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Based on review of grievance procedures, grievance files, and staff interview, it was determined that the hospital did not fully adhere to its own procedures which require disclosure to complainants regarding options for the filing of grievances with regulatory authorities.

Findings include:

Review of the hospital's complaint and grievance procedure titled, "Patient Complaints and Grievances- Subject No. A3-106" on 3/14/13 found that this policy requires the complainant to be informed of the option of referring the problem to the State Regulatory Agency in the event of dissatisfaction with the hospital's response, and that the contact telephone number of the State Agency is provided. The facility did not follow its grievance procedure as follows:

Review of 33 applicable grievance files on 3/13/13, which covered the period from January 2013 through March 2013, determined that none of the written grievance responses contained instructions for filing a complaint with regulatory authorities in the event that the complainant disagrees or is dissatisfied with the hospital's response.

Examples include:

Grievance#1.
Patient complained in writing on 1/19/13 about communication issues involving lactation and alleged provider failure to notify the patient of an infection. The facility's finalized written response dated 3/4/13 did not include the option of filing a grievance to the State Regulatory Agency in the event of dissatisfaction with the hospital's response.

Grievance#2.
Patient complained on 1/10/13 about inadequate pain management and the staff tone in communication during an inpatient hospital stay. The second response letter dated 2/21/13 addressed the concerns and noted review of pain administration records as well as review of the concerns with nursing staff. However this document did not include the option of filing a grievance with the State Regulatory Agency in the event of dissatisfaction with the hospital's response.

Grievance#3.
The daughter of an inpatient filed a written complaint on 2/8/13 about inadequate supervision of medical resident staff and insufficient communication with medical staff regarding the patient's condition. The final letter of 2/26/13 contained detailed explanation of findings but did not include the option to contact the regulatory agency in the event that the complainant was dissatisfied with the outcome of the hospital's investigation.

Similar findings were identified regarding incomplete response letters in 27 additional complaint/grievance records covering the period from January 2013 through March 2013, which did not include notification to complainants regarding the option to contact regulatory agencies for grievance resolution in 12 additional grievance records reviewed.

Interview with the Administrative staff on 3/15/13 confirmed this finding.

Refer to Grievance files Grievance #4 - #30.
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Based on review of grievance procedures and records, it was determined that the facility's procedures did not establish a process or system to ensure timely turnaround for responses to grievances.

Findings include:

The facility's procedure titled, "Patient Complaints and Grievances- Subject No. A3-106" that was reviewed on 3/14/13, and notes that written acknowledgements to grievances are responded to within seven days. Investigation by and reports of departmental investigations are due within seven days. The facility responds to patients within 4 to 6 weeks. This procedure also notes that if the case needs to be investigated longer than 6 weeks, the complainant is informed of the delay and this is documented in the department database.
The existing procedure does not consider additional written notification at specific intervals on a case by case basis.

Interview of the Patient Services Director on 3/14/13 found that the department does track responses and the number of days for grievance response resolution was 22.5 days during the time frame of 1/1/13 to the present time.

It was also stated and noted in data files that sometimes the patient must sign a release for communication with the hospital before the complainant is entitled to information but this process was not included in the written grievance procedure.

Example:

Review of the grievance tracking spreadsheet for February 2012 and grievance file Grievance #31 found that this written grievance was received 2/22/13. The patient complained about the management of care in the emergency department, insufficient communication, and billing. The department's response letter dated 2/22/13 noted a detailed review was initiated and that a response would be provided within six weeks.

This concern regarding protracted time frames in existing procedures for provision of resolution and response was shared with the facility staff on 3/15/13.
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Based on review of medical record and hospital policy it was determine that the physician and or other licensed health care practitioners failed to appropriately assess the patient's condition in order to plan an adequate course of treatment.

