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.

Based on review of documents and staff interviews, it was determined that the hospital did not develop a system to prohibit steering of home care agency referrals to particular agencies nor ensure a process to confirm patient choice in the selection of certified home health care agencies.

Findings include:

The hospital has not developed or implemented a procedure to ensure non-discrimination in patient selection of certified home health care agency providers (CHHA's).

1. Interview with staff #12 (Director of Case Management Services) on 5/31/11 at approximately 3 PM determined the hospital has not developed a formal written policy for referrals to certified home health care agencies. It was stated the current practice is that the hospital case manager provides a list of home care providers to patients in order to elicit the patient's choice. The case manager will refer the patient to the agency of choice, which might include a referral to one of three available contracted home health care agency providers who work on-site in the hospital and who perform pre-discharge assessments of skilled nursing needs.

2. Review of the facility contracts on 6/2/11 found that the hospital has transfer agreements in effect with three (3) certified home health care agencies (Visiting Nurse Services NY, Shorefront Jewish Geriatric Center, and Visiting Nurse Association of Brooklyn) for home health care agency representation at the hospital . The wording of these contracts includes: "To the extent reasonably possible in the circumstances, the Hospital shall give preference to CHHA in the admission of CHHA patients, if space is available."

3. The facility did not implement a practice that ensures no steering or limitation in patient selection of home care agency, where feasible.
Review of the written home care notification letter and attached list of CHHA options given to patients determined there was a flawed process which did not fully encourage freedom of choice in patient selection of agency.
This home care agency notification form letter describes a referral is made to an agency that is selected by the staff and explains that a nurse from the selected agency is available at the hospital to help make post discharge plans. The letter contains a space and line so that the staff can enter the name of the selected agency on this form letter.
The notification letter subsequently documents a home care agency list is attached to the letter in the event the reader wishes to select another agency, but also advises choice may be limited by insurance carriers. The letter continues to state that the list is not an endorsement or recommendation of any particular agency by the hospital. However, the attached agency list documents three (3) of (21) agencies in bold print. The agencies listed in bold font represents the three agencies having contracts with the hospital for preferential referrals (Metropolitan Jewish Health System, VNR- Visiting Nurse Regional -formerly VNAB, and VNS -Visiting Nurse Services).
There is the potential for the reader to select one of the agencies listed in bold print, each of which has a written contract with the hospital.
The home care agency form letter used by the hospital first notifies patients that a particular agency is selected. The attached list of agencies denotes three agencies in bold print which represent agencies that have a contractual arrangements with the hospital and which have on-site staff available to perform pre-discharge intake assessments. The display of information in this manner may influence the reader to select the agencies in bold print which have a contractual relationship with the facility.

4. The hospital's practice for home care referrals did not ensure objectivity in patient selection of home care provider and did not fully comply with the requirement prohibiting steering or limitation in the selection of home care provider.
Specific reference is made review of MR # 5 in which it was noted in discharge planning notes on 5/4/11 that the agency providing services prior to hospitalization for this patient declined to re-accept the patient due to a change in level of care needed. The worker contacted the patient's daughter and noted on 5/4/11 "educated about hospital policy to refer patient to CHHA agency in the CIH: VNAB, MJGC, and VNS." The patient was referred and rejected by intake nurses from all three agencies that have an agreement with the hospital. The patient was discharged in 5/12/11 to a skilled nursing facility.
Five of fifteen remaining applicable records reviewed on 6/2/11 specifically for new home care referral processing found that none of the five cases (with no history of prior agency involvement) had documented evidence that patients or their representatives were advised of home care agency choice. Refer to MR#s 6, 7, 8, 9, 10.
Based on observation, it was determined that the director of food and nutrition services failed to ensure the kitchen is clean and in good sanitary condition.

Findings include:

On 5/31/11 during a tour of the kitchen it was observed that windows and window sills of the main kitchen and the dry storage room were dirty and dust laden. A window in the dry storage room was open and leaves from outside were seen spread all over the floor.

Based on interviews, review of medical records and other documents, it was determined that the facility failed to ensure that therapeutic diets are provided in accordance with physician orders. This finding is noted in one of 20 records reviewed.

