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.

INTERFAITH MEDICAL CENTER 1545 ATLANTIC AVENUE BROOKLYN, NY 11213 Feb. 11, 2016
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0160
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based document review, in 2 (two) of 6 (six) medical records reviewed, it was determined that the facility did not ensure that each patient restrained had a comprehensive medical assessment (Patient #2, Patient #4).

Findings include:

Review of the medical record for Patient #2: Patient, [AGE] year old female, with history of depression, bipolar disorder, schizophrenia and depression, was brought to the facility's ED on 02/09/16 21:04 (9:41 PM) by ambulance. The emergency service report indicated, "The patient was found outside, states that she was feeling depressed." It was noted that on 02/10/16 0051 (12:51 AM), there was an order for Ziprasidone (Geodon); 02/10/16 0051 Lorazepam (Ativan) & 02/10/16 0051 manual hold-emergency use only. On 02/10/16 1204, physician order notes, "discharge psych patient".

The physician's assessment and evaluation was not located in the record. The nursing documentation did not include if medications were administered to the patient. There was no record of nursing monitoring conducted after medications were administered to the patient.

Review of the medical record for Patient #4: The patient, [AGE] year old female, arrived in the facility's psych ED on 2/9/16 2306 (11:06 PM). The presenting problem was that the patient was picked up from the street secondary to bizarre behavior. On 2/10/16 at 0525 (05:25 AM), the nurse noted, " Patient remains disorganized, pacing, disrobing and harassing other patients by approaching them too closely. Patient refused to take medications orally and was given Ativan 2 mg and Geodon 20 mg IM." It was noted on 2/10/16 0507 (5:07 AM) Ziprasidone (Geodon) and Lorazepam (Ativan) was ordered. There was another order for Lorazepam (Ativan) on 2/10/16 1915 (7:15 PM). However, there was no physician assessment and evaluation of the patient documented in the medical record.

Hospital Administration Policy & Procedure, titled, "Management of Patients in Restraints and Seclusion " was reviewed. The policy stated, "If physical holding for forced medication is necessary for a violent patient, the one (1) hour physician face-face equation is required. " This policy was not implemented, as there was no evidence that the physician who wrote the order to medicate Patients #2 and #4 completed assessments of these patients prior to administration of medications.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, document review, medical record review, and staff interview, it was determined the facility failed to develop and implement policies and procedures to ensure safe management and care of patients presenting to the Emergency Department with psychiatric related complaints.

This may have placed all patients at risk for potential harm and adverse outcomes.

Findings:
See citations: Tag A 131; Tag A 133; Tag A 144; Tag A 160; Tag A 206.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on document review and staff interview, in 1 (one) of 8 (eight) medical records reviewed, it was determined that the facility did not have a policy that addresses the right of the patient who is not incapacitated, to designate a representative to make informed decisions regarding his or her care (Patient #8).


Findings include:

Review of the medical record for Patient #8, noted, a telephone consent for treatment was obtained from the patient's friend. There was no documentation in the record that the patient delegated a representative to make decisions regarding her care.

During interview with Staff T, on 2/11/16 at approximately 1:30 PM, this staff reported that the patient is currently alert but at admission, she was unable to make decision.

A faxed copy of the Health Care Proxy form from the nursing home, where the patient resided, was submitted on 2/11/16 at approximately 3:32 PM. This form was not signed. It was written on the form, "resident unable to sign proxy statement due to her diagnosis. However, her friend will be involved in her care."


Hospital Administrative Policy and Procedure Manual, Number RI-05: Titled: "Informed Consent and Refusal to Consent" was reviewed on 2/11/16. The hospital policy did not have a provision, which includes the right of the patient who is not incapacitated, to delegate his health care wishes to another person.
VIOLATION: PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION Tag No: A0133
Based on staff interview, in 7 (seven) of 8 (eight) medical records reviewed, it was determined that the facility did not have a policy addressing notification of patient family/representative or the physician of his/her admission (Patient #1, #3, #4, #5, #6, #7 & #8).

Findings include:
Review of medical records for patients#3 to patient #7, noted, there was no documentation in the records that the patients' physicians and/or patients' representatives were notified of the admissions.

