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NYC HEALTH + HOSPITALS/CONEY ISLAND 2601 OCEAN PARKWAY BROOKLYN, NY 11235 Jan. 11, 2011
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on observations noted during tours, interviews, and record reviews, it was determined that the facility did not maintain the physical environment to ensure the health and safety of patients. Specifically, the facility failed to ensure that windows and air conditioning units were properly maintained to assure patients were not exposed to drafts and cold temperatures, failed to monitor temperatures in patient rooms and failed to adequately respond to patient and staff complaints about the cold temperatures in patient rooms. These findings were observed in 13 rooms affecting 40 patients.

Findings include:

During the tour of 3W and 3E on 1/11/2011, the three windows in the room 3W9 were found in disrepair. It was also noted that the facility failed to provide adequate insulation around the air conditioner unit installed on one of the three windows. Therefore a cold draft was felt by patients in these rooms. In addition, a gap of 3/8 of an inch was observed along the ledges of the window sills. Dust and debris had accumulated on the two heaters and on the vents of the air conditioner unit in this room. Similar observations were made during the inspection of in-patient rooms on the third and sixth floor of the building.

1- In room 3W10 it was observed that there was a noticeable vertical gap of approximately 1 " under the first window pane on the left side of the room, and material (plastic chucks) were stuffed into the edges of the 2nd window pane located on the left side of the room.
2- In room 3W8 it was observed that there were cloth towels stuffed between the lower gap between the air conditioner unit and the window pane, and that the corking between the window pane and the wall for all the window panels were found to be cracked and/or missing.
3- In room 3W11 it was observed that there was a small crack in the glass of the window pane located closest to the right of the room.
4- In room 3W12 it was observed that various sized pieces of Plexiglas were placed over gaps formed between the air conditioner and the window pane. However, the Plexiglas did not completely cover the gaps.
5- In room 6E13 there is a gap at the bottom of two windows.
6- In room 6E12 (Dialysis) there is plastic chucks on three windows.
7- In room 6W14, the air conditioner has a rubber cord insulating the left side of the air conditioner. This insulation was not found on the other sides of the air conditioner. There was a draft coming from the third window. Window shades were taped together to form a barrier to prevent drafts from coming through the window.
8- In room 6W15, wound tape and a plastic chuck was used on the windows to prevent draft from entering the room. A draft was felt coming from the bottom of the air conditioner. There was no insulation on the bottom of the air conditioner.
9- In room 6W10 there was plaster missing from a crack along side of the windows on the window sill. Window shades were taped and used as shield against the draft.
10- In room 6W12 the air conditioner vents were filled with dust. There was no insulation at the bottom of the air conditioner.
11- In room 6W13 there was a crack in the second window at the lower right corner.
Wound tape was covering the crack in the window. Plastic chucks were tucked between two windows.
12- In room 6W11, plaster was missing in a crack on the window sill that extended from one side to another.

Two patients were transferred out of their room due to complaint of cold temperature in their rooms. Patient #1 was transferred to another unit (7E) and the other patient (Patient #2) was transferred to another room (Room 8 to Room 9) on the same unit. Patient #2 was interviewed by the surveyor; the patient stated that her current room was cold. Upon review of the Nursing Management Report dated 1/8/2011; the allegation of Patient #2 was noted to be documented. The facility corrective action was to cover all vents of the air conditioner unit. However, during the tour it was observed that the corrective action was not implemented.

Upon review of Emergency Incident Report created on 1/7/2011 in regard to an open window in room 3W9, it was noted that the facility contacted the window vendor immediately to repair a crack in the window of room 3W9. During the tour on 1/11/2011, it was noted the window had not been repaired.

During interview on 1/11/2011 with the Senior Associate Executive Director, he stated this facility had appropriated the funds necessary to repair the damaged windows and were planning on replacing these windows this coming spring. Record review of the ' Coney Island Hospital Capital Plan FY11-15 ' confirmed the statements made by the Senior Associate Executive Director.

During interview on 1/11/2011 with the Director of Engineering, it was determined that there was no specific mechanism for monitoring of temperatures in patient rooms. The Director of Engineering stated that there was no specific policy/mechanism regarding monitoring room temperatures. It was further stated the room temperature is only adjusted when a work order is submitted, and that the change in temperature is made by adjusting one or two of the heaters installed in each room.

Record review of the facility ' s Engineering and Maintenance Management Plan, revised on June 14, 2006, revealed that the Engineering Department is responsible for the maintenance of the patients rooms. Specifically, in the above mentioned policy and procedure it states that the Engineering Department is responsible for Safety, Hot and Cold Water, and Renovation/Construction services.

Record review of the facility's QAPI minutes revealed that the facility reviews the engineering department work orders that were performed each month. But the facility failed to discuss and implement a repair plan concerning the deteriorating condition of the windows in patients' rooms.

While the temperature of several rooms when checked by facility staff were found to be within the range of 71-75 degree Fahrenheit, the deficient pratices (lack of response to multiple complaints from patients and staff, the lack of monitoring and QA, the inadequate/unsafe corrective measures taken to repair the windows and insulate around the air conditioners) posed an immediate and serious threat to patient safety and welfare.

Therefore, immediate jeopardy was declared on 1/11/2011 at approximately 4:30 PM. The facility was required to formulate and implement an immediate plan of correction. The facility immediately provided additional blankets to all affected patients and implemented an action plan to repair windows and cover and properly insulate around air conditioners to reduce or eliminate drafts.

The immediate jeopardy was abated on 1/11/2011 at 5:30 PM when it was confirmed that corrective action plan was in place. Follow-up with the Director of Risk Management on 1/12/2011, revealed that the facility completed the caulking of the windows and covering and caulking around the air conditioners at 11PM on 1/11/2011. The facility also reported that patients were no longer complaining about feeling cold.

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VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observations noted during tours, interviews, and record reviews, it was determined that the facility did not maintain the physical environment to ensure the health and safety of patients. Specifically, the facility failed to ensure that windows and air conditioning units were properly maintained to assure patients were not exposed to drafts and cold temperatures, failed to monitor temperatures in patient rooms and failed to adequately respond to patient and staff complaints about the cold temperatures in patient rooms. These findings were observed in 13 rooms affecting 40 patients.

Findings include:

See A700.

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