Findings include:

Review of MR#4 on 6/1/11 noted an alert and oriented elderly patient was admitted on [DATE] with myocardial infarction. Initial Nutrition Assessment on 5/8/11 at 1311 noted patient on a CCU/CRU diet. Diet is of solid texture.
It was documented that patient had poor tolerance to diet due to an inability to chew. Diet was changed to CCU/CRU- Pureed, documented on patient nutritional follow-up by Dietitian. Patient remained on a Pureed diet which was documented on all Dietitian ' s follow-up notes (5/15, 5/20, 5/26 and 5/31/11) and documented that the diet should be maintained. During tour on T616 with the Associate Executive Director of Food Service, it was observed that the patient received mechanical soft food on his tray. The food was left untouched and was not eaten by the patient. At interview with the patient, he stated he did not like the food and did not want the food. Upon reviewing the patient's menu; the patient received mechanical soft food instead of pureed as prescribed by the physician. The menu was for a pureed diet but written on the menu was a note for mechanical soft food. There was no evidence of a diet prescription for mechanical soft food or a recommendation by the Dietitian for mechanical soft foods.
Based on observation, review of records, and staff interviews, it was determined the hospital's system for the form and structure of medical records system does not promote effective interdisciplinary communication. Specific reference is made to the finding that documentation maintained in an electronic recording system used to record discharge planning activities was not readily accessible to essential clinical staff working on inpatient units outside of the Case Management and Social Services Departments.

Findings include:

During review of medical records and tours of patient care units ME 6W and T6W on 5/31/11, it was observed that nursing staff interviewed were not able to access the most recent electronic discharge planning notes in patient records. Discharge planning notes in Canopy software system are not accessible to unit based nursing staff.

Nursing staff interviewed on 5/31/11 during the afternoon (staff #s 17, 18, 19, 20) confirmed that that nurses and social workers document assessments and discharge planning/utilization activities in an electronic format in this computerized "Canopy" system. This information is accessible to nursing supervisors only and cannot be accessed by unit based nursing staff that need the most up to date patient discharge information.

Users of the the electronic Quadramed system cannot access essential documentation in the Canopy software system since both systems do not permit exchange of patient information with one another.
It was reported by staff that Information technology staff (IT) is in the midst of getting Canopy and Quadramed software systems to"speak to each other" to resolve this problem.

The lack of immediate access to the most up to date electronic data by clinical staff creates the potential for errors in interdisciplinary coordination in that the most up to date discharge planning information is not readily available to unit based staff without access to Canopy.

Based on observation, interview and record review the facility failed to ensure a safe environment consistent with recognized infection control practices.

Findings include:

1. The hospital's Central Supply infection control policy and procedure ( P & P) revised 5/00,6/03,5/05,12/05 5/08 and 6/10 states that biological indicators are to be used to ensure the sterility of operating room (OR) instrument autoclave sets. The practice, however, has been to use a non-biological indicator "challenge pack". Review of autoclave records indicated that the challenge pack has been in use since January 2007.

2. The hospital received a customer notification letter from the manufacturer of the "challenge pack" dated March 16, 2011. The letter stated that the manufacturer of the product received a warning letter from the FDA that the Verify SixCess Challenge Pack is not a substitute for a biological indicator. Although the letter was initialed as having been received by the director of central supply on March 23, 2011 action was not immediately taken. Review of the purchase order revealed that biological indicators were not ordered until 5/26/11 and were received by the hospital on [DATE]. Use of the biological indicator was reintroduced on 6/3/11.

3. Interview with the director of infection control revealed that this individual was not aware that biological indicators were not being used to verify the sterility of the autoclave sets as the hospital's policy and procedure dictates.

4. The most recent evaluation of the central supply assistant dated 4/10/11, who does the testing for spores in the sterilization process, was performed by an individual not trained in this very technical process.

5. During a tour of central supply on the morning of 6/1/11 it was noted that medical supplies that would likely come into direct contact with patients were not protected from contamination. Open boxes of sterile supplies were adjacent to cardboard shipping boxes. Supplies included but were not limited to IV sets, IV catheter, gloves, syringes, alcohol preps, suction drainage, etc.

Based on observation tour and interviews, it was determined that the facility did not ensure the kitchen and patient nourishment refrigerators were kept clean and in good sanitary condition.

Findings include:

1- On 5/31/11 during a tour of the kitchen it was observed that windows and window sills of the main kitchen and the dry storage room were dirty and dust laden. A window in the dry storage room was open and leaves from outside were seen spread all over the floor.

2-A tour on inpatient unit (T6W) conducted with the unit interim head nurse on 6/1/11 at 12:30 PM found that patient nourishment refrigerator was not labeled for patient use only. The refrigerator was labeled "Food only". The patient's nourishment refrigerator contained foods brought in to the unit from commercial vendors; there were foods in brown bags without name or date; a bottle was observed with a red liquid; a ? gal bottle was labeled FAGG and a paper bag contained a Tupperware bowl with a cover. The refrigerator also stored nourishment items from the hospital food service and foods brought in by staff and patients' families. The food brought in from the outside food vendors were not monitored, identified or dated. The interim nurse was unable to identify all the food items.

