HospitalInspections.org

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Based on document review and interview, the facility failed to ensure that the Emergency Department Register contained all of the required New York State information.

Findings:

Review of the facility Register titled "JTM Daily Log" on 08/29/14 at approximately 11:00AM revealed that it did not include the patients' zip code, payor source and/or means of departure for patients being treated in the Emergency Department.

This was confirmed during the review with Staff #2.
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Based on observations and staff interview, the facility failed to ensure the patients' right to privacy including: the patients' presence and location in the hospital. This was evident on two (2) of ten (10) Nursing Units toured.

Findings:

During a tour of 3 South on 08/28/14 at 09:25AM, the telemetry monitors were observed hanging on the walls of the main hallway with seven (7) patients' full names (last and first names) in full view of anyone on the Unit.

During an interview on 08/28/14 at 09:30AM, Staff #3 stated "We didn't think it was a problem because it doesn't have any other information on it".

A tour conducted on the Cardiac Care Unit (CCU) on 08/29/14 at 10:30AM revealed that there were two (2) telemetry monitors mounted on the wall at the Nurses' Station turned outward, which listed the first and last names of all five (5) patients housed on the Unit in full view of anyone coming to the CCU.

On interview at that same time, Staff #14 stated "The purpose of these monitors is to enable the staff to see the patients' status from the WOW 'Workstation on Wheels' in the hallway, if an alarm goes off".
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Based on record review and staff interview, the facility failed to ensure that the Nursing staff: a) developed Nursing Care Plans with interventions that were patient specific, and b) the Nursing Care Plans were based on accurate staging of pressure ulcers by the Nursing staff. This was evident for six (6) of thirty (30) Medical Records reviewed (Patients #2, #9, #10, #11, #14 and #22).

Findings:

a) Review of Patient #2's Medical Record revealed that the patient was admitted to the facility on 08/24/14 with diagnoses including Lung Cancer and Pyelonephritis.

A Physician's Order dated 08/24/14 documented Alprazolam (Xanax) 1mg oral at bedtime, and Sertraline (Zoloft) 50mg oral daily.

Review of the patient's Plan of Care dated 08/24/14 to 08/27/14 lacked documented evidence that a Care Plan was developed for the patient's condition being treated by the above medications.

On 08/27/14 at 2:15PM during the Medical Record review, Staff #11 stated that the patient was very anxious.

Review of Patient #9's Medical Record revealed that the patient was admitted to the facility on 08/26/14 with diagnoses of Cellulitis and Abscess.

Review of the Patient Profile dated 08/26/13 revealed that the patient complained of back, leg and groin pain.

Review of the Physician's Order dated 08/26/14 documented Percocet 325mg two (2) tablets every four (4) hours for moderate pain and Fentanyl Transdermal 25mcg every seventy-two (72) hours.

Review of the patient's Plan of Care lacked documented evidence a Care Plan was developed for the problem of pain which was identified.

Review of Patient #10's Medical Record revealed that the patient was admitted to the facility on 07/30/14 with the diagnosis of Right Foot Gangrene and on 08/25/14 the patient had a Right Above Knee Amputation.

Review of the patient's Plan of Care lacked documented evidence that a Care Plan was developed post-operatively for the amputation and for pain.

During an interview with Staff #8 on 08/27/14 at 2:04PM, the staff member stated that the patient Care Plan is started within twenty-four (24) hours of admission and the Care Plan is initiated on admission by the Admission Nurse. Staff #8 stated that the Primary District Nurses do the Care Plans for their patients and the Care Plan is updated daily, or as needed.

Review of Patient #11's Medical Record revealed that the patient presented to the Emergency Department on 08/25/14, was admitted with a diagnosis of Cellulitis, and was being treated with intravenous antibiotics.

The patient's Care Plan dated 08/27/14 was not patient specific and did not include a Care Plan for Cellulitis.

During an interview, when asked if a Cellulitis Care Plan was available as a drop down option, Staff #6 said "Yes" and showed the Surveyor the drop-down box option that included Cellulitis. When Staff #6 was asked if the patient should have a Cellulitis Care Plan, the staff member responded "Yes, it should be there".

