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 Dec. 3, 2020
VIOLATION: PATIENT RIGHTS Tag No: A0115
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Based on medical record review, document review and interview, the facility failed to protect patients at risk for elopement. Specifically, the facility failed to implement its policy and procedure titled "Elopement" to identify patients at risk for elopement and implement measures to prevent elopement. This failure was identified in three (3) of 15 medical records reviewed (Patient #s 1, 2, and 3).

This failure may result in serious adverse outcome to patients.

See Tag A144.
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VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on medical record review, document review and interview, the facility failed to protect patients at risk for elopement. Specifically, the facility failed to implement its policy and procedure titled "Elopement" to identify patients at risk for elopement and implement measures to prevent elopement (Patient #s 1, 2, and 3).

This failure may result in serious adverse outcome to patients.

Findings include:
Patient #1 is a [AGE]-year-old female who was brought to the ED from a supervised residential home on 8/31/20 for complaint of vaginal bleed.
The patient's medical history included schizophrenia, bipolar disorder, bipolar personality disorder, moderate intellectual disability. At 10:30 am, after an initial evaluation by a Physician Assistant, the patient eloped from the ED. The patient was found on the streets approximately 10 hours later by staff members of the group home who were searching for her.

There was no documented evidence that the patient was assessed for risk of elopement in the ED.

Review of the "Elopement" policy last revised 12/02/2019 notes "(1) every patient is assessed by clinical staff at triage in the Emergency Department and upon admission to the patient units of the hospital for wandering and elopement risk. If the answer to any of the above items is yes, the patient is deemed "high risk": (2) The determination of the patient's "high risk" status must be documented in the medical record by the provider. The safety measures appropriate for the patient need to be part of the interdisciplinary treatment plan & discussed among treatment team ...."

Based on the facility's elopement policy, the patient met the criteria for a high risk for elopement. A patient is considered high risk if the patient meets one of the following criteria that includes: Patient with psychiatric disorder. Mental/physical impairments that increases their risk of harm to self and others.

During an interview with Staff Q, Triage Nurse on 11/20/2020 at approximately 11:00 am, she stated the patient was alert and oriented to time, date, and place and she did not observe any abnormal behavior or symptoms of mental illness in the patient.

Patient #2 is a [AGE]-year-old who arrived in the ED by ambulance on 6/10/20 at 4:28 pm for evaluation of aggressive behavior. The patient had a history of Schizoaffective disorder and polysubstance abuse. Nursing triage assessment indicated the patient was not at risk for elopement based on an ED elopement assessment tool.

Occurrence report dated 6/10/20 noted the patient ran out of the ambulance triage area after triage assessment.

Patient #3 is a [AGE]-year-old male who was admitted on [DATE] for evaluation of psychotic disorder with delusions. The patient's medical history included anxiety disorder, depression and Post Traumatic Stress Disorder. The elopement risk assessments conducted by the nurse on 7/18/20 at 9:25 pm and at 10:48 pm indicated the patient was not at risk for elopement.

On 7/20/20 at 3:40 pm, while the patient was in the Radiology Department for a diagnostic procedure, he eloped. The patient was brought back to the ED on 7/20/20 at 6:10 pm.

Review of the ED tool for determining patients at risk for elopement revealed it did not include the same high-risk criteria such as psychiatric diagnoses and mental disabilities noted in the elopement policy for identifying patients at high risk for elopement. If the ED assessment tool was consistent with the hospital's policy, patients #2 and #3 would have been identified as having a high risk for elopement.

These findings were acknowledged on 11/24/20 at approximately 3:50 PM by the Staff Z, Chief Executive Officer, Staff W, Chief Nursing Officer and Staff Aa, Chief Quality Officer.
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VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
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Based on medical record review, document review and interview, the facility failed to ensure that elopements from the ED and inpatient units were reported, investigated and corrective actions implemented to prevent elopement.

Findings include:

Review of the facility's Quality of Care Executive Review Committee (QCERC) report dated 9/15/20 revealed there were a total of nine (9) elopements during the first quarter (Jan-March) and three (3) during the second quarter (April-June) 2020.

