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.

Based on review of the medical record (MR), document review, and interview, it was determined the Governing Body failed to maintain its responsibilities for the oversight and operation of all services provided to maintain the health and safety of patients.
This failure to ensure the safety and welfare of patients, put all patients at risk.

Findings include:

The Governing Body failed to meet the Conditions of Participation.

See Citations:
Tag A0049- Medical Staff
Tag A0068- Care of Patients
Tag A0144-Patient ' s Rights
Tag A0309-Quality Assurance and Performance Improvement
Tag A1104-Emergency Department Policies

Based on medical record review, document review, and interview, in 7 of 9 medical records reviewed, the medical staff did not provide patient care consistent with the facility's policy and procedure. The facility's Emergency Department (ED) policy required comprehensive medical assessment to be completed in the psychiatric ED, including but not limited to, Electrocardiography,(EKG) and Chest X-ray.
(Patients A, B, C, D, H, G, and F)

Findings include:

Per medical record review:
Patient A (MDS) dated [DATE] at 9:48 AM accompanied by Emergency Medical Services (EMS) for chief complaint of hearing voices and not taking medications. The patient had medical history for HIV, Hepatitis, Asthma and Hypertension. There was no evidence that an EKG was done.

Patient B (MDS) dated [DATE] at 11:16 AM accompanied by EMS for chief complaint of anxiety and past medical history of hypertension. The record review revealed the patient did not get an EKG.

Similar findings were noted in medical records for Patients C, D, and H who also did not have an EKG documented at disposition from the ED.

Patient G (MDS) dated [DATE] and did not have a chest x-ray obtained prior to admission to the psychiatric unit.

Similar finding was noted in review of medical record for Patient F where ED treatment did not include a chest x-ray at time of disposition.

Review of the facility's policy titled "Emergency Department Patient Workflow/History and Physical Examination in the Psychiatric ED," effective date October 6th 2014 (last review date April 6, 2015), identified 2 components, EKG and chest x-rays, were to be completed for ED psychiatric patients.

During an interview on 07/21/15 at 2 PM, Staff #2 (ED Physician) stated, "The policy (noted above) might have been in place but it was not happening."

The facility did not ensure compliance with its policy for emergency services.
Based on medical record (MR) review, document review, and interview, the facility did not ensure an Anesthesiologist is readily available at all times to respond immediately to a cardiopulmonary arrest (Code 33) as per hospital policy.

Findings include:

Review of Patient A ' s MR on 07/21/15 documented: on 06/24/15 at 8:58 PM a cardiopulmonary arrest Code 33 was initiated. Documentation identified the patient suffered a cardiac arrest at the psychiatric unit at 8:58 PM. Anesthesia did not respond until 9:25 PM when patient was in the ICU.

Review of " Cardiac Arrest Record " form IMC- (07/07) dated 06/24/15 timed at 8:58 PM, under the section for " Names of Persons Responding " to code where " Anesthesiologist " was printed, instead of anesthesiologist ' s name (Staff # 14, Anesthesiologist), the word " none " was documented.

The documentation in Patient A ' s medical record showed an Anesthesiologist was not available to provide medical care for this patient who was in cardiopulmonary arrest.

Review of " Cardiac Arrest Record " forms revealed similar findings:
During the period of June 1st to June 30th 2015, anesthesiologists failed to respond 8 times out of 10 cardiac arrest Codes 33s activated.
During May 2015, the anesthesiologist failed to respond in 8 out of 9 cardiac arrest codes activated.
During April 2015, the anesthesiologist failed to respond in 12 out of 14 codes.
During March 2015, the anesthesiologist failed to respond to a total of 18 out of 21 codes.

