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.

NYC HEALTH + HOSPITALS/CONEY ISLAND 2601 OCEAN PARKWAY BROOKLYN, NY 11235 Oct. 25, 2016
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on observation, staff interview and record review, in one (1) of one (1) medical record reviewed, nursing staff did not: (1) implement the facility's protocol for sequential utrafilitration and (2 ) ensure that physician orders are obtained for sequential ultrafiltration during dialysis treatment. (Patient #1)

The failure to implement the appropriate sequential ultrafiltration protocol can lead to elevated sodium in dialysis bath, which may cause patient harm.

Findings include:

(1) During the tour of the critical care unit on 10/21/16 at approximately 12:30 PM, the surveyors observed Patient #1 in room T 631 receiving hemodialysis treatment. It was also observed that blood pressure monitor was alarming with elevated blood pressure of 169/94 and the conductivity of the dialysate displayed on the dialysis machine was noted to be at 14.7 mEq/L. Review of the treatment flow sheet and the dialysis machine readings revealed that the patient was in the third hour of treatment.

Upon further investigation of the dialysis machine settings, it was noted that the sodium base was set at 147 mili Equivalent per liter (mEq/l).

Interview of the hemodialysis nurse on 10/21/16 at 12:35 PM, staff stated that the base sodium was manually changed from the standard (140 mEq/l) to 147 mEq/l to manage the patient's cramping episodes during treatment.

Upon interview of the Staff L, Nephrologist on 10/21/16 at approximately 12:45 PM, it was revealed that the physician had verbally ordered sequential dialysis for the patient, thereby allowing the hemodialysis nurse to alter the base sodium.

Review of the policy and procedure titled "Sequential Ultrafiltration" last revised on 08/16/16, notes that the the nursing staff can manually vary the "dialysate Na (150mEq/l in the first hr, 142 in the second and 137 in the third)."

It was noted that the base sodium in the dialysate during the third hour of treatment, was 10 mEq/l higher than allowed by the facility's sequential ultrafiltration policy.


(2) Review of the Treatment Flow Sheet and Physician Orders for Patient #1, revealed that there was no written documentation of physician order for the sequential dialysis mode of treatment and alteration of the base sodium to 147 mEq/l.

Staff L, during interview on 10/21/16 at approximately 12:45 PM, acknowledged that there was no order and that the Electronic Medical Record System, did not have an avenue to document the sequential dialysis order.
VIOLATION: UNUSABLE DRUGS NOT USED Tag No: A0505
Based on observation, it was determined that staff did not ensure that outdated products were not available for patient use.

Findings include:

During a tour of the medication storage room in the OR suite on 10/20/16 at approximately 11:00 AM, one (1) Futurabond 5 cc container and two (2) Sprayzoin (Tincture of Benzoin compound) 4 Fl. Ounces, with expiration dates of 2016-09, were noted in the medication storage room.
These expired items were acknowledged by Staff J, Nursing-OR Director, who was present during the tour.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation and staff interview, the facility failed to maintain the physical plant in a manner to provide a safe and sanitary environment for the treatment of patients.

Findings include:

1. During the tour of the Equipment Storage Room in the operating room Suite on 10/20/16 at approximately 11:30 AM, it was noted that this room was unkept, disorganized and cluttered with clean equipment and clean supply storage carts. The room was observed to be approximately 400 square feet. The equipment and supply carts located at the back of the room was not easily accessible without moving the equipment and storage carts around.

During the tour of the Respiratory Department on the 5th Floor of the main building on 10/24/16 at approximately 2:30 PM, the surveyors noted clutter in a storage room 510-A. This storage room had approximately 30 cardboard boxes stacked on the floor, and contained heater elements for the respirators. There were two plastic bins on the floor, with materials and supplies used in the training of resident physicians.

The practice of disorganized [DIAGNOSES REDACTED] is a potential risk for safe evacuation and easy accessibility to equipment and supplies in an emergency. In addition, this arrangement does not allow the cleaning services to obtain access to all the nooks and crannies in the room to provide a sanitary environment.


2. During the tour of the inpatient Psychiatric on 10/24/16 between 10 AM and 12: 00 noon, the shower head in room #s 308 A and 543 were protruding from the wall and had a flat top surface, allowing ligatures to be formed. Upon further investigation it was revealed that this type of shower heads were also installed in Room #s 326, 327, 329, 338, 505, 510 and 532.


