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.

WOODHULL MEDICAL AND MENTAL HEALTH CENTER 760 BROADWAY BROOKLYN, NY 11206 Nov. 22, 2017
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation and staff interview, in 1 (one) of 5 (five) inpatient units toured, the facility failed to maintain and provide a clean and sanitary environment in a patient care unit.

Findings include:

During the tour of the Intensive Care Unit on 11/21/17 at approximately 10:00 AM, it was observed that the base of 6 (six) Medication Carts were heavily laden with dust.

Staff U, Assistant Director of Nursing was interviewed on 11/21/17 at approximately 10:00 AM, she confirmed the findings and she was unclear if the nurses were responsible for cleaning the base of medication carts.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation and interview, in one (1) of two observations, nursing staff failed to implement the Centers for Disease Control and Prevention (CDC) guidelines for preventing the transmission of infectious agents in healthcare settings. Specifically, multi-dose vial medication was prepared in a patient's room.

Findings include:

Review of CDC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings recommends the following, "Do not keep multi dose vials in the immediate patient treatment area ..., discard if sterility is compromised or questionable."

During observation of medication administration on 11/21/17 at 11:45AM, Staff B wheeled the medication cart into a room that housed two patients, she prepared the insulin injection from a multi-dose vial and administered it to Patient #1.

Staff U, the unit Head Nurse, was interviewed on 11/21/17 at 12:15 PM, she confirmed that the multi-dose vial was taken into the patient's room, and the insulin vial is used on the unit for multiple patients.

During follow up interview with Staff V, Assistant Director of Nursing on 11/21/17 at 1:30 PM, she acknowledged the findings.