Review of the facility Policy titled "Nursing Process Policy" dated 03/13 documented on Page N-8-4 that "the Registered Nurse in collaboration with other disciplines is responsible for developing the Interdisciplinary Plan of Care for the patient." It is also documented in the section marked "(NOTE): A Plan of Care, including interventions and patient outcome / goals will be developed within twenty four (24) hours of the patient's admission".

b) Review of Patient #22's Medical Record revealed that the patient was admitted to the facility on 08/23/14 with diagnoses including Diabetes Mellitus Type II and Prostate Cancer.

The Patient Profile dated 08/23/14 documented on Page 5 of 8 that the patient had no Pressure Ulcer.

An Assessment / Intervention (A/I) Flow Sheet dated 08/23/14 documented intact redness to buttocks, with non-blanchable erythema to coccyx. The Flow Sheet lacked staging of the pressure ulcer.

A Wound Treatment Initial Evaluation dated 08/26/14 documented "Consulted to see the patient with non-blanchable erythema to coccyx and bilateral buttocks which was present on admission. Skin is reddened but slowly blanchable. Some moisture associated skin damage noted to left buttock". The Evaluation also lacked staging of the Pressure Ulcer.

The A/I dated 08/28/14 at 8:34AM documented "Stage II pressure ulcer to the buttocks and left lower buttocks" then at 11:33PM on 08/28/14 documented "Pressure Ulcer Stage III to bilateral buttocks and left lower buttocks".

However, an observation of the wound conducted on 08/29/14 at 11:09AM revealed bilateral buttocks excoriation (superficial) consistent with a Stage II Pressure Ulcer.

Staff Members #7 and #8 were present and confirmed these findings.

Review of Patient #14's Medical Record revealed the patient was admitted to the facility on 08/25/14 with diagnoses including Left Arm Weakness and Transient Cerebral Ischemia.

A Patient Profile dated 08/25/14 documented on Page 4 of 7 that the patient had a healing wound on the Sacrum. Page 5 of 7 documented a healing Stage I Pressure Ulcer. And the Electronic Flow Sheet dated 08/25/14 documented a healing Stage II to the Sacrum.

Staff Members #8 and #9 were present for these findings.

Review of the facility Policy and Procedure titled "Pressure Ulcer" (P-42-1) documented under Responsibility, the Registered Nurse (RN) is responsible for assessment, reassessment, and the implementation of a Plan of Care.
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Based on observation and staff interview, it was determined that the facility failed to ensure that the Nursing staff were able to conduct appropriate testing of the Defibrillator. This was evident on one (1) of nine (9) Units toured.

Findings:

During a tour of the Telemetry Unit conducted on 08/28/14 at 1:30PM, while demonstrating a test of the Code Cart and Defibrillator, Staff #10 was unable to complete all the steps needed to perform the test. Staff #9 was then observed verbally and manually assisting Staff #10 in completing the test.

Staff #10 was interviewed immediately on 08/28/14 at 1:30PM and stated that they "do not routinely check the Code Cart and Defibrillator".

An interview was conducted with Staff #9 on 08/28/14 at 1:40PM, and the staff member stated that "All Registered Nurses on the Telemetry Unit should be competent in checking the Code Cart and Defibrillator".

Staff Members #8 and #9 were present for these findings.
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Based on record review and interview, the facility failed to ensure that the patients' allergies were accurately reviewed and consistently documented by facility staff to ensure patient safety in drug administration in two (2) out of thirty (30) Medical Records reviewed (Patients #5 and #12).

Findings:

Review of the Medical Record for Patient #5 revealed that the patient presented to the Emergency Room at 11:48AM on 08/12/14 with complaints of weakness and low blood pressure. The Triage Record documented that the patient was sent via ambulance by the Visiting Nurse.

The Triage Nurse's Note documented the patient's home medications and that the patient was allergic to Tylenol and Aspirin. However, the current "Catholic Home Care" Medication List sent with the patient documented that the patient was allergic to Lactose, Avandia, Bactrim and Seafood.

