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 & MENTAL HEALTH CENTER 760 BROADWAY BROOKLYN, NY 11206 June 18, 2019
VIOLATION: EMERGENCY SERVICES Tag No: A1100
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Based on medical record review, document review and interview in three (3) of nine (9) patients' records reviewed, the facility failed to implement its Emergency Department (ED) policies and procedures to ensure that all patients admitted into the Comprehensive Psychiatric Emergency Program (CPEP) received violence risk assessment and management prior to discharge (Patients #1, #2, and #3).

This failure may have placed all patients and the public at risk for harm.

See Tag A1104
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on medical record review, document review and interview in three (3) of nine (9) patients' records reviewed, the facility failed to implement its Emergency Department (ED) policies and procedures to ensure that all patients:
a) admitted into the Comprehensive Psychiatric Emergency Program received an appropriate risk assessment using the Broset Violence Checklist (Patients #1, #2, #3) and
b) all patients discharged from the Comprehensive Psychiatric Emergency Program met all hospital discharge criteria that includes the ability to function in the community (Patient #1).

These failures may have placed all patients/public at risk for harm.

Findings include:

Review of the CPEP policy titled "Comprehensive Psychiatric Emergency Program Management of Violent Patients," last reviewed 04/04/19, documented:

- "In the Comprehensive Psychiatric Emergency Program (CPEP) all patients are assessed for the risk of violence and assaultive behavior.

-All patients will be assessed with the Broset Violence Checklist (BVC).

-Patients with a violent potential must have an intervention plan that addresses this risk.

-The CPEP Psychiatrist assess all patients for risk of violence.

-Documents the risk on the psychiatric assessment and treatment plan.

-Communicates the risk to the Nursing staff.

-Ensures the effectiveness of treatment to minimize the risk of violence is reviewed with the treatment team.

-The CPEP Nurse initiates the Broset Violence Checklist for ALL patients.

-The BVC is a numerical checklist (scoring 0-6 with number greater than 2 considered high risk) used to help predict violent behavior.

-The BVC will be completed upon admission (to CPEP) and at the end of each tour until the patient scores less than 2 each tour for 72 hours.

-Ensures that the patients 'Medical Record is 'red flagged' if the patient has scored 2 or above on the BVC."

Review of medical record for Patient #1 indicated this [AGE]-year-old (MDS) dated [DATE] at 3:52 PM. The patient was accompanied by his two sisters who reported the Patient had a long-standing history of Schizophrenia with Paranoia and had been maintained in the community for over two decades without need for inpatient hospitalization . The patient requested a psychiatric evaluation for recent changes to his prescribed antipsychotic medication and stated he "came into the hospital because he "wasn ' t ' t feeling too good." The Psychiatric Nursing Triage Assessment documented the patient was guarded, with poor focus, and unable to answer questions. He was noted as paranoid, quietly stating to himself, "they are going to kill me." He was observed fidgeting, anxious and muttering to self at intervals.

At 5:59 PM, the Psychiatrist documented a Mental Status Examination and noted that the Patient was observed anxious and guarded. His eye contact was poor, and he looked down and had paucity of speech (a negative symptom in Schizophrenia, also known as 'poverty of speech', meaning the speech is lacking in content) ..., he was constricted and blunted (also a negative symptom in Schizophrenia that means there is no emotional expression) and his thought process was illogical and blocked (negative symptom in Schizophrenia). The Patient's sister stated he was maintained with Mellaril (A first generation antipsychotic medicine) 100mg daily for twenty years until recently when his doctor changed his prescription to Geodon (A second-generation antipsychotic medicine) 40mg daily ...and he had now decompensated ...the patient stated, "I don't like it (Geodon) at all. " The physician documented that the patient had 'failed' this medication treatment. The Psychiatrist switched the medication to another medication that was not the requested Mellaril. The patient was provided with a prescription for this new medication, Thorazine (a first generation antipsychotic medicine) and discharged home at 7:53 PM.

There was no documented evidence that the patient received the Violence Risk Assessment (Broset Violence Checklist) by the Triage Nurse and Psychiatrist as per facility policy.

Review of MR for Patient #2 documented a psychiatric evaluation in the CPEP on 06/01/19 at 1:06 PM and discharge into the care of her father. There was no documented evidence that the patient received the Violence Risk Assessment (Broset Violence Checklist) by the Triage Nurse and Psychiatrist prior to discharge.

Review of MR for Patient #3 indicated the patient was brought into the emergency room by Law Enforcement on 06/01/19 at 11:08 PM. The patient had been non-compliant with the court appointed Assisted Outpatient Treatments (AOT). At 12:39 PM, the Psychiatric Triage Nurse documented that as per the AOT worker the Patient had missed three appointments. The patient was very aggressive and attempted to choke a staff member in the Triage Area. The Nurse noted the patient was anxious, pacing and superficially cooperative. The Broset Violence Checklist (BVC) was initiated at 12:22 PM and the score was zero.

