The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

LINCOLN MEDICAL & MENTAL HEALTH CENTER 234 EAST 149TH STREET BRONX, NY 10451 Nov. 16, 2015
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation and staff interview, it was determined the facility failed to maintain the physical plant and overall hospital environment in such a manner that the safety and well-being of patients and staff was assured.

Findings includes:

Findings A

During tours of the hospital from 11/9/2015 to 11/16/2015, the following findings were identified in the presence of the The Director of Facilities Management and the Senior Associate Director for Capital Design, who accompanied the State Surveyor throughout the survey.



Surgical Intensive Care Unit: SICU, tour conducted on 11/9/2015 at approximately 2:15, identified:

1) 1 (one) ceiling tile of the Isolation room and the outer surface of the smoke head were
observed to have brown stains.

2) The clean linen sheet covering the bed of room 7 of the SICU was found to have stains
and not clean. It should be noted that the room was marked clean ready to receive
patients.

3) The floor of room 5 was not clean and had yellow stains, especially at its periphery.

4) Four soiled linen hampers were observed being stored outside the staff lounge room.

5) An area approximately 8 inches x 6 inches of the wall above the hand-wash sink was
broken and the soap dispenser was ripped off the wall.


Outpatient Clinics:

1) The electrical closet RP2-1F on the corridor of the outpatient clinics was found not to have one hour fire rated walls, and had penetrations on its walls that were not sealed off with the proper fire stops.

2) The electrical outlets of the Eye Clinic waiting area and other parts of the clinic were not the tamper resistant that is required where children are being cared for at the clinics. It
was noted that children are being cared for at the eye clinic.

3) The Procedure Room 2-234 of the Dental Clinic was found to have a neutral air pressure contrary to the required positive air pressure that is required for this type of room.

4) Procedure Room 2-233 of the Dental Clinic was found to have a negative air pressure instead of the required positive air pressure.

5) The Dental Laboratory cast -room 2-238 was found to have a positive air pressure instead of the required negative air pressure.

6) The Soiled Utility Room 2-213 of the Urology Clinic was found to lack an exhaust vent and did not have a negative air pressure as required for this type of room.


4th Floor - Pediatric Department:

1) The tracks of the ceiling of the Isolation Room were harboring dusts, some were bent
and there were gaps between the ceiling tiles.


Psychiatric Unit 10 A:

1) There were 4 (four) broken floor tiles on the corridor outside Room 1024. These broken tiles are potential for tripping hazard.

2) There were electrical conduits and data wires affixed to the wall of the dining room with gaps between these wires and the conduits, which is a potential for risk of looping.

3) The TV box in the dining room is rectangular in shape and has openings in its sides. The shape and the openings of the TV box are potential of looping.

4) The lower edge of the mirror on the bathroom of patient Room 1032 A was observed being sharp and carries a risk of patient injury.

5) The metal strike plate of all the door frames are protruded and impose a risk of patient injury.

6) Patient Room 1041 was observed missing a cove base. Also, some ceramic tiles around the edge of the mirror of that room are missing and others were loose.

7) The hinges of the patient cupboards on Rooms 1044 and 1052 were not extended to the top ends, leaving spaces that are potential of looping.

8) The patient Shower Room 1051 A was observed missing its shower curtain.

9) Small flies were observed in many rooms of the Psychiatric Unit A.

10) The Seclusion Room 1002 B did not have a bathroom.


Psychiatric Unit 10 C:

1) The metal strike plate of all the door frames are protruded and impose a risk for patient injury.

2) The Plexiglas box around strobes and horns of the Psychiatric Units A and C are square shaped, that were mounted approximately 7 feet from the floor, and are potential of looping.

3) The shape and the openings of the TV box in the dining and activity room has openings in its sides and the rectangular shape renders it to a looping hazard.

4) The cabinets in the Activity Room of Unit 10 C had door handles and pad locks that are potential of looping.

On the morning of 11/13/2015, during a tour of the fifth floor of the hospital, the Soiled Utility Room 5B 143, was found to have a positive air pressure instead of a negative air pressure that is required for this type of room.

Findings B

1) During a tour of the hospital on Tuesday 11/10/15 at approximately 11:30, the floor of the Maintenance Supply Room in the basement, was noted to be strewn with papers and other debris. This deficiency can pose a hazard to staff working in the area as it may contribute to slip and fall type injuries.

