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Based medical records review, document review and interviews, in 3 of 9 medical records reviewed the facility did not consistently facilitate effective communicate and furnish patient right's information in a language or manner that the patient/representative can understand.

Findings include:

Review of Patient #1's medical record noted that this 69-year-old male admitted to the facility on 3/18/18. Nursing admission assessment on 3/18/18 noted that the patient's preferred language as Spanish.

There is no documentation in the medical record indicating that the physician communicated with the patient through an interpreter or that the physician spoke directly to the patient in her preferred language when he conducted the patient's History and Physical assessment (H&P).

Review of Patient #2's medical record noted that this 46-year-old male presented to the facility on 8/31/17 with new-onset left hip/thigh pain. The surgical H&P noted the patient's preferred language as Mandarin Chinese.

There is no documentation in the medical record indicating that the physician communicated with the patient through an interpreter or that the physician spoke directly to the patient in her preferred language when he conducted the H&P.

The facility policy and procedure (P&P) titled "Language Assistance Services for Limited English Proficient (LEP) Individuals", last reviewed 9/17, described the following:" NYC Health + Hospitals/Elmhurst providers/staff members must document in the medical record the use of language services, patient's documented need, and identification of interpreter who provided the services. Once a patient is identified as LEP, his or her preferred language must be documented in the patient's medical record...

When a Bilingual Clinical Provider communicates medical information directly to the LEP patient, in their language of choice, it must be appropriately documented in the patient's Electronic Medical Record (EMR), Ex: "Provider spoke directly with the patient in their preferred language...

Whether Face-To-Face (F2F) or telephonic, every single interpretation service must be documented. The types of information that should be documented include name of interpreter (if applicable) and ID #, type of interpreter (e.g., dual role interpreter, telephonic interpreter etc.), language, and date and time of encounter.

During interview with Staff A, Associate Director of Quality Management on 3/26/18 at approximately 11:30 AM, she acknowledged the findings.




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Review of MR for Patient #3 noted: This 46-year-old with history of alcohol abuse, seizure and psychiatric history who was admitted on 3/16/18.

During interview with Patient #3 at bedside on 3/22/18 at approximately at 11:55 AM, the patient stated he was given a patient information package on admission but has did not looked at it. The patient handed the package to the surveyor and it was noted the patient right's information was written in Spanish. The patient stated he only spoke English.

Review of the patient's medical record noted that the patient spoke English.

During interview with Staff B, Nursing Supervisor on 3/22/18 at approximately 12:00 PM, she acknowledged the findings.

Based document review and interview, the composition of the facility's Utilization Review Committee Members could not be determined.

Findings include:

During interview with Staff Hh on 3/26/18 at approximately 2:30 PM, staff stated the Utilization Review Committee meets Quarterly.

Review of Utilization Review/Case Management Committee Meeting dated March 17, 2017 under "Committee Restructure" noted that the committee members agreed to a quarterly meeting and that additional members would be added.
The names and sign- in sheet for committee members that attended the meeting was not provided.

In the Utilization Review Committee Minutes dated September 15, 2017, it was documented that a quorum was present.
The sign-in sheet and the committee members that attended the meeting was not included.

The facility submitted information on Utilization Review and Medical Audit Committee. The information provided did not distinguish the Utilization Review Committee members from the Medical Audit Committee members.
In addition, there was no date or members' signature on this document.

Based on observations and staff interview, the facility failed to ensure the overall hospital environment is maintained in a such a manner that the safety and well-being of patients are assured.

Findings:

On 03/19/2018 at 2:45 PM, three (3) stained ceiling tiles, approximately 12 inches by 12 inches were observed by the medical record Break-Room.

On 03/22/2018 at 10:30AM, two stained ceiling tiles were observed in room A5-29 (Patient Consultation Room).

On 03/22/2018 at 11:43 AM, two (2) stained ceiling tiles were observed in room A-9-01 (After school program room).

