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INTERFAITH MEDICAL CENTER 1545 ATLANTIC AVENUE BROOKLYN, NY 11213 May 22, 2012
VIOLATION: EMERGENCY SERVICES Tag No: A1100
Based on interviews, review of medical records and other documents, it was determined that the care of a pediatric patient in the Emergency Department was not provided in accordance with acceptable standards of care.

Specific reference is made to the patient referenced in MR #1.

Findings include:

Record review and interview determined the hospital did not provide a pediatric patient with timely and appropriate emergency interventions. In addition the hospital attempted to transfer an unstable pediatric patient.

1. Review of MR#1 on 5/22/12 found that the hospital failed to provide timely emergency intervention for an infant who presented with respiratory symptoms at 0217 . The emergency department medical staff did not intubate, draw blood for labs or obtained a venous blood gas, or implement intravenous access (peripheral or interosseous) until the patient went into full cardiac arrest and expired. Review of the ED record nursing notes found numerous references to the patient's rapid deterioration over a 4 hour and 30 minute period.

Treatment was limited to albuterol and saline nebulizers, and administration of oxygen. When the patient was grunting, she was placed on a cardiac monitor. The rhythm strips prior to the code were not available during the survey. The only diagnostic intervention was a chest X-Ray at 0401 . The pediatric consult was called at an unknown time but arrived in the ED about 0446, 2 1/2 hours after being seen by the ED attending. The emergency medical staff planned on a transfer to a tertiary care facility with a pediatric intensive care unit (PICU) at about 0500. Review of the transfer logs and progress notes found that the LIJ- Schneider Children's Hospital ambulance arrived at 0633 and the patient was on the LIJ stretcher unresponsive and was coded at 0645.

Review of the ED progress notes found that the medical staff did not make any attempts to administratively override the parents' decision to withhold diagnostic tests and treatment when it was evident that their decisions were not in the best interest of the child. .


2. Review of MR #1 on 5/22/12 found that the emergency department attempted to transfer a critically unstable 2 month old infant to another hospital without making every effort to stabilize the patient. The infant was in respiratory distress with respiratory rate as high as 56, grunting, suprasternal and subcostal retractions noted at 0446 hours. Grunting and laborious breathing was noted at 0400 hours. The ED staff failed to intubate the patient, provide IV access, obtain labs or a venous blood gas prior to attempting to transfer this patient to a tertiary care facility.

Review of the inter-hospital transfer form found under the section titled Medical treatment modalities the note: " failed attempt IV access ". Under laboratory/ radiology data it was stated : " not applicable. " The respiratory rate is noted at 56 and the physical symptoms note " mild respiratory distress. "

When the pediatric critical care team from the receiving hospital arrived the patient was found by the transport team to be in full cardiac arrest while on the transporting stretcher and could not be resuscitated. A code was called and at that time the patient was emergently intubated, an interosseous (bone) needle placement established, and a venous blood gas was drawn.

At interview with the ED attending and the pediatric consulting attending on 5/22/12 it was stated by both that numerous attempts at obtaining IV access and venipuncture failed and that the family allegedly refused to allow them to make further attempts. There was reference to this on progress notes. There was no attempt to intubate this patient prior to transfer even though there was evidence of rapid clinical deterioration and no venous or arterial blood gases drawn. There was reference in the ED record of the father's refusal to allow this intervention.

The ED made transfer arrangements with a facility over 1 hour away instead of attempting to transfer to a much closer facility with a PICU ( Pediatric intensive care unit ). Interview with facility administration on 5/22/12 found that while LIJ has an "agreement" to accept critically ill pediatric cases, there was no contract submitted to the surveyors onsite.
VIOLATION: ORGANIZATION OF EMERGENCY SERVICES Tag No: A1102
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of records and staff interviews, it was determined that the organization and direction of the emergency department did not include monitoring of the emergency department electronic record system to ensure accurate documentation in patient records.

Findings include:

During review of MR #1 on 5/22/12 it was noted that the care provided to a 2 month child who (MDS) dated [DATE] with respiratory distress did not contain separate and complete documentation for assessments provided by two different physicians that were performed at different times.

Specifically, it was determined that the format of physician documentation in the electronic record did not provide accurate documentation of the medical assessments provided to this infant.
The electronic record noted an assessment form titled "ED physician documentation". The record did not contain separate and distinct assessments performed by two physicians at different times.

The first physician (MD #1) noted an assessment at 2:30 AM on 5/9/12 and this note also contained the merged results of an assessment performed by a second physician (MD#2) at 4:46 AM. The physical exam portion of the combined physician documentation note contained contradictory information about respiratory status. The physical exam section noted accessory muscle use and suprasternal retraction and subcostal retractions. However, another section of the physical exam segment also noted no respiratory distress and "rapid breathing, but no accessory muscle use".


This note was a combined note that included the assessments of two physicians that were performed at divergent times.
This note intermittently documented the name of either physician in different sections for history, review of systems, and physician exam results.