Review of policy titled " Emergency Resuscitation Response, " effective date 12/2014 documented, " a code team has been established to respond to all emergency situations in the hospital when a patient is in Cardio-Pulmonary Arrest, the team is compromised (actual word used) of the following ... including Anesthesiology. "

Review of policy titled " Cardio-Pulmonary Resuscitation/Respiratory Care ' s Role, " effective date 02/2014 documented, " When a Code 33 is called, immediate response and care must be provided by a code team. Following intubation of the patient by Anesthesia, the Respiratory Therapist will attach the manual resuscitator to the Endotracheal Tube and ventilate the patient. "

During interview on 07/23/15 at 12:30 PM, Staff #14 (Anesthesiologist) stated, " On 06/24/15 in the evening, when I heard Code 33 on my beeper, I was in the OR (Operating Room) working on an eye case, it was an elective surgery. I was the only anesthesiologist working, the Certified Registered Nurse Anesthetist (CRNA) had left for the day at 5 PM, and the other anesthesiology doctor had left at 7 PM. So, usually, if I am in a case and I can ' t come to the Code, I will call the ED physician and ask him to go instead because I can ' t be in two places at once. But that night, I didn ' t do that because I was finishing up the case so I brought the patient into the recovery area and instead of calling the ED doctor, I went to the code myself and when I got there, I was told the patient was in the ICU and I went there instead. When I got to the ICU, the patient was being ambu-bagged by the Respiratory Therapist. When I got closer to the patient, I heard a noise and I knew right away the tube wasn't in place where it should be in the trachea, so I checked the tube and when I opened the mouth, I could see the ET tube was in the esophagus and not in the airway. So, I removed it and re-intubated the patient. "

The June 2015 Anesthesiologist OR Schedule for 06/24/15 confirmed Staff #14 (Anesthesiologist) was the only anesthesiologist on duty at 8:58 PM when the Code 33 was activated.

Upon review of Staff #11 (Post Graduate Year, PGY-II) and Staff #12 (PGY II) Department of Medicine Credential Logs, there is no documented evidence of proficiency in intubation of patients or evaluations regarding management of patient airways during intubations.

Review of Interfaith Medical Center (IMC) Department of Medicine PGY-I Manual 2015-2016 documented, " When you begin working here, you are considered as non-credentialed and cannot perform any procedures unless you are supervised by someone who is credentialed in that particular procedure. You will be given a credentialing booklet in which you will log the procedures you will perform on patients (e.g., IVs, Lumbar Punctures, and Thoracentesis) and have them counter signed by the person who is supervising you at the time of the procedure. "

Review of the IMC Department of Medicine PGY-II Manual 2015-2016 documented, " PGY-IIs are members of the code team, and should look to the PGY-III who is the code leader for instructions. The PGY-II role is not just limited to obtaining IV access and administering medicines. "

Review of IMC Department of Medicine PGY-III Manual 2015-2016 documented, " PGY-IIIs are code leaders. "

On 07/26/15 at 1:25 PM, during interviews with Staff #5 (Chief Medical Officer) and Staff #22 (Director of Residency Program), it was confirmed that there is no mechanism or process for ascertaining proficiency of the PGYs I, II, and III residents on intubation techniques. The facility does not have a surgical residency program.

Staff #22 stated, " Ideally, it would be best if the residents could accompany the anesthesiologist in the OR (Operating Room), and in a controlled environment intubate patients. Currently, during an emergency code situation, the PGY-III could ask a PGY-II if he has ever intubated a person before to see how comfortable the PGY-II level is before doing the procedure. "

On 07/26/15 at 1:45 PM, Staff #5 stated, " We have a medical residency program here but don ' t do enough surgery cases for the residents to rotate through. They do work with the pulmonologists on their ICU and telemetry rotation but we don ' t include intubation as part of their mandatory credentials; only the Advanced Cardiac Life Support (ACLS) is mandatory, but ACLS include simulated intubation. "

On 07/26/15 at 1:45 PM, Staff #5 was asked how frequently the medical residents intubate patients when anesthesiologist does not attend a code. Staff #5 stated, " The number of times the anesthesiologist doesn ' t attend, subtracted by the patients who were already intubated when the code was called, so the remaining times is when the residents intubate the patient. "

On 07/27/15 at 1:25 PM, during an interview, Staff #12 stated, " At the time of the code on 06/24/15, I was a PGY-II. In July, I became a PGY-III. That night, when I opened the patient ' s mouth, I saw his dentures and removed them out of the way but don ' t remember any food there and I was able to visualized the airway with the laryngoscope and confirmed the Endo -Tracheal Tube (ETT) was properly placed. I have intubated two (2) times before in this facility. Once with an anesthesiologist during the night time when the patient self extubated himself and one other time, I think, but I don ' t remember where it was and when. But I was a doctor in India and intubated many times there. " Staff # 12 stated, " The pocket log (that all interns /residents carry with them) for evaluation of intubation procedures was not signed by the anesthesiologist because it is not a part of their mandatories in this hospital. "