On 03/23/2018 at one (1) stained ceiling tile was observed inside room 618( Janitor's closet) in the facility's extension clinic (Hope Pavilion).

Staff Ff, Associate Director of Facilities acknowledged these findings at the time of observation.

Based on observation, review of documents and staff interview, the facility failed to provide adequate oversight and ensure that
A. the sterilization of surgical equipment were performed and recorded by staff in accordance with Centers for Disease Control (CDC) recommendations and The Association for the Advancement of Medical Instrumentation (AAMI) standards.
B. failed to maintain the clean areas of the central Sterile Department in a sanitary manner


Findings include:

A.1. During the tour of the Central Sterile Department on 03/20/2018 at approximately 2:00 PM, it was noted that the facility was using the two sterrads (low temperature sterilizer) to sterilize surgical instruments. Review of the sterilization records revealed that the facility did not consistently perform and record the test results of the biological indicator on a daily basis as recommended by CDC under "Guideline for Disinfection and Sterilization in Health-Care Facilities."

For example: Review of the sterilization records for the month of March, 2018 for loads sterilized by Sterilizer #6 (NX Sterrad), it was noted that the facility did not perform and read the test results of the Biological Indicator (BI) on 03/04/2018, 03/08/2018, 03/12/2018 and 03/13/2018.

2. The facility did not have a consistent practice of incubating the Biological Indicator (BI) for 1 hour and reading the test result. Review of records for Sterilizer #2 for the month of January 2018, revealed that the central staff did not consistently incubate the BI for 1 hour and did not read the result prior to release of the loads sterilized. There were 2 loads of instruments sterilized in this sterilizer every day.

For Example:

a. Review of the Sterilizer Load Report for 01/08/2018 revealed that there was no documented evidence of BI test for the first and second loads. For load #2 staff documented "No biological was added to this load." under "Biological Results".However, there was a hand written note stating "is a biological in this load." There was no evidence of incubation and reading of the test result.

b. Review of the Sterilizer Load Report of 01/28/2018 revealed that BI was put into the incubator at 3:17 PM on 01/28/2018.
The BI time out and the test result were not documented on the report. Therefore, there was no evidence to indicate that the BI was incubated for at least 1 hour and that the results were read and documented prior to the release of loads sterilized on that day.

3. In addition, test results of the control were not being consistently recorded either. During interview of the Asst. Director of Central sterile on 03/26/2018 at approximately 1:30 PM, it was stated the software Abacus used in the documentation of sterilizer test reports did not allow the documentation of control results on all the BI tests. This practice is contrary to the AAMI recommendations,which require comparing and documenting the BI test result along with the Control result.

4. Review of documents and staff interview revealed that he leadership staff of Central Sterile Department (CSD) did not provide adequate oversight over the performance of BI tests, the test result read out and the high-level disinfection process performed by other Central Sterile Staff.

For example:

a. Review of the Sterilizer Load Report for Sterrad # 5 performed on 03/14/2018, the final visual read out of the BI test at 8:46 PM on the same day was documented as "Positive" for the load. There was no documented evidence of any follow-up sterilization of the loads that were sterilized on this sterrad. Staff Dd, the Director of Central Sterile and Staff Ee, the Asst. Director of the Central Sterile Department were not aware of the positive test result prior to the surveyor's review of the reports.

b. During the tour of the Central Sterile Department on 03/20/2018 at approximately 2:30 PM, it was noted that the facility used Medivators (Automatic Endoscope reprocessor) for high level disinfection of Laryngoscope blades.

During review of the process of high level disinfection with Staff Dd, it was noted that the facility did not have documented evidence of monitoring the potency of Rapicide(Disinfectant) as required by the manufacturer. It was also noted that the equipment did not have a fail safe mechanism to stop the reprocessing in the event that the disinfectant is below the minimum required concentration.

