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.

KINGSBROOK JEWISH MEDICAL CENTER 585 SCHENECTADY AVENUE BROOKLYN, NY 11203 Aug. 14, 2014
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interviews, review of medical records, policies and procedures and camera footage recordings, it was determined the facility failed to comply with the Condition of Participation for Governing Body. Specifically, the Governing Body failed to provide oversight of the operation and maintenance of the hospital to ensure the safety of patients.

This was evidenced by:

a) The Governing Body failed to provide a safe environment for patients through staff education, and implementation of policies and procedures. Refer to Tag A-0144 and A-1100;

b) Failure to establish policies to assure building and grounds are safe and secured. Refer to Tag A-0144;

c) Failure to ensure surveillance equipment is maintained. Refer to Tag A-0144.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interviews, review of medical records, policies and procedures and camera footage recordings, it was determined the facility failed to comply with the Condition of Participation for Patients' Rights. Specifically, the facility failed to assure that Patient #1 who was evaluated in the Emergency Department and noted to be confused and delirious, and had been identified as an elopement risk was kept safe.

Findings include:

The facility failed to continuously review and evaluate the care needs of Patient #1 and implement a care plan that assures the patient's safety. Patient #1 was found dead at the facility on 8/4/14 after he eloped from the Emergency Department on 8/3/14. (Refer to Tag A-0144 and A-1100).
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interviews, review of camera footage, policies, and procedures it was determined the facility failed to establish a security protocol for timely and efficient search of missing patients. Specifically, Patient #1 who had eloped from the Emergency Department on 8/3/14 at 8:21 PM was found dead in the hospital premises more than six hours later on 8/4/14 at 3:00 AM. Finding was noted in 1 of 4 applicable records reviewed.

Findings include:

Patient #1 is a 71- year-old-male with multiple medical conditions who was evaluated in the Emergency Department on 8/3/14 at 2:41 PM for disorientation and was admitted at 6:16 PM with diagnosis of Delirium NOS (Not Otherwise Specified). The patient was deemed a risk for elopement at triage on 8/3/14 at 2:41 PM and a WanderGuard bracelet #5860 was applied to patient's ankle in accordance with facility's policy titled "Elopement Risk Prevention and locating missing patient ".

-The facility's security policy and procedure for elopement risk prevention and locating missing patient is ineffective in the prevention of elopement and does not ensure that a patient at risk for elopement is confined to the desired location. The policy notes, "Upon triage, patients determined to be at risk for elopement will be placed on Wander Guard bracelet . . . . and in hospital issued gown, and his /her personal clothing/items shall be secured". The policy does not prescribe the level of monitoring for patients deemed at risk for elopement.

At interview with Staff #2, Security Manager on 8/12/14 at 1:15 PM, he stated WonderGuard sensors are installed on exit doors of the building and would only alarm if the patient were to exit the building. He confirmed that WanderGuard sensors are not installed on all exit doors within the building and there would not have been an activation of the WonderGuard alarm when the patient left the ED.

-The policy on Elopement Risk Prevention and Locating Missing Patient further notes, that for missing patients, "the nursing staff quickly attempts to locate and retrieve the patient. If unsuccessful, security is notified by dialing 888 and calling an "Assist 13".

The review of the ED camera footage on 8/12/14 between 12:30 and 1:00 PM showed the patient eloped from the ED on 8/3/14 at 7:45 PM. At 7:50 PM, he was escorted back by a security staff and four ED personnel. The patient again eloped from the ED at 8:21 PM.

Although the ED Security Guard was seen on the video footage exiting the ED back door at 8:25 PM in search of Patient #1, the Security Supervisor was not contacted and informed of the elopement until 8:30 PM, eight minutes after the patient eloped.

"Code Orange", a missing person code was not timely announced. The facility's report notes Code Orange was announced over the Public Address System at 9:37 PM; that was 76 minutes after the patient left the ED. As a result, a Ward Clerk who encountered the patient at 8:30 PM was not aware that the patient had eloped from the ED and that a search was being conducted. In addition, a transporter reported after Code Orange was announced that he saw someone fitting the patient's description in the conference room on the 4th floor.

-At interview with Staff #4 on 8/13/14 at 3:00 PM, she stated that training/education on elopement is provided only to nursing and security staff members. Therefore, the Ward Clerk who encountered the patient at 8:30 PM would not have identified the patient based on his hospital gown and WanderGuard bracelet as an eloped patient.