Staff A was interviewed on 2/11/16, approximately 4:00 PM. This staff stated that the facility does not have a policy, which addressed notifying patients' family/representative and the patients' physicians upon admission.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**







Based on observation, staff interview and document review, in 5 (five) of 7 (seven) medical records reviewed, it was determined that the facility did not ensure that each patient presenting to the Psych Emergency Department (ED) receives comfort and emotional care in a safe environment (Patient #1, #2, #3, #5 and #6).

Findings include:

Review of the medical record for Patient #1 identified, Patient, [AGE]-year-old Hispanic male, with past history of Schizoaffective Disorder, was seen in the facility's ED on 9/7/15. The presenting complaint was feeling depressed with suicidal thoughts. The patient arrived in the ED on 9/7/15 2041 (8:41 PM) and he was triaged at (9:35 PM) and placed in triage category 3. He was later transferred to the Psych ED on 9/7/15 2143 (9:43 PM). The physician wrote an order to admit the patient on 9/8/15 0632 (6:32 AM).
On 09/08/15 at 10:55 AM, the patient was still in the Psych waiting area; approximately 12 hours after the patient presented to the Psych ED for treatment. It was unclear if this patient was fed, as there was no order for meals noted in the record.
On 09/08/15 at 10:55 AM, the nurse noted; "writer responded to a help call from the patient waiting area and upon arrival at the scene in patient waiting room, observed safety officer and patient in locked arms. Patient was sitting with back rested on the wall and blood noted on his shirt. A quick assessment indicated that blood was coming from the patient left ear, which was observed to be partially detached from the top, and there was a laceration to left side of the head, about 3.5 cm long. First Aid was performed and the patient was immediately taken to the medical emergency room for evaluation and treatment."
Facility video tape, dated "9/8/15, Psych ED," was (MDS) dated [DATE]. It was observed the patient was pacing; patient threw garbage can in the hallway and security staff returned the garbage can to its original place; patient picked up the garbage can and tossed it again. At that point, a second security staff approached the patient and there was a physical struggle between the two. There were no clinical, therapeutic interventions implemented to address the patient's agitation prior to the security intervention.


The Psych ED Department was toured on 2/10/16 at approximately 11:30 AM. It was observed that there was one patient laying on a stretcher in the hallway at the entrance, and there were fifteen (15) patients in waiting area. Patients were sitting on plastic chairs and others were pacing. There were no beds, stretchers, or recliners for patients to rest. There was limited space to care for patients. For example, if a patient became ill requiring medical attention, there was no room for a stretcher.
The overcrowded condition in the Psych ED waiting area was brought to the attention of the Medical Director; the facility's protocol on diversion was discussed. This staff stated that the facility would go on diversion if the census was over thirteen (13). This staff also stated that the current census was fifteen (15) but there were three (3) patients slated to be discharged .

The following patients were in the waiting area, and the medical records were reviewed: Patient #2, Patient #5 and Patient #6.

Review of the medical record for Patient #2, identified: Patient, [AGE] year old female with history of depression, bipolar disorder, schizophrenia , paranoid and non-complaint with medication, was brought to the facility's ED on 02/09/16 21:04 (9:04 PM) by ambulance. The patient was transported to the emergency department as EDP (emotional disturbed person) - with chief complaint, " I feel depressed." The patient was triaged 2/9/2016 at 2125 (9:25 PM); the triage nurse noted that the patient was found wondering the street all day depressed; triage level 3. The patient had an ED BH (Behavior Health) triage assessment 2/10/16 at 0221 (2:21 AM). The vital signs were as follow: Temperature 97, Pulse rate 63, Respiratory rate 18, Oxygen Saturation 98 %; Blood Pressure 97/63. This patient's waiting time in the Psych ED was over 12 hours; overnight on a plastic chair. There was an order to discharge the patient dated 2/10/16 1204 (12:04 PM). The Nursing discharge assessment was dated 2/10/16 1411 (2:41 PM). However, a physician assessment of the patient was not documented in the medical record.

Review of the medical record for Patient # 5: Patient, [AGE] year old male, presented to the facility's ED on 2/9/16 1550 (3:50 PM) requesting to be seen for "drinking alcohol. " The patient was triaged on 2/9/16 1558 (3:58 PM) with vital signs as follows: Temperature 98; Pulse rate 95, Respiratory rate 17, Oxygen Saturation 96 % and Blood Pressure 146/89. The patient was transferred to Psych ED 2/9/16 at 1644 (4:44 PM). Psych ED triage assessment dated [DATE] at 1743 (5:43 PM). On 2/9/16 at 1749 (5:49 PM), the nurse noted, "Patient presents with history of hypertension and hypercholesterolemia." There was an order to admit the patient on 2/10/16 at 0214 (2:14 PM). This patient remained overnight in the Psych waiting area and he was still there during the unit tour on 2/10/16 11:40 AM.