On 07/27/15 at 1:25 PM, during an interview, Staff #11 stated, " At the time of the code on 06/24/15, I was a PGY-II. In July, I became a PGY-III. I have never intubated a person. I have ACLS and intubated on a mannequin. "

On 07/23/15 at 7:25 PM, during an interview, Staff #13 stated, " I am a PGY-II. When I responded to a code, I can give medicines, and start intravenous. But I have not intubated a person. I have my ACLS and have practiced intubation during the ACLS classroom training on a dummy. "

The facility did not ensure compliance with the policy to have PGY staff supervised and credentialed before performing any procedures
Based on medical record review, document review, and interview, the facility failed to implement procedures to ensure the safety and welfare of all patients. This was evident in 3 of 6 medical records reviewed. (Patients I, E, and J)

Findings include:

See Citations:
Tag A144
Tag A309

Based on record review and interview, the facility did not ensure that all Medicare beneficiary patients/patients ' representatives were provided with the standardized notice, " An Important Message From Medicare About Your Rights (IM) within two (2) days of admission as an inpatient, and that the facility presented a copy of the IM in advance of the patient ' s discharge to the patients/patients ' representatives, but no more than two (2) calendar days before the patient ' s discharge. This was evident in 3 of 6 medical records reviewed. (Patients I, E, and J)

Findings include:

Patient I ' s MR identified: patient was admitted to the facility on [DATE] and discharged on [DATE]. The record review lacked documentation that the patient/patient ' s representative were provided with the standardized notice " An Important Message From Medicare About Your Rights " (IM) on admission and prior to discharge.

Patient E ' s MR identified: patient was admitted to the facility on [DATE] and discharged on [DATE]. The record review lacked documentation that the patient/patient ' s representative were provided with the standardized notice " An Important Message From Medicare About Your Rights " (IM) on admission and prior to discharge.

Patient J ' s MR identified: patient was admitted to the facility on [DATE] and discharged on [DATE]. The record review lacked documentation that the patient/patient ' s representative were provided with the standardized notice " An Important Message From Medicare About Your Rights " (IM) on admission and prior to discharge.
Based on medical record review and interview, in 1 of 10 medical records reviewed, the facility did not ensure that required consents were obtained for a patient who lacked the capacity to make decisions regarding his care.

Findings include:

Medical record review for Patient A documented on 06/24/15 at 9:48 AM, the patient presented via ambulance to the Emergency Department with a chief complaint of Auditory Hallucinations. The " Emergency Department General Consent " dated and timed 06/24/15 at 9:56 AM was unsigned.

On 06/24/15, a psychiatric ED physician documented on the Emergency Admission Section 9.29 Mental Hygiene Law Form, " The patient has history of psychiatric illness, has been depressed, hearing voices with suicidal thoughts. Patient is potentially dangerous to self and others. " This legal form in the medical record of Patient A is dated and timed 06/23/15 at 1:00 PM, prior to the patient ' s presentation to the ED.

The patient was diagnosed with Schizoaffective Disorder and admitted involuntarily to a locked Behavioral Unit for psychiatric services on 06/24/15.

During interview with Staff #9 (Chief Compliance Officer) on 07/27/15 at 9:50 AM, staff acknowledged the finding but stated nothing to the Surveyor when asked why the date and time were incorrect.
Based on review of medical record, document review, interview, and video observation, in 1 of 10 patients reviewed on the Behavioral Health Unit, it was determined that the facility did not implement procedures or develop policies to ensure the safety and welfare of all patients.

This failure placed all patients at risk.