Based on interviews, the review of medical record and other documents, the hospital Emergency Department did not demonstrate timely identification and reporting of a child abuse/maltreatment case. This finding was noted in 1 of 20 applicable records.

Findings include:

This13 months-old child (MR #11) with past medical history of cardiac surgery was brought to the Emergency Department by his parents on 1/22/11 at about 2010. The baby ' s mom initially reported that the child rolled off the bed while sleeping and hit back of his head on the floor. The baby was apparently normal after the incident at about 1300 until four hours later when parents witnessed seizure activities. However upon interview of the patient ' s mother at 0127 on 1/2311 she stated that the patient fell from a standing position onto a hard floor after grabbing onto a chair and not from the bed as previously noted. Also of concern was that the parents provided an address in Queens and sought medical care in Brooklyn.
The physician's assessment did not address the inconsistency in reports regarding the events leading to the injury. There was also no explanation recorded to support whether the mechanism of injury was consistent with the parent's report of how the injury was sustained.

Physical examination in the ED revealed dilated right pupil, constricted left pupil and a hematoma in the right occipital-parietal region. CT of the head showed large, right, frontal/parietal epidural hematoma with mass effect; compression of the right ventricle and midline shift 1.3 cm to the left; right parietal calvarial fracture; soft tissue scalp hematoma. The patient was underwent emergency craniotomy for the evacuation of epidural hematoma on 1/22/11. The patient was transferred to Maimonides Medical Center on 1/23/11 for further care.

Although there was evidence in the medical record that this case was reported to the appropriate authority at the receiving hospital, the ED staff at Coney Island Hospital failed to implement the facility ' s policy and procedure on " Child Abuse and maltreatment " . The policy mandates the ED social worker, if available, to call in all cases of possible child maltreatment. The social worker will complete the assessment. If he/she feels that there is child abuse/neglect, then he/she will initiate the report.

At interview with staff #13 (Director, Social Services) on 6/2/11, she stated the ED social worker was not on duty at the time the patient (MDS) dated [DATE] at about 2000. However, as per the facility policy the ED Coordinator, in the absence of the ED Social/Caseworker, will assist the pediatric attending/resident with reporting cases of suspected abuse/neglect to the New York Central Register and would act as liaison with administration for Children Services or Emergency Children's Services regarding the disposition of the child. The review of the Child Protection Coordinator job responsibilities noted the Coordinator is available for consultation to hospital staff 24 hours a day, 7 days a week regarding child abuse/maltreatment. However, at interview with Child Protection Coordinator (staff #14) on 6/2/11, she stated she had no knowledge of the case.

At interview with the Chief Nursing Officer (CNO) on 6/2/11, it was stated that when there is a serious trauma, the priority is medical care, not interviews with family or investigations of abuse. In this case, it was stated that the child was emergently sent to the O.R. and then transferred to another facility for specialized neurosurgical care.

Based on interviews with patients and staff and the review of medical record and other documents, the facility did not ensure that its policy addresses the use of safety belts in patients with cognitive impairments. This finding is noted in 2 of 2 applicable records.

Finding includes:

During observation tour of the Emergency Department on 5/31/11, two patients (MR# 1 and 2) were noted wearing red gowns and both had a safety belt around their waists which was secured to their bed frames. At interview with the Registered Nurse at the bedside, she stated that safety belts were not considered restraints and therefore does not require physician authorization and documentation of patient monitoring as with restraints.

MR #1 is an [AGE] year old male with medical history significant for dementia. The patient was brought by EMS to the ED on 5/30/11 for elevated blood pressure and diarrhea. Nursing assessment showed the patient was confused and disoriented to place and time. He was deemed a high risk for elopement as well as a high risk for fall based on a fall risk score of 19. A safety belt was applied and documented at 2236. There was conflicting documentation by nurses regarding the patient's ability to self release the belt. At 0834 on 5/31/11, a nurse noted the patient took out the safety belt; however, at 1224 another nurse noted the patient was attempting to get out of bed and wants to go home. The nurse further noted that the patient is wearing a red gown and safety belt is in place. At interview with the patient on 5/31/11 at 1230, the patient was asked if he knew how to remove the safety belt. The patient was observed fiddling with the belt but could not figure out how to release the belt.

MR #2 is a [AGE] year-old male with a history of ETOH abuse who was brought in by ambulance on 5/31/11for alcohol intoxication. The patient was extremely agitated and combative on arrival requiring management with Ativan and Haldol. At 1036, nurse noted that a safety belt was applied and the patient was advised to stay in bed. Nursing note at 1223 indicated the patient was wearing a red gown and a safety belt in place as he attempted to get out of bed and leave. At interview with the patient at 1230, the patient appeared confused and did not follow the surveyor ' s instruction to release the safety belt.