Findings include:

Review of MR # 6 on 3/12/13 noted that this patient was admitted on 2/8/13 with dizziness, generalized weakness and abnormal labs. Multiple stage IV pressure ulcers were noted on the left buttock 3x2 cm, right buttock 3x3 cm and the right ankle 2x1.5 cm. The physician's orders for care on 2/8/13 indicated for the left ischial (stage IV with bone exposure), diluted Betadine with NS 0.9, Kerlix packing, for the right ischial (stage IV), wet to dry dressing with 0.9 %NS, for the left lower ext. tendon exposure wet to dry dressing with 0.9% NS, and the upper wound- collagenase. The physician' orders failed to specify the frequency per day for treatment of multiple pressure ulcers.
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Based on review of medical records and hospital policy, it was determined that the hospital failed to ensure that patients' care plans was kept current with regards to when pressure ulcers were present.

Findings include:
Review of MR # 6 on 3/12/13 noted this 50 year old patient was admitted on 2/8/13 with dizziness, generalized weakness and abnormal labs. On admission the physician noted four (4) pressure ulcers. 2 pressure ulcers to the left posterior leg, stage II non-purulent, and 2 bilateral pressure ulcers to the buttocks- right stage III non-purulent non-erythematous and the left unstageable.

The physician's orders for care on 2/8/13 indicated the left ischial (stage IV with bone exposure) - diluted Betadine with NS 0.9, Kerlix packing, for the right ischial (stage IV)- wet to dry dressing with 0.9 %NS, for the left lower ext. tendon exposure -wet to dry dressing with 0.9% NS, and the upper wound- collagenase.

Nursing documentation on 2/9/13 identified three (3) stage IV pressure ulcers located on the left and right buttocks measuring 3x2 cm and 3x3 cm respectively and the right ankle 2x1.5cm. Nursing documentation failed to assess the pressure ulcers to the left posterior leg until 2/20/13, 12 days after admission, noted to be stage IV measuring 3x2x0.3cm and 1x1x0.5 cm.

There was no documentation by nursing that collagenase was administered to the ulcers on the left posterior leg until 2/20/13.
Nursing failed to adequately assess the patient's skin integrity and implement a plan of care for the pressure ulcers.


Review of MR # 9 on 3/12/13 noted a 53 year old patient was admitted 12/30/12 for 1 day of altered mental status secondary to hypoglycemia and scratching of skin lesions. On admission the skin was noted to be free of pressure ulcers. Nursing documentation on 1/22/13 noted a stage II pressure ulcer on the sacrum that was pink in color measuring 1.5 x0cm. On 1/24/13 documentation indicated an unstageable pressure ulcer two days after stage II pressures ulcer were observed. The patient's skin went from intact to stage II and then unstageable in the following two (2) days. Nursing failed to adequately monitor the patient's skin integrity and implement a plan of care.

Review of MR # 10 on 3/14/13 noted this patient was admitted on 12/26/12 for altered mental status and being lethargic. The right knee was noted to be red and the lower leg was warm on admission. Nursing documentation on 3/11/13 noted an unstageable pressure ulcer measuring 7x2.5 cm with eschar on the left lateral foot. The skin went from intact to unstageable with no documented skin change prior to being unstageable. Nursing failed to adequately monitor the patient's skin integrity and implement a plan of care.

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Based on review of medical record and facility policy it was determine that dietary services failed to appropriately assess the patient's condition in order to plan an adequate course of treatment.

Findings include:
Review of MR # 6 on 3/12/13 noted this 50 year old patient was admitted on 2/8/13 with dizziness, generalized weakness and abnormal labs. On admission the physician noted multiple pressure ulcers: 2 pressure ulcers to the left posterior leg, stage II non-purulent, 2 bilateral pressure ulcers to the buttocks- right stage III non-purulent non-erythematous and the left unstageable. On 2/14/13 the patient was assessed by the dietician, 6 days after admission. The registered dietician failed to assess the patient's nutritional status in a timely manner.

Lack of a timely nutritional assessment for patients with pressure ulcers also noted in
MR #7 and #8.
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During the tour of the facility from 03/11/13 to 03/15/13 between 11:00 AM to 4:00 PM, the following issues were noted which were verified with the staff accompanying the surveyor.

