HospitalInspections.org

Based on document review and interview, the facility does not ensure all staff receive training and/or education on topics required by New York State Title 10 regulations, as evidenced for 6 of 7 staff (Staff #4-9). The topics include:
- Annual training on infection control and fire safety, under 405.3(b)(4).
- Training during orientation and ongoing related to abuse, neglect, and related reporting requirements, under 405.9(d)(1).
- Education related to patient safety, patient rights, injury prevention, professional misconduct and legal/malpractice issues, under 405.6(b)(7)(viii).
- Training in the requirements governing orders not to resuscitate, under 405.43(r)(1).

Findings include:

Personnel file review on 3/13/12 for Staff #4-9 did not reveal evidence in their files of training/education in the areas of infection control, fire safety, abuse and neglect, patient safety, patient rights, injury prevention, professional misconduct, legal/malpractice issues and do not resuscitate orders.

Interview on 3/14/12 with Staff #18 and 19, and on 3/16/12 with Staff #1, confirmed that not all staff are provided with the trainings listed above.

Based on medical record review and interview, a written copy of patient rights is not provided to patients as required by this regulation, and by New York State Title 10 regulation 405.7(a)(2), as evidenced for 3 of 9 patients. (Patient # 22, 31 and 32)

Findings include:

Medical record review on 3/15/12 for Patient #22, 31 and 32 did not reveal evidence that they had received a written copy of the patient rights.

Based on medical record review, document review and interview, the operator does not ensure that restraints are implemented in accordance with hospital policy for 3 of 3 patients. (Patient # 9, 29, 30)

Findings include:

Review of facility policy titled Restraint/Patient Safety Devices effective 1/26/10 revealed a provider will provide a face to face evaluation of the patient in restraints within one hour of application.

Review of medical record for Patient # 9 revealed restraints were implemented during episodes of confusion and agitation per nursing. Although restraints were ordered on 3/8/12 and renewed on 3/9-10/12 there is no evidence a provider provided the required face to face evaluation following the application of restraints.

Interview with Staff # 31 on 3/16/12 revealed the providers seldom provide face to face evaluation within one hour of restraint application.

Review of medical record for Patient # 29 revealed restraint orders for 3/12-14/12. There is no physician documentation to indicate a face to face evaluation within one hour of restraint application.

Review of medical record for Patient # 30 revealed a phone order for restraints on 3/11/12 with a renewal of the order via phone on 3/12/12. There is no documentation to indicate a face to face evaluation within one hour of restraint application.

Based on medical record review and interview, medications are not documented in accordance with accepted standards of practice in 5 of 5 cataract surgical patients. ( Patients #3, 4, 24, 25, and 26)

Findings include:

Review of medical records for cataract surgical Patient # 3, 4, 24, 25, and 26 on 3/14/12 revealed one administration of four different eye drops.

Review of the physician order for the eye drops revealed the four different eye drops were to be administered at "10 min, 15 min, 30 min, and 45 min."

Interview with Staff # 22 on 3/16/12 revealed the statement, "The electronic medication administration record (MAR) does not have the capability to record administration of the eyes drops as ordered. Some nurses use a spot on the electronic medical record to make additional notation of eye drop administration, but the MAR doesn't have the capability to document consecutive drops of the same medication. If newer administration times are documented for the same eye drop- it automatically deletes the previous documentation of the eye drop administration."

These findings were verified with Staff # 21 on 3/16/12 at 1 PM.

Based on medical record review, the facility does not ensure all entries in the medical record are legible, complete, dated, timed, and authenticated.