3. A tour of the Laboratory Room on the inpatient Psychiatric units on both floors, revealed that the syringes and needles were kept in unlocked cabinets, making it readily accessible to unauthorized staff and patients.

These findings were made in the presence of Staff M, who acknowledged the deficiencies.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, staff interview and document review, the facility did not ensure:
(1) proper disinfection of environmental surfaces, (2) compliance with proper storage procedures to decrease the risk for contamination, and (3) proper airflow in rooms which require negative pressure, to mitigate risk of infection.

Findings include :

1. During the tour of the Operating Room (OR) suite on 10/20/16 at approximately 10:30 AM, a staff member was cleaning operating room #6 after a surgical case. The surveyors observed the cleaning technique and noted that the housekeeping staff member obtained a clean disinfectant soaked wipe to clean the blood splattered operating table, the wipe was then used to clean the metal table located at the perimeter of the room, and the same wipe was consequently used to clean the metallic kick bucket.
It was also observed that this staff member did not remove a tie wrap around an arm rest (used during the surgical procedure) prior to cleaning and disinfecting it, and did not wipe the glass frame of the surgical lights.

The cleaning and disinfecting technique of this employee using one wipe to disinfect various surfaces is a cause for cross-contamination and potential risk for spread of infections.


During the tour of this OR #8, reddish brown stains were noted on a metallic table and the metallic bucket had reddish brown residues in it.

Review of the terminal log on 10/21/16 at approximately 2:00 PM, revealed that the nursing staff inspected OR #8 that morning, but failed to take note of the contaminated equipment in the room.

This observation was made in the presence of Staff M, Director of Facilities, who acknowledged the findings


During the tour of the decontamination room of the Respiratory Department on the 5th Floor of the main building on 10/24/16 at approximately 2:00 PM, the surveyors noted that this room had metallic ceiling tiles with holes. The small holes in the ceiling tiles has a potential to harbor moisture and promote microbial growth.



2. During the tour of the Operating Suite on 10/20/16 at approximately 12:30 PM, the surveyors observed a Radiology Technician storing a portable X-ray equipment along with another two X-ray equipment in an alcove at the front end of the Operating suite.

Interview with Staff J, X-ray Technician on 10/20/16 at approximately 12:40 PM, he stated that these equipment were cleaned in the operating rooms prior to being stored in the alcove and rolled into the operation rooms when needed

Upon inspection of the Portable X-Ray equipment, pieces of old tape was observed to be stuck on the surface of the clean equipment and therefore it was not adequately cleaned.


During the tour of the equipment room in the OR suite on 10/20/16 at approximately 11:30 AM, it was noted that the facility was storing clean supplies in enclosed carts in this room. Inspection of the carts revealed that the shelves were dusty and heavily soiled.


During the tour of the OR suite, the surveyors observed that the facility was storing suture supplies such needles etc., in a storage closet 7N-14. The metallic shelves used in the storage of these supplies were dirty and dust laden. The outside surfaces of the cartons containing the suture supplies were observed to be in disrepair, discolored and contaminated.
The facility was observed to store open boxes of these supplies on a very low-lying shelf in close proximity to the floor.


During the tour of the sub-sterile room between OR #s 5 and 6, the surveyors observed 4 (four) blue sharp containers, opened and more than half filled with blades and sharp instruments. There were 3 (three) additional sharp containers, that were half filled, inside this sub-sterile room.
This practice of storing soiled biohazard containers in the sub-sterile room, is potential of causing cross contamination.

Upon interview of Staff L, Nurse Manager for the peri-operative services, on 10/20/16 at approximately 12:00 noon, she stated that the facility was storing used single-use laproscopic instruments for pick-up and re-processing by the manufacturer, and that the staff called for pick-up of the sharp containers when they are 3/4 full.



During the tour of the hospital, the surveyors noted that the facility was storing clean supplies on uncovered metal carts in the clean supply room. Further observations revealed that the bins used in storing the supplies were collecting dust and debris.



During the tour of the Respiratory Department on the 5th Floor of the main building, on 10/24/16 at approximately 2:00 PM, it was observed that clean supplies for respiratory services were stored in open metal carts in the corridor, leading to the decontamination room.