2) On Monday 11/9/15 at approximately 1:30 PM, in the 3rd floor Mechanical Equipment Room, numerous cardboard boxes were found to be stored directly adjacent to heat generating mechanical equipment. This room is not sprinklered and such storage poses an increased risk of fire in this area.

3) On Monday 11/9/15 at approximately 11:45 AM, signage throughout the Emergency Department was noted to consist of temporary paper signs instead of Americans with Disabilities Act (ADA) compliant signage, required by ADA Accessibility Guidelines for Buildings and Facilities, Section 4.30.
On Tuesday. 11/10/15 at 2:10 PM, ADA compliant signage was noted missing from patient restrooms and a shower room in wing 8C. This deficiency was also noted at a patient shower room in wing 9B on Thursday 11/12/15 at approximately 11:15 AM. Failure to provide ADA compliant signs may compromise the comfort and safety of patients with disabilities as they try to access the appropriate room/lavatory.

These findings were verified at the time of observation by the Interim Director of Engineering and the Associate Director of Fire Safety.


4) On Thursday 11/12/15 in the Outpatient Hemodialysis Area, the ceiling was noted to be stained throughout. Also noted in this area, a substantial amount of dried dialysate leakage was found on the baseboard heater behind patient station #6. Lack of cleanliness in the Dialysis Unit can negatively impact patient health and safety.

This finding was verified at the time of observation by the Interim Director of Engineering and the Medical Director of the Hemodialysis Unit.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation and document review, in two (2) of three (3) medical records (MR) reviewed, it was determined that the facility did not ensure; (a) that medical records were protected from fire, (b) all entries in the patient's medical record were accurately written.

Findings include:

1. On 11/16/15 at approximately 11:30 AM during tour of the medical record file room, two (2) microwaves were observed plugged into electrical outlets next to the terminal record files. This present a fire hazard.

This finding was confirmed with staff A ( Director of Health Information Management ).



2. Review of the Patient MR #2 noted that on 9/29/2015, Social Work Comprehensive Assessment, dated 9/29/2015 0610, indicated that the patient was a [AGE] year old who presented to the ED ( Emergency Department) with complaint of SOB (shortness of breath). The MICU (Medical Intensive Care Unit) attending physician note, dated 9/29/2015 0746, stated: "this is a [AGE] year old F with a PMH of COPD s/p intubation x 1, a fib on Coumadin and [DIAGNOSES REDACTED] on chemo." There was a discrepancy in the patient's age.

Patient MR #3 is an [AGE] year old patient, who arrived in the facility 11/8/2015 1030, and was discharged on [DATE] 12 45. The Social Worker's discharge summary indicated that the disposition was nursing home placement. The MD disposition indicated that the patient was discharge home w/out services. There was discrepancy in the patient's disposition.

The inconsistency in documentation was brought to the attention of staff C, D & E, on 11/16/2015 at approximately 11:00 AM.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on review of documents, video tape and staff interview, in 1 of 7 medical records (MR) reviewed, the hospital did not effectively assure that its Quality Assurance Program (QA) identify and thoroughly investigate the allegations of abuse made by the patient.
(MR#1)

Findings include:
Review of the Patient MR #1 noted, on 9/25/2015 0435, the provider documented "the patient made allegation of being hit by EMT (Emergency Medical Technician) staff who brought her in to the ED (Emergency Department)."
Review of the Risk Management investigation and Security Incident report, which were submitted to the surveyor on 11/12/2015, identified that an investigation of the allegation was conducted and the case was closed, based on review of a video tape. The surveyor requested copy of the video tape on 11/12/15 3:45 PM.
On 11/13/15 at approximately 10:00 AM, a meeting was requested by hospital leadership. During this meeting, the hospital leadership stated that the patient complained to Behavior Health Administration on 9/26/2015 that "officer Henry" pushed her down. They also stated that this administrator reported the allegation to Risk Management. Risk Management investigated the allegation, by reviewing the video tape, and found the allegation unsubstantiated. However, this staff did not review the video in its entirety. After the surveyor's request, the video was re-reviewed on 11/12/2015, and it was discovered that the hospital police did not use proper de-escalation technique when the patient was transported into the Emergency Department

The video tape, dated and timed 9/25/2015 approximately 2:45 AM, was reviewed by the surveyor on 11/13/15, while leadership was present. It was observed on the video tape, on one occasion two officers appeared to be holding the patient down. In addition, the patient was laying on the stretcher, on her stomach handcuff behind her by New York City Police (NYPD). The hospital police closer to the stretcher appeared to be pushing the patient's head down on the stretcher and pulling her hair.

