HospitalInspections.org

Based on medical record review, document review, and interview, in 1 (one) of 15 medical records reviewed, the facility did not provide the standardized Medicare notice to the patient's representative as required, for a patient who was admitted and assessed to have altered mental status, communication problem, and right sided weakness secondary to intracranial bleed.

Findings include:
Review of Patient J's medical record of 10/14/15 and 10/15/15, identified: Patient was admitted on 7/11/15. The "Important Message From Medicare About Your Rights" (IM) form, in Section for Patient Signature or Representative, "not ready" was written and was dated 7/12/15. A notation under Patient Signature or Representative was written "unable to sign" and was dated 7/24/15.

There was no documented evidence in the medical record that the IM notice was provided to the patient's family as required.

During interview of the Associate Director of the Patient Relations, on 10/14/15 at 5:06 PM, the staff stated that the Patient Relations are responsible to provide the IM notice to the patient 48 hours within admission and 48 hours before discharge. Staff was unable to validate who provided this form to the patient.

Based on document review, videotape and interview, it was determined that the hospital staff allowed the continued use of a manual hold by a family member, to restrain a patient who attempted to elope from the Psychiatric Emergency Department.

Findings include:

Review of MR# A, on 10/8/15 at 9:30 AM, identified that the patient was brought to the adult Emergency Department (ED) by 911 FDNY (Fire Department -New York ) on 5/23/15 1652 (4:22 PM), with the complaint by the family of "argument with parents, said he is going to kill himself. Patient denies.'' Patient was triaged and assigned to the ED Behavioral Health at approximately 1706 (5:06 PM). There is documentation that the patient was transported to the Psychiatric Emergency Department, accompanied by the patient's family. There is reference in the record of the patient attempting to elope from the Psychiatric ED by running to the exit door, which was being opened for the exit of the patient's family. It specifically stated that the brother prevented the patient from leaving the hospital.

A videotape, dated 5/23/15 at 2009 (8:09 PM), reviewed by the surveyor on 10/13 /15 at 10:35 AM, showed that the patient ran toward the partially opened exit door of the Psychiatric ED. A young male Caucasian, had the door ajar and the patient ran by the Behavioral Health Associate (BHA) and exited that door into the hall. The video shows that the young male Caucasian, appearing in his 30's and in shorts (later identified as the patient's brother and an off-duty Police Officer), taking the patient down to the floor immediately in a manual hold. The patient was taken down to the floor of the area directly outside the exit door. Less than 30 seconds later, Hospital Police officers responded and assisted the family in immobilizing the patient, and transported the patient, with each person carrying the patient by his arms and legs, into the Psychiatric ED.
It was noted, when Hospital Police arrived, the young male Caucasian continued to hold down the patient and assist the Hospital Police and clinical staff in removing the patient from the hall back into the Psychiatric ED

At interview with the RN on 10/15 /15 at 2 PM, it was stated that the BHA (Behavioral Health Associate) who assisted in the incident informed him that he repeatedly requested that patient's brother (off-duty NYPD officer) stop leaning on the patient's neck. Interview with the BHA found that he asked the brother to let the hospital staff immobilize the patient.

Interview with the Hospital Police Officer (Employee #26), on 10/20/15 by phone, found that he stated that there was no supervision of the incident by any Psychiatric ED medical or nursing staff. The nursing staff present where BHA's who participated in the manual restraint of the patient and carrying the patient back into the Psychiatric ED.

Based on interview, it was determined that the nursing staff utilized hospital police to enforce compliance with medical regimens, including isolation.

Findings include:

At interview with the Emergency Department (ED) RN, it was stated, respiratory isolation is enforced by hospital police, who are placed in the area in back of the ED and watch isolation patients.

At interview with the ED staff RN on 10/13/15, it was stated that if an isolation patient with rule out TB or other contagious disease refused to stay in his room, she would ask for an order to put the patient into 2 point restraints.
There is no facility policy for handling patients on isolation who refuse to stay in their room.

Based on review of document and interview, in 5 (five) of 7 (seven) medical records reviewed, it was determined that the hospital Emergency Department (ED) staff used chemical restraints for patients with a presumptive diagnosis of Alcohol Intoxication and failed to use less restrictive method of restraints.


Findings include:

On 10/08/15, review of the Pyxis system revealed that 5 of 7 patients with a diagnosis of Alcohol Intoxication, were given 5 mg of Haldol and 2 mg of Ativan, referred to as 5&2; allowed to sleep for a period of time and then discharged home.

Review of Patient MR# I, on 10/15/15, identified: as per physicians' orders 5mg of Haldol and 2mg of Ativan was administered by the nurse. The patient was administered Haldol 5mg/IM, Ativan 2 mg/IVP (Intravenous Push) based on the presumptive diagnosis of alcohol intoxication. His blood alcohol level was found to be less than 10.