During interview of MD #2 on 5/22/12, it was stated that when two physicians document a note in the ED, the results of the first note will be canceled if the results of the second physician's exam are exactly the same. Data will print out and merge the common elements of the physicians' assessment and will differ in content only when the material written in sections for each element are different.

This format does not permit an individualized and distinct assessment of the patient by two providers performed at different times when any element of the assessment is similar.

This limitation would make it impossible to perform effective quality oversight of the quality to ensure completeness and accuracy of patient emergency assessments. In addition, review of back-up documentation subsequently provided had found that MD #1 uninitialized and canceled a notation in MR #1 at 0538 AM and then edited the document at 707 AM.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on staff interview and review of records and procedures, it was determined that the facility did not implement effective emergency procedures for the assessment, care, and management of patients.

Findings include:

The facility did not implement effective procedures for children presenting with suspected child abuse/ maltreatment and for pediatric patients where the parent or legal guardian refuses emergency care.


1. The facility did not implement its procedures for the appropriate management and safe discharge of a pediatric patient assessed in the emergency room for suspected child abuse. Specific reference is made to MR #2.

Review of the 2011-2012 log for child abuse and maltreatment reports from the emergency department on 5/21/12 found that on 12/6/11, the facility reported to Agency for Children's Services (ACS) a situation observed by a staff member who witnessed a parent jerking a 5 year old child's head into the wall on the hospital premises. The employee's written statement dated 12/6/11 at 11:15 am indicated that she heard a child's head hit against a wall and then had observed the child's mother violently jerking the child towards her and yelling at her. The observation was reported to Security staff.

The child, referenced in MR # 2, was seen in the ED on 12/6/11 at 1122am for a chief complaint of a cold. The child was triaged as ESI level 3 with vital signs. The physician wrote a statement attached to the ACS report in the child abuse log recounting the events that were reported by the employee. The medical record did not demonstrate any medical examination of the child as required by the facility's Victims of Abuse/Child Abuse , which includes documentation of evidentiary data. The only notation in the record besides triage was the time of patient discharge to home on 12/7/11 at 1323 (1:23PM).

At interview with the Nurse Manager of the ED on 5/22/12 it was stated that the physician who saw the patient was terminated after this case for sub-standard performance. The child was in the hospital with her mother to be seen for a cold. The hospital Security staff called Police and interviewed the family. Security reports were not provided. It was not known if the child was directly interviewed. It was reported that the physician had cleared the child for discharge to home with ACS follow up but the clearance by social services and ACS staff was not documented in the child's record.

No follow up with Child protective agency staff was noted in order to provide safety clearance for discharge to home.

2. The facility's procedures for the assessment, care, and management of persons presenting for suspected child abuse or neglect were incomplete.


Review of Victims of Abuse procedures revised 8/10, which combines child abuse, domestic violence,and elder abuse procedures, was found to be incomplete. Specific reference is made to lack of process to ensure safe discharge of at-risk children reported for suspected abuse and neglect who are seen in the emergency department and who are not admitted to the hospital. There is no stated direction or process to follow to secure safety clearance from Agency for Children's Services prior to discharge.

The policy did not provide written guidance in instances where a child is not admitted for protective custody or "hospital hold". The policy did not include actions to be implemented in cases where the child is reported to ACS for intervention and where ACS hold or hospital protective hold is not implemented.

It was stated by ED management staff during interview on 5/21/12 that children are admitted as necessary. It was also stated the hospital is in the process of updating these procedures.

Procedures did not describe in detail specific evidentiary actions to be implemented for cases of child sexual abuse other than a general reference directing staff that this evidence must be collected, retained, and stored. The policy referenced that the Brooklyn District Attorney Special Crimes Unit special protocol for evidence collection but did not describe the use of the kit or the specific roles of staff responsible for collection.

Procedures were not included for children meeting criteria for joint response, which includes actions to be coordinated with Police and the local Child Protection Agency.

3. The hospital failed to develop or implement specific procedures in the emergency room to guide staff in instances where a parent or guardian refuses care and does not act in the best interest of a child, or for instances of parental interference in treatment for children who require immediate medical interventions.

Procedures did not include specific guidelines to follow in the emergency department for children who require immediate treatment and for whom the parent or guardian is not acting in the best interest of the child. While the child abuse policy does describe the need for reporting of "delays in seeking medical attention or reluctance to give information", it did not specifically address the need for reporting of instances where there is parental or guardian interference in the need for immediate care of a minor.

Specific reference is made to MR #1 for a 2 month old female who (MDS) dated [DATE] with respiratory distress. The staff stated at interview the parents refused bloods or intubation, despite evidence that the child continued to deteriorate. The parents eventually consented for transfer after the condition of the child continued to worsen. The child decompensated and expired prior to transfer to another facility where the child could receive intensive care.

It was stated at interview with ED physician on 5/22/12 that if it was necessary to provide emergency care or intubation, the physician would override the parent's refusal. It was stated by ED administrative staff this is not a policy but is a practice.