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Based on observations, interviews, review of policies and procedures, medical records reviews and document reviews, it was determined that the Governing Body failed to demonstrate that it is effective in carrying out its responsibilities for the operation of the hospital. It did not provide the necessary oversight and leadership as evidenced by the lack of compliance with the standards cited in the Conditions of Participation at 42 CFR 482.21 Quality Assurance Performance Improvement and in 482.55 Emergency Services.

Findings include:

1. The medical staff did not provide emergency care consistent with prevailing standards of practice to patients presenting in the emergency department (ED) and for inpatients requiring emergency care. See citations at A 049 and A 1112.

2. The facility did not measure, analyze and track care related problems in its Quality Assurance Improvement program to improve the quality of care provided to its patients. See Citation at A 0267.

The governing body failed to ensure that quality care was provided to the patients in 7 of 43 medical records reviewed. This was found in MR #s 1, 2, 3, 6, 9, 10 and 11.

Findings include:

1) The patient, MR #2, was classified as a moderate risk for falls on admission on 3/10/09 with a score of 10. On 3/16/09 at 12:15 AM, the nurse documented that the patient fell on the floor. The patient complained that his leg got weak getting back to bed. A review of the patient's medication administration record reveals the patient had been medicated with Ambien 5mg at 10:00 PM on 3/15/09. The nurse documented another fall risk assessment on 3/16/09 at 12:46 AM and the patient was still classified as a moderate risk for fall with a score of 15.

After the fall, the patient was evaluated by a House Physician and neuro checks every 4 hours. The nurse called the patient's private MD at 6:30 AM and documented that a CT-Scan and chest x-ray were ordered. Neurology checks were not performed and the patient's vital signs were not measured after the fall on 3/16/10 until 6:41 AM. The vital signs were BP 160/90, P 64, RR 28 and T 99.7. These results were not reported to any physician.

Documentation on 3/16/09 at 8:45 AM to 10:00 AM, indicated that a physician responded to a Rapid Response (RR) call for the patient who was now unresponsive to painful stimuli, had a witnessed seizure, had decerebrating movements of both arms, was tachypneic and frothing in the mouth, had pupils that were equal and had scattered crepitation in the chest which was partially cleared by oropharyngeal suctioning. Oxygen 100% was given via a non- rebreather mask and the patient was transferred to ICU for ETT intubation and airway protection before CT-Scans. The physician documented that the patient was critical and had "?CNS pathology."

A code was not called and the patient was not intubated until 0905 on 3/16/09 in the ICU.
A review of the CT scan of the head performed on 3/16/09 showed "Large left subdural hematoma with subarachnoid extension, brainstem bleed and mass effect with shift of midline." The CT scan of the chest showed bilateral pleural effusion. The intubation was delayed until after the patient was in the ICU.

A review of the facility policy on Activation of Rapid Response Team indicates the team is composed of a House MD, Nursing Director of critical care or designee and respiratory therapist (if available). During interview on 9/22/10 at 3:30 PM, Staff #8 confirmed that the Rapid Response team does not bring any equipment/medication to the location of an RR call but would declare a code if needed. Staff #8 also confirmed that the code carts were removed from the units because of pharmacy concerns that the medications were frequently expired.

On 9/23/10 at 10:15 AM, it was revealed during interview with Staff #9 that the code carts were removed from the medical surgical units during the 2nd quarter of 2009. Staff #8 was interviewed again on 9/23/10 and stated that Endotracheal Tubes are not on the medical/surgical units. She also stated that the carts removed were "supply carts" with a box for emergency resuscitation medications on top of the carts. She stated that if the RR team comes to assess the patient and intubation is required, a code is called and the elevator is on hold to transfer the patient to ICU for intubation.