-Security staff failed to review camera footage promptly to track the location of the patient.

At interview with Staff #5, Security Supervisor on 8/13/14 at 1:00 PM, he stated he reviewed all necessary footage on 8/3/14 between 8:45 PM and 9:00 PM after he had notified all security post and secured the perimeter of the facility.

There was no indication that security staff reviewed the camera footage that shows the patient taking the Kartz Building elevator on the ground floor to the 1st floor. Another camera's footage shows that the patient took the same elevator on the 2nd floor at 8:22 PM. Still another camera's footage shows the patient, at 8:23 PM, on the 4th floor. The patient is then seen wandering around on the 4th floor before entering the Medicine Administration Building at 8:27 PM.

Although the facility report did not indicate when the Ward Clerk and the transporter reported the patient sighting to the ED nurse, the camera footage shows the transporter and a nurse entering the Medicine Administration Office at 9:52.36 PM, almost 90 minutes after the patient eloped. Security staff and two other nurses were seen entering the Medicine Administration Office at 10:03 PM. The search of the Medicine Administration Office by security staff occurred more than 60 minutes after the review of the camera footage by Staff #5 on 8/3/14 between 8:45 PM and 9:00 PM.

The facility's report notes that staff entered into the conference room on the 4th floor at 9:50 PM and found "the room was trashed, the blind was pushed out of shape, the head of the patient's cane was on the floor, and his brown address book was on the floor". The report also noted the window of the conference room was one foot open and the plan was to obtain flashlights and search the construction area of the building. However, there was no indication a thorough search of the building exterior was immediately conducted.

Staff #5 on 8/13/14 at 1:00 PM stated the perimeter of the building was immediately searched again after the conference room in the Medicine Administraion Office was searched on 8/3/14 at approximately 10:00 PM.

The facility report notes the patient was discovered by a Security Guard about five hours later on 8/4/14 at 3:00 AM, below the open window of the 4th floor conference room. The patient was pronounced dead by a physician at 3:12 AM.


-The facility failed to ensure the time on cameras utilized for surveillance is synchronized to assure that actual timing of events are accurate. At interview with Staff #2 on 8/12/14 at 1:00 PM, he stated the time on some cameras is inaccurate; the camera that shows the patient entering the Medicine Administration Building on 8/3/14 at 8:27 was off by six minutes. It was also noted that the time on the ED camera was inaccurate; the ED camera footage shows the patient arriving in the ED at 2:51 PM; however, the medical record notes the patient was triaged at 2:41 PM.


-The facility did not ensure that camera footage in the hospital was accessible to all members of the security staff.

At interview with Staff #2 on 8/12/14 at 1:00 PM, he stated some camera footage is only accessible to security supervisors and managers. He added that the DVR (Digital Video Recorder) containing the footage of these cameras could be viewed on the computer and are secured by password.

It was noted that Staff #5, supervisor on duty on 8/3/14 was charged with other responsibilities related to the elopement and delayed reviewing the DVR containing the camera footage until between 8:45 to 9:00 PM on 8/3/14.

-The facility failed to establish and implement policies to ensure that sections of the hospital closed for business are secured. Patient #1 gained access to the Medicine Administration Office on Sunday, 8/3/14 at 8:27 PM.

During the tour of the Medicine Administration Office on 8/12/14 at 11:48, Staff #6 stated the office is in operation Mondays through Fridays from 9:00 AM to 5:00 PM. He added that the Medicine Administration Office is always locked after business hours. However, at interview with Staff #2 on 8/12/14 at 1:00 PM, he stated the office is never locked.
VIOLATION: EMERGENCY SERVICES Tag No: A1100
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on tour of the Emergency Department, interviews conducted, review of medical record, Emergency Department camera footage and policies and procedures, it was determined that Emergency Department staff failed to review and evaluate the adequacy of care provided to a patient to assure that patient care needs met. This finding was noted in 1 of 4 applicable records.

Findings:

Patient #1 is a [AGE]-year-old male with multiple medical conditions that include hypertension, Coronary Artery Disease (condition caused by plaque building up along the inner walls of the arteries of the heart.), Diabetes Mellitus (metabolic disorder affecting blood sugar levels, and End-Stage Renal Disease (chronic kidney disease) on hemodialysis (treatment for kidney failure).