Review of the medical record for Patient #6: Patient, [AGE] year old male with a history of hypertension, bipolar disorder and substance abuse, presented to the facility's Emergency Department on 2/9/16 1948 (7:48 PM), requesting detox. It was noted that there was an order to admit on 2/10/16 1552 (3:52 AM). It was noted that this patient was in the waiting area on 2/10/16 at 11:40 AM.

Review of the medical record for Patient #3 noted similar finding of a patient who was waiting for treatment, but remained in the Psych ED from 2/10/16 0945 (9:45 AM) to 02/11/16 0303 (03:03 AM). On 02/10/16 at 23:52 (11:52 PM), the physician noted that the patient was found to be anemic and was transferred to the Medical ED. The physician's order to admit was updated on 2/11/16 at 0303 (03:03 AM).

The conditions in the psych ED was brought to the attention of VP of Operations on 2/11/2016 at approximately 3:00 PM. He acknowledged that the facility was aware of the problems.

Hospital Administrative Policy and Procedure, PC 35.0: titled, "Emergency Department Patient Work flow/History and Physical Examination in the Psychiatry ED," effective date August 2015. This policy indicated, "Once the patient moves to the Psychiatric, ED each patient slated for admission must receive a complete history and physical examination and medical clearance prior to being transported to the inpatient behavior unit."
This policy does not address the time frame patients can remain in the Psych ED after their disposition is determined.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0206
Based on staff interview and the review of 3 (three) of 5 (five) Security staff personnel files, it was determined the facility did not ensure that all security staff who assist staff in restraining patients, manual holding of patients and monitoring of patients in restraints, are trained in the use of first aid techniques and cardiopulmonary resuscitation. (Staff P, Q & R)

Findings include:
The file for Security Officer, Staff P lacked evidence of training in First Aid and cardiopulmonary resuscitation.

Similar findings regarding the lack of training and competencies in first aid and cardiopulmonary resuscitation were found for Staff Q &R reviewed.

During interview conducted on 2/10/16 at approximately 11:45 AM, Staff P reported that security staff often assists clinical staff when they are administering medication to patients, and as per physician's order, apply manual holds.

During interview on 2/11/16 at approximately 2:45 PM, Staff S acknowledged that not all security staff received training in first aid and cardiopulmonary resuscitation (CPR).

The document, "Job Description - Security Officer," revised 01/08, indicated that one of the Principal Duties and Responsibilities of a security officer included; "Responds to emergency calls for assistance to control disorderly conduct or combative patients, including assisting patient care staff in restraining patients."
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and staff interview, in 4 (four) of 7 (seven) medical records reviewed, it was determined the facility did not ensure that patients presenting to the Emergency Department (ED) in unstable emotional states, receive timely medical screening and appropriate evaluations and interventions, as per the facility policy. (Patient #1, #2, #3 & #4)
Findings include

Review of the medical record for Patient #1: This [AGE] year old male patient with diagnosis of schizophrenia presented to the facility's Emergency Department (ED) on 9/7/15 2041 (8:41 PM). The presenting complaint; "feeling suicidal, " cut/lacerations noted to left forearm. The patient was triaged on 9/7/15 2135 (9:35 PM) with vital signs as follows: Temperature 98.3; Pulse rate 85, Oxygen Saturation 96 %; Respiratory rate 18; Blood Pressure 137/93. The patient was placed in triage level 3. The patient was transferred to the Psych ED 9/7/15 2145 (9:43 PM).
The emergency medical physical examination and evaluation, prior to the transfer to the Psych ED, was not located in the medical record.
It was noted that the patient was admitted on [DATE] 0632 (6:32 AM). The initial medical evaluation was dated 09/08/15 0948 (9:48 AM); psychiatric evaluation was dated 9/8/2015 11:44 AM. This patient did not receive a medical evaluation of self-inflicted injuries he sustained prior to his transfer to the Psych ED.

