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Based on record review, observations, and staff and patient interviews, the facility failed to be in compliance with the Condition of Participation of Patients Rights. This was evident by the scope of the facility's failure to ensure the patients rights regarding grievance, Advanced Directives and receiving care in a safe environment.

Findings are:

The facility failed to conform to its procedures for resolution of patient complaints/grievances. This finding was noted in 1 of 1 applicable verbal complaint records reviewed. (MR #6). (See tag A118)

The facility did not conform to its process for the implementation of an advance directives and issuance of " Do not resuscitate " (DNR) orders. This finding was evident in 1 of 2 applicable inpatient rehabilitation records reviewed. (Patient #7). (See tag A132)

The facility failed to provide a safe environment by the failure to implement effective monitoring of a patient on elopement precautions who was able to leave a locked inpatient psychiatric unit undetected. This finding was evident in one of one records reviewed for a psychiatric inpatient who attempted elopement. (patient #8) (See tag A 144)

The facility failed to implement assignment of designated staff which were consistent with orders for continuous observation levels and did not develop procedures for alternative forms of nursing monitoring in effect. This finding was relevant to four of four patients where two to one nursing observation was in progress. (See tag A144)

Based on staff interview, review of documents, and review of the procedures for complaints and grievances, it was determined the facility failed to conform to its procedures for resolution of patient complaints/grievances. This finding was noted in 1 of 1 applicable verbal complaint records reviewed. (MR #6)

Findings include:

The patient referenced in MR #6 was interviewed on 2/18/14 at approximately 11:00 AM, when the patient stated that all of his identification papers were lost in the hospital. These documents included his driver license, non driver identification, and birth certificate. He stated that despite a report filed with Patient Advocacy, he could not obtain reimbursement from the hospital. The patient was homeless and stated he needed to go to a Social Services agency to address his monetary needs.

During follow up interview with Staff #12 on 2/18/14 at approximately 11:30 AM., it was stated the hospital will pay for replacement of documents but will not provide the cash as requested.

Review of a social work note documented on 2/18/14 at 12:00 noon that the patient was advised he would need to present a receipt of purchase to the Patient Advocacy Office for reimbursement of lost documents. However, this instruction requiring that the patient must present a receipt does not explain how the patient would be able to pay for the document replacement due to lack of financial resources.

Review of the patient's complaint file was conducted on 2/20/14 at 4 PM. The verbal complaint was received from Nursing on 2/11/14. The incident date of 2/10/14 noted the patient claimed he lost his wallet which contained $27 in cash, debit card, insurance cards, and other business cards.

The timeframe for response to the complaint was logged as 7 days. The complaint was opened by Patient Relations staff on 2/13/14 and the investigator noted a history trail included a search of areas where the patient had been, including the cashier and security staff. No belongings were found. The complaint was substantiated. On 2/13/14, the Patient representative noted in the complaint file that the social worker requested that the patient be provided with money so he could leave the hospital. The patient representative advised that the Patient Relations does not provide money to patients. The complaint file was closed on 2/13/14.

Under the complaint form section titled outcome, an entry documented by the manager referenced a discussion with the unit psychiatrist. It was noted Patient Relations could reimburse for lost funds and assist in advising on replacement of documents, but that no additional funds could be provided for financial needs as requested. It was noted the patient expressed being comfortable with this option and that Social workers should be contacted to assist further with discharge planning and financial needs follow up. The psychiatrist agreed to call the social worker.

At interview with the staff # 13 and Staff #14, on 2/21/14 at approximately noon, it was stated that the complaint was accidentally closed. It was stated the cash and cost of document replacement is reimbursed by the facility but the Patient Relations staff will not assist with applications for document replacement. It was stated the patient agreed with the plan to follow up.

This complaint was not classified as a grievance because it was stated by the staff that this would have been resolved while the patient was still hospitalized and the patient instead wanted to go home and was satisfied. This response did not address the inability to close this complaint prior to discharge, given the subsequent instructions noted in the patient medical record on 2/18/14, which required the patient to present a receipt of purchase to the Patient Advocacy Office for reimbursement of lost documents. The staff stated details of the attempts to locate the belongings are in the Security Department report, which was not provided prior to the conclusion of the survey.