The BVC assessment was not appropriately scored and was inconsistent with the Nurses Triage history. Triage documentation indicated that the patient had exhibited violent behavior by attempting to choke a staff person.

During interview on 06/11/19 at 1:55 PM Staff J (CPEP Provider/Psychiatrist) did not know about the Comprehensive Psychiatric Emergency Program Management of Violent Patient policy and the need for all patients to have a BVC. Staff J was shown a copy of the Policy and stated, "I don't know what this policy is."

During interview on 06/12/19 at 11:35 AM Staff F (CPEP Provider/Psychiatrist) stated, "we don ' t use this (violence risk assessment) policy. The Nurses do that, it's their policy. With violence we go by behavioral observations, history by chart, and family input. "

Both Providers, Staff J and Staff I, were not familiar with the CPEP policy on Management of Violent Patient and their delineated role and responsibilities within the policy.

During interview on 06/12/19 at 12:10 PM Staff G (CPEP Registered Nurse) acknowledged that the Broset Violence Checklist (BVC) was not completed for Patient #1.

b) Review of the facility's policy titled "CPEP (Comprehensive Psychiatric Emergency Program) emergency room Screening, Admission, Discharge and Follow-up," last reviewed 04/04/19, documented:
-Discharge Criteria from CPEP:
A. Patient will not be acutely dangerous to self or others. (i.e. neither acutely suicidal or homicidal).
B. Patient should not have acute symptoms, for example hallucinations, delusions) which impair their ability to function in a community environment.

On 5/23/19 at 3:52 PM, the Nursing Triage Assessment, documented Patient #1 carried a history of Schizophrenia with Paranoia since 1992. The Nurse noted the patient verbalized paranoid ideation, stating "they are going to kill me."

At 5:59 PM, Psychiatrist documented the Mental Status Examination "Patient endorses paranoid ideations of being followed and feeling that people are trying to hurt him. He states, "they are going to find me dead... insight, judgement, and impulse control are all poor. The provider documented the 'History of Present illness': Diagnosis is Paranoid Schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly)...has not been hospitalized inpatient since 1992 and has been taking Mellaril (typical antipsychotic medication) for over twenty years when his outpatient psychiatrist suddenly switched him to Geodon (atypical antipsychotic medication) about one month ago with poor effect. He came here today asking to be switched back to Mellaril. Patient is accompanied by his two sisters who report the patient has completely decompensated, become increasingly paranoid and isolative, stopped speaking to other family members, become belligerent, thrown objects (eating utensils) at their mother for no apparent reason, and generally displayed bizarre behavior since being switched from Mellaril to Geodon last month. The family is very concerned regarding his safety as well as their elderly mothers' safety when she is in his presence. He reports insomnia and lives alone in an apartment, never married, no kids and doesn't work.

The Provider documented the hospital Pharmacy informed the doctor there was a three-month backlog for Mellaril and suggested Thorazine (typical antipsychotic medication) instead. The physician ordered a one-time dose of Thorazine 100 mg by mouth, which the Nurse administered at 5:11 PM.

At 5:59 PM, the Providers' ED Disposition Note documented, "The patient does not require inpatient hospitalization ."

At 7:10 PM, Nurse's Note documented, "the Patient was seen by psychiatrist, he left the unit on 5/23/19 at 7:53 PM."

There was no documented evidence that the patient's acute symptoms including, paranoid, persecutory delusions, thought blocking, poor judgement, insight and impulse control were addressed prior to his discharge two hours after Psychiatric evaluation.

Thirty hours later, on 05/25/19 at 1:50 AM, the patient returned to the ED covered in blood, escorted by New York Police Department Officers. The patient was admitted to CPEP Extended Observation Unit and the psychiatrist documented that the patient was severely decompensated with illogical thoughts and auditory hallucinations. The patient stated he went out into the street last night in his pajamas and left his apartment door wide open, he started fighting people, because he believed they would attack him. He never started the Thorazine and already stopped taking the Geodon. On 5/26/19, The NYPD visited him with an arrest warrant. He was placed under police custody and arraigned for repeatedly stabbing his father and fatally stabbing his (step) mother.

During interview on 06/11/19 at 1:55 PM Staff J (CPEP Psychiatrist) acknowledged that the patient's sisters were very concerned because his behavior had recently changed. He had become more paranoid and isolative from the family and he had recently thrown utensils at their mother during dinner. He was guarded on examination and had delusional thinking of persecution that others wanted to harm him. When the patient arrived with his sisters for a medication refill, much of my session with them was spent on Psychopharmacology education.
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