Findings include:



B2 LEVEL-GUGGENHEIM PAVILLION (GP)

1. During the survey of the B2 level of the GP building on 03/11/13 at 12:00 PM, many ceiling tiles in the corridors were noted to have brown stains indicating a water pipe leak above the ceiling tiles.

2. Clean linen carts that were ready to be used by patients were noted stored in the corridor not covered and had potential to be vulnerable to environmental contaminants.

3. The main clean linen storage room was noted dusty and dirty around its perimeters. Some of the carts were noted parked directly below structural beams where there was potential of dust fallout that result in cross-contamination.

This room did not have any drop ceiling to prevent contamination of the clean linen. As per AIA 1996-97 section 7.28.B8 it is stated that 'In dietary areas and in other areas where dust fallout may present a problem, provide a suspended ceiling'.



SURGICAL UNIT/ORs-GP FLOOR 3

1. During the tour of the Surgical Unit on 03/11/13 at 02:30 PM it was noted that there were two stained tiles in the medical supply room #125.

2. Tapes and tape residues on stretchers and other equipment were noted in different areas including but not limited to OR #24.

3. In OR #20 the floor did not have a hole/dent and thus was not monolithic to enable effective cleaning.

4. The stretcher/bed cover in PACU Bay #3 was noted to have a stain.

5. The patient toilet in the PACU area was noted to be small and had the door opening inwards only.

As per AIA 1996-97 section 7.28.A4 'rooms that contain bathtubs, sitz baths, showers, and/or water closets for inpatient use shall be equipped with doors and hardware permitting emergency access from the outside. When such rooms have only one opening or are small, the doors shall open outward or in a manner that will avoid pressing a patient who may have collapses within the room'.



PSYCHAITRY SERVICES CHILD/ADOL & ADULT- ICAHN BUILDING FLOOR 6 & 5

1.During the survey of the 6 & 5 floor Psychiatric units in the Icahn Building it was noted that the patients rooms had carpets that were noted to be very dirty and dusty.

2. The waiting room chairs on the 6th floor were noted dirty with food particles in the crevices of the chairs and dried fluid streaks on the side of the chairs.

3. Various rooms on the 6th floor including rooms #606 and #608 were noted to have chipped paint, dirty dusty door hinges, dirty bed or bed sheet, dirty and dusty mechanical exhausts of the toilets, and the window sills were dirty and dusty.

4. Some of the patient toilets had loopable hazards as the shower valve/faucet was not of the type approved for Psychiatric units.

5. The ice-machines on the 6th and 5th floor by the nurse's station were noted to be very dirty.

6. The mechanical vent in the medication room on the 6th floor was noted to be covered by a cardboard. This had the potential of compromising the air-pressure of the room.

7. The access for the duct in the 'Tub room' of the 6th floor was noted open.

8. The 6th floor had 8 patient rooms for adolescents and these rooms did not have an attached toilet/shower. The facility has only one shower room and as per the staff there was a tub room but the tub room was never used.

As per AIA 1996-97 section 7.6.B5 'In psychiatric nursing units, a bathtub or shower shall be provided for each six beds not otherwise served by bathing facilities within the patient rooms'.

9. The door of the soiled utility room on the 5th floor did not latch positively.

10. In patient room #512 the floor drain in the shower/toilet was noted to be broken. This had potential to cause patient harm.

11. The perimeters around the dining room on the 5th floor was noted dirty and dusty. The units on the 5th floor and the 6th floor had dust and dirt and along the perimeters.

12. On the 5th floor it was noted that there were lights on the corridors had black dots/particles inside the light cover. On 03/13/13 the Senior Director of Engineering (SDE) confirmed that those black spots/dots were infact 'Black Gnats/flies'. The facility does not have any preventive maintenance program to clean those lights.

13. The Janitorial closet on 6th floor had neutral air pressure.


ENDOSCOPY SUITE-1184 7TH FLOOR

1. During the survey of the Endoscopy suite on 03/13/13 at 2:45 PM , it was noted that the dirty side of the sterilization room did not have wrist blade faucet handles on the hand washing sink.