Review of the facility complaint and grievance policy on 2/21/14 documented that a complaint is considered a grievance when " it is postponed for later resolution, referred to other staff for later resolution, requires investigation, and /or requires further actions for resolutions" . The facility did not follow this policy.

The complaint investigation did not address if the facility followed its Patient Valuables procedure, which requires an inventory of all personal property and whether it is sent home, kept by the patient, or deposited in a hospital safe. The after visit summary form in the patient record only recorded the patient was given his clothes back.

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Based on staff interviews and review of records and procedures, it was determined the facility did not conform to its process for the implementation of an advance directives and issuance of " Do not resuscitate " (DNR) orders. This finding was evident in 1 of 2 applicable inpatient rehabilitation records reviewed. (Patient #7)

Findings include:

During tour of the 9 North Inpatient Rehabilitation unit located in the Hospital for Joint Disease site on 2/19/14 at approximately 10 AM, the staff provided a list of patients hospitalized on the unit. The list identified patients that had an advance directive in place.

Patient record # 7 was reviewed on 2/19/14 at approximately 10:30 AM. This 86 year old female was admitted on 1/27/14 for rehabilitation with history significant for Embolic Stroke. A copy of the patient ' s health care proxy was on file, dated 7/9/13 in which two health care agents were named (the reported son and daughter).

This declaration signed by the patient included a directive to withhold or terminate medical treatment and procedures in situations when recovery would be unlikely due to disease or other conditions that would render the patient unable to communicate medical decisions or where restoration of a cognitive life is not likely.

Form AD-3 titled " Adult Patient without surrogate: Consent to Withhold and/or Withdraw Life-Sustaining treatment (including DNR/DNI (Do Not Intubate) " was present in the patient record. This form is to be utilized when all of the following criteria are met: 1) for adult use only; 2) the patient lacks capacity, 3) the patient does not have a health care proxy or the person is unavailable; and 4) the patient does not have a surrogate. This form had been signed by the physician on 1/29/14 at 10 AM where it was noted the patient lacked capacity to make a DNR decision and the cause and extent of the incapacity includes "stroke and cognitive deficits". The section for decision and clinical criteria for withholding or withdrawal of life-sustaining treatment (including DNR/DNI) was signed by the physician. The completion of the remaining sections of the form including the Attending Physician statement of prior decisions related to withholding or withdrawing life sustaining treatment were blank. This form was incomplete in that there was no determination of incapacity by a concurring (second) practitioner. The consent form (#AD-3) that was utilized by staff was incorrect in that the patient actually did have a health care agent/proxy who was available.

Review of electronic health record patient information sheet and current code status section found that on 1/23/14 at 4:11 PM the patient was identified as a "full code" and it was noted the patient had capacity to make goals of care decisions.

At 4:50 PM on 1/27/14 an order for full code indicated that the goals of care discussion included the presence of the patient, daughter, and staff members including the Nurse practitioner, nursing staff, and patient. Comments noted the patient did not have capacity to make goals of care decisions. The reason noted for the lack of capacity was "Aphasia vs. delirium " .

At 6:16 PM on 1/28/14, a DNR order was in effect. Under the comments section, the goals of care discussion were held with the presence of family members and patient. It was noted the patient did not have capacity to make goals of care decisions and the reason for this lack of capacity included "cognitive deficits/delirium ".

It was not explained why the patient had progressed from having capacity on 1/23/14 to lacking capacity on 1/28/14.

There was no further documentation to explain why the decision had changed to DNR. The determination of " aphasia versus delirium " or " cognitive deficits/delirium " did not sufficiently explain whether this is a permanent loss of capacity or irreversibility of condition that would warrant DNR.

The surveyor attempted to interview this patient on 2/19/14 at approximately 10:45 AM. The patient was awake and alert and fully verbal. She expressed that she was in pain and had a stomachache. When repositioned in bed by the nurse, the patient was queried whether the pain persisted and she denied ever having stomach pain. The patient ' s mental status as observed was not consistent with aphasia as reported on 1/28/14. The justification for DNR as noted in the patient's consent as stroke with cognitive deficits does not warrant lack of capacity as there is no determination of irreversibility.