The medical record notes the patient was triaged in the Emergency Department on 8/3/14 at 2:41 PM and reports that he ran into the streets because some people are after him and now he is tired of running and hungry. He did not remember if he was dialyzed on Friday. The initial vital signs at 2:46 PM were as follows: Temperature 98.7 degree Fahrenheit, Respirations 21 (per minute), Pulse 111 (per minute), Blood Pressure 166/101, and Sp02 (oxygen saturation - concentration of oxygen in the blood) 99%.

The patient was identified as an elopement risk during the triage assessment conducted on 8/3/14 at 2:41 PM. The nurse notes that Wander Guard #5860 was applied. Patient was also identified as a fall risk due to "impaired memory/judgment, confusion, altered mental status, ambulatory aids, unsteady gait, and weakness". Nurse noted that fall risk intervention was implemented that included safety precautions and the use of yellow non-skid socks when ambulating.

Psychiatric consultation was requested at 3:45 PM by the ED physician and the patient was evaluated at 5:20 PM. The psychiatrist noted the patient is alert, oriented to place and persons, but not to time. The patient is preoccupied with people in his apartment with knives threatening to kill him, he reports that some of them were killed by his family and the news about the dead people is on television. The patient denied suicidal and homicidal ideation. The impression was "Delirium, Not Otherwise Specified". The plan was to admit the patient to Medicine Service for further evaluation and management. Medications recommended for the management of the patient included Risperdal (Antipsychotic medicine) 0.5 mg (milligram) orally every night; Haldol (antipsychotic medicine) 3 mg IM (intramuscular) every eight hours as needed and Ativan (Anti-anxiety medicine) 1mg intramuscularly every eight hours as needed for agitation.

The review of the ED camera footage on 8/12/14 between 12:30 and 1:00 PM showed the patient eloped from the ED on 8/3/14 at 7:45 PM and at 7.50 PM; he was escorted back into the ED by a security officer and nursing personnel.

At interview with Staff #1, the patient's nurse on 8/13/14 at 10:15 AM, she stated the patient was calm, cooperative and was not confused when he initially left the ED. She stated the patient was looking for his walking cane that was later found in the bathroom. This statement was contrary to a late note written by the nurse on 8/3/14 at 11:37 PM. The nurse indicated that at 8:11 PM, patient had an outburst and became agitated and went over to paramedics stating "That is them they are here to get me, watch the news". She noted the patient walked out of the ED into the hallway and he was brought back by several nursing staff members.

The nurse failed to confer with the ED physician regarding the patient's "outburst and agitation " as well as the elopement incident that occurred at 7:45 PM on 8/3/14. The patient was not assessed by the physician following the incident and the current plan recommended by the psychiatrist to manage the patient's agitation was not implemented. In addition, there was no revised plan to assure patient's safety. The patient continued to wear a WanderGuard bracelet with no additional safety precaution.

At interview with Staff #2, Security Manager on 8/12/14 at 1:15 PM, he stated WanderGuard sensors are installed on exit doors of the building and would only alarm if the patient were to exit the building. He confirmed the patient's WanderGuard bracelet would not have prevented him eloping from the ED.

At interview with Staff #3 on 8/13/14 at 11:20 PM (ED physician responsible for the care of the patient), he stated the patient was not agitated when he was assessed on 8/3/14 at 3:50 PM. He stated that the psychiatrist evaluation conducted later at 5:20 PM also indicated the patient was not agitated. Staff #2 added that his tour ended on 8/3/14 at 10:00 PM and he was not informed the patient had eloped from the ED twice on 8/3/14.

There was no indication the patient was closely monitored after the first elopement. Review of the camera footage on 8/12/14 showed the patient walked out of the ED through the ED back door on 8/3/14 at 8:21 PM. Four minutes later, at 8:25 PM, a Security Guard was seen leaving through the same back door in search of the patient.

An ED physician noted that "Code 99" (A message announced over a hospital's public address system warning of a medical emergency requiring resuscitation) was called overhead on 8/4/14 at 3:00 PM; he responded and found patient in a sunken well containing some ventilation structures. The patient was pronounced dead on 8/4/14 at 3:12 AM in the presence of police officers that responded to the incident.