2) The patient, MR #3, arrived at the ER on 8/7/10 at 12:44 AM with a complaint of chest pain, Acute Exacerbation of COPD and CHF. The patient was classified as semi-urgent level 3 and was seen by the ER physician at 5:11 AM. The patient fell in the emergency room at 7:35 AM on 8/7/10. After the fall, the patient was not re-evaluated by the physician before she was admitted to the medical/surgical unit at 8:30 AM where it was noted there was pain from the right femoral head fracture she sustained from the fall in the ED.

3) MR #3 also developed hypoxia while on 100% O2 via a non re-breathing mask on 8/10/10. The O2 Sat was noted low at 72% at 10:15 AM on 8/10/10. The patient was transferred from the medical floor for intubation in the ICU while in severe respiratory distress. A code was not called and the patient was not intubated until she arrived in ICU. The nurse documented on 8/10/10 at 11:07 AM "Transfer from medical floor patient in severe respiratory distress on 100% non-rebreathing mask. Patient unable to answer question. O2 sat low 72% Ambu with 100% O2 and patient intubated on arrival to ICU by Dr ... ..... "

Staff #2 was interviewed on 9/23/10 at 2:45 PM and he stated that he prefers intubation to be done in ICU where all the needed equipment is available.

Consequently patients who require intubation are not immediately intubated but are transferred by elevator vertically within the facility while on a non-rebreathing mask to ICU for intubation with resultant increased hypoxia over an extended period of time.

See also citations at A1112.

Based on observations, interviews, reviews of policies and procedures, medical record reviews and document reviews, the facility did not identify, analyze, track and correct problems identified in its Quality Assurance program.

Findings include:

The facility's Quality Assurance program did not gather data on cardio-pulmonary arrests and patients' self-extubations and therefore did not analyze these problems as these areas were not considered areas for improvement. See citations at A 0267.

A. Based on observations, interviews, review of policies and procedure and document reviews, the facility did not measure, analyze and track events to improve the quality of care provided to its patients.

Findings include:

1. A review of the Quality Assurance Performance Improvement minutes for 1 year revealed there was no review of rapid responses, unplanned extubations, codes, morbidity and mortality reviews and sub-optimal tests. These problems were identified in various medical records reviewed. For example, in MR#10, the CT was suboptimal in that the appendix was not identified. However, there was no review of this finding.

2. The rapid response and code forms do not contain the necessary information to formulate an adequate QA. This includes documentation for the arrival of the rapid response team, code cart and the code team. These are important factors since each unit does not have emergency supplies such as ETT for intubation. In addition, the rapid response team does not bring any emergency supplies for emergencies. There was no review to determine if a code should have been called instead of a rapid response. Where the facility has both a code team and a rapid response team, QA should include criteria for calling a rapid response team or code, whether one should have been called rather than the other, and if any improvements need to be made or staff education provided to the staff.

3. There was no evidence of any incident reports of unplanned extubations that could form the basis for a review of the circumstances surrounding the event and an analysis of the clinical impact of the incident.

Staff #2, the Chief Medical Officer, stated on September 24, 2010 at approximately 10:50 AM, that the facility no longer reviewed codes since there were no problems identified during past reviews.

4. There were no formal and written morbidity and mortality reviews incorporating interdisciplinary and interdepartmental reviews. Throughout the survey, various staff acknowledged that there were no formal audits, reviews, analyses or tracking of the above issues.

5. The facility's QAPI program failed to identify the discrepancy in MR #1 where on the Resuscitation Record for 8/1/10 at 3:10 AM, the size of the ETT was documented twice as 7.5 and on one occasion as 8.0.

B. Based on observation and interview, the facility failed to ensure that the contents of code carts are maintained and readily available to be used emergently.

The facility has formulated and implemented a procedure in which code carts are placed at sites in the hospital in a manner that requires that they be retrieved during a code to cover other areas. Some locations require vertical other than horizontal movement of the carts. This deviates from the usual practice of a fully stocked and checked code cart on each unit in an area proximal to patient rooms and in a location easily accessible for staff use. This was confirmed by interview and inspection. Where the facility elects such a process, QAPI involvement in auditing inspections of the carts and whether their placement is suitable must be implemented.