The practice of storing clean supplies on uncovered carts poses risks for contamination of clean supplies, due to collection of dust particles on them.



3. During the tour of the Respiratory Department on the 5th Floor of the main building, the surveyors upon testing the air flow of the decontamination room 512-A, noted that the room did not have negative airflow, as required.

Upon interview of the Staff M, on 10/24/16 at approximately 2:15 PM, it was revealed that the HVAC System for that room was originally not designed to provide the required negative pressure.
VIOLATION: CRITERIA FOR DISCHARGE EVALUATIONS Tag No: A0800
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based medical record (MR) review, document review and interview, in four (4) of nine (9) medical records reviewed, it was determined; (a) staff did not follow the facility's screening process to identify patient's discharge planning need at an early stage of hospitalization , (b) the facility did not ensure the screening all inpatients at an early stage of hospitalization for discharge planning.
(Patient #2,#4, #6 & #7).

Findings include:
During the unit tour, on 10/19/2016, MR for Patient #2 was reviewed. This [AGE] year old patient with a history of COPD (chronic obstructive pulmonary disease), Polysubstance abuse, HTN (hypertension), hepatitis C, and GERD (Gastroesophageal reflux disease), was admitted to the facility on [DATE] with respiratory failure. The initial Nursing Assessment to determine the patient's discharge planning need was dated 10/17/2016.
The facility' s Policy # 327 "Discharge Planning," revised 3/15, states: "Early Identification of patients who require discharge planning on Medical/Surgical Units is accomplished by a Risk Assessment Screening; Risk Assessment Screening is part of the initial Nursing Assessment Screening and is completed by RN within 24 hours."
The Risk Assessment Screening was not completed within the required time frame.
Although the patient met the risk factors for discharge planning assessment, the initial Nursing Assessment, dated 10/17/2016, did not identify this patient as needing discharge planning.
Similar findings were identified for Patient #4, who was not identified during initial screening, as needing discharge planning.
During the unit tour (MICU), on 10/19/16 10:50 AM, it was observed that Patient #6 was intubated. The patient's wife was at the patient's bedside. The patient's wife was Russian speaking and an interpreter was requested. The Patient Relations Staff #G was used as an interpreter. The patient's wife stated that the patient was newly diagnosed with cancer. An attempt was made to discuss initial discharge planning with the patient's wife, but Staff #G responded that it was too early to discuss discharge planning.
Review of the MR for Patient # 6 noted, this [AGE] year old male with history of lung cancer, was admitted on [DATE]. There was no Initial Discharge Planning Assessment located in this record.
The charge nurse, Staff # H was interviewed on 10/19/16, at approximately 12:15 PM. As per Staff # H, discharge planning will begin when the patient is transferred to the floor or if a family member request to see a social worker.
The facility's Policy # 327 "Discharge Planning," revised on 3/15, states that in Maternity/Pediatrics (inpatient), discharges and assessments are on referral basis. The Intensive Care Units i.e. MICU and SICU are on referral based by medical/nursing staff or self- referral by either patient and/or family.
This discharge planning policy indicated that the facility is not screening all inpatients at an early stage of hospitalization , for discharge planning.
Similar finding was noted for Patient # 7 during the tour of the unit (SICU), on 10/19/16 at 12:33 PM.
Review of the MR for Patient # 7 noted that the patient was admitted on [DATE]. However, the Initial Nursing assessment did not include a Risk Assessment Screening for discharge planning.
Staff # G , Nursing Administrator, was interviewed on 10/19/2016 at 12:33 PM. The staff stated that the patient was to be transferred from SICU to a surgical floor for further management either today (10/19/16), or tomorrow. According to Staff # G, discharge planning will begin in the step down unit.
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, in three (3) of nine (9) medical records (MR) reviewed , it was determined that patient discharge planning evaluations did not include an evaluation of the patient's ability for return to the pre-hospital care, when making a determination of the post-hospital care. ( Patient #1, #3, #5).

Findings include:
Review of the MR for Patient #1 noted: this [AGE] year old patient was admitted to the facility, on 9/5/2016, due to deteriorated medical condition; was intubated and transferred to ICU on 9/8/2016. On 10/11/2016, the patient's Health Care Proxy (HCP) agent contacted the facility and was informed by the discharge planner that the physician recommended SNF (skilled nursing facility) as post-hospitalization care. The discharge planning evaluation did not include the reasons why the SNF placement was necessary; and did not not include why the post-hospitalization care and/services care could not be provided in the community.