2. The mechanical exhaust located on the clean side of the sterilization room above the endoscope processors was noted to be dusty and dirty.

3. The Endo room #5 was noted to have negative air pressure instead of positive air-pressure.

4. The water out of the hand washing sink was more than the required 110*F.

5. The light in the IT/Telephone closet was found not to be working.



MECHANICAL/ELECTRICAL/INFORMATION TECHNOLOGY CLOSETS

Most closets observed in the facility were noted to be very dirty and dusty.

All above findings were verified with the respective staff on the floor and the Senior Director of Engineering.

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Based on observations and staff interview, the facility did not ensure that supplies and equipment were maintained to ensure an acceptable level of safety and quality.

Findings include:

1. During observations of the patient units from 03/11/13 to 03/15/13 between 11:45AM and 3:30PM, it was observed that some equipment in the facility did not have their inspection stickers indicating when they were due. Some equipment had stickers that indicated that their inspection was past due.

Examples include:

(a) On 03/15/13 at 12:15 PM, during the tour of the Dialysis unit it was observed that machine # F6 which was not in use but tagged as 'Ready for use' had its electrical inspection due on 11/2012. No current inspection sticker or record was provided for this dialysis machine.

(b) On 03/15/13 at 2:00 PM, during the tour of the Dental Unit it was observed that the 'CT PAX SCAN' in x-ray room #2 did not have a sticker indicating when it underwent its last preventive maintenance.

Staff on the Dental unit was requested to provide the physicist report and verification the current preventive maintenance and but this information was not provided.

(c) Some equipment such as the 'Endoscope Processors' did not have any maintenance stickers on them. As per the endoscope processing staff, the stickers must have fallen off due to the area being wet. Although the Biomedical personnel provided the latest preventive maintenance, the staff working on the unit were not aware of the current preventive maintenance due date so that they could ensure that the equipment was safe for use.

2. The facility did not have any policy and procedure based on manufacture's guidelines regarding the ventilation/exhaust for the Endoscope drying cabinet.

3. (a) On 03/15/13 at 12:15 PM, during the tour of the Dialysis unit and review of the dialysis machine maintenance records it was noted that the facility did not have any process to monitor if the 'Deareation brushes' are changed on every machine after every 8000 hours as per manufacturer ' s requirement.

For example, machine #F3 (5KOS-753D) was running at 16,402 hours on 11/14/12. In the Annual preventive Maintenance checklist it indicated by a check mark that the brushes were replaced, but brushes are not a part of each annual maintenance and are a separate kit. The Technical Manager acknowledged that this check mark did not indicate if the brushes were changed on this machine.

No other documentation regading the change was provided.

(b) During the tour of the water room in the Dialysis unit it was noted that on the table in the room there were hardness test strips and Peracetic Acid test strips that were not dated and had expired (11/2012 and 02/2012 respectively) . The Technical Manager acknowledged use of these expired hardness strips. However it was stated that the Peracetic Acid test strips were not being used and he had other strips in the office. The other strips that were brought were not dated, therefore his statement could not be verified.

4. On 03/14/13 at 2:30 PM, during the review of the policies for ventilators it was noted that the staff are required to perform SST test between each patients. The Director of Respiratory Therapy indicated that this test was done between each patient. However, there was no documented proof that the SST test and other tests as prescribed by the manufacture and facility's own policies, was being performed between each patient or before the start of the ventilator operation.
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Based on observation and staff interview, it was determined that the facility did not ensure a safe environment consistent with a system for identifying, reporting, investigating, and controlling infections and prevention of cross contamination.

Findings include:

1. During the tour of the Cardiac Surgery Intensive Care Unit (CSICU) [5th floor GP building] on 03/13/13 at 12:30 PM, the Director of Nursing stated that Heart Transplant patients are treated in this unit. The staff was asked about if there was any special care or environment provided for transplant patients. The Director of Nursing stated that those patients were specially taken care of in room #6 and room #7. As per Senior Director of Engineering, these two rooms were 'Negative Air-pressure rooms' and they cannot be converted to positive air pressure rooms.