The facility, however, failed to ensure that the contents of these carts were maintained in a manner that ensured that they could be safely used emergently. Where the facility has elected to use such code carts in a manner distal from the areas covered, periodic inspection by nursing and pharmacy to ensure that they are ready for immediate use should be audited during the QA process.

Findings were as follows:

1. During an inspection conducted on 9/24/10 at approximately 11:00 AM, it was noted that the code cart in the ICU designated for the medical/surgical floors lacked the required 1 Liter of N/S. The cart had 2 red top blood tubes with expiration date of 7/10 and the cart was missing 2 each of yellow, blue, lavender, and pink top blood tubes. The policy requires that the cart has 2 of above mentioned items. The cart also lacked gloves as per policy.

2. Similarly, at that time, the ICU designated cart was missing a pediatric Ambu bag as required per policy. One D5W 250ml expired on 8/10, and the other D5W 250 ml expired 4/10. The middle side drawer had the only 1 Liter LR solution expired on 3/10. The bottom drawer was missing the D5W 500ml, D5W 250 ml x2, and the D5W 250ml Aviva solution as required per policy. The Aviva solution is required for Nitroglycerine IV and Amiradone IV administration. These findings were verified by Staff #8 at that time. The missing items could potentially have an impact on the outcome of a code, an issue that would have been noted in QA.

3a. On 9/21/10 at 1:55 PM, the Emergency Department code cart was observed with the following expired items while Staff #11 witnessed the findings:
i) 1 Glide scope with the expiration date of 11/26/07.
ii) 1 V Pacing Probe with the expiration date of 03/10.
iii) 3 Statlock Catheter Securement devices with the expiration date of 2/10.This code cart with the expired items is used in the ER level and locations below that level of the facility to respond to emergency code calls.

This code cart with the expired items is used in the ER level and locations below that
level of the facility to respond to emergency code calls.

b. At 2:00 PM the storage cart for supplies was observed with the following expired supplies which Staff #10 witnessed:
i) 3 Polysorb 30 " 75cm with the expiration date of 01/05.
ii) 2 Soft silk 4.0 with the expiration date of 01/08.
iii) 1 Soft silk 2.0 with the expiration date of 06/10.


4. See also citations A049.


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5. The patient MR #14 was status post overdose of drugs with her own supply of Methadone and facility administered Percocet and was revived with administration of Narcan on 3/14/09. The patient required intubation because of noted hypoxia/tachycardia and was tachypneic according to the physician progress note on 8/14/09 at 8:00 AM. According to the Nurses Patient Notes, on 3/17/09 at 0001 the patient self-extubated herself.
During interview on 9/21/10 at 12:10 PM, Staff #1 stated that the facility does not collect data on patients who self-extubated themselves.

Based on observations, interviews and medical record reviews, the facility failed to ensure that physicians wrote complete orders and that the nursing staff administered medication appropriately in the ED in 2 of 2 patients on titrated medications.

Findings include:

1. Dopamine was administered without documented evidence of the prescribed rate in accordance with acceptable standards of practice. A review of MR #1 revealed an order documented on 8/01/10 at 5:00 AM revealed "dopamine started at 10mcg/kg."

Another entry written at 5:15 AM revealed an order for "Dopamine 400mg/500ml NS at cc/hr (for 70kg at 10mcg/kg/min start at 53cc/hr IVPB."

Similarly, at 5:25 AM that morning, review of MR #1 revealed an order for "Dopamine 400mg/500 ml NS at cc/hr (for 70kg at 10mcg/kg/min start at 53cc/hr) IVPB."

Another order for Dopamine 400mg at 2:30 PM that day revealed that Dopamine was an "additive" for NS 500cc at 53ml/hr. There was no documentation to indicate how or when the medication should be titrated.

