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 Oct. 19, 2018
VIOLATION: INTEGRATION OF EMERGENCY SERVICES Tag No: A1103
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record (MR) review, document review and interview, in 3 of 14 medical records reviewed, it was determined that the facility did not implement its process to ensure that each patient seen in the ED for alcohol abuse was appropriately referred (Patients # 1, #5 & #6).

Findings include:

Review of the facility protocol titled "Emergency Department & Substance Use Disorder Addiction Lead Service", dated 12/20/2017 noted several steps in the management of intoxicated patients. The first of these is the requirement that such patients should be referred to the Social Work Department for further evaluation. This request is to be made by the ED physician.

Review of MR for Patient # 6: A [AGE] year old was brought by ambulance to the Emergency Department (ED) on 10/16/18 5:36 AM for evaluation post fall incident and alcohol intoxication. As per Emergency Medical Services, the patient was found lying in the street with laceration to the back of the head and vomitus on clothing.

On 10/16/18 at 3:41 PM, the discharge instruction indicated the patient was evaluated in the ED for alcohol intoxication and noted the patient was instructed, "Do not drink so much alcohol".

There was no documented evidence that the patient was referred to the Social Work Department for an assessment and referral.

Review of MR for Patient #1: The patient arrived at the facility's ED by EMS on 5/11/18 at 12:29 am. The patient denied pain/discomfort, reported she was intoxicated and had vomited.
The alcohol screen revealed "the patient takes a drink containing alcohol about 3 times on a typical day". The patient was discharged to home or self-care with a diagnosis of "alcohol use, unspecified with intoxication."

There was no documented evidence that this patient who was identified with alcohol abuse had appropriate referral at discharge.

Similar finding was noted for Patient #5 who was treated in the ED and diagnosed with alcohol abuse and intoxication. This patient did not have a complete assessment and a referral prior to discharge.

The findings were acknowledged by Staff A (Chief of Emergency Medicine) on 10/19/2018 at approximately 3:30 PM.
VIOLATION: CRITERIA FOR DISCHARGE EVALUATIONS Tag No: A0800
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on medical record review, document review and interview, in one (1) of eight (8) medical records reviewed, the facility did not ensure that a complete discharge planning evaluation was conducted timely (Patient #18).

Findings include:

Review of MR # 18 noted: A [AGE]-year-old who was admitted on [DATE] for management of elevated blood pressure, diabetes and abdominal pain.

On 10/17/2018 at 4:41 PM, the medical provider documented that the patient was medically ready for discharge home today, but he wanted his home attendant to pick him up in the hospital because he had no food at home. The patient became a social hold and was placed on Alternate Level of Care (ALOC).

The initial discharge evaluation dated 10/17/18, the date of the intended discharge, revealed that the patient lived alone with home care services (Home Health Aide) 7 days a week. The discharge planner documented that the patient confirmed that he had home care services and had no food at home. The planner documented that the patient must be discharged tomorrow, 10/18/18 when home services will be reinstated.

There was no documented evidence that the patient's discharge needs were timely identified and met.

Review of facility policy titled "Assessment, Reassessment and Risk Criteria," last revised 6/1/2018, indicated that a patient requiring discharge planning who is screened at moderate risk would be evaluated within forty-eight hours of referral. The policy does not address the discharge planning for patients who require a complete discharge planning assessment before the 48 hours of referral.

During interview on 10/17/18 at approximately 3:00 PM, Staff H, Social Worker, confirmed that Patient #18's discharge was delayed due to hospital screening protocol.
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on medical record (MR) review, document review and interview, in three (3) of eight (8) medical records reviewed, each patient's discharge evaluation was not individualized to meet the patient's post- hospitalization care needs (Patients #2, #15 & #17).

Findings include:

1. Review of MR for Patient # 2 noted: A [AGE]-year-old with history of mild dementia and legal blindness who was admitted on [DATE]. The patient alleged that she was abused by her son who resides in the home with her. The Adult Protective Services (APS) was involved in the case. The patient was discharged on [DATE] to a Skilled Nursing Facility (SNF).