As per AIA 1996-97 Section 7.2.D- Protective Environment Room "Many facilities care for patients with an extreme susceptibility to infection e.g immunosuppressed patients that are extremely susceptible to infection, with prolonged granulocytopenia, most notably bone marrow recipients; OR solid organ transplant recipient, and patients with hematological malignancies who are receiving chemotherapy and are severely granulocytopenic." These patients are required to be put in a room that has positive air pressure.

As per the Center of Disease Control document of Guidelines for Environmental Infection Control in Health-Care Facilities dated June 6, 2003 / 52(RR10);1-42 under Section III Infection Control and Ventilation Requirements for Protective Environment rooms subsection (A), it is indicated that solid-organ transplant are example of one of the immunocompromised patients and are candidates for positive air-pressure/protective environment room.
2. During the tour of Cardiac Surgery Intensive Care Unit (CSICU) on 03/13/13 at 12:30 PM, the following issues were noted:
(a) The perimeters of the bays were noted dirty and dusty. Furthermore, the vinyl base cove was noted to be getting detached from the wall.
(b) The tracks of the door of bay #16 were noted very dusty and dirty. The tracks of room #7 , the designated negative air pressure room, were also noted to be very dusty and dirty.
(c) The soiled utility room was noted to be exhibiting positive air pressure.

3. On 03/11/13 at 12:30 PM during the tour of the Central Sterile Supply Room (CSSR), the following issues were observed:

(a) Tape was noted to be stuck on the sterilizing tray/cart.

(b) Dust and dirt accumulation could not be removed from behind the steam sterilizers.

(c) The vinyl coved by the sterilizer and around the perimeter of the room was dirty and dusty.

(d) The metal ceiling tiles were noted to be stained in the CSSR.

(e) The drain by the back of the washer on the clean side of the Central Sterile Supply Room was noted to be open.

4. On 03/11/13 at 2:30 PM during a tour of the OR suite in Guggenheim Pavilion, the following issues were observed:

(a) The vents of the ORs were dusty from inside.

(b) The Soiled Utility Room by OR #12 exhibited strong positive air pressure.

(c) Packed Sterilized instruments were being stored in the OR corridor. As per the Senior Director of Engineering, these corridor are not being monitored for humidity.

All sterilized equipment should be stored in an area where humidity can be monitored as per AIA 1996-97 Table 2.

(d) The Sub-sterile room of OR #20 was positive to the OR.

(e) The facility has dedicated a treatment/procedure room in the PACU area where they want to do small Oncology cases. The Nurse Manager stated that this room should be positive since they are treating Oncology patients. At the time of survey the room exhibited neutral air pressure. The Senior Director Of engineering stated that the engineering staff never monitored this room for positive air pressure. An oncology patient was treated on 03/11/13 at 10:05 AM in this room.
5. During the tour of Medicine Services East & Center [11th floor GP building] on 03/13/13 at 01:00 PM, the following issues were noted:
(a)The perimeters of Room #303 were noted to be dusty and dirty.
(b) A gap in the ceiling tile was noted in room #306.
(c) Negative air pressure was noted in the Laminar Flow unit/suit ( LAF unit) going from the inside corridor to the patient bays.
(d) Room #217 was noted very dirty under the radiator/heater. Furthermore, the toilet door hinge was noted to have an accumulation of dust.

(e) Staff was asked regarding the use of portable HEPA filter in the facility. The Senior Director of Engineering stated that portable filters were only used for construction purposes and were not used in patient care areas.

As per Center of Disease Control document of Guidelines for Environmental Infection Control in Health-Care Facilities dated June 6, 2003 / 52(RR10);1-42 Section III in Subsection (G) states that 'Maintain backup ventilation equipment (e.g., portable units for fans or filters) for emergency provision of required ventilation for PE areas and take immediate steps to restore the fixed ventilation system'

6. (a) During the survey of the Endoscopy Suite and the Dental Clinic on 03//13/13 and 03/15/13 respectively, it was observed that the ceiling tiles in the sterilization rooms were not of monolithic, and cleanable.