Review of MR for Patient # 3 noted: a [AGE] year old who was admitted to the facility on [DATE]. The admission diagnosis was cerebral infarction. The initial Nursing Discharge Risk Assessment Screening was completed on 9/24/2016 and the patient was identified as needing discharge planning. It was noted that the initial Discharge Planning Assessment was dated 10/5/2016. The discharge planning assessment indicated that prior to admission the patient lived at home with family; the patient was self-ambulatory and semi-independent with ADLs; and the patient had prior HA (home health Aide), home care services. The case was discussed during multidisciplinary round, and post hospital needs identified as SNF and transportation. The patient was discharged to a SNF on 10/10/2016.
The discharge planning evaluation did not include the reasons why the patient could not return to home after discharge and why the post-hospitalization care and/services care could not be provided in the community.


Review of MR for Patient #5 noted: a [AGE] year old male with medical history of [DIAGNOSES REDACTED]. The initial Nursing assessment dated [DATE], indicated that there was no need for Social Work discharge planning assessment.
On 10/18/2016, the physician ordered a rehab consultation and Social Work Service reassessment of post-hospital needs. There was no evidence that the patient was seen by social services for a reassessment of the patient's discharge plan.
On 10/19/2016, the patient had Physical Therapy (PT) evaluation 10/19/2016 and the PT evaluation indicated that the patent would benefit from acute rehab. The patient had a follow-up PT on 10/20/2016. This assessment did not indicated that the patient no longer required PT for post-hospitalization care.
The Medicine Discharge Summary, dated 10/19/2016; 1051, indicated that the disposition was SNF. This discharge assessment did not include why the post-hospitalization care and/services care could not be provided in the community.

The findings were discussed with Staff #C, #D, #E and #F.
VIOLATION: TIMELY DISCHARGE PLANNING EVALUATIONS Tag No: A0810
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, in three (3) of nine (9) medical records (MR) reviewed, it was determined that patients identified as needed discharge planning, did not receive timely and complete discharge planning evaluations. (Patient #1, #2, #8).

Findings include:
During a tour of the 7E Medical/Surgical unit, on 10/18/2016 at approximately 11:45 AM, with the discharge planning team, Staff # A, Staff # B and Staff # C.
Staff # A stated that Patient # 1 was to be discharged today to a skilled nursing facility (SNF).
Staff # B, discharge planning nurse, stated that she had not seen the patient but she was in the process of completing the discharge instruction, prior to discussing the discharge instruction and medication with the patient. Staff # C entered the nursing station and stated that she just spoken to the patient's sister, and the sister stated that the patient could not be discharged before she arrives in the hospital.

Review of MR for Patient # 1, noted: this [AGE] year old male was brought to the Emergency Department by ambulance from home on 9/4/2016. The presenting problem was recent fall and ETOH abuse. The patient was admitted on [DATE]; his medical condition deteriorated and he was intubated on 9/8/2016 and transferred to medical intensive care unit (MICU) for further management. The patient was transferred from MICU to this unit on 10/6/2016.
On 9/9/2016, the social service staff indicated that discharge plan will be discussed with the patient/ family when the patient was medically stable. The discharge plan was discussed with the patient's Health Care Proxy (HCP) agent, Sister B, on 10/11/2016 1517 (3:17 PM); over 30 days after the patient was admitted .
On 10/13/2016, it was documented that the patient's sister (not HCP) requested the patient remained in hospital until the family inspected some of the SNFs from the list provided by the hospital. It was explained that the patient was medically cleared and he cannot stay in hospital indefinitely. There was no documentation that this information was explained to the HCP on 10/11/2016.
It was noted that on Friday, 10/14/2016, the social service staff discussed options/responses on SNF with the HCP and provided a list of accepting facilities. The HCP informed the staff that she would call back Monday, 10/17/16. The patient was placed on ALOC (alternate level of care) on 10/17/2016
On 10/18/2106 the patient's sister (HCP) confirmed her SNF choices, and the patient was accepted by a SNF selected by the patient's sister.


