Based on medical record (MR) review and interview, in one (1) of 12 medical records reviewed, the facility did not ensure that staff in the Comprehensive Psychiatric Emergency Program (CPEP) provided appropriate intervention to a choking patient. (Patient #1) Findings include: Medical Record (MR) review documentation identified this [AGE] year old brought in by ambulance to the Emergency Department (ED) on 1/16/16 at 7:16 AM and was subsequently admitted to the Comprehensive Psychiatric Emergency Program (CPEP) due to increased agitation and irrational behavior at the group home. On 1/17/16 at approximately 4:15 AM, the Certified Nurse Assistant (CNA) assigned, observed the patient vomiting while eating a sandwich and notified the primary Registered Nurse (RN). From initial vomiting episode, the patient's condition progressed to unresponsiveness. Rapid Response Team was activated at 4:23 AM after finger sweep was done by the Physician Assistant (PA), followed by Cardiac Code Team (711 Code) at 4:24 AM. Emergency resuscitation was provided, and patient was emergently transferred to the medical ED at 4:45 AM. Resuscitative measures provided were unsuccessful. Patient subsequently expired on [DATE] at 5:17 AM. There was no record of assessment of the patient's airway by Nursing staff or the implementation of maneuvers to relieve the obstruction. Intubation Procedure Note dated 1/17/16 at 4:45 AM documented: "Indication for intubation: Code 711...ET Placement Verification: bilateral breath sounds; no breath sounds at epigastric area; chest rise movements; End Tidal CO2 (Carbon Dioxide) Detection by color." There was no documented evidence in the medical record that continuous ventilatory assessment and reassessment including bilateral breath sounds, were conducted to validate proper placement of the Endotracheal Tube (ET). An autopsy report dated January 18, 2016, documented that the ET tube was found in the esophagus. Cause of death: Asphyxia due to obstruction of airway by food bolus and Manner of death: Accident (choked on food). Interview with Staff B, ED Director of Psychiatry on 8/2/16 at 11:30 AM, staff acknowledged there was a problem with intubation and ET placement.

Based on record review and interview, in 1 (one) of 11 (eleven) medical records (MR)rewiewed, it was determined that the CPEP ( Comprehensive Psychiatric Emergency Program ) failed to ensure the safe discharge of mentally impaired psychiatric patients. Findings include: Review of MR #A on 9/25/15 identified that this patient, diagnosed schizophrenia with reported IQ (intelligence quotient ) of 41, was discharged alone from the CPEP to the street on 7/24/15 at 1055 AM with a Metrocard, without notifying the family or guardian. The CPEP nursing triage note written on 7/24/15 at 0003 hours ( 12:03 AM ) stated "Patient is illiterate and was unable to state his address or his correct age. Patient is a poor historian." The documentation stated the patient was given discharge instructions which were "understood by the patient " and are signed with an " X." The mark " X " is found on multiple CPEP forms that are complex and needed to be explained to the patient and there is no documented evidence that this was done. He was given " transportation money " by the social worker" and there was no documented re-assessment of his inability to report his address or how to get home . Review of the record found no specific discharge instructions regarding medications received or prescribed or any specific follow up. At interview with Staff #3, CPEP Psychiatric Director, on 9/30 /15 at 2:00 PM, it was stated the CPEP attending physician failed to communicate with the PA (Physician Assistant) prior to discharging the patient, as to the specific need for a family member to accompany the patient home due to mental retardation. He further stated that in his investigation of the incident that the PA was aware of the patient's guardian's specific request that he be notified of the patient's discharge in that the patient was mentally retarded. .