(b) Furthermore, the sterilization room/area of the Endoscopy suite was not arranged to have separate dirty and clean rooms with negative and positive air pressures respectively.

(c) The exhaust of the clean sterilization room in the Dental suite was noted to be dusty. There was a fan in the corner of the room with very dusty and dirty blades.

(d) There was dust accumulation noted behind the sterilizer in the clean sterilization room of the Dental suite.

(e) The Clean sterilization room exhibited neutral air pressure.

7. During the survey of the Dialysis unit on 03/15/13 at 11:45 AM, a review of the disinfection logs for the dialysis machines was made. The Technical Manager stated that the staff should disinfect the machines every Friday with bleach. Review of the logs indicated that the staff members were not consistent in documenting the negative for bleach result prior to patient use.

Example includes

On 03/07/13 (which was as Thursday) machines #16,14, 24, 21,20, 10, 5,11,17,9 and 12 were bleached. There was a check on 03/08/13 that in the AM the bleach result was negative for all machines. However, machine #5 was again bleached on 03/08/13 (no reason documented) and there was no negative check for machine #5 on 03/09/13 prior to patient use.
On 03/08/12 machine #5 also went through an acid and heat disinfection.

Similarly machine #14 was bleached on 03/06/13 , no negative check made on 03/07/13.

All above findings were verified with Senior Director of Engineering, VP of Operations, and Environmental Heath staff.

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10331


Based on review of records, procedure, and staff interviews, it was determined the facility did not implement an institution - wide practice to ensure signed written receipt of discharge instructions by patients or their representatives, in order to validate communication and understanding of discharge plans implemented prior to release from the facility.

Findings include:

1. The facility did not establish or implement a practice or process to ensure that care instructions provided at discharge were actually received and signed by the patient or their representative prior to discharge.

Review of procedure titled, "Discharge of Inpatients", Subject # A2-301 on 3/15/13 found that regulatory forms such as the Important Message from Medicare about Your Rights, references as the "IM" are provided to patients and that patients are requested to sign the document to confirm receipt. Item #8, indicates that written discharge instructions are provided to patients prior to discharge. However this process does not require a signature to confirm receipt and understanding by the patient or their representative.

Interview with staff from the emergency department and administrative staff on 3/13 and 3/15/13 found there is no current requirement for patients to sign confirmation of receipt of discharge instructions on inpatient services and emergency departments prior to discharge.

Documents were provided from the contracted electronic medical record provider, EPIC, on both dates. This document, titled "Patient Discharge Instructions" indicated that the nurse reviews discharge instructions with the patient prior to printing and that this represents an electronic signature which eliminates the need for the nurse or the patient to sign the hard copy.


2. Review of 5/5 applicable emergency and inpatient medical records on 3/13/12 and 3/14/13 found that written discharge instructions and plans provided to patients or their representatives lacked evidence of signature to confirm receipt of discharge plans by either patients or their designated representatives.

Example:

The patient referenced in MR #1 is a 58 year old male referred to the emergency room for shortness of breath, CHF and scrotal edema. The patient had been referred from the clinic, where he was assessed on the same date where it was noted he had shortness of breath, somnolence, and difficulty with urination due to swelling. Patient was sent to the ER via ambulance for assessment of needs for possible diuresis and foley catheterization. The patient's history was significant for cardiomyopathy , DM, HTN, and schizophrenia and the patient resides in a group home residence. It was noted that the patient was unable to sign consent or other documents for proxy in the emergency room due to his clinical condition.

On 11/27/12 at 1910Hrs the patient was noted to be able to follow commands but had poor safety awareness and poor judgment as per nursing documentation. The patient was subsequently cleared and nursing documentation at 2214Hrs recorded that the patient's condition had improved and discharge papers were provided with understanding verbalized. Examination of the discharge instruction document revealed no signature was elicited from this patient to confirm receipt. The electronic form included furosemide 40 mg prescription but no follow up arrangement of appointment was noted.