On 5/14/18, the patient was transferred from the SNF to the facility's Emergency Department (ED) for an evaluation of altered mental status (AMS).
The patient was medically cleared to return to the SNF. The SNF refused to readmit the patient and the patient was unwilling to return to the facility. The patient was discharge home from the ED on 5/15/2018 at 1:53 PM against APS objection to discharge patient home to her son.

There was no documented evidence that discharge planning evaluation included, an assessment of elder abuse in the home and how the patient's care needs will be better met at home rather than placement in another SNF.

The facility's Policy titled "Adult and Elder Abuse and Neglect "revised 2/15/18 states Social Work provider" discusses options regarding return to same situation/environment" of abuse with the patient.

There was no documentation evidence that there was a discussion with the patient regarding her return to same environment where she alleged abuse.

On 9/8/2018 at 6:59 AM, the patient returned to the facility's ED, with allegation of elder abuse from her son who was her caregiver. The patient was admitted for social reasons and for possible placement due to physical evidence of abuse.

The discharge planning assessment, dated 9/8- 12:44 PM noted the following: The patient preferred to return home with home care services. She may benefit from home care services, but she would need 24/7 home care. She was not open to nursing home as she felt that it was her home and her son should be the one to leave. The patient had an open case with APS and Victims Service Police. The patient agreed to nursing home placement but eventually she would like to return home.

There was no documented evidence that the patient's discharge evaluation included the reasons the patient could not receive 24/7 home care services. There was no documented evidence that the discharge planner coordinated with all the agencies involved in the patient's care (APS and Victim Services) to ensure a safe discharge to her home as requested by the patient.

On 10/19/18 at 11:45 AM, during interview, Staff E (Social Work Supervisor) and Staff F (Director of Social Work) acknowledged findings.


2. Review of MR for patient #15 noted: A [AGE]-year-old patient with multiple comorbidities including End Stage Renal Failure on Hemodialysis who was admitted to the facility on [DATE] for an infected hemodialysis catheter. The patient was discharged on [DATE].

The initial discharge planning evaluated, dated 6/23/2018 at 2:45 PM, indicated that prior to hospitalization , the patient lived at home alone with home health aide services for five hours a day, five days a week.

On 7/30/2018 at 12:25 PM, the discharge planning evaluation indicated the patient was recommended for subacute rehabilitation. The patient was discharged home on 8/4/2018 at 12:48 PM with reinstated home care services.

There was no documented evidence that the discharge planning evaluation included the reason the patient no longer requires subacute rehab placement. In addition, there was no reassessment to determine if the patient's prior home care hours were sufficient to meet the patient care needs.

During interview with Staff I, Social Worker on 10/17/2018 at 11:30 AM, she acknowledged findings.


3. During interview with Patient # 17 on 10/17/2018 at approximately 3:15 PM at bedside, the patient stated she was discharged and awaiting to be picked up. The patient stated she had home care services and her son was her home attendant. She stated she had three (3) hours a day for five (5) days week, she complained that her home care hours were not enough. She stated she requested more hours, but she was not sure if this request was approved.

Review of MR for patient # 17 noted: A [AGE]-year-old with history of CHF (Congestive Heart Failure), HTN (hypertension) Asthma, and arthritis of the knees who was admitted on [DATE]. The patient was referred to social work as moderate risk for having services prior to admission. It was documented the patient had HHA (home health aide), Monday - Friday from 10:00 AM - 1:00 PM. The discharge planner documented the patient's HHA hours will be reinstated, but added that the patient would like more hours as 3 hours a day was not enough.

There was no documented evidence that the discharge planning evaluation included the reason for home care services and if the current home care services hours were sufficient to meet the patient's care needs. The documentation did not include if the patient's request for more home care hours was approved or the reason why this request was not granted.