At interview with staff # 15 on 2/19/14 at approximately 11 AM it was stated he was not the physician of record who signed the DNR order and could not explain why this form was utilized.

Review of procedures titled: " Advanced Directives/health care proxy (HCP) " on 2/21/14 at 4 PM notes the attending physician /nurse practitioner or physician assistant is accountable to " complete the appropriate Do Not Resuscitate/Do Not Intubate (DNR/DNI) form including signatures and obtaining any other required signatures. "

Review of procedures titled " Consent Policy " on 2/21/14 notes that " a concurring determination is required by a second attending physician if a surrogate ' s decision concerns the withdrawal or withholding of life sustaining treatment " . This procedure requires a determination of incapacity prior to decisions obtained from a surrogate and also that " specific informed consent forms be signed by all patients undergoing procedures or the appropriate health care agents or surrogates. "

Review of the form titled " AD-1: Adult Patient With Capacity or with Health Care Agent/Proxy: Consent to Withhold and/or Withdraw Life-Sustaining treatment (including DNR/DNI) " found that the form is to be used for adults where the patient either has capacity or where the patient lacks capacity and has an available health care proxy. Examination of this consent finds that there is a clause that requires explanation of medical condition/diagnosis/prognosis as well as a list of medical treatments to be withheld or withdrawn. This form also contains a section for the patient or health care agent ' s signature.

The facility failed to adhere to its procedures due to the failure to utilize the correct consent for DNR (AD#1), failure to obtain a second corroborating medical confirmation for lack of capacity, and failed to elicit the written consent of the available health care agent.
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Based on staff interview and review of procedures, records, and incident reports, it was determined the facility failed a) to provide a safe environment by the failure to implement effective monitoring of a patient on elopement precautions who was able to leave a locked inpatient psychiatric unit undetected. This finding was evident in one of one records reviewed for a psychiatric inpatient who attempted elopement. (patient #8) b) The facility failed to implement assignment of designated staff which were consistent with orders for continuous observation levels and did not develop procedures for alternative forms of nursing monitoring in effect. This finding was relevant to four of four patients where two to one nursing observation was in progress.

Findings include:

a) On 2/20/14, one of four incidents was reviewed in which elopement was attempted from a locked inpatient psychiatric unit by an inpatient on 11/13/13.

Review of the patient's record # 8 on 2/20/14 found this 18 year old patient was admitted on 11/13/13 secondary to obsessive thoughts containing religious and sexual themes along with compulsive behaviors that included handwashing and wandering. Nursing noted at 12:57 AM documented that the patient remained hospitalized in a gown and had signed an elopement treatment agreement. The patient had attempted to push a door open but was able to be redirected.

At 3:17 PM on 11/13/13 the psychiatric admission note indicated that the patient is to remain in the hospital pajamas because he was twice observed making an effort for the door. It was noted he could be safely observed under the usual floor protocol.

During interview with Staff #22 on 2/20/14 at 3:00 PM, the usual floor protocol was identified as every 30 minutes.

Nursing note documented at 7:36 PM on 11/13/13 that a call was received at 6:45 PM from the Urgent Care Center nurse that the patient had eloped from the locked inpatient psychiatric unit and took the stairs down from the tenth floor to the first floor.

During the process of transporting patient back to the unit, the patient broke free and sprinted to the other end of the lobby. The patient continued to attempt to break free of staff grip multiple times to run. The patient was physically escorted back to the unit and placed on 1:1 observation and medicated with Ativan by mouth. The patient, on interview, stated he eloped from the rear of the unit as the food service staff left the unit.

At interview with staff # 16 and staff # 17 on 2/20/14 at 3:00 PM it was reported the patient was discovered by a nurse in a different area (Urgent Care Center) in the hospital lobby wearing pajamas. According to staff, the patient was already on elopement precautions, which includes donning of hospital pajamas, checks every 30 minutes, and completion of a written treatment agreement to not walk past the ping pong table on the unit and linen closet. It was stated the video on the unit was reviewed which showed the patient creeping behind a dietary food cart while exiting the unit. Since then, the remote opening of unit doors was disengaged by security. The staff also state that 24 hour security is in effect while the sallyport doors are under construction.