During staff interviews on September 22, 2010 at approximately 10:15 AM, Staff #3 acknowledged the above findings and stated that the medication was to be titrated to maintain the systolic blood pressure at 90. Staff #3 further stated that the computer software does not permit such documentation. The lack of documentation of a precise order is not an acceptable practice because medications that are to be titrated should specify the concentration, rate and conditions for which the drug should be given. Therefore the order was incomplete. Furthermore, there was no evidence of a corresponding order that mandates the frequency that the systolic blood pressure be checked to determine if it is at 90, or if not, the dose required to be given to raise it.

2. Versed was administered without parameters. During a tour of the ED on September 21, 2010 at approximately 2:10 PM, it was noted that a patient on a ventilator was being administered Versed intravenously. During staff interviews at that time, the nursing staff stated that the medication was being given for sedation. The nurse did not state the protocol as to how much should be administered and under what conditions the drug should have been titrated. The patient was on a ventilator and it was not specified as to whether the desired effect was somnolence or respiratory depression so there would be no patient competition with the ventilator.

There was no evidence of a policy and procedure to specify the parameters for levels of consciousness that would be governed by the Versed drip and no specific guidance as to the dosing levels requisite to meet those levels.

Based on medical record reviews, interviews, document reviews and review of policies and procedures, the facility failed to develop a policy for controlling community infections and communicable diseases. This was found in 1 of 1 re-admission to the NICU. MR #5.

Findings include:

A review of MR #5 revealed that this 11 day old infant was admitted from the community to the NICU on 9/21/10 with a history of fever of 100.4 F. A request was made for the facility's policy for admissions to the unit from the community However, only a policy for "Transfer of Neonate From Tertiary Center to St. John's Riverside Hospital" was provided.

The patient's admission to the unit was verified by Staff #1 on 9/23/10 at approximately 10:00 AM.

A review of the Infection Control Meeting minutes for April 22, 2010 and July 20, 2010 revealed there had been at least 2 infants admitted to the NICU with community acquired MRSA infection. This poses a risk for hospital acquired infections.

Based on observations, interviews, review of policies and procedures, medical record reviews and document reviews, it was determined the facility failed to provide emergency care consistent with acceptable standards of practice.

Findings include:

1. Patients requiring emergency care were not triaged by appropriate personnel to ensure timely nursing and medical care. Refer to A1112.

2. Patients awaiting triage, registration or medical care could not be visualized in 9 chairs. There were a total of 43 chairs in the ED waiting area. During observations and interviews with facility staff (the ED Medical Director and the Risk Manager) at 2:00 PM, on September 24, 2010, it was determined that 9 chairs could not be seen by the triage nurse or any other members of the medical or nursing staff from the triage booth, the security post, or even inside the ED. These chairs were located in the alcove area of an L-shaped waiting room.

3. Policies for triage were formulated and implemented that did not conform to current standards of emergency practice and there was a lack of congruence between the triage policies and statements made by medical staff. See A1112.

a) Review of the ED triage policy and procedure on 9/22/10 at 11:00 AM found that there were five categories for triage and that the policy for nursing re-assessment was "recommended," not mandatory and ranged from "continuous until stabilized" for critical emergent to hourly for urgent, within 3 hours of triage for semi urgent, 4 hours for non urgent and non urgent/ fast track. While re-assessment is defined in ED policy as a variety of parameters, it does not define which is mandatory (vital signs). While the policy does address medical screening by a medical provider within a certain period of time dependent on triage, the word "screening," not "treatment," for "urgent" in 1 hour is used. The word "screening" is used in some policy and "treatment" on another.

However, in interview with the ED Medical Director on 9/22/10 at 10:00 AM, he stated that the ED had no policy that defined when an MD must see a patient based on triage.

A. Based on observations, staff interviews, reviews of policies and procedures, document reviews, medical record reviews, and review of credentialing/personnel files, the facility failed to ensure that medical and nursing personnel were available and qualified to perform their duties in the emergency department (ED). MR #4, #5, #6, #7, #9, #12, #13, #15 and #16.