During interview on 10/17/2018 at 11:30 AM, Staff F (Director of Social Work) acknowledged findings.
VIOLATION: DOCUMENTATION OF EVALUATIONS Tag No: A0811
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on medical record (MR) review, document review and interview, in one (1) of eight (8) medical records reviewed, the facility did not discuss patient's discharge planning evaluation with individuals acting on the patient's behalf (Patient #2).

Findings include:

Review of MR for Patient #2 noted: A [AGE]-year-old with multiple medical conditions including legal blindness who was admitted on [DATE].
It was documented that prior to admission, the patient resided with her adult son who was the caregiver. On 9/10/2018 at 2:35 PM, the Social Worker received a call from the patient's son to discuss her discharge plan. The patient's son requested to be contacted when the patient was medically ready for discharge.

The patient had a psychiatric evaluation on 9/11/18 at 1:10 PM. The psychiatrist indicated that "although the patient had capacity to participate in discharge planning and agreed to placement, she had a limited understanding of the available options". The recommendation was that attempts be made to contact patient's other children and involve them in the discharge planning.

There was no documented evidence that this recommendation was implemented.

On 9/18/2018, the patient was discharged to a Skilled Nursing Facility (SNF).

There was no documented evidence that the patient's son, who was the caregiver, or other family member was informed of the discharge plan and the patient's transfer to a SNF.

During interview with Staff E (Social Work Supervisor) on 10/19/18 at 11:45 AM, she was unable to explain the reasons the patient's son was not informed of the discharge to a skilled nursing facility or the reasons why the patient's daughter was not notified of the admission and discharge.

The facility's policy titled "Social Work- Discharge Planning" revised 12/13/2017 states "the social worker documents the development of the discharge plan and the patient/family/significant others participation and agreement in the medical record."

There was no documented evidence that patient's family participated in the development of the patient's discharge plan.
VIOLATION: LIST OF HOME HEALTH AGENCIES Tag No: A0823
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on medical record and interview, in two (2) of eight (8) medical records reviewed, the facility did not consistently inform patient/patient's representative they have a choice in post-hospital providers (Patients # 2 & #15).

Findings include:

Review of MR for Patient #2 noted: A [AGE]-year-old with multiple medical conditions including legal blindness was admitted on [DATE] and discharged to a Skilled Nursing Facility (SNF) on 9/18/2018.

The discharge planning assessment, dated 9/14/2018 at 12:51 PM, indicated a SNF was interested in admitting the patient, and the patient verbally agreed. The discharge planner documented that a list of SNF was put at bedside and the patient reported that her preference was in Brooklyn.

There was no documented evidence that assistance was provided for this legally blind patient during the selection process.

Review of MR for Patient #15 noted: A [AGE]-year-old patient with multiple comorbidities including End Stage Renal Disease on Hemodialysis who was admitted to the facility on [DATE] and discharged on [DATE].

The discharge planning evaluation, dated 8/01/2018 at 11:24 AM, indicated referral was made to a Certified Home Health Agency (CHHA) for medication management. The discharge planner documented that the patient was not given a list of CHHA because the patient's insurance recommended this network provider.

There was no documented evidence that the patient was involved in the selection of provider.

During interview on 10/19/18 at 11:45 AM with Staff E (Social Work Supervisor) and Staff F (Director of Social Work), they acknowledged findings.
VIOLATION: REASSESSMENT OF DISCHARGE PLANNING PROCESS Tag No: A0843
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Based on document review and interview, it was determined that the hospital did not reevaluate its discharge planning process to ensure effectiveness.

Findings include:

Review of Annual/Performance Improvement Program Evaluation for Social Work/Discharge Planning Services (2017 and 2018), and Quality Patient Safety Council Departmental Report for 2018 revealed there was no documented evidence of discussion of assessment and reassessment of all discharge plans or the process that triggers re-evaluation of post discharge needs. In addition, there was no documented evidence that readmissions were tracked for improvement.

During interview on 10/19/18 at approximately, 12:00 PM, these findings were discussed with Staff F (Director of Social Work).