HospitalInspections.org

Based on document review and staff interview, in 15 of 20 personnel files reviewed, the facility failed to follow its policy regarding criminal background check for history of abuse, neglect and mistreatment upon employment. (Staff A, E, F, G, I, J, K, L, O, P, Q, R, S, T, and U).

This failure may place patients at risk for abuse, neglect and mistreatment.

Findings include:

The facility policy and procedure titled, "Background Investigation of NYC Health and Hospitals' Employees," dated 5/6/2016, notes that a criminal background is initiated after a condition of offer of employment has been made.

The review of personnel files for the following staff revealed no evidence of a criminal background check upon hire:

Staff A with Date of Hire: 2/6/2006;

Staff F with Date of Hire: 2/16/2007;

Staff O was hired on 8/2/2020.

Review of the queried report for Staff A, F and O, dated 9/17/20, revealed no evidence that the criminal background check was conducted upon hire.
Similar findings regarding the lack of criminal background check were noted in personnel files for Staff E, G, I, J, K, L, P, Q, R, S, T, and U).

During interview with Staff Mm, Associate Director of Human Resources on 9/17/2020 at approximately 2:30 PM, staff stated that some of their personnel records were destroyed during the "Sandy Hurricane (October 2012)." She indicated there was no background checks done after, because they knew and were familiar with the staff.

This finding was acknowledged and validated by Staff Ll, Director of Human Resources who was present during the review.

Based on observation, review of document and interview, the facility failed to implement measures to prevent the transmission of COVID-19 as per current guidance issued by the Centers for Disease Control and Prevention (CDC). Specifically, the facility failed to:

1) Screen staff and visitors for signs of respiratory illness in 23 of 23 staff and multiple visitors interviewed;

2) Post signage at entrances with visitation restrictions and screening procedures;

3) Implement isolation precautions in accordance with CDC in 3 out of 10 COVID-19 positive patients/Persons Under Investigation (PUI) for COVID-19.

This failure may result in the spread of COVID-19.

Findings include:

Review of the Infection Control Guidance by the Centers for Disease Control and Prevention (CDC), titled "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic" last updated July 15, 2020, notes " Screen everyone (patients, HCP, visitors) entering the healthcare facility for symptoms consistent with COVID-19 or exposure to others with SARS-CoV-2 infection and ensure they are practicing source control. Actively take their temperature and document absence of symptoms consistent with COVID-19. Fever is either measured temperature ?100.0°F or subjective fever."

Review of "Hospital Visitation Guideline" (Received 09/18/20) revealed that "all visitors will be screened upon entering the hospital and will be asked: Do you have fever, cough, sore throat, shortness of breath or difficulty breathing, runny nose, muscle aches, new loss of taste or smell, nausea, vomiting, or diarrhea? Have you had close contact with anyone who is laboratory - confirmed Coronavirus (COVID-19) case? In the last 14 days, have you traveled from geographically affected areas, including China, Iran, Italy, Japan, South Korea or locations in New York State South and Putnam counties, including New York City or Long Island?"


1) On September 16, 2020 at 11:50 am, during the tour of the facility entrances, auxiliary staff members were observed taking temperature of visitors at the main facility entrance and the Ocean Parkway entrance. The staff members did not check the screen of the thermometer to read the temperature of each visitor. In addition, the staff members were not screening visitors for symptoms consistent with COVID-19.

During a concurrent interview with Staff W (Patient Care Technician), she stated that if she were to ask every visitor the COVID-19 screening question, "the line will back up to Ocean Parkway."

During interviews with 23 random staff members, they all stated they do not receive a COVID -19 screening before the start of their work shift.

2) During observation of the facility entrances on 9/16/20 at approximately 10:00 am, the entry point at the "Ocean Parkway" street had no sign posted to instruct individuals seeking medical care with symptoms of respiratory infection on infection control measures they must adhere to.

On September 16, 2020, at 12:00 pm, during an interview with Staff Y (Patient Care Technician), she stated that "there were no signs since last week; signs were taken down because they are planning to paint the walls."

On September 18, 2020, at approximately 5:00 pm, these findings were brought to the attention of facility's administrative personnel during an exit conference.


3) On September 17, 2020, at 11:00 am, during the tour of Tower 4W (Medical Surgical Unit), it was observed that the door of the isolation room was left open. The occupant of the room, Patient #34 was under isolation as a person under investigation (PUI) for COVID-19.

During an interview with Staff Jj (RN, Unit Supervisor) she acknowledged findings but stated, "We keep the curtains closed."

On September 17, 2020, at 11:45 am, during the tour of Tower 8 W (Labor & Delivery Unit) Staff K (MD, Director of Neonatology) was observed exiting the room of a COVID 19 positive patient (Patient #36) with no isolation gown over her lab coat.

During a concurrent interview with Staff K, she stated, "I needed to ask the patient some questions. I did not go within 6 feet of the patient."

Review of the policy titled "Guidance Criteria to Guide Evaluation of Patients Under Investigation (PUI) for COVID-19" (Effective: March 12, 2020), revealed that "All personnel enter the room should adhere to PPE recommended in CDC's interim infection control guidance for Coronavirus disease: N95 respirator or facemask if respirator is not available, goggles .., clean isolation gown, one pair of clean non-sterile gloves ..."

On September 17, 2020, at 01:35 pm, during an interview with Staff Gg (Infection Control Director), and Staff Hh (Infection Control Assistant Director) finding were brought to their attention. Staff Gg said that staff entering the room of a COVID 19 positive patient should wear a gown.

On September 17, 2020, at 12:30 pm, during the tour of the Emergency Department (ED), two patients under investigation for Covid-19, Patient #s 37 and 38 were observed in separated cubicles and their curtains opened. Both patients were not appropriately isolated, and Patient #37 did not wear a mask.

During an interview with Staff Bb (MD, ED Chairman), he stated that all admitted patients are tested for COVID-19. Patients #37 and #38 were admitted patients waiting for bed availability and transfer to the units.


On September 17, 2020, at 01:35 pm, the finding was brought to the attention of Staff Gg (Infection Control Director), and Staff Hh (Infection Control Assistant Director), Staff Hh stated that any patient with COVID 19 infection or PUI will be placed on isolation or a private room and the door to the room must be closed. Staff Gg stated that if isolation is not immediately possible, the patient should have a mask on.

Review of the policy titled "Guidance Criteria to Guide Evaluation of Patients Under Investigation (PUI) for COVID-19" (Effective: March 12, 2020), revealed ...if a patient meets the above criteria for a suspected COVID-19 infection: immediately offer the patient a surgical mask, and alcohol based hand rub..."

The facility did not implement its policy for Patients Under Investigation.

On September 18,2020, at approximately 5:00 pm, these findings were brought to the attention of facility's administrative personnel during an exit conference.