Review of the Central sterile Policy and Procedure on 03/20/2018 at approximately 3:00 PM, it was noted that the policy did not direct the staff to check and document the potency of the Rapicide (disinfectant).


B. During the tour of the Central Sterile department on 03/20/2018 at approximately 2:15 PM, the surveyors observed a huge pile of uncovered and unclean surgical instruments stored on a table in the prep and pack area of Central Sterile.

Upon interview of Staff Dd, it was revealed that they were loaned instruments and have been piled up for pick-up and return. This staff member also stated that the instruments were being stored on that table for long time as the vendors were not reachable via phone and that the department did not have an inventory of all instruments that were piled up on the table.

The practice of storing uncleaned and uncovered surgical instruments creates a potential risk for safety and possible cause for cross-contamination due to human error.

Based on medical record (MR) review, document review and interview, in three (3) of sixteen (16) medical record reviewed, the facility did not consistently and timely identify all patients who needed discharge planning evaluations. Specifically, the initial social work screening assessments did not identify patients' post discharge needs (Patient #s 16, 9 and 12).

Findings include:

During interview with Staff D, on 3/19/18 at 12:15 PM, staff stated that all patients are screened for social work intervention within 24 hours of admission.

During interview on 3/20/18 at 9:55 AM with Staff C and staff D, Social Work Administrators, they stated that social workers are responsible for screening and coordinating discharge planning. They also stated discharge screening is based on social services criteria.

Review of MR for Patient #16 noted: This 55-year-old patient with psychiatric history was admitted on 1/25/18 after a fall. On 1/26/18 at 9:18 AM, the social worker noted that the patient screened in for services and that the patient's discharge plan was pending medical course.

The social work screening assessment did not identify the patient's post discharge needs.

Review of MR for Patient #9 noted: This 84-year-old patient was admitted to the facility on 02/07/18 from home after a fall. The patient had a psychosocial assessment on 2/7/18 at 3:31 PM. The discharge plan was pending medical clearance.

This initial social work assessment also did not identify the patient's discharge needs.

Review of MR for Patient #12 noted: This 18-year-old pregnant patient, at 36 weeks gestation, presented to the Labor and Delivery on 3/13/18 at 6:31 PM and she was admitted. The patient delivered the baby on 3/20/18 and she was discharged home on 3/24/18.

This patient with a history of sexual abuse, teen pregnancy, and first baby, was not screened for discharge planning evaluation until 3/21/18 at 2:43 PM, seven days after admission.


The facility Administrative Policy and Procedure (P & P) Manual, titled "Discharge Planning Program", last revised 2/18 did not include all of the requirements for Discharge Planning Needs Assessments for example:
1. It did not include that all inpatients must be screened to determine which ones are at risk of adverse health consequences post-discharge.
2. When will the discharge screen be completed
3. The staff members responsible for conducting the discharge planning screening and evaluation.

Based on medical record (MR) review, document review and interview, in four (4) of sixteen (16) medical records reviewed, the patient's discharge planning evaluations did not include complete review of the individual patients' post-hospitalization needs (Patient #s 3, 8, 9, 12 & 16)

Findings include:

Review of MR # 9 noted: This 84-year-old, with past medical history of cardiac disease and prostate cancer who was admitted on 2/7/18 after a fall at home. The patient's daughter lived in the same apartment building as the patient, but on a different floor. Therefore, prior to admission this patient resided alone. The patient was discharged to home on 2/9/18. However, the discharge note indicated that the patient was discharged home with family.

The discharge evaluation did not include the patient's post discharge living arrangement and the reason this setting was appropriate for the patient.

On 2/9/18, a Physical Therapist recommended the patient to have Outpatient physical therapy. The patient was in agreement with outpatient physical therapy.

The patient's discharge plan did not include a referral for Outpatient Physical Therapy.


Review of MR # 8 noted: A 56-year-old with significant chronic pancreatitis and substance disorder who presented to the facility by ambulance on 3/18/18 with complaint of abdominal pain. The patient was admitted to Medicine Services for further management.