The facility received this allegation from the patient on 9/26/2015. The hospital conducted an investigation of the allegation and closed the case, based on review of a video. However, the video tape was not fully reviewed at the time of the hospital's initial investigation. The facility did not identify the staff's action and did not take corrective actions , until 11/12/2015, after this surveyor requested to view the video tape.
VIOLATION: CRITERIA FOR DISCHARGE EVALUATIONS Tag No: A0800
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Base on medical record review, document review and staff interview, in 3 (three) of 8 (eight) medical records reviewed, it was determined the facility did not; (a) identify the need for discharge planning at an early stage of hospitalization , (b) provide adequate discharge planning for patients.

Findings include:
Patient MR #4 is a [AGE] year old patient with past medical history of [DIAGNOSES REDACTED]"no SW (Social Work) intervention needed as the patient did not fit into any high risk criteria." It was noted that this assessment did not include if this patient had any post hospitalization needs. The initial discharge plan was not documented.

Patient MR #5 is an [AGE] year old patient, with past medical history of [DIAGNOSES REDACTED]. The patient was admitted to Medicine Service on 10/18/2015 1903 (7:03 PM) and discharged on [DATE]. The Nursing Admission Assessment indicated "moderate risk factors: elderly over 70 yrs, needs assistance with ADL's and /or home care services. Referral will be sent to SW by system." The record indicated that this patient was discharged on [DATE]. This patient was not screened for discharge plan; in addition, the patient was not seen by a social worker for a discharge planning evaluation.

Patient MR #6 is a [AGE] year old who presented in the ED, on 11/3/2015 after falling off a ladder, and was admitted with hip pain. The patient underwent Left Hip Open Reduction surgical procedure. The patient had social assessment on 11/6/2015; the assessment indicated that the patient had no social work intervention need. The patient had a PT (Physical Therapist) evaluation on 11/8/2015. The Physical Therapist evaluation indicated that the patient will benefit from continued therapy to address his impairments and functional limitation. PT recommend "DC home with crutches and OPD rehab." The patient was discharged on [DATE].
The patient was identified as not needing discharge planning. There was no evidence that this patient was referred to Outpatient Physical Therapist or the reason why this was not done.

Staff D & E were interviewed on 11/16/2015 at approximately 10:20 AM. Staff stated that the social worker is the staff responsible for discharge planning. It was also stated that nursing staff screen all patients based on social work criteria, and a patient who fits the high risk criteria is seen within 24 hrs; moderate risk within 72 hrs. This staff was unable to explain what happens to the patient who is placed in moderate risk criteria with a length of stay 2-3 days.

The facility's policy and procedure (Policy ADM 0168) "Discharge Planning Process," last revised 9/30/2015, states that Nurse: screen all patient on admission according to established criteria. Identify High Risk and/or Moderate Risk patients; Refer patients to Social Work by using the computer to generate risk referral for social work intervention.
This policy does not state that nursing screens for discharge planning. This policy does not address patients who fits the 72 hours criteria but was discharged before 72 hours.
VIOLATION: LIST OF HOME HEALTH AGENCIES Tag No: A0823
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review and staff interview, in 2 of 8 medical records reviewed, it was determined that the facility did not consistently , as part of the discharge planning process, inform the patient or the patient's family of their freedom to choose post-hospital care services.

Findings include:

Patient MR #7 is [AGE] year old patient who was admitted to the facility on [DATE] and discharged on [DATE]. The Discharge Planning Evaluation dated 11/6/2015 1449 (2:49 PM), indicated that the discharge plan was "home with home care services." On 11/9/2015 1606 (4:06 PM), Social Work noted, disposition home with services from new referral to "HHC" home care service. Worker noted, sent home care referral to "HHC" and patient was accepted for services. Patient is aware and agreement with this plan. There was no documentation that the patent was given a choice of Home Care Agency.

Patient MR #8 is a [AGE] year old who was admitted to the facility on [DATE], after an assault by hammer. The patient was discharged on [DATE]. The discharge plan was "home with home care services." It was noted that a referral was made to a Home Care Agency. There was no documentation why this was the only Home Care Agency referral for this patient.

The facility's policy and procedure (Policy ADM 0168) "Discharge Planning Process," last revised 9/30/2015, was reviewed. This policy did not state that patients must be given a choice of post-hospital care service.

Staff D & E were interviewed on 11/16/2015, at approximately 10:20 AM. The staff acknowledged that they were aware that during the discharge planning process, patients must be given a choice of post-hospital care services.