Findings include:

Medical record review on 3/13-15/12 revealed the following:
- Patient #1: The anesthesia record was illegible and the post operative assessment was untimed.
- Patient #2: The physician orders were not timed.
- Patient #4: The physician orders were not signed or dated.
- Patient #5: Verbal orders given on 2/28/12, 3/3/12, 3/7/12 and 3/10/12 were not authenticated by the provider within 48 hours. Review on 3/14/12 revealed no evidence of authentication.
- Patient #7: Verbal orders given on 3/9/12 were not authenticated by the provider within 48 hours. Review on 3/14/12 revealed no evidence of authentication.
- Patient #8: Verbal orders given on 3/9/12 and 3/10/12 were not authenticated by the provider within 48 hours. Review on 3/14/12 revealed no evidence of authentication.
- Patient #9: Verbal orders written on 3/8/12 and 3/9/12 were not authenticated by the provider within 48 hours. Review on 3/14/12 revealed no evidence of authentication.
- Patient #13: The Emergency Department physician orders lacked a date and time.
- Patient #17: A physician progress note lacked a date and time.
- Patient #18: The discharge summary sheet of a deceased patient dated 2/14/12 at 8:00 PM was blank for UNYTS suitability information and signature by the registered nurse.
- Patient #19: The discharge summary sheet of a deceased patient dated 12/18/11 at 1:22 AM was blank for UNYTS suitability information and signature by the registered nurse.
- Patient #22: A physician progress note dated 9/29/11 lacked a time and signature by the physician.
- Patient # 29: Progress notes dated 3/10-11/12 written by Staff # 8 were illegible.
- Patient #30: The physician orders are illegible and verbal orders are not authenticated within the 48 hour time frame. Progress notes by Staff # 41 on 3/10/12 and 3/12/12 are illegible. This finding was verified with Staff # 31 on 3/14/12.

Based on observation, medical record review and interview, the facility does not ensure patient medications brought from home are verified in accordance with facility policy prior to administration.

Findings include:

Review of policy titled- Patient's own Medication - For use in the Hospital on 3/14/12 revealed hospital staff will deliver any medications from home to the pharmacy for identification and labeling by pharmacy prior to administration by staff on the floor.

Observation on 3/12/12 at 12:15 PM of Patient #26's medication drawer in the 2nd floor Pyxis room revealed a bottle of Bystolic 10 mg. There was no evidence of a verification tag from pharmacy and/or labeling from the facility.

Medical record review on 3/12/12 for Patient #26 revealed the following:
- Medication order entry (no date or time) revealed an order to use Patient #26's own medication: Bystolic 10 mg by mouth every day. The medication was ordered by the emergency department physician.
- Medication order entry dated 3/9/12 at 5:55 PM revealed an order for Bystolic 10 mg by mouth daily by the attending physician, but does not indicate the medication was brought from home by the patient.

During interview on 3/12/12 at 2:15 PM, Staff #25 stated that the protocol for verifying a patient's home medication is that the medication is sent to pharmacy for review, a label is placed on the bottle and a document accompanies the medication back to the floor and is usually located in the patient's medical record. No document of verification was found in Patient #26's medical record, and there was no other evidence that pharmacy verified the bottle of Bystolic.

Inspection of medication room revealed a MIDI of Symbicort not labeled by pharmacy in a drawer for Patient #14.

Interview with Staff #27 on 3/16/12 revealed that the medication was "probably" brought from home and should have been sent to pharmacy for labeling for patient use or safekeeping storage.

Inspection of medication room revealed a vial of Phenergan 25 mg/ml not labeled by pharmacy in a drawer for Patient #7.

Interview with Staff # 27 on 3/16/12 revealed the medication was probably taken from the pyxis and should have been returned to the Pyxis.

These findings were verified with Staff # 26 on 3/16/12.

Interview on 3/13/12 at 1:35 PM with Staff #27 revealed nursing staff bring the medications brought in from home by patients to pharmacy with a physician order. The pharmacist inspects and verifies the medication. A facility label with the patient's information and the medication information is placed on the bottle and it is sent back up to the floor. If it is a controlled medication, it is placed in the Pyxis machine. The pharmacy keeps a copy of the medication verification document and one is kept in the medical record.

Based on interview and observation, the facility does not provide training to staff related to emergency access of patient rest rooms.