In Patient MR#B, the patient was administered Haldol 5mg IM and Ativan 2mg. IVP with the presumptive diagnosis of alcohol intoxication, after he was loud and verbally abusive to staff. No alcohol level was drawn and he was discharged.

Similar findings were identified in MR# C, D and E, when Haldol 5mg/IM, Ativan 2mg IVP was administered to patients with a diagnosis of alcohol intoxication. There was no documented reason in the medical record for the use of these medications or that less restrictive measures were tried or considered.


At interview with Staff #3, ED nurse, on 10/15/15, it was stated that the facility does not use chemical restraints. Reference was made to the Policy for the use of Patient Restraints and seclusion.

At interview with Staff #2, ED physician, on 10/15/15 at 3 PM, it was stated that the ED uses mechanical restraints and progresses, if necessary to "medical restraints." The physician then stated that he calls chemical restraints, "medical restraints."
He stated that in the ED, there is no need to explore a less restrictive intervention, in that these patients are so agitated, combative, and intoxicated that no lesser restrictive measures could safely be considered. He emphasized that the patient population drinks very heavily.

Review of policy titled " Patient Restraints and Seclusion," revised 02/06/15, states "Chemical Restraints are not allowed at Coney Island Hospital."

Based on review of document and interview, it was determined that the hospital did not ensure that all staff who are involved in the application of restraints are trained and certified in the use of First Aid Intervention and Cardiopulmonary Resuscitation.

Findings include:

Review of restraint policy and procedure titled " Policy for the use of Patient Restraints and Seclusion," last reviewed 4/2011, and revised 2/6/15, identified that there is no requirement that Hospital Police have current certification in CPR.

Review of 6 Hospital Police Officers' personnel files found no evidence of current CPR certification.

Interview with Risk Management Director on 10/14/15, found that they were not aware of any such requirement for employees who are not part of medical or nursing staff but do use manual holds to assist clinical staff in the application of restraints, to have any such certification or current training.

This is not in accordance with the Federal regulation for education training for appropriate staff utilized in the application of restraints.

Based on medical record review, document review, and interview, the nursing staff did not ensure that: (a) the patient's inadequate nutritional intake was evaluated by a licensed nurse and reported to the physician, (b) Nutrition Consult was obtained for patient assessed to have dysphagia (difficulty swallowing).

Findings include:

Review of the medical record (MR) on 10/14/15 and 10/15/15 documented: an 85 year old female admitted to Coney Island Hospital on 7/11/15 for chief complaints of altered mental status with right sided weakness. The patient had a CT-scan of the head and revealed right temporo-parietal intracranial bleed. The patient was admitted to the Medical Intensive Care Unit (MICU) and was followed-up by specialists including Neurology, Cardiology, Intensivist, and Rehabilitation team.
On 7/13/15, the Rehab Therapy Clinical Dysphagia Evaluation Record, written by Speech/Language Pathologist documented: "Patient demonstrated Dysphagia secondary to intracranial hemorrhage. Change diet to pureed solids, thin liquids, and meds crushed with apple sauce. Supervision: Dependent-must be fed by staff-. Instructions: Position patient as upright as possible for all oral intake. Remain upright after oral intake for at least 30 minutes."

The Nursing Aide Flowsheets on patient's intake of 7/15/15 through 7/24/15, review documented the following:
Diet: Pureed/Mechanical Soft
7/15/15: Breakfast=50% Lunch=No record Dinner=75%
7/16/15: Breakfast=50% Lunch=No record Dinner=25%
7/17/15: Breakfast=50% Lunch=No record Dinner=25%
7/18/15: Breakfast=No record Lunch=50% Dinner=25%
7/19/15: Breakfast=25% Lunch=25% Dinner=25%
7/20/15: Breakfast=50% Lunch=No record Dinner=25%
7/21/15: Breakfast=50% Lunch=No record Dinner=50%
7/22/15: Breakfast=25% Lunch=25% Dinner=25%
7/23/15: Breakfast=50% Lunch=25% Dinner=25%
7/24/15: Breakfast=25% Lunch=No record Dinner=No record


Review of the Nursing Aide Flowsheet of 7/15/15 through 7/24/15 revealed inconsistent documentation of the patient's meal intake, and no notation regarding dietary tolerance for this patient with dysphagia and right sided weakness.


There was no documented evidence that the Nursing Aide Flowsheets (of 7/15/15 through 7/24/15) were reviewed by the licensed nurse, and that patient intake was evaluated and reported to the responsible physician.
There was no documentation in the medical record that the inadequate dietary intake of 7/15/15 through 7/24/15 was addressed.

The facility's policy and procedure on "Nutritional Consultation" last reviewed on 1/7/15 identified: "A nutrition consult shall be written by a physician if nutrition intervention is needed within 24 hours."

During interview of the Registered Dietician on 10/14/15 at 3:56 PM, she indicated, "I would expect that an intake of 25% to 50% must be communicated by nursing to the physician so that the physician could make a referral to the dietician. The physician is the one responsible to make a dietary referral."