Findings include:

1a. Patients were pre-triaged by unqualified personnel. During a tour of the emergency department on September 21, 2010 at approximately 1:12 PM, it was observed that a security guard, Staff #7, was conducting pre-triage of a patient. Staff #7 asked the mother the patient's name, age and presenting problem. When the mother provided the necessary information which included the baby's (MR #5) age which was 11 days and complaint of fever, the security guard proceeded to ask the mother how high was the infant's temperature. Staff #7 entered this information into the computer, then directed the mother to sit in the waiting area.

b. This finding was also observed by the Director of Risk Management and Quality at that time.

c. A review of MR #5 on September 22, 2010 at approximately 10:05 AM confirmed that Staff #7 had entered information in the medical record; however the content of his documentation could not be determined, although there was evidence of an electronic signature of the security guard.

d. When the Medical Director and Director of Security/Assistant Vice President of Support Services were interviewed at 10:00 AM on September 22, 2010, they acknowledged that it is the facility's policy that security personnel staff can perform pre-triage and document this information in the patient's medical record in Emergisoft. The staff further stated that the security guard should not have asked how high the infant's temperature was.

2. Based on facility policies and procedures, the "Pre-triage-Greeter Screens" protocol in the Emergisoft provides direction on the procedure to conduct at pre-triage.

3. A review of the job description for a security officer revealed the following:
Security guard assigned to the emergency department can:
"1. Assist with registration of patients.
2. Greet' patients arriving at the ED area.
3. Immediately ascertains medical problem.
4. Following protocol enter patient into Emergisoft.
5. Emergency situation-The Security Officer will alert Medical Staff of emergency patient arrival."

The policy further directs security personnel to make an "immediate call to triage and or medical staff" in the event of the following patient symptoms:
Difficulty breathing
Chest pain
Active bleeding
Profuse vomiting
Change in mental status
Acute pain
Child with complaint of high fever
any child <4 months (regardless of complaint)

4. At survey on 9/24/10 at approximately 11:00 AM, the Director of Security added sexual assault and suicide ideation to the list of those issues that would require notification of medical or nursing staff.

5. There was no evidence that the security guard notified the nursing staff immediately of MR #5, according to the facility's policy.

6a. Interviews with the Director of Security and reviews of training for security staff revealed that security personnel received training on BLS and first aid and the syllabus of this course included instruction in the application of splints, tourniquets and dressing of wounds. The card issued to the security guard states that the certification is in Adult First Aid, CPR, AED, and emergency oxygen administration.

b. While the security personnel job description defines their role in triage as asking certain questions of a clinical nature, it does not specifically prohibit them from applying the knowledge obtained by taking and passing the course. The facility security director presented certificates of completion for each security guard on completion of this course. Without such a specific prohibition in the job description, security staff could construe the course completion as permission to perform such duties.

B. Based on observations, staff interviews, and medical record reviews, the Emergency Department (ED) did not triage patients appropriately.

Findings include:

1. During observations made in the ED- Dobbs Ferry Pavilion on 9/22/10, MR #13 arrived at 7:18 AM on 9/22/10 with complaint of back pain at 10/10 x 2 days, history of emphysema, shortness of breath on arrival and pulse oxymeter of 87% on room air. The patient had decreased breath sounds with oxygen saturation up to 92% on oxygen. The patient was triaged as 3 semi-urgent. Given the above assessment, the triage classification was not appropriate.

2. During observations made in the ED- Andrus Pavilion on 9/21/10, MR #4, an 81 year old patient, arrived at 12:52 PM on 9/21/10 and was pretriaged at 12:57 PM that day with "stated complaint" of "other" per Staff #7, the security guard. The patient was triaged by a nurse at 12:58 PM with complaint of palpitations. The patient had been sent to the hospital by her physician for a pacemaker. Vital signs showed pulse 139, and B/P 147/103. The patient was triaged as "3 semi-urgent." The patient was not appropriately classified. The patient was found by the survey staff to be still in the waiting room one hour later and would not have been brought in for treatment had the survey team not notified the facility.

