medical record (MR) review and interview, the facility failed to ensure that a positive urinalysis was followed up with a urine culture and that the patient (Patient #1) was notified of a potential urinary tract infection (UTI). Findings include: -- Per review of Patient #1’s MR, on 1/1/2025, they presented to the obstetrics (OB) unit at Hospital #1 in active labor. A urinalysis was performed at admission, which was found to be positive for a large amount of white blood cells (WBC’s). After normal vaginal delivery Patient #1 was discharged home on 1/3/2025. On 1/4/2025, Patient #1 presented to Hospital #2 with tachycardia (elevated heart rate), fever, and abdominal pain/pressure. Workup revealed possible sepsis, a UTI, possible pyelonephritis (infection of the kidney), and concern for retained product in uterus. Patient #1 was started on antibiotics. On 1/5/2025, Patient #1 was transferred back to Hospital #1 for further obstetrical and gynecological (OB/GYN) evaluation. Workup at Hospital #1 upon readmission, revealed a UTI. Patient #1 was continued on antibiotics and symptoms improved. On 1/7/2025, Patient #1 was discharged home. -- Per interview of Staff A, Clinical Staff on 9/24/2025 at 9:35 am, they indicated they believe the process is that if a urinalysis showed presence of bacteria, a urine culture would then be ordered. If a urine culture is found positive, the provider is responsible to follow up and provide the results to the patient. -- Per interview of Staff B, Staff C, and Staff D, Clinical Staff on 9/24/2025 at 1:45 pm, they indicated that a urinalysis reflex to microscopic test means that if the initial urinalysis detects cells or bacteria, it triggers a microscopic examination. It is then the providers responsibility to determine if a culture should then be ordered. This test does not automatically trigger a culture. -- Per interview of Staff E, Clinical Staff on 9/24/2025 at 12:30 pm, a urine culture was not ordered following a large amount of WBC’s being found microscopically in Patient #1’s urinalysis. A urine culture should have been ordered.”

“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: 49512 Based on document review and interview, in one adverse event reviewed, the facility’s Quality Assurance Performance Improvement (QAPI) Program lacked adequate follow through of corrective actions identified during its investigation. This could lead to other similar adverse events. Findings include: -- Per review of adverse events documented in the hospital’s QAPI Program, in one event, a patient had an untoward outcome. The facility identified corrective improvement actions. Review of documentation did not reveal that corrective actions were completed. -- During interview of Staff F, Non-Clinical staff on 9/25/2025 at 11:15 am, they acknowledged the above finding.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(6) Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN). This Standard is not met as evidenced by: 46619 Based on medical record review, document review and interview, in 1 of 15 (Patient #13) medical records reviewed, a chemical restraint was ordered to be given on a PRN basis (as needed) and administered on a PRN basis. Findings include: -- Per medical record review, Patient #13 was admitted for management of severe constipation and anemia. Patient #13 had a past medical history of intellectual disability and schizoaffective/bipolar disorder. A physician documented on 7/12/2024 at 9:56 pm, that the patient has been agitated and interfering with care, and received multiple doses of sedatives and antipsychotics to calm them down with little to no improvement. On 7/13/2024 at 2:41 am, the physician ordered a chemical restraint, Versed 2 milligrams (mg) given intravenously, every 2 hours PRN for agitation. Registered nursing staff administered Versed, at 3:07 am, 5:07 am, 7:29 am, and 9:31 am. -- Per interview of Staff N, Quality Manager, on 9/5/2024 at 11:15 am, they acknowledged the above findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(13) States are free to have requirements by statute or regulation that are more restrictive than those contained in paragraph (e)(12)(i) of this section This Standard is not met as evidenced by: 46619 Based on document review and interview, the hospital has put in place, through its policy and procedure and supporting education, the option for a specially trained registered nurse (RN) to conduct face-to-face evaluations, in lieu of a physician or other qualified licensed provider, when restraints are applied in an emergency. The hospital did not comply with New York Codes, Rules, and Regulations, Title 10 § 405.7 - Patients’ rights, which requires the hospital to ensure that all patients including inpatients, outpatients and emergency service patients, are afforded their rights as set forth in subdivision (b) of this section. Specifically, section (5) limits the use of physical restraints to those patient restraints authorized in writing by a physician after a personal examination of the patient, for a specified and limited period of time to protect the patient from injury to himself or to others. In an emergency, the restraint may be applied only by or under the supervision of and at the direction of a registered professional nurse who shall set forth in writing the circumstances requiring the use of restraints. In such emergencies, a physician shall be immediately summoned and pending the arrival of the physician, the patient shall be kept under continuous supervision as warranted by the patient’s physical condition and emotional state. When state regulations are more restrictive regarding the types of practitioners who may conduct the 1-hour face-to-face evaluation, hospitals are required to comply with these state regulations. Findings include: -- Per review of the hospital’s policy and procedure titled, “Restraints for Behavior Management (Violent Behavior),” last approved 4/23/2024, “in an emergency/violent situation that jeopardizes the immediate physical safety of the patient, a staff member, or others: a qualified RN may identify the need for and initiate the use of physical restraint prior to obtaining an order... a. The physician, other qualified licensed provider (QLP), or trained nursing supervisor must see the patient face-to-face within one hour after the initiation of restraints to evaluate: - the patient’s immediate situation - the patient’s reaction to the intervention - the patient’s medical and behavioral condition; and - the need to continue or terminate the restraint. b. The goal of the face-to face evaluation if to determine if there is a medical cause for the behavior and correct it so the restraints can be discontinued. c. If the evaluation is conducted by a trained nursing supervisor, the supervisor shall consult the physician or other QLP responsible for the care of the patient as soon as possible after completion of the evaluation. Telephone consultation is acceptable and the physician/QLP is not required to come to the hospital to see and evaluate the patient.” -- Per review of the hospital’s annual education titled, “Restraint Policies: Medically Necessary and Behavioral Restraints, Annual Education,” dated March 2024, “the decision to use a restraint should only be implemented following a comprehensive individual assessment by the RN and/or physician or other QLP ... If the RN completes the assessment, they shall consult the physician or other QLP ... A 1 hour face-to-face assessment must be completed by the physician, other QLP, or trained nursing supervisor. The physician, other QLP, or trained nursing supervisor must see the patient face to face within 1 hour. If the evaluation is conducted by a trained nursing supervisor, the supervisor shall consult the physician or other QLP responsible for the care of the patient as soon as possible after completion of the evaluation. Telephone consultation is acceptable and the physician/QLP is not required to come to the hospital to see and evaluate the patient. -- During interview of Staff N, Quality Manager, on 9/5/2024 at 11:15 am, they acknowledged the above findings.”