Review of written procedures titled, "Management of the patient at risk for Elopement:" on 2/21/14 determined the elopement precautions in Psychiatry include pajamas, observation every 30 minutes, and escort off the unit accompanied by psychiatry staff and escort staff. The policy further notes "if the patient on elopement precautions demonstrates further risk for elopement then initiate a one to one constant observation by a patient care technician" . Daily reassessment by the treatment team is also required. This policy did not include mention of the treatment contract as an option.

Review of medical record determined there was insufficient monitoring in place prior to the patient's attempted elopement. The patient was placed on monitoring every 30 minutes and was not considered for 1:1 monitoring despite having attempted elopement twice. Therefore the facility did not adhere to its policy that requires one to one constant observation when the patient poses additional elopement risks.

Further, review of incident review documentation in Incident Management Committee meeting minutes of 12/31/13 found there was no exploration of reasons why the patient missing status was not initially discovered by the unit-based inpatient psychiatry staff.
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b) During tour of the 9 North inpatient Rehabilitation unit located in the Hospital for Joint Disease site on 2/19/14 at approximately 10 AM, the staff provided a list of patients hospitalized on the unit.

During interview of staff # 18 on 9 South, it was stated that four patients were assigned to 2:1 nursing observation level in room # HJ914 and in HJ919. It was stated that one nursing aide is assigned to monitor 2 patients simultaneously who require close monitoring. This monitoring option is implemented for patients who need enhanced supervision for safety reasons.

The patient referenced in MR # 9 was observed in bed in room 919-02 with an aide seated in between bed 1 and bed 2. The patient was anxious and repetitively asked to leave the hospital. The aide was interviewed and confirmed she is responsible for watching both patients but the patient assigned to bed #1 was not in the room. It was reported the other patient, (Patient #10) was off the unit in the gym receiving Physical therapy.

When asked about assigned duties, the aide replied she watches both patients in the room and records their activity. If a patient requires toileting she will accompany the patient to the bathroom to assist as needed. She could not explain who will accompany or provide back-up relief assistance as required.

Review of MR # 9 found this patient is a 21 year old male who was admitted on 2/15/14 for traumatic brain injury following a skateboarding accident. The patient had a frontal lobe contusion, T10 fracture and bulging discs at T11-T12. Patient noted to have mobility and gait deficits, and cognitive -communication deficits. Periods of agitation were noted with safety, fall prevention, and behavioral needs that required low stimulus environment and employment of non pharmacological strategies. Review of orders found that the patient was ordered to 1:1 continuous patient observation on 2/16/14 and 2/18/14. No reason was noted for the observation, but interview of nursing staff confirmed this was employed for patient safety.

During the time of observation on 2/19/13, the head nurse confirmed the patient was assigned to 2:1 nursing observation.

The hospital has no policy for alternative monitoring levels where 2 patients are assigned to one nursing staff member.

Review of procedures titled, "Management of the Patient Requiring Constant observation (1:1 Observation)" was performed on 2/19/14. This procedure described that constant observation may be applied to patients for safety where there is risk for falls. Direction is provided for patients who are disoriented or agitated with measures that include, but are not limited to, decrease in room stimulation and use of reassurance and reorientation.

This policy did not describe the use of alternative monitoring levels, including 2:1 nursing observation.

The Security Department procedures titled "Patient Watches (1:1) Restraints & Managing Disruptive situations" were reviewed on 2/21/14, which permit security staff to provide continuous observation in instances where a patient poses a danger to self or to others and where the health care provider is consulted for clinical issues. However, this policy did not indicate the use of 2:1 monitoring in effect on the inpatient rehabilitation unit.

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Based on observation and staff interview, it was determined that the facility failed to consistently ensure the confidentiality of patient's medical record. Specifically, the facility failed to ensure that patient's Electronic Medical Records (EMR) was secured from unauthorized access at all times.

Findings:

During tour of the Dermatology Clinic on 2/21/14 at approximately 1:20 PM, two (2) computers in the work station (skin center 607 and skin center 606) were left unattended with screens un-locked and were readily accessible by non-clinical staff and other patients.

On observation it was noted that the screens of the two computers did not lock after it was left unattended for five (5) minutes. Access to patients' medical record were obtained by easily moving the mouse.

