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 Nov. 3, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
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Based on observation, medical record review, document review and interview, the facility failed to: (a) maintain a safe environment for a patient on the psychiatric unit, (b) provide timely medical treatment for a patient on the psychiatric unit, (c) implement procedures to protect patients from all forms of abuse, including physical assault. This was evident in 2 (two) of 2 (two) medical records reviewed.

This failure to protect patients put all patients at risk for harm.

Findings:

See Tag 0131

See Tag 0144

See Tag 0145

See Tag 0162


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VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, the facility did not ensure timely notification to the patient's representative of an occurrence. This was found in one (1) of two (2) medical records reviewed. (Patient #1)


Findings:

Review of medical record revealed Patient #1 was admitted on [DATE] with chest pain, history of cardiac disease and dementia. On 10/22/16, at 10:55 PM, the patient sustained a witnessed violent physical assault.

The family was not immediately notified by the physician of the patient's head trauma on 10/22/16, or of the abnormal CT report on 10/23/16, when patient was found to have a massive acute intracerebral brain hemorrhage with midline shift. The physician notified the patient's wife by telephone on 10/23/16 at 6:50 AM, when a telephone consent was obtained for emergency surgery to perform craniotomy and evacuation of hematoma.

There is no "Physician Providing Anesthesia" signature certifying consent was obtained.

There no evidence of physician documentation in the patient progress notes of the wife being informed regarding a significant change in her husband's condition.

Review of Policy titled, "Disclosure of unplanned or unexpected outcome information," effective date 07/13/15, states, "When an event that is unplanned or unexpected, and results in temporary or permanent harm to a patient, the attending Physician must disclose outcome information with the patient and/or appropriate designee and document in the medical record."

During interview on 11/02/16 at 3:00 PM, Staff A, Vice President of Nursing and Patient Services stated, "It is the physician who is responsible to notify the family of any changes in the patient's condition."

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VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, document review and interview, the facility failed to initiate a rapid medical response and evaluation to a critically injured patient on a Behavioral Health Inpatient Unit. This was found in one (1) of two (2) medical records reviewed. (Patient #1)

Findings:

Review of facility video surveillance tape dated 10/22/16 10:54 PM, a staff member was observed talking to Patient #1 in the hallway outside the bedroom of Patient #2. At 10:54 PM, the patient turned away from the staff member and is seen going into the bedroom of Patient #2, where he remained for about thirty seconds.

At 10:55 PM, Patient #1 was ejected from the room, his feet were not touching the floor and his body was fully extended horizontally in the air. Patient #1 was observed falling to the ground onto his left side. Patient #2 came out of the room and punched Patient #1 with a closed fist on the face and then stomped with his right foot onto the side of the head of Patient #1. Moments later at 10:55 PM, two staff were observed picking up Patient #1 into a fully upright standing position. A minute later at 10:56 PM, the patient is sat onto a wheelchair and blood pressure was taken. The patient was wheeled to the Nurses Station and placed on a stretcher. At 11:04 PM the patient was wheeled from the unit.

Medical record review for Patient #1, identified a 77 year patient admitted on [DATE] with a diagnosis of Dementia. The patient had no prior psychiatric history. The patient was noted as confused and disoriented.

On 10/22/16 at 11:40 PM, the ED physician documented the patient was assessed following an assault. The patient was medically examined 45 minutes post injury.

Ct scan of the brain obtained on 10/23/16 at 6:20 AM, showed a large area of acute left cerebral hemispheric bleed 11.6 x 6.2 x 7 centimeters with surrounding low density vasogenic edema. This large acute hemorrhage produced a mass effect herniation of 13 millimeter left to right midline shift.
The Ct scan was obtained 7 hours and 25 minutes post assault.


During an interview on 11/2/16 at 12:50 PM, Staff C, RN Charge Nurse, acknowledged the patient was removed from the psychiatric unit at 11:04 PM and when asked why was it that the patient was moved, stated; "we sent the patient downstairs to the ED for a doctor there to see him. He wasn't seen by a doctor on the unit, we just knew he needed to go down to the ED. We called for the Psychiatrist and he came to the floor but he was involved with Patient #2."

During interview on 11/2/16 at 12:30 PM Staff B, Chair of Psychiatry, confirmed when a change in the patient's condition occurs they take the patient down to the ED. Staff B stated,this is the practice of the staff on the psychiatric units.

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VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on document review, medical record review and interview, it was determined the facility failed to ensure that a violent and aggressive patient, had ongoing risk assessments and modification of treatment plans, following multiple episodes of assaultive behavior. This was found in one (1) of two (2) medical records reviewed. (Patient #2).


Findings:

Review of the medical record revealed Patient #2 presented on May 8, 2016 with aggression, agitation and an altercation with a peer at a Skilled Nursing Facility. The patient was admitted to psychiatric services for psychosis and paranoid schizophrenia.

Documentation in the medical record revealed the patient had ongoing episodes of assaultive and violent behavior towards peers and sexual preoccupation towards female staff, from May 8th through October 22nd 2016.

An Initial Risk Assessment and a Comprehensive Treatment Plan was implemented in May, and the Broset Violence Checklist was performed on 05/09/16 and on 08/21/16. There were weekly interdisciplinary meetings to discuss treatment goals, and there were intermittent episodes of 1:1 observations following assaultive behaviors. There is no documentation of ongoing risk assessments or Broset Violence Checklist or modification of the written plan of care.

During interviews on 10/31/16, 11/01/16 and 11/02/16, Staff B, Chair of Psychiatry was asked about the frequency of Physician re-assessments of patients. On 11/02/16 at 11:50 AM, Staff B stated, "The Broset Violence Checklist is done daily and the Physician modifies the treatment plan according to the reassessment checklist. This is also documented in the daily physician's patient progress notes. Reassessments are required at minimum on a daily basis and modifications that will be initiated are reflected in a progress note or consult follow up notes."

Review of Patient #2 medical record, documented no evidence that the Broset Violence Checklist was done daily or that the Physician modified the treatment plan according to this reassessment checklist. This finding was confirmed by Staff B on 11/02/16.

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VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0162
Based on observation, document review and staff interview, the facility failed to: (1) obtain a physician order for the medical management of a violent aggressive patient placed in seclusion,
and (2) develop and implement a written policy and procedure on the management of patients with violent and aggressive behavior. These findings were noted in one (1) of one (1) medical record reviewed. (Patient #2).


Findings:

Observation of surveillance video dated 10/22/16 revealed: at 10:55 PM, Patient #2 returned to his room after assaulting Patient #1. At 10:56 PM Patient #2 emerged from his bedroom and chased after a female staff member. At 10:59 PM two male staff escorted Patient #2 to the seclusion room. The staff placed the patient in the room, closed the door and remained outside the room.

From 11:02 PM to 11:07 PM, Patient #2 remained inside the Seclusion room with clinical staff and security officers standing outside the seclusion room.

Medical Record review for Patient #2, showed no documented evidence of a Physician order for seclusion/ restraints.

During interview on 11/03/16 at 12:45 PM, Staff B, Chair Psychiatry stated, "Patient #2 wasn't in seclusion because the door wasn't locked, but we wouldn't have let him leave the area and put others at risk."

Review of facility's policy titled, "Use of Restraint and Seclusion," last revised July 2016 states: "Involuntary confinement of a person in a locked room which is not possible for the patient to open from the inside."

The facility does not have a written policy and procedure to guide staff on the management of patients with violent and aggressive behavior.

This finding was confirmed during interview with Staff A, Vice President Patient Services and Staff B, Chair of Psychiatry, on 11/02/16 at approximately 3:00 PM.


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