Findings include:

Interviews and observation with Staff #37 on 3/12/12 at 1:45 PM, and with Staff #38 on 3/13/12 at 2:30 PM, revealed that they were unable to use the emergency access hardware equipped on the patient rest room doors.

These findings were verified with Staff #1 on 3/13/2012.

Based on observation, the facility does not maintain patient care supplies in acceptable safety and quality.

Findings include:

Observation during facility tour on 1/9/12 revealed the following:

- At 10:15 AM in the labor and delivery storage cabinet:
-1 box of 3-0 sutures expired 7/11.
-1 box of 2-0 silk sutures expired 7/11.

- At 10:30 AM in the nursery storage cupboard:
-8 full boxes of Meditrace 4603 cloth ECG wet gel electrodes expired 6/10.
-4 - 50 ml - 5% Dextrose IV solution expired 9/11.
-2 - 500 ml - 5% Dextrose IV solution expired 9/11.
-Power Loc-Safety infusion sets:
8 expired 12/07.
11 expired 4/10.
9 expired 4/10.
-ProtectIV Plus Safety IV cath:
24g x 3/4 - 5 expired 12/11.
1 expired 5/11.
18 g x 1 1/4 - 2 expired 4/11.
1 expired 2/11.
22 g x 1 1/4 - 1 expired 1/11.
-11 U-Bag single specimen collection units expired 8/06.
-12 lavender top microtainer expired 11/11.
-12 Needle Pro devices expired 4/03.

- At 10:50 AM in the labor and delivery nursery code cart:
-1 red top tube expired 1/12.
-1 3.5 ET tube connector expired 9/10.
-5 3.0 ET tube connectors expired 4/11.
-1 package of surgical gloves expired 11/11.
- 4 3.0 ET tubes expired 6/07.
-2 2.5 ET tubes expired 8/08.
-5 cotton umbilical tube sutures expired 7/11.

- At 11:00 AM in the 3rd floor medical/surgical unit code cart:
-1 culture swab expired 12/9/11.

- At 11:15 AM in the 3rd floor medical/surgical unit storage room:
-1 8 French universal catheter kit expired 10/11.
-1 Arglaes powder bottle expired 8/11.

- At 11:20 AM in the 3rd floor medication room:
- 1 bottle of Stat-Strip-Glu-Test Strips was open and undated.

- At 11:25 AM in the 2nd floor pediatric unit:
-4 pediatric emergency intubation kits expired 10/11.
-1 pediatric emergency system expired 8/11.
-1 arterial blood kit expired 9/11.

- At 11:35 AM in the 2nd floor "ouchy" treatment room storage cabinet:
-2 urine culture and sensitivity tube kits expired 3/09.
-2 urine culture and sensitivity tube kits expired 10/09.
-1 culture swab expired 10/10.
-1 open box of Chlorscrub swabs expired 4/11.
-BBL CultureSwab - collection and transport system
8 - expired 8/11.
3 - Expired 8/10.
9 - expired 6/11.
-StarSwab II
2 - expired 12/11/11.
1 - expired 10/23/11.
1 - expired 12/2/10.
1 open box of Povidone-Iodine Prep Pads expired 10/10.
1 - 1800 cc bag of 0.9% Sodium Chloride for Irrigation.

- At 11:50 AM in the intensive care unit code cart:
-1 suction catheter tray kit expired 8/08.
-1 22 gauge IV catheter expired 4/09.
-1 18 gauge IV catheter expired 8/07.
-2 18 gauge IV catheters expired 8/11.
-2 18 gauge IV catheters expired 10/08.
-2 24 gauge IV catheters expired 9/08.
-1 20 gauge IV catheter expired 4/11.
-1 20 gauge IV catheter expired 5/11.
-2 20 gauge IV catheters expired 7/07.