Review of MR for Patient #2 noted: this [AGE] year old with history of COPD (chronic obstructive pulmonary disease), Polysubstance abuse, HTN ( hypertension), hepatitis C, and GERD (gastroesophageal reflux disease) was admitted on [DATE] with respiratory failure.
The initial Discharge Plan was dated 10/18/2016. The discharge planner documented the patient is "medically stable to be discharged tomorrow," and the discharge plan was home with home care services.
On 10/19/2016 1352 (1:52 PM) , as per MD order, due to history of falls, PT (physical therapy) to be done. The patient agreed to consider SNF Rehab placement. On 10/19/2016 1444 (2:44 PM), the discharge planner noted that the MD canceled the patient's discharge and stated that the patient is not medically cleared for discharge. The discharge planner approached patient on SNF Rehab placement; the patient refused SNF Rehab placement stated that she prefers to attend the facility's outpatient PT clinic. The social work services Discharge Summary dates October 20, 2016, stated patient is medically cleared and discharge home today with prior services reinstated.

The initial discharge planning was documented approximately one (1) day prior to planned discharge. There discharge plan did not indicate complete discharge planning. There was no documentation in the record that this patient had the physician ordered physical therapy or the reason why this service was not provided. There was no explanation why the patient was discharged home with the same pre-hospitalization services. The patient 's request for PT at the facility's outpatient clinic was not addressed in the discharge plan assessment.

Similar findings noted for review of the MR for Patient #8 ,who remained in the hospital due to lacked of timely and complete discharge planning evaluation.
VIOLATION: LIST OF HOME HEALTH AGENCIES Tag No: A0823
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, in one (1) of nine (9) medical records (MR)reviewed, the patient and/or patient's representative was not informed of their freedom to choose post- hospital care services. (Patient #4).

Finding include:
During interview with Staff #C, discharge planner, on 10/19/2016 at approximately
11:30 AM, this staff stated that Patient #4 was to be discharged with home care services.

Review of the MR for Patient # 4 noted : a [AGE] year old male was admitted on [DATE]. The initial Nursing Assessment, dated 10/17/2016, did not identify the patient needing discharge planning.
On 10/19/2016, the social services progress notes indicated: as per MD, surgery, patient to be discharged ; referral to a CHHA (Certified Home Health Agency) was made. Patient is aware of his medical clearance and stated he wants to go home, but is in pain.
The social work services Discharge summary, dated 10/20/2106, indicated patient is medical clear and ready for discharge today. CHHA referral provided.
The reason for the referral to the home health agency was not documented. The choice of certified home health agency given to the patient and the agency selected by the patient was not documented.

This findings were discussed with Staff # C.
VIOLATION: REASSESSMENT OF DISCHARGE PLANNING PROCESS Tag No: A0843
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review, in one (1) of nine (9) medical records reviewed, it was determined the hospital was not effectively reassessing its discharge planning process. (Patient #5)

Findings include

Review of the medical record for Patient #5, noted: the patient was admitted on [DATE] with diagnosis of infectious gastroenteritis and colitis. The initial Nursing assessment, dated 10/14/2016 1641 (4:41 PM), indicated that there was no need for social work Discharge Planning Assessment. On 10/18/2016, the physician ordered a rehab consultation and also ordered for social work service reassessment of post-hospital needs. There was no evidence that the patient was seen by social services for a reassessment, so that the patient may have a Discharge Planning evaluation.
The Discharge Planning Administrative Staff D, E, and F, were interviewed on 10/24/2016 at approximately 12:04 PM. The staff stated, as per facility (Policy # 327), patients who were not identified as needed discharge planning will be captured, because social worker/caseworker on the unit, re-assess patients within three to five days of admission.
There was no documented evidence that Patient #5 was reassessed by social worker/caseworker on the unit, within three to five days of admission.

The facility document, "Psycho-Social Assessment Documentation Performance," dated March 2015 - May 2015, was reviewed. For " Reassessment of Post-Hospital Needs and/or SW Progress Note was done within three to five days of completion of the Initial-Psycho-social assessment, " documentation for reassessments were as follows: [DATE] was 72%, April 2015 - 67 % and May 2015 - 69 %. A plan to improve reassessment of discharge planning was not provided. There was no data for 2016.