Findings include:

On 07/20/15 at 4:45 PM, observations of the surveillance video recorded on 06/24/15 were made in presence of Staff # 6 (Assistant Vice President Quality Assurance/Performance Improvement) and Staff #9 (Chief Compliance Officer). Time stamped 8:53 PM, Patient A enters the 9 East Dayroom, where three (3) other individuals are observed sitting (all three individuals are identified as patients by Staff #9, no staff members are present in the Dayroom. Patient A is seated in a chair in the far corner of the room with a cup and a plate of food and is observed awake, alert, and eating. At 8:55 PM, Patient A is observed with head falling downwards on to his chest. At 8:55.21, a person (identified as a patient) approaches Patient A, and another person (identified as another patient) is seen leaving the Dayroom. At 8:55.43 PM, a staff nurse (identified as Staff #3, RN) is observed entering the room and approaches Patient A. At 8:56 PM, Staff #3 (Staff RN) is seen standing next to the patient. It is not evident on observation of video recording that the staff member performed emergency medical interventions with Patient A.

Reported by Staff #9 that on 06//24/15 at 8:56 PM, Staff #3 (Staff RN) assessed Patient A including placing a BP (Blood Pressure) cuff and calling a Code 77 (Rapid Response Code). This is not observed on the video recording.
At 8:56.30 PM, four additional staff enter the room.
At 8:57.37 PM, one of these staff lower Patient A to the floor and appear to start chest compressions.
At 8:58 PM, " Code 33 " (Emergency Resuscitation Response) is activated. Crash cart is observed brought into the dayroom.
At 8:59 PM, an MD staff (Staff #10, PGY-III) enters the dayroom. Numerous pieces of medical equipment from the crash cart are observed in piles placed on a table in the room. Observations noted a stretcher arrives in the Dayroom at 9:14 PM and the patient is transferred from the floor to stretcher and leaves the room at 9:15 PM.

Review of (Patient A's) "Rapid Response Team Record " dated 06/24/15 timed 8:56 PM documented by the nurse, " Primary reason for call. Seizures. Patient was observed with jerking movements while in the dayroom sitting in a chair. Eyes observed rolling backwards. Assisted to floor and code 77 was called. Vital signs BP= 130/88 (normal range=120/80 mm Hg), HR= 90 (normal range=60-80 beats per minute), RR=20 (normal range=16-20 breaths per minute), SaO2= 95% (saturation of oxygen in blood, normal range=95% to 100%). Became unresponsive and a code 33 was initiated. Chest compressions initiated and patient was not responsive to verbal stimuli. Pulse was checked and patient was pulseless. "

" Cardiac Arrest Record " (IMC- 07/07) dated 06/24/15 documented that Basic Cardiac Life Support (BCLS) was initiated at 8:58 PM on 9 East. Review of record identified that pertinent information were missing and/or incomplete including circumstances for arrest, vital signs, procedure, arterial gases and blood glucose results, and confirmation of placement for endotracheal tube.

The Cardiac Arrest Record and Patient A ' s medical record do not have cardiac monitor strips attachments and when asked by the surveyor, the facility could not provide cardiac rhythm strips for the code activities that occurred on 06/24/15 from 8:58 PM to 9:23 PM.

Although the code was on-going, a second/continuation of " Cardiac Arrest Code Sheet " (IMC- 06/2013) is noted in the medical record. This second record, dated 06/24/15 documented Code 33 was initiated at 8:58 PM in the Behavioral Unit 9 East. Sections of this record identified to have pertinent information that are missing and incomplete including vital signs and cardiac rhythm. This " Cardiac Arrest Record Sheet " documented the code was terminated and the patient pronounced dead at 10:11 PM.

Staff #20 (Assistant Vice President Patient Services) verified on 07/21/15 at 12:45 PM that the " Cardiac Arrest Record " (IMC- 07/07) and " Cardiac Arrest Code Sheet " (IMC- 06/2013) are inconsistent and stated that (IMC- 06/2013), " is the form that the staff should use for all hospital wide Code 33 documentation. " Staff #20 could not provide an explanation why the Cardiac Arrest Code Sheet was incomplete and did not have all the required information documented by the nurses.

The policy titled " Emergency Resuscitation Response (Code 33), dated 09/2012, noted " A registered nurse will manage the Crash Cart and document on the Code Flow Sheet. "

The nursing staff failed to ensure compliance with the policy for documentation of monitoring/ assessment of a patient during Code 33.