Similar findings regarding the lack of validated patient signature and receipt of discharge instructions were noted in the following records: MRs #1,2,3,4,5.
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Based on review of procedures, records, and staff interview, it was determined that the facility did not develop or implement a safe process for coordination of discharge plans for vulnerable patients returning to residential care facilities who are evaluated in the emergency department and discharged. Specific reference is made to 1/1 applicable emergency record for a patient who was discharged alone late at night to a group home residence via ambulette. There was an incorrect address for the group home.

Findings include:

1. The patient referenced in MR #1 is a 58 year old male who was treated and released from the hospital's emergency department (ED) on 11/27/12 at an undetermined time around 2345Hrs without a safe discharge arrangement, and without being accompanied by an aide from his group home residence.

Following discharge from the emergency room, the patient was found on the sidewalk intoxicated at 10:25 AM on 11/28/12. He was taken via ambulance to another acute care facility at 10:51 AM on 11/28/12 where he was noted to have altered mental status and hypothermia. He was subsequently intubated in the emergency room and transferred to intensive care. The patient went into cardiac arrest and subsequently expired at 4:22 AM on 11/29/12.

Review of MR #1 on 3/13/13 determined that this patient received an unsafe discharge from the emergency room on 11/28/12, where this patient was assessed and treated for symptoms related to shortness of breath, and urinary difficulty with scrotal swelling.
The patient had been referred to the ED from the IMA clinic. Patient was sent to the ED via ambulance for assessment of needs for possible diuresis and foley catheterization.


The patient's history was significant for cardiomyopathy, DM, HTN, and schizophrenia . The patient resided in a group home residence for persons with psychiatric illness. It was noted that the patient was unable to sign consent or other documents for proxy in the emergency room due to his clinical condition. This patient was noted to have periods of altered mentation while being treated in the emergency room. During triage at 5: 37 PM on 11/27/12, the patient was oriented to person and place yet the suicide/abuse risk assessments could not be conducted since it was noted by staff, "unable, secondary to AMS (altered mental status)". Review of referring clinic record found notes dated 11/27/12 that the patient's mobility required ambulation with use of a walker.


On 11/27/12 at 1910Hrs the patient was noted to be alert, able to follow commands but had poor safety awareness and poor judgment per follow up nursing notes.


The attending physician note at 1947 Hrs on 11/27/12 noted a recent hospital discharge for CHF exacerbation but referred from clinic for somnolence, worsening lower extremity edema, penile/scrotal edema, and possible urinary obstruction At that time the patient was unable to provide history, was awake, and noted to have moderate scrotal swelling. The plan included to perform tests for troponin and bedside sonogram to assess retention. There was also a plan to see if patient could ambulate.


The attending physician noted at 1951Hrs that the patient was able to answer basic questions and denied SOB, abdominal pain, or difficult urination.


The patient was subsequently cleared medically at 1958 Hrs where it was noted that pre-void and post-void amounts were completed . The PA discussed with another MD that the lasix was increased from 20 mg BID to 40 MG BID and that the patient was not in urinary retention. The plan noted that the patient was to return to the group home where he resides.


At 2151Hrs the PA called for social work consultation and at 2207Hrs the social worker was connected to the emergency staff. Interview of the ED staff on 3/13/13 determined that this was solely for authorization of transportation and that no formal social work consult was initiated.


Nursing documentation at 2214Hrs recorded that the patient's condition improved and discharge papers were provided with understanding verbalized. However, the record lacked documentation of validated patient signature to confirm receipt of discharge instructions. No arrangement for follow up outpatient appointment was noted.


The ED nurse recorded that the patient was discharged at 10 22 PM on 11/27/12 and was still waiting for ambulance. The nurse recorded, "patient discharged, condition improved, discharge papers provided, understanding verbalized. Patient exited ED safely. Patient awaiting transport to group home via Lifestar EMS, confirmation # 5307525". In the patient's electronic medical record there was no documentation of final handoff by hospital nursing staff to ambulette staff.


