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 June 25, 2015
VIOLATION: CRITERIA FOR DISCHARGE EVALUATIONS Tag No: A0800
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and staff interviews, it was determined that the facility failed to ensure that staff complied with the facility's Discharge Planning Protocols and Policies which resulted in Patient #B's discharge from Interfaith Medical Center (IMC) into the community without appropriate resources, including prescriptions. This was evident in one of seven medical records (Patient #B, #I, #J, #K, #L, #M, #N).


Findings:

Medical Record for Patient #B documented a [AGE] year old resident of a skilled nursing facility (SNF) was transferred to the hospital emergency room on [DATE] at 9:30 AM with chief complaint of Altered Mental Status (AMS). The patient had a history of Seizure Disorder and was receiving Phenytoin Sodium extended 100 mg three times a day (TID) and Phenobarbital 30 mg twice a day (BID) for seizure control in the SNF where he lived prior to admission. Patient #B was discharged into the community without prescriptions for these medications on 12/31/14 at 3:30 PM.

A copy of the IMC occurrence report discussion, regarding the incident, was provided. The report dated 01/21/15 documented, "prior to admission Patient #B was receiving Phenytoin Sodium extended 100 mg three times a day (TID) and Phenobarbital 30 mg twice a day (BID) for seizure control and that toxicology result was positive for alcohol and barbiturates at time of discharge into the community. "

Interview on 6/23/15 at 2 PM Staff #1 stated, "an internal investigation was performed for the incident, which involved discharging Patient #B to the community instead of back to the Nursing Home and discharging him without the benefit of prescriptions to control his seizure disorder."

On 06/24/15 the IMC nursing policy and procedure (P&P) regarding discharge of patients from the Emergency Department (ED) was reviewed. The hospital policy and procedure titled "Discharge Process for the emergency room Patient", effective date 09/2010 indicated, "Patients who present to the emergency room will receive a medical screening exam and if discharged will receive clear follow up instructions, with prescriptions, physician contact information, and follow-up instructions with phone numbers and addresses for referral to appropriate clinics, agencies, and programs."

On 6/23/15 in the morning Staff #11 verified that this was the P&P in place on 12/31/14 when Patient #B was discharged from the IMC ER to the community without prescriptions and stated "as of 6/24/15, Patient #B whereabouts remains unknown."

There is no documentation produced by the facility that the hospital a made reasonable attempt to communicate and coordinate patient search with the nursing home staff when the nursing home called and inquired about the patient's whereabouts.
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and staff interviews, it was determined that the facility failed to ensure a patient (Patient #B) was transferred back to the Skilled Nursing Facility where he lived. Instead the patient was discharged into the community without appropriate resources including necessary medical information, community follow-up, and prescriptions. This was evident in one of seven medical records (Patient #B, #I, #J, #K, #L, #M, #N.).


Findings:


Patient #B, a [AGE] year old resident of a skilled nursing facility (SNF) was transferred to the hospital emergency room on [DATE] with chief complaint of Altered Mental Status (AMS).

Emergency Department - Registered Nurse (ED-RN) Triage assessment dated [DATE] at 9:26 AM documents: "A 59 year old, male arrive to the ED on stretcher accompanied by EMS, picked up from Nursing Home for altered mental status and suspected alcohol abuse with altered mental status. The patient had history of altered mental status, septic shock, pneumonia, head injury, sudden cardiac arrest, and testicular hernia. The patient has No Known Allergies, vital signs are within normal range, and GCS=15. The patient is breathing spontaneous to room air and in no apparent distress with oxygen saturation of 96%. Level of Consciousness: Awake and alert, and oriented to person and place. Triage Category: Level 3 (ESI)."

[Note for above paragraph: EMS = Emergency Medical Services; GCS = Glasgow Coma Scale - a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person - The lowest possible GCS is 3 (deep coma or death, while the highest is 15 (fully awake person); and ESI = Emergency Severity Index - is a five-level emergency department triage algorithm - the ESI levels are numbered one through five, with level one indicating the greatest urgency, and level five non-urgent.]

RN-Nurse's Notes dated 12/31/14 at 9:59 AM documents: "Patient with Doctor." The Electronic Medical Record (EMR) did not have documentation of the physician patient evaluation.

Laboratory Reports dated 12/31/14 revealed: ". . . Ethanol = 149 (Reference = 0-5) mg/dl . . . Barbiturates = Positive H (High) (Reference = Cut Off = 200 ng/ml . . ."

RN Nurse's Note (Same RN who admitted ) dated 12/31/14 at 1530 (3:30 PM) documents the patient is discharged home to self-care as per MD order. The written discharge instructions did not include prescriptions for the seizure medications and transportation arrangements.

Medical record review for Patient B lacked a discharge planning evaluation.

On 6/23/15 at 9:45 AM Staff #3 stated, "she recalled caring for Patient #B on 12/31/14 and noted on triage the patient was transferred from a nursing facility for altered mental status, but that her assessment found him to be completely alert and oriented and he was able to transfer from the emergency services (EMS) stretcher to the emergency room (ER) stretcher independent of her assistance." Staff #3 stated, "The patient had a blood alcohol level, of 149 mg/dl, but did not appear to be inebriated nor could she detect alcohol on his breath." She stated, "The patient had been transferred by EMS from a nursing facility and that he admitted to having a history of seizure activity due to head trauma, but this information flew out of her brain at the time of his discharge to the community." The nursing transfer information did not accompany the patient when he entered the IMC ER and she did not contact the facility about her patient. She did not recall her communications with the doctor concerning patient B's discharge and that she could not recall any details of the discharge despite the presence of her signature on patients B's discharge sheet. Staff #3 commented that patient B was given a generic information sheet about alcoholism, but no discussion took place concerning a community resource follow-up. Staff #3 said that one week after patient B was discharged , the Nursing Home contacted IMC to inquire as to patient B's status. That contact triggered an investigation into Patients B care since his whereabouts were unknown and remain unconfirmed."

On 6/23/15 at 11:15 AM Staff #2 stated during interview, "on assessment of patient #B he did not demonstrate any neurological deficits and denied having a history of seizure disorder and did mention that he did admit to having had done some drinking prior to his admission." Staff #2 did not recall having seen any documentation which would have indicated that he was transferred to IMC from a nursing facility and he did not mention he was a nursing home resident.

Interview on 6/24/15 at 1:30 PM Staff #4 stated, "when he interviewed the physician (Staff #2) who attended to Patient #B the physician failed to read the electronic medical record nursing notes concerning documentation that the patients domicile was recorded as a Skilled Nursing Home Facility, which had transferred him to the IMC ED. This resulted in him being discharged to the community without any communication with the SNF. The physician also failed to document the patient physical exam and assessment."