The patient's Admission Profile then documents on 08/12/14 at 4:21PM, under "Allergy, Intolerance, Adverse Events: No Known Allergies: Active".

A "North Suffolk Cardiology - History and Physical, placed in the Medical Record on 08/19/14 at 4:09PM, then documented on Page 3, "Allergies: Avandia (chest pain and shortness of breath) and Bactrim".

These discrepancies were confirmed with Staff #14 during the Record review for Patient #5.

Review of Patient #12's Medical Record on 08/28/14 documented that the patient was brought to the Emergency Department (ED) on 08/27/14 via Emergency Medical Services (EMS) ambulance. The patient's allergies were documented in the ED Medical Record as "No Known Allergies", however, review of the patient's "EMS Report" revealed that the patient did have an allergy to Penicillin.

This discrepancy was confirmed with Staff #6 during the Record review for Patient #12.

Review of the Nursing Policy titled "Patient Allergy Policy: A-9" dated 08/12 states "At the time of admission the Registered Nurse will determine the patient's allergies and document in the Allergy Section of the Electronic Medical Record" and "If at any time during the patient's hospital stay more allergies are assessed" then "The Medical Record will be updated".

Review of the Pharmacy Policy titled "Medical Order Review - Medication Allergies Policy: M-16a" states "No medication ordered may be processed without record of the patient's allergy". "The Allergy Header must be completed for all inpatients in the Electron Profile" and "Emergency Department Medication Orders are faxed to the Pharmacy with all required elements (including allergies) noted on the top banner" "should there be any questions with the Allergy Profiles, the Pharmacist will call to speak with the Practitioners".
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33919

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Based on observation and interview, the facility failed to ensure that expired medications and biologicals were not available for patient use and that medications no longer being used were removed from circulation. This was evident on one (1) of nine (9) Nursing Units toured.

Findings:

A tour of the Emergency Department (ED) "Chest Pain Room" on 08/28/14 at 01:40PM revealed the following expired medications and biologicals:

One (1) 150cc bag of 5% Dextrose had expired 11/12.

Five (5) 150cc bags of 5% Dextrose had expired 04/13.

Two (2) 150cc bags of 5% Dextrose had expired 05/13.

One (1) 150cc bag of 5% Dextrose had expired 01/14.

One (1) box of Vicryl 3-0 Sutures had expired 07/14.

During interviews with Staff Members #4 and #5 on 08/28/14 at 1:40PM, Staff #5 stated "We don't even use those anymore because we don't mix meds. They come up from Pharmacy pre-mixed." Staff #4 then concurred.

In an interview with Staff #2 on 08/28/14 at 1:45PM, when asked who was responsible for stocking, replied "The supplies come up from Central Supply, and the Nurses stock the carts as needed". Staff #2 further stated "The Nurses are checking the expiration dates as they stock and then Central Supply comes up once a month to check the carts".
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Based on observation and staff interview, it was determined that the facility failed to ensure that supplies were maintained in an acceptable level of safety and quality. This was evident on two (2) of nine (9) Nursing Units toured.

Findings:

During a tour conducted on the Second Floor East Medical Surgical Unit on 08/28/14 at approximately 10:30AM with Staff Members #13 and #8, cleaning solution was observed to be stored on the floor under sink in the Soiled Utility Room.

During an interview with Staff #13 on 08/28/14, the staff member stated Housekeeping staff stored their cleaning supplies under the sink.

A tour of the Dirty Utility Room for the Surgical Area in the afternoon on 08/28/14 found eleven (11) teal colored recycle Operating Room bins, twenty (20) large red colored Sharps containers and twelve (12) medium red colored Sharps containers stored on the floor.

This observation was confirmed with Staff Members #14 and #15 at the time of the tour.
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Based on Personnel Record review and staff interview, it was determined that the facility failed to ensure that infection control practices were implemented to prevent the spread of infection. This was evident in one (1) of fifteen (15) Personal Files reviewed (Staff #12).