Medical record reviewed on 07/21/15 at 12:15 PM, documented Patient A was admitted involuntarily under Mental Hygiene Law (MHL) section 9:39 to the Inpatient Behavioral Unit with diagnosis Schizoaffective Disorder. The nurse documented a note on 06/24/15 at 5:02 PM, " Vital signs Blood Pressure 130/88, Pulse 88. Respirations 20, Temperature 98. O2 saturation 99%. Patient oriented to the unit and made aware of the rules and regulations of the unit. Patient denies suicidal or homicidal ideation. Patient with paranoid delusion and stated ' everybody gets me upset on the street. ' "

The 9 East Unit " Fifteen Minute Observation Sheets (for patients) " documented that Patient A ' s arrival time to the unit was 06/24/15 at 3:45 PM and his activities were noted as " slept in bed " throughout the afternoon.

Review of physician ' s note (Staff #10, PGY-III) dated 06/25/15 timed 11:54 AM, documented, " When I arrived at 8:57 PM, the patient was on the floor and not responsive to verbal or external stimuli, I started CPR immediately as per ACLS protocol. While checking the airway, food particles and the dislodged dentures were found obstructing the pharyngeal cavity. The dentures and some of the food particles were removed. The patient was placed on monitor and ETT was placed successfully by medical team. During the transfer, the patient remained pulseless and CPR with ambu bag and oxygen was performed throughout. "

On 07/22/15 at 12:45 PM, during an interview, Staff #10 (PGY-III) stated, " I heard the rapid response called and when I got there, I was told the patient had been eating and the nurse said to me she thought he was having a seizure. We talked a little about performing the Heimlich and whether it was done but it was her understanding that the patient maybe having seizure so it wasn ' t ' t done. When I got there, the patient was lying on the floor and was not responsive, he wasn ' t ' t having a seizure activity and had no pulse. There were lots of people around inside and outside the room. There was so much noise and movement from people in that room which was very small. Security was trying to push them away. The patient was lying on his back next to a wall of the dayroom. So, I got down on my knees and there was no pulse, and he was not responsive. So, we started chest compressions and it was a very difficult situation. It was hard to work on the patient in that tight space and the room was very small. There were lots of people moving about and a lot of talking, it was chaotic and it was hard to make myself heard. It was very dark in the room and difficult to see. We were doing everything on our knees. We were given everything we needed from the nurses eventually, but, some items we asked for took them sometime to hand them to us. They were searching for things that we were asking for but we did eventually get everything we needed. We couldn ' t ' t get a peripheral intravenous (IV) started so Staff #12 (PGY-II) put in an endotracheal tube (ETT) and we gave double doses of epinephrine to the patient. We (the medical resident PGY II) confirmed the ETT placed by auscultation and heard breath sounds, we saw the chest rise and obtained a capnography that was positive for CO2. (Capnography is a device used to measure the presence of carbon dioxide from the lungs to determine proper ETT placement and proper ventilation occurring). We tried to get a femoral access but were unable to finish it. Nursing wanted us to move the patient away from the unit to the Intensive Care Unit. But it ' s not ACLS (Advanced Cardiac Life Support) protocols to move the patient at that time without a pulse and we were still working on trying to get an IV line. We never got a detectable pulse on the patient in 9 East. There was no return of spontaneous circulation when we moved the patient. At first I said, we couldn ' t ' t move the patient because we were still working on him but the nurse kept saying to move him so I thought maybe it was some policy that the patient shouldn ' t ' t stay on that unit. Any way, it took a while to get a stretcher but then when it arrived, the decision was made to move the patient. But we never stopped the CPR and kept doing the chest compressions the whole time we were in the elevator but during that time, we never regained a pulse. Later, when we got to the ICU then the anesthesiologist showed up and told us that the ET tube was in the esophagus, it ' s possible it may have been displaced when we moved the patient. "

On 07/27/15 at 1:25 PM, during an interview, Staff #12 (PG-II) stated, " We tried to start a femoral central intravenous access but it takes time to complete the procedure. We were able to get the guide in and the cannula and confirmed placement with blood return. We were told that the patient was being transferred to the ICU and a stretcher was brought into the room. So, we removed the wire from the patient ' s femoral site before he was moved so that the needle wouldn ' t ' t slip into the vein. We needed more time to put the femoral line in but they needed to move the patient right then. Later in the ICU, I was able to put the central line to his femoral site. Of course, it would have been better to have been able to have had time to finish putting the line in when we first tried in 9 East, because we had it in the vein but couldn ' t ' t keep it in, it wouldn ' t ' t have been safe to transport the patient with the procedure not completed. "

Nursing staff failed to coordinate with the medical staff to stabilize an unresponsive patient and complete code activities prior to transferring a patient away from Behavioral Health Inpatient Unit.
Based on document review and interview, the Quality Assurance and Performance Improvement department failed to ensure measurable improvement in staff remediation during " Mock Code 33's " conducted during 2015.