Despite the nursing discharge note, two more sets of follow up vital signs were noted. Follow up vital signs were taken at 2217Hrs with elevated blood pressure of 178/130. Another set of vital signs were recorded at 2345Hrs for Respiration=17, BP=169/98. Level of consciousness noted was "wide awake" but no further assessment of mental status was recorded.

It is also noted that the ED physician attestation to certify review of data and exam of the patient was dated 12/6/12 at 1045Hrs, eight days following discharge.

The record lacks evidence of follow up mental status testing or assessment of ambulation. The record lacks documentation that hospital emergency room staff contacted group home residence staff for notification of the patient's impending transfer and return to the group home.

2. Interview with medical and nursing staff from the Emergency department on 3/13/12 found that the group home worker who accompanied the patient to the emergency department had left the patient in the hospital. Staff stated that the group home aides normally are required to stay with the patient until final disposition. There was no recollection by staff interviewed of any contact made with the residential facility staff to request that an attendant return.

There was no contact with the group home residence for notification of patient discharge and pending return to the residence.

3. Staff provided additional documents for review on 3/12 and 3/13/13.
The first document was in a format titled, "Patient Care Timeline", derived from the patient electronic medical record. This document noted that the last contact with the patient was at 2345Hrs for vital signs on 11/27/12. At 2:21:58 AM on 11/28/12 the nursing note records from "room south 14 to room discharge".

This timeline document mentions that the patient was to be admitted at 1856 Hrs on 11/27/12. However, the staff interviewed reported that there was no plan to admit this patient. This was at variance with the follow up timeline information documented in the electronic medical record which indicated that the initial plan stated admission for this patient.

In addition, two clinical notes from the 11/27/12 ED patient encounter were filed by the physician assistant on 12/4/12, and by the emergency physician attestation on 12/6/12, which were six days and eight days post patient discharge, respectively.

Additional documents obtained by the hospital from the ambulette company during the survey on 3/13/12 suggest that the patient was actually picked up by the ambulette at 11:00PM on 11/27/12 . The subcontracted ambulette company noted that the patient referenced in MR #1 was picked up at 11:00PM and dropped off at an address different from his residence, 106 West 142nd Street NYC at 11:35 PM on 11/27/12. The form records the destination as the Emergency room and the pick up address is listed with the incorrect address as 142nd Street where the patient had been dropped off.

An e-mail dated 3/12/13 from the transportation company found that the transport request was received for the patient referenced in MR #1 for the correct destination address. The driver was dispatched but did not receive the patient's address as the driver claimed familiarity with the patient.

A second transport request was delivered at 10:50PM for a different patient from the hospital noting the address where MR #1 had been incorrectly dropped off. At 11:29 PM on 11/27/12 the driver requested the address of MR #1 but was given the incorrect address for the second patient by the operator. This resulted in MR #1 being dropped off at a destination intended for a different patient.

The time referenced by the ambulette company records the patient pick up as 11:00 PM. This time is at variance with the time of discharge recorded in hospital records, which show the last set of vital signs were taken at 11:45 PM on 11/27/12 and which did not record discharge until 2:21 AM on 11/27/12. The 2:21 AM note on 11/28/12 did not record any clinical information associated with discharge or the manner in which the patient departed.


4. The hospital's existing discharge planning procedures for the emergency department do not address referrals for interventions for vulnerable patients from residential facilities who are discharged from the emergency room, and where safety needs must be considered for patients with mental and/or functional/physical impairments.

Review of Social Work Services Policy # 8.1 for Patient care: Emergency Services Adult & Pediatric Emergency services includes criteria for referrals of patients. These include notification procedures for patients returning to the hospital for admission from nursing homes after hospital discharge. However, there is no process to address the need for safe discharge planning for vulnerable patients who return to residential facilities directly from the emergency room. Cross referenced procedure, "4.2 Patient care: General Services Transportation Arrangements" notes social work and nursing staff responsibility during off hours for authorization of transportation".
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