During interview on 1/21/14 at approximately 1:27 PM, the staff members (Staff #2 and Staff #3) logged on to the computers (skin center 607 and skin center 606), stated that they minimized the screens when walking away from the work stations but leave themselves still logged on to the EMR .



This finding was brought to the attention of staff #1 on 2/21/14 at 1:28 PM.
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Based on observation and staff interview, the Food Service Director did not ensure that the daily operation of the food service department is maintained in a sanitary manner.

Findings include:

A tour of the kitchen at New York University Hospital (NYU) and Hospital for Joint Disease (HJD) was conducted on 2/14/14 and 2/20/14 respectively between 09:30 AM and 10:30 AM on both days. The surveyor was accompanied by staff # 7, Senior Food Service Director. The following issues were observed, included, but are not limited to, the following:

1- Unsanitary Environment/ Food Safety

2- Hand sink was observed to have ice cubes, grape juice and margarines. (NYU)

3- Plastic garbage throughout the kitchen was observed to be uncovered and not in use. (NYU)

4- Condiment containers that had been opened were not labeled to include the date they were opened and the date of expiration. (NYU)

5- Four trays of sandwiches and individual salads were not labeled. (NYU)

6- Walk-in freezer #2 had an extreme case of condensation with a heavy build-up of ice. (NYU). The floor beneath the motor was covered in ice. (NYU)

7- Food cart located in the walk- in refrigerator contained packages of foods. These packages of food belonged to employees. (NYU)

8- A build- up of ice in the motor of the walk-in refrigerator was observed. Food was stored on shelves of a metal rack underneath the motor. (HJD)

9- A reach-in refrigerator was observed to have different saran wrap food packages that were not labeled. These foods were Goat cheese, croutons, celery stalks, carrots, sliced American cheese, and Swiss cheese. (HJD)

10- Another reach -in refrigerator had a bag which contained serving scoops, paper, a scissor and knives. (HJD)

11- The hospital has a colored dot system that shows when the food was made and a color chart that shows when to discard the food. Some color dots were the same for foods that are freshly made and those to be discarded. A interview with staff #23, a cook, on 2/20/14 at 10:30 PM, he was asked what color of dot would be placed on foods made today (Friday 2/20/14), he initially stated a blue dot but later indicated a yellow dot would be placed on foods. However, the Food Service Director who was present during the interview stated a black dot is used on Fridays.

Foods in reach-in refrigerator did not follow the dot system mentioned above. Some food items had a black dot others had dates and some had no dot or label such as sliced ham, 2 pans of tuna, 2 pans of chicken salad and 1 pan of egg salad. (HJD)

It was evident that this process for labeling food was confusing for kitchen employees and may cause foods to be left on the shelf after their expiration dates. (HJD).

12- Mini floor model Hobart mixer was dusty and the area where the attachment hooks up was dirty. (HJD)

13- The window sill that extends from one side of the kitchen to the other was dusty. Part of this window sill is above the cold prep table. (HJD)

14- The pot wash room had clean pans directly across dirty pans. The clean wet sheet pans were placed one on top of the other. There was over 50 wet sheet pans piled on top of each other. (HJD)

15- Some ceiling tiles were detached from each other promoting a habitat for insects. (HJD)

16- A Hobart mixing bowl lying on the side, a large mixing bowl paddle and a coffee can was stored beneath the dirty pot washing counter. (HJD)

17- An Ice cream freezer was observed to be packed with ice. The freezer had no thermometer to obtain freezer temperature. (HJD)

18- Review of 24 random samples of the documents titled " Test Tray Measurement Forms " (dated from 5/6/13 to present) was conducted at NYU on 2/18/14 at approximately 1:00 PM. The Senior Food Service Director and Director of Patient and Clinical Nutrition Service were present during the review. The review of temperature showed that 24 of 25 test tray (96%) of cold food items such as milk and dessert did not meet the standard temperature for cold food items. The cold food items were all above 45 degree Fahrenheit.

- Review of hot food temperature taken on the patient units and noted on the " Test Tray Measurement Form " at NYU showed that the standard temperature of 140 degrees Fahrenheit was not achieved on 11 out of 26 trays (