- At 12:15 PM in the 2nd floor medical/surgical Pyxis room:
-1 yellow top tube expired 8/06.
-90 sodium poly yellow top tubes expired 12/11.

- At 12:30 PM in the ICU medication room:
- 1 bottle of Stat-Strip-Glu-Test Strips was open and undated.

- At 13:50 PM in the emergency department critical care room:
-4 culture swabs expired 7/28/10.
-7 culture swabs expired 1/5/11.
-2 14 gauge IV catheters expired 3/07 (located in a needle decompression kit).
-2 Surflow IV catheters expired 8/02 (located in a needle decompression kit).
-2 petrolatum gauze expired 10/05 (located in a needle decompression kit).
-1 petrolatum gauze expired 11/09 (located in a needle decompression kit).
-1 ET tube connector expired 5/11 (located in the newborn resuscitation box).
-1 CO detector expired 4/10 (located in the newborn resuscitation box).
-3 normal saline syringes expired 3/11 (located in the newborn resuscitation box).
-1 normal saline syringe expired 10/09 (located in the newborn resuscitation box).
-3 purple top tubes expired 11/09 (located in the newborn resuscitation box).
-1 red top tube expired 6/09 (located in the newborn resuscitation box).
-6 24 gauge IV catheters expired 11/08 (located in the newborn resuscitation box).

These findings were verified with Staff #1 and 34 on 1/9/12.



23054

Based on interview, the facility does not provide electrical safety related to testing ground fault circuit interrupters (GFCIs) throughout the building.

Findings include:

Interview with Staff #35 on 3/14/12 at 9:30 AM revealed the Facilities Department staff do not test GFCI outlets annually as required by this regulation.

Based on observation, the facility does not provide proper HVAC (Heating Ventilation and Air Conditioning) for storage of clean patient care supplies, to meet the requirement of storage in a positive pressure room.

Findings include:

Observation during facility tour on 3/12/12 between 11:10 and 11:30 AM revealed patient supply closets for IV Therapy (second floor) and Respiratory Therapy (third floor) had no ventilation.

Observation during facility tour on 3/12/12 at 11:45 AM revealed the clean supply room of the ICU had negative HVAC pressure.

These findings were verified with Staff #35 on 3/12/12.

Based on medical record review and interview, the operator did not perform complete history and physical prior to operative procedures.

Findings include:

Review of Patient # 37 medical record revealed the patient was seen for a colonoscopy on 3/13/12. The patient history and physical was blank except for"rectal bleeding". No other information and/or medical history was noted.

Review of Patient # 27 medical record revealed the patient was seen for a colonoscopy on 1/10/12. The patient history and physical was blank except for"screening colonoscopy". No other information and/or medical history was noted.

Review of Patient # 28 medical record revealed the patient was seen for a colonoscopy on 1/24/12. The patient history and physical was blank except for"latex and benzocaine allergy and apparent history of constipation". No other information and/or medical history was noted.

These findings were verified with Staff # 26 on 3/16/12.

Based on medical record review, document review and interview, the operator did not ensure that patient received a documented post anesthesia evaluation.

Findings include:

Review of policy and procedure - Completion of Anesthesia Record Sheet effective 4/29/11 revealed providers will document the patient's status including respiratory, cardiac, level of consciousness and any complications related to anesthesia.

Review of medical record for Patient #34 on 3/16/12 revealed the patient had delivered a baby via C-section on 3/14/12. The post operative note for anesthesia was signed by Staff # 39 but was undated and the assessment was blank.

These findings were verified with staff #26 on 3/16/12.

Review of medical record for Patient #5 revealed of a post-operative note of "d/c when stable" but no documented evidence of assessment of the patient's respiratory, cardiac and level of consciousness was noted.

Interview with Staff #22 revealed the patients are discharged as stable when they are a "16" on the Aldrete score.

Review of the policy and procedure manual did not show evidence of use of the Aldrete scoring systems as parameters for discharge.

This finding was verified with Staff # #34 on 3/16/12.