The patient had an initial psychosocial assessment 3/21/18 at 2:15 PM. The social work assessment indicate the discharge plan was to offer the patient chemical dependence services. The patient was discharged to home on 3/26/18. There was no documented evidence in the medical record that a referral to chemical dependence services was offered to the patient.

Similar findings were noted in medical records for Patient #s 3, 12 & 16, whose records lacked complete discharge planning assessments.


During interview on 3/20/18 at approximately 9:55 AM, these findings were brought to the attention of Staff C, Associate Executive Director of Social Work and Staff E, Social Work Director.

Based on medical record (MR) review and interview, in two (2) of sixteen (16) medical record reviewed, the facility did not consistently discuss the discharge plan with all patients or their representatives prior to discharge (Patients #3 & #12).

Findings include:

Review of MR for Patient #3 noted: A 46-year-old with history of alcohol abuse, seizure and psychiatric history.
The social work note indicated that the discharge plan was "home with self-care and a referral to chemical Dependence program."

Patient #3 was interviewed at bedside on 3/22/18 at 11:55 AM. The patient stated that hospital staff did not meet with him to discuss his discharge plan. he reported he had issue with restriction of his medications.

There was no documentation in the medical record that the patient's concerns has been identified in his discharge assessment.

Review of MR for Patient #12 noted: An 18-year-old pregnant patient, at 36 weeks gestation who presented to Labor and Delivery unit on 3/13/18 at 6:31 and was admitted. The patient delivered her baby via Cesarean-Section (A surgical procedure involving incision of the walls of the abdomen and uterus for delivery of offspring) on 3/20/18 and she was discharged home on 3/24/18.

On 03/25/18 at 7:38 AM, the nurse documented that, at the time of the discharge, the patient was in no distress. Home care referral for previous history of depression was done. It was documented that the patient resided with her sister-in law who was her guardian.

There was no documentation in the discharge planning evaluation that the patient and/or patient's guardian were in agreement with home care services.

Based on medical review (MR), document review and interview, in one (1) of sixteen (16) medical record review, the hospital did not reassess the appropriateness of the patient's discharge plan with the patient (Patient #16).

Findings include

Review of MR for Patient #16 noted: A 55-year-old male with past medical history of psychiatric history who presented to the facility's Emergency Department on 1/25/18 8:57 AM after a fall at home. The patient sustained shoulder and multiple rib fractures. The patient underwent surgical procedures on 2/16/18 and he was transferred to the facility's inpatient rehabilitation unit on 2/27/18. The patient was discharged from the rehabilitation unit to a sub-acute facility on 3/22/18.

Reviewing of the discharge planning noted:
On 1/28/18 9:18 AM, the social worker noted that the anticipated discharge plan was home pending medical course.

The social worker documented that the patient progressed well in acute rehabilitation program, but the treatment team advised that the patient would benefit from a referral to a sub-acute rehabilitation facility for ongoing inpatient care.

The initial discharge plan was home with home care services. The reassessment did not include the reason the patient could not return to his home with home physical therapy.

On 3/1/18, the patient had concerns about rent payment at his residence. The Social Worker documented that the landlord will be fine once he pays his rent at discharge.
The discharge reassessment did not include how long the patient would remain in the Acute Rehabilitation Facility and if the patient will still have a place to reside after discharge from the facility.

Patient selected two acute-rehabilitation facilities of choice, but he was not accepted at both facilities. The patient agreed to be discharge to a facility that was not his choice or preferred location. The patient expressed concerned going straight to rehab from hospital instead of home. The patient wanted his own clothes and make sure his rent was paid. The SW provided patient with clothes but the issue with the rent was not resolved. The discharge planner did not reassess this plan to determine if this plan was appropriate for the patient.

During interview on 3/20/18 at approximately 9:55 AM, these findings were brought to the attention of Staff C, Associate Executive Director of Social Work and Staff E, Social Work Director.