Based on interviews and the review of medical records and other documents, it was determined that the facility failed to provide adequate assessment and intervention to ensure patients ' nutritional needs was met. This finding is noted in 1 of 15 applicable records.

Findings include:

MR# 3
This is a [AGE] year old male with past medical history significant for septic arthritis, ETOH abuse, and ETOH hepatitis with marked elevations of liver enzymes. The patient was admitted on [DATE]for treatment of cellulitis and abscess. In the " Initial Adult Nutritional Assessment " completed on 5/25/11, the dietician did not document the prescribed diet in the assessment but notes that the diet was appropriate and meets patient ' s nutritional needs. The current order at the time of assessment was regular diet.

The dietician notes the patient food intake was fair and pain was interfering with eating. Blood chemistries and CBC revealed Albumin 1.8 (very low), Hemoglobin 8.7 and Hematocrit 25.0 (low). However, the diet plan recommended did not take account of the patient protein needs. There was no protein supplement recommended by the Dietitian to improve the patient ' s nutritional status. At interview with the Dietitian on 6/1/11, she stated the patient was identified as a moderate risk at the time of the assessment and was aware that his albumin levels have been low. The dietician said the patient would be reassessed today and would recommend protein supplements.

The review of the follow-up " Adult Nutritional Assessment " on 6/2/11, day #9 of admission noted a weight gain of 17 Ibs since admission. The dietitian recommendation was to follow-up weights. The patient weight gain was not evaluated nor was there a discussion with nursing staff regarding the accuracy of the weights. The review of the patient weight record showed the patient weighed 63.5 kg on 5/23/11 at 1946 and 71.2 kg on the same day at 2039.
Based on observation and interview during tours of the facility on 5/3/, 6/1,/6/2,6/3,and 6/6/2011 the hospital did not ensure that the condition of the physical plant and overall hospital environment was developed and maintained in a manner to ensure the safety and well being of patients.


1. During a tour of the pediatric and adult emergency departments ( ED's) on the morning of 5/31/11 testing of the nurse call nurse system revealed that the audible component of the system did not work.

2. The nurse call in the toilet rooms of the pediatric, special disposition and psych holding units did not work at all.

3. A nurse call system was not available in the women's and men's toilet rooms in the adult ED waiting area.

4. The fluorescent bulbs in 4 of 6 overhead lights in the ceiling fixtures of the women's toilet room were burned out.

5. There was no provision for privacy in the toilet room of the special disposition observation unit as there was no door or curtain available.

6. Exhaust vents throughout the hospital were noted dust laden.

7. The floor and shelves of the IT closet in the pediatric ED and the floor and overhead conduit in 2 electrical closets in the ED corridor were noted extremely dust laden.

8. Dirt, dust and debris was noted in all exit stairs throughout the hospital.
Based on document review and interview the hospital failed to ensure proper ventilation and ventilation controls.


1. Review of the OR temperature and humidity tracking log on the afternoon of 5/31/11 revealed readings outside the range of 30-60 % allowed by the hospital's P & P and by AIA. The log showed greater than 60% humidity from 5/15 through 5/30 20l1. The log also indicated that OR staff contacted the boiler room but no documentation of corrective action by the boiler room was noted. Interview with the chief engineer provided no explanation for lack of follow up. The hygrometer / thermometer combination monitoring device in each operating room was replaced the following day i.e. 6/1/11 and % humidity was found to be acceptable. There was no procedure in place to ensure that humidistats had been calibrated.

2. On the afternoon of 5/31/11 it was noted that there was no supply ventilation and very little exhaust ventilation in the surgical instrument decontamination room off the OR corridor. Documentation regarding regarding the number of air changes being provided in the room was requested but not available.

3. On the morning of 6/1/11 it was noted that there was no supply ventilation and very little exhaust ventilation in the surgical instrument decontamination room of Central Sterile supply. A large fan was noted in use. Documentation regarding the number of air changes being provided in the room was requested but not available.

4. Review of maintenance records for the Isoaide Ventilation / Filtration Unit model number AETP3092-M used in the hospital's isolation rooms shows that they are not maintained in accordance with the manufacturer's requirements. The manufacturer of the unit states that the UV filter be replaced every six months. Records show that the UV filters were changed in August of 2010. There is no documentation to show that UV filters were changed since. The manufacturer recommends a bubble testing of the fan housing for leakage every six months. It also recommends that a few drops of non-detergent 'twenty weight" oil be added every 12 months. There was no documentation available to show this maintenance was performed. The hospital contract with the vendor states that "All units be tested and certified to the appropriate manufacturer and national standards ...". It also states that "all work be performed by a NSF Accredited Technician". Credentials for the technician performing the work were requested but not provided.