3. During observations made in the ED - Andrus Pavilion on 9/21/10, MR #6, a 21 year old patient was "carried" into the ED on 7/10/10 at 3:04 AM with a triage "Stated Complaint: Ectopic pregnancy, syncope and collapse" and nursing assessment "chief complaint: lower abd pain, vag bleeding, dizziness." Significant vital signs showed B/P 84/45 upon arrival. There was documentation that the mode of arrival was "carried in." The patient was inappropriately triaged as 3 semi-urgent. The ultrasound was ordered 6:49 AM, completed at 9:05 AM and was not "officially read" until 9:06 AM that morning, 6 hours after arrival. The Ultrasound was not performed and officially read in a timely manner. The patient was sent to the OR where 1 liter of blood was found in the abdomen.

4. Review of medical records #12, #20 and #21, revealed that these three patients all presented to the ED-Andrus with newly diagnosed stroke symptoms (aphasia, one sided weakness, slurred speech) and they were all triaged as a level 2 - Urgent. The facility is a designated Stroke Center. According to the facility's policy entitled, "Management of Cerebrovascular Accident (Acute, Suspected) in the Emergency Department", revised January 2009, patients presenting with stroke symptoms will undergo "Emergency Triage" or immediately, because of specific time constraints associated with the stroke protocol.

5. Review of MR #9, found that the patient, who had a stab wound to the chest, was discharged with a pericardial effusion. The patient presented with a stab wound to the chest to Dobbs Ferry but had gone to another facility ED and left AMA. The complaint was documented as having pain on breathing. No EKG was done. The chest x-ray was noted as negative and bedside sonogram was noted as negative for peri-cardial effusion. The patient presented 24 hours later to the St Johns - Andrus Pavilion with dyspnea, and a chest CT demonstrated a hemopericardium.(moderate pericardial effusion). The patient was transferred to a trauma center.

6a. Review of medical record #7 revealed that this 5 year old presented to the facility's Dobbs Ferry emergency department (ED) on 5/8/10 with trauma to the head sustained in a fall from a trampoline at home. Staff #4, a physician, examined the patient in the ED. The patient was discharged from the ED and sent home with no CT or X Ray.

b. Staff interview and facility documents revealed that patient #7 went to her pediatrician and was transferred to a tertiary hospital where it was discovered that the patient had a skull fracture and comminuted lateral orbital fracture.

c. There was no evidence that the facility staff conducted an investigation to determine if the trauma was correlated with child abuse or neglect. There is no documented evidence in the medical record (MR#7) to show that Child Protective Services was contacted.

d. Review of credentialing file of Staff #4 found that the physician involved had been credentialed and privileged to perform emergency medicine even though she was a surgeon and not ACLS certified or Board certified in emergency medicine as stipulated in the facility policy.

7. Review of MR #10 on 9/22/10 found that the pediatric patient presented to the ED on 7/6/10 at 4:19 PM with complaint of abdominal pain consistent with appendicitis. The patient was assigned a non urgent triage classification (priority 4). Pain scale was 10 out of 10. The CT of the abdomen was suboptimal in that the appendix was not identified. The patient was transferred to a tertiary care facility 12 hours later.

8. Review of MR #11 on 9/22/10 found that the 5 year old pediatric patient presented at 1300 hours with complaint of fever, anorexia, headache, and vomiting. There was a physician's note that referred to peri-umbilical pain. There was a documented suspicion of appendicitis. Patient was triaged as semi-urgent (level 3) even though her pulse was 132 and temperature was 102. p.o. The patient had a history of subdiaphragmatic hernia repair as an infant. The patient was transferred to a tertiary care facility 4 hours later.

9. Review of the personnel file of Staff #5, an ED nurse, revealed that her BLS certification expired on 8/08 and her ACLS certification expired on 10/09.