Based on medical record review and interview, during the discharge planning process, the facility did consistently inform patients/patients' representatives they have a choose of post-hospital providers. This was noted in two (2) of sixteen records reviewed (Patient #s 11 & 12).

Findings include:

Review of medical record for Patient #11 noted: A 75-year-old male who was admitted to the facility on 03/15/18 with diagnosis of pneumonia. The initial psychosocial assessment/discharge planning dated 3/16/18 11:45 AM indicated that the patient was interested in home care referral upon discharge. The psychosocial assessment, dated 3/19/18 at 8:52 PM, indicated the patient requested home care services, rolling walker, shower chair. The patient was discharged to home on 3/20/18. The discharge summary dated 03/20/18 10:54 PM indicated a referral for home care services was sent to Royal Home Care Agency.

There was no documented evidence the patient was given a choice of service provider. The proposed date the requested services will be implemented was not documented.


Review of MR for Patient #12 noted: An 18-year-old pregnant female at 36 weeks gestation who presented to Labor and Delivery on 3/13/18 at 6:31 PM with pruritus (itching). She delivered her baby by Cesarean-Section (A surgical procedure involving incision of the walls of the abdomen and uterus for delivery of offspring) on 3/20/18 and she was discharged home on 3/24/18.

On 03/25/18 at 7:38 AM, the nursing staff documented at the time of the discharge that the patient was in no distress. Home care referral for previous history of depression was done.

There was no documented evidence that this patient was given a choice of home care services.

During interview on 3/26/18 at approximately 9:55 AM, the findings were brought to the attention of Staff C, Associate Executive Director of Social Work and Staff E, Social Work Director.

Based on document review and interview, it was determined that the facility was not effectively reassessing its discharge planning process for effectiveness.

Findings include:


Review of Social Work MED/SURG Unit Minutes from the January 2017 to December 2017 noted the discussions did not include the assessment and reassessment of all discharge plans or a process that triggers reevaluation of patients' post-discharge needs.

During interview on 3/20/18 at approximately 9:55 AM, these findings were brought to the attention of Staff C, Associate Executive Director of Social Work and Staff E, Social Work Director.

Based on medical record, document review and interview, in one (1) of four (4) applicable medical records reviewed, the facility did not ensure there was a properly executed informed consent form in the patient chart before the performance of a surgical procedure.

Findings include

Review of medical record for Patient #12 noted: An 18-year-old pregnant female at 35 weeks 6 days gestation age who presented to Labor and Delivery Department on 3/13/18 and was admitted.

Review of An informed consent form for invasive, diagnostic, medical & surgical procedures dated 03/13/18 at 11:00 PM noted that the patient gave permission to OB (obstetric) team to perform the following medical treatment: " Antepartum management, possible management of labor and deliver".

The patient delivered her baby a boy on 3/20/18 at 5:02 PM via Cesarean-Section (A surgical procedure involving incision of the walls of the abdomen and uterus for delivery of offspring).

The informed consent form for invasive, diagnostic, medical & surgical procedures signed by the patient on 03/13/18 did not include the name of the provider who will perform the surgical procedure, and the surgical procedure to be performed. In addition, there was no documentation of risks, benefits, and alternatives discussed with the patient.


A request for a copy of the informed consent form for Cesarean-Section was requested from Staff Hh, Sr. Associate Executive Director Quality Management & Regulatory Affairs on 3/28/2018 at approximately 12:45 PM. On 3/28/18 at 1:11 PM, Staff Hh resubmitted the same consent form that was signed by the patient on 3/13/18, which authorized the facility to provided medical treatment for "Antepartum Management, possible management of labor and deliver."

The facility's Administrative Policy and Procedure titled, "Functions: Rights and Responsibilities - Subject: Consent Procedure" Revised 8/16 lacked information on the elements of a properly executed informed consent.