Review of the medical record for Patient #2: Patient, [AGE]-year-old female, was brought to the facility's ED on 02/09/16 at 21:04 (9:04 PM) by ambulance. The patient was transported to the Emergency Department as EDP (emotional disturbed person) - with chief complaint, "I feel depressed." The patient was triaged 2/9/2016 at 2125 (9:25 PM). The patient was placed in triage category 3. The patient had an ED BH (Behavior Health) triage assessment 2/11/16 0221 (2:21 AM). The vital signs were as follows: Temperature 97, Pulse rate: 63, Respiratory rate 18, Oxygen Saturation 98 %; Blood Pressure: 97/63. There was an order to discharge the patient on 02/10/16 1204 (12:04 PM). There was no medical screening evaluation located in the record.
On 2/10/16 1439 (2:39 PM), the clinical coordinator/collateral note "met with patient in the psych ED and spoke with patient's mother. Writer explained that as per psychiatrist, patient does not currently meet criteria for inpatient psychiatry at this time." The psychiatrist evaluation was not located in the record.

Review of the medical record for Patient #3: Patient, [AGE] year old female, with history of mental illness was brought to the facility's ED by EMS (emergency service) on 2/10/16 at 0919 (9:19 AM). The presenting problem: "the patient's neighbors called EMS because the patient was anxious and constantly knocking at neighbor's doors." The patient was triaged on 2/10/16 at 0938 (9:38 AM) with the following vital signs; Temperature 98.2; Pulse rate 96, Blood pressure 123/65; Oxygen saturation 100%. This patient was placed in triage category 2. The patient was transferred to the Psych ED 2/10/16 at 0945 (9:45 AM). The physician ordered the patient to be admitted on [DATE] at 1803 (6:03 PM); the admission evaluation wasdated 2/10/16 at 18:24 (6:24 PM).

There was no indication of a medical evaluation and clearance prior to the transfer of the patient to the Psych ED. This patient remained in the Psych ED waiting room from 2/10/16 at 0945 (9:45 AM), to 02/10/16 to 23:45 (11:45 PM). On 2/10/16 at 2345 (11:45 PM), the nurse noted; patient was transferred back to the ED secondary to hemoglobin of 6.5 gm/dL.


Review of the medical record for Patient #4: Patient, [AGE] year old female, arrived in the facility's ED on 2/9/16 at 2306 (11:06 PM). The presenting problem was that the patient was picked up from the street secondary to bizarre behavior. The ED BH (Behavior Health) triage assessment was dated 2/10/16 at 0253 (2:53 AM). The vital signs were as follows: Temperature: 97.9; Pulse rate 77; Respiratory rate 20, Oxygen Saturation: 98 %; Blood pressure 122/68. There was a medical order for Ziprasidone (Geodon) 2/10/16 at 0507 & Lorazepam (Ativan) at 2/10/16 at 0507 and order for admission 2/10/16 at 1912 (7:12 PM).
There was no medical or psychiatric evaluation noted in the patient's medical record.

During interview conducted on 2/11/16 at approximately 12:00 PM, Staff A stated, as per policy all patient requiring psychiatric evaluation must be medically cleared in the main ED before they are transferred to the Psych ED. Regarding Patient #1 not receiving a timely medical evaluation, this staff responded that there is the possibility that this was a documentation issue and she would discuss it with the ED Medical Director. The explanation from the ED Medical Director was never provided.

Hospital Administrative Policy and Procedure PC 35.0: titled "Emergency Department Patient Work flow/History and Physical Examination in the Psychiatry ED," effective date August 2015, states the following: "all psychiatric patients will be seen and medically cleared in the Main ED before going to the Psychiatric ED."
This policy did not indicate that the physician must complete the emergency medical screening evaluation and document the evaluation in the medical record.
The Emergency Department policy does not include the requirement that the Emergency Department physicians complete the medical screening and document the final disposition and the rationale for the disposition.


Policy & Procedure titled "Psychiatry Patient in the Main ED," revised February 5, 2015, indicated that patient who exhibit gravely impaired judgement and consider danger to self and/or others will be assigned a triage acuity of Emergency Severity Index (ESI) Level 2. This policy was not properly implemented, as evidenced by the following:
Patient #1's medical record indicated the patient was a danger to self. This patient was placed in triage category level 3.
However, Patient #3 who was assessed as not being at risk to self or others, was assigned category level 2, and was placed on observation status every 30 minutes.