Findings:

Review of Staff #12's Personnel File revealed that an Annual Health Screening Assessment and the Annual Mantoux Tuberculin Skin Testing (PPD) were not conducted since 02/06/13.

During an interview with Staff #1 conducted on 08/29/14 at approximately 2:00PM, Staff #1 stated that Staff #12 was out on leave at the time their Annual Health Assessment was due. Staff #1 further stated that Staff #12 returned to full duty in May 2014, however, Staff #12's Health Assessment and PPD were not completed. Additionally, Staff #1 stated that the facility has thirty (30) days after the due date to complete the Health Assessment.

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Based on record review and staff interview, the facility failed to ensure that the Nursing staff: a) developed Nursing Care Plans with interventions that were patient specific, and b) the Nursing Care Plans were based on accurate staging of pressure ulcers by the Nursing staff. This was evident for six (6) of thirty (30) Medical Records reviewed (Patients #2, #9, #10, #11, #14 and #22).

Findings:

a) Review of Patient #2's Medical Record revealed that the patient was admitted to the facility on 08/24/14 with diagnoses including Lung Cancer and Pyelonephritis.

A Physician's Order dated 08/24/14 documented Alprazolam (Xanax) 1mg oral at bedtime, and Sertraline (Zoloft) 50mg oral daily.

Review of the patient's Plan of Care dated 08/24/14 to 08/27/14 lacked documented evidence that a Care Plan was developed for the patient's condition being treated by the above medications.

On 08/27/14 at 2:15PM during the Medical Record review, Staff #11 stated that the patient was very anxious.

Review of Patient #9's Medical Record revealed that the patient was admitted to the facility on 08/26/14 with diagnoses of Cellulitis and Abscess.

Review of the Patient Profile dated 08/26/13 revealed that the patient complained of back, leg and groin pain.

Review of the Physician's Order dated 08/26/14 documented Percocet 325mg two (2) tablets every four (4) hours for moderate pain and Fentanyl Transdermal 25mcg every seventy-two (72) hours.

Review of the patient's Plan of Care lacked documented evidence a Care Plan was developed for the problem of pain which was identified.

Review of Patient #10's Medical Record revealed that the patient was admitted to the facility on 07/30/14 with the diagnosis of Right Foot Gangrene and on 08/25/14 the patient had a Right Above Knee Amputation.

Review of the patient's Plan of Care lacked documented evidence that a Care Plan was developed post-operatively for the amputation and for pain.

During an interview with Staff #8 on 08/27/14 at 2:04PM, the staff member stated that the patient Care Plan is started within twenty-four (24) hours of admission and the Care Plan is initiated on admission by the Admission Nurse. Staff #8 stated that the Primary District Nurses do the Care Plans for their patients and the Care Plan is updated daily, or as needed.

Review of Patient #11's Medical Record revealed that the patient presented to the Emergency Department on 08/25/14, was admitted with a diagnosis of Cellulitis, and was being treated with intravenous antibiotics.

The patient's Care Plan dated 08/27/14 was not patient specific and did not include a Care Plan for Cellulitis.

During an interview, when asked if a Cellulitis Care Plan was available as a drop down option, Staff #6 said "Yes" and showed the Surveyor the drop-down box option that included Cellulitis. When Staff #6 was asked if the patient should have a Cellulitis Care Plan, the staff member responded "Yes, it should be there".

Review of the facility Policy titled "Nursing Process Policy" dated 03/13 documented on Page N-8-4 that "the Registered Nurse in collaboration with other disciplines is responsible for developing the Interdisciplinary Plan of Care for the patient." It is also documented in the section marked "(NOTE): A Plan of Care, including interventions and patient outcome / goals will be developed within twenty four (24) hours of the patient's admission".

b) Review of Patient #22's Medical Record revealed that the patient was admitted to the facility on 08/23/14 with diagnoses including Diabetes Mellitus Type II and Prostate Cancer.

The Patient Profile dated 08/23/14 documented on Page 5 of 8 that the patient had no Pressure Ulcer.