Review of the facility's 2020 Quality Assessment, Performance Improvement & Patient Safety Plan revealed no documented evidence of monitoring and assessment activities and corrective action plans for the elopement data.

During interview on 11/23/20 at 12:30 PM, Staff U, Director of Risk Management stated: The data in the form of occurrence reports are entered on a spreadsheet. The data is reported to the Quality of Care Executive Committee including those incidents that requires a Root Cause Analysis.

During interview on 11/23/20 at 11:36 AM, Staff O, Chief Quality Officer acknowledged the finding.
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VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on medical record review, document review and interview, in 1 of 15 medical records reviewed, the facility failed to conduct pressure injury assessment and reassessment as per facility policy and in accordance with acceptable standard of practice to ensure appropriate management of wounds (Patient #4).

Findings include:

Review of medical record for Patient #4 identified the following: This [AGE] year old female (MDS) dated [DATE] at 10:42 AM with complaints of generalized weakness and left facial droop. The patient had previous medical history of Congestive Heart Failure (CHF), Coronary Artery Disease (CAD), Cerebral Vascular Accident (CVA), Diabetes Mellitus (DM), Hypertension (HTN), and Vascular Dementia of which she was on medications. CT of the Head Without Contrast performed in the ED on 3/27/2020 revealed no acute stroke but there was an old stroke identified. Chest x-ray showed Congestive Heart Failure with pulmonary vascular congestion. A repeat CT scan on 3/30/2020 showed no changes.

Nursing admission note on 3/28/2020 at 05:08 AM, documented that the patient's skin was intact and warm to touch ... At 8:25 PM, the patient with darkened blotch-skin tear to buttocks ...Flowsheet on 3/28/2020 revealed Braden Score (prediction for risk for pressure injury with Score of 15 to 18= Mild Risk; 10-12=High Risk; 9 or less is very high risk) was 16=Low; Integument (Skin) WDL (Within Desired Limits).

Nursing Note on 3/29/2020 at 1:40 PM: skin tear to buttocks were unchanged ... At 2:34 PM, the patient with skin tear left lower buttocks more pronounced than the right ...local skin care given, skin kept free from excrement. Physician notified of same...Flowsheet on 3/29/2020: patient had a Braden Score of 16; Integument WDL.

Nursing Note dated 3/31/2020 at 7:51 PM: sacrum area hard to touch. At 7:55 PM, foam dressing applied to blister on buttocks area. Sacrum are hard to touch. Flowsheet on 3/31/2020: Braden Score at 3:00 PM was 14, and 15 at 02:00 AM; Integument with blister to sacrum.

Similar nursing notes were noted on 4/1, 4/2, 4/3 and 4/4/20 where there were no documented evidence that pressure injury assessment and reassessment were conducted to include wound characteristics such as size, stage (Pressure Ulcer/Injury Stage I, II, II, IV, Deep Tissue Injury, Unstageable), color, location, odor, drainage, granulation, tunneling, and undermining, as per facility policy and in accordance with acceptable standard of practice.

The facility's policy on "Pressure Injury Prevention and Treatment Policy" last revised on 6/18/2020 was reviewed. The policy documented the following but not limited to: All admitted patients will be assessed and properly scored for pressure injury risk and presence of pressure injury on admission and every shift.
The physicians, with the nurses will assess the patient for any existing pressure injury inclusive of location, stage, size (length, depth, and width in cm), characteristics of wound (granulation, drainage amount, odor, color, tunneling and undermining).
The physician will be notified of the patients with Braden Score of 18 or below.
The health care team (RN. MD, Nutritionist) will reassess the healing progression of the pressure injury and revise plan of care on weekly basis.

As per interview with Staff Y, ADN, Wound Care Nurse on 11/19/2020 at 10:18 AM, Staff Y was asked what the facility expectation was for documentation of wound assessments; she responded that wound assessments and interventions are documented in EPIC medical record in accordance with the Pressure Injury Prevention and treatment policy.

During interview of Staff I, Staff RN on 11/20/2020 at 12:20 PM, she reported that nursing assessments and interventions should be documented in the medical record. Staff I stated that she had no recollection of the care provided to Patient #4.

During interview with Staff X, Chief Director of Medicine on 11/20/2020 at 3:14 PM, Staff X acknowledged findings.