Findings include:

Review on July 24 th 2015 of Mock Code Reports revealed:

On January 16 th 2015, a Mock Code was performed in 9 East Psychiatric Unit and debriefing deficits observed by Nursing Education were documented as, " Improper use of Defibrillator ... " Remediation was documented as, " reeducation on the proper use of defibrillator. "

On February 2nd 2015, a Mock Code was performed in 9 West Psychiatric Unit and debriefing deficits observed by Nursing Education were documented as, (1) " Failure to check pulse, (2) Automatic external defibrillator pads placed incorrectly, (3) Improper depths during chest compressions. " Remediation was documented as, " Recommended to go to ABCS class. "

Similar findings were identified during Mock Codes of the following:
On February 20 th 2015, a Mock Code was performed in East Psychiatric Unit
On March 6th 2015, a Mock Code was performed in Psychiatric ED
On April 2nd 2015, a Mock Code was performed in 8 West (Psychiatric Unit)
On May 8th 2015, a Mock Code was conducted in 8 West (Psychiatric Unit)
On June 4th 2015, a Mock Code was performed on 9 West (Psychiatric Unit)
On June 28 th 2015, a Mock Code was performed in 8 West (Psychiatric Unit)
On July 10 th 2015, a Mock Code was performed in 6 West (Psychiatric Unit)

During interviews conducted on 07/27/15 at 11:15 PM with Staff #7 (Chief Nurse Officer) and Staff # 8 (Director of Nursing, Nursing Education), quality data and nursing education regarding Mock Codes was discussed. Staff #8 stated, " Nursing Education provided remediation during real time. "

Staff #s 7 and 8 could not provide documented evidence that staff who participated in Mock Codes from January 2015 through June 2015 attended recertification for Basic Life Safety classes.

Review of a sample of nursing staff personnel files did not document performance evaluation and proficiencies in Mock Codes.
Based on document review and interview, the facility did not ensure that the ED department established written policy and procedure that coordinates medical and psychiatric emergency care and services, and approved by the Chairman of the ED and the Governing Body.

Findings include:

Review of the Table of Organization for IC provided to the Surveyor on 07/21/15 documented: Staff #4 (Director of ED Medicine) identified as the Chairman of the Emergency Department.
Review of the facility policy provided to AS on 7/21/15 at 12:15 PM titled " Emergency Department Workflow/History and Physical Examination in the Psychiatric ED, " (last review date April 6, 2015) documented: the policy was created, recommended, and authorized on April 6, 2015 by Staff #18 (Director of Quality Assurance Behavioral Health), and Staff #19 (Medical Director Psychiatry/Director Acute Psychiatric Services.)
The policy revisions dated 04/06/15, stated, "If a patient tests positive for Multiple Sclerosis with Dysphagia, an order must be entered into Mediate for Aspiration Precautions with instructions (from the physician) to provide supervision during meals and snacks."
There is no documented evidence that the policy revisions were approved by the Chairman of the ED and the Governing Body.
During interview on 07/21/15 at approximately 1:15 PM, Staff #4 stated, " I have nothing to do with the IC Psychiatric Emergency Department, and Staff #s 16 (Administrative Director of Psychiatric ED) and 19 (Medical Director of Psychiatry) were the Directors in charge of all psychiatric services at the facility on 06/24/15. "
During interview of Staff #s 6 (Assistant VP QA/PI) and 9 (Chief Compliance Officer), on 07/22/15 at 12:30 PM, the staff stated: " This policy revision was made without going through us. It does not have the signatures of the Chief Compliance Officer or Chief Executive Officer (Governing Body). "