An Assessment / Intervention (A/I) Flow Sheet dated 08/23/14 documented intact redness to buttocks, with non-blanchable erythema to coccyx. The Flow Sheet lacked staging of the pressure ulcer.

A Wound Treatment Initial Evaluation dated 08/26/14 documented "Consulted to see the patient with non-blanchable erythema to coccyx and bilateral buttocks which was present on admission. Skin is reddened but slowly blanchable. Some moisture associated skin damage noted to left buttock". The Evaluation also lacked staging of the Pressure Ulcer.

The A/I dated 08/28/14 at 8:34AM documented "Stage II pressure ulcer to the buttocks and left lower buttocks" then at 11:33PM on 08/28/14 documented "Pressure Ulcer Stage III to bilateral buttocks and left lower buttocks".

However, an observation of the wound conducted on 08/29/14 at 11:09AM revealed bilateral buttocks excoriation (superficial) consistent with a Stage II Pressure Ulcer.

Staff Members #7 and #8 were present and confirmed these findings.

Review of Patient #14's Medical Record revealed the patient was admitted to the facility on 08/25/14 with diagnoses including Left Arm Weakness and Transient Cerebral Ischemia.

A Patient Profile dated 08/25/14 documented on Page 4 of 7 that the patient had a healing wound on the Sacrum. Page 5 of 7 documented a healing Stage I Pressure Ulcer. And the Electronic Flow Sheet dated 08/25/14 documented a healing Stage II to the Sacrum.

Staff Members #8 and #9 were present for these findings.

Review of the facility Policy and Procedure titled "Pressure Ulcer" (P-42-1) documented under Responsibility, the Registered Nurse (RN) is responsible for assessment, reassessment, and the implementation of a Plan of Care.
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33919

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Based on record review and interview, the facility failed to ensure that the patients' allergies were accurately reviewed and consistently documented by facility staff to ensure patient safety in drug administration in two (2) out of thirty (30) Medical Records reviewed (Patients #5 and #12).

Findings:

Review of the Medical Record for Patient #5 revealed that the patient presented to the Emergency Room at 11:48AM on 08/12/14 with complaints of weakness and low blood pressure. The Triage Record documented that the patient was sent via ambulance by the Visiting Nurse.

The Triage Nurse's Note documented the patient's home medications and that the patient was allergic to Tylenol and Aspirin. However, the current "Catholic Home Care" Medication List sent with the patient documented that the patient was allergic to Lactose, Avandia, Bactrim and Seafood.

The patient's Admission Profile then documents on 08/12/14 at 4:21PM, under "Allergy, Intolerance, Adverse Events: No Known Allergies: Active".

A "North Suffolk Cardiology - History and Physical, placed in the Medical Record on 08/19/14 at 4:09PM, then documented on Page 3, "Allergies: Avandia (chest pain and shortness of breath) and Bactrim".

These discrepancies were confirmed with Staff #14 during the Record review for Patient #5.

Review of Patient #12's Medical Record on 08/28/14 documented that the patient was brought to the Emergency Department (ED) on 08/27/14 via Emergency Medical Services (EMS) ambulance. The patient's allergies were documented in the ED Medical Record as "No Known Allergies", however, review of the patient's "EMS Report" revealed that the patient did have an allergy to Penicillin.

This discrepancy was confirmed with Staff #6 during the Record review for Patient #12.

Review of the Nursing Policy titled "Patient Allergy Policy: A-9" dated 08/12 states "At the time of admission the Registered Nurse will determine the patient's allergies and document in the Allergy Section of the Electronic Medical Record" and "If at any time during the patient's hospital stay more allergies are assessed" then "The Medical Record will be updated".

Review of the Pharmacy Policy titled "Medical Order Review - Medication Allergies Policy: M-16a" states "No medication ordered may be processed without record of the patient's allergy". "The Allergy Header must be completed for all inpatients in the Electron Profile" and "Emergency Department Medication Orders are faxed to the Pharmacy with all required elements (including allergies) noted on the top banner" "should there be any questions with the Allergy Profiles, the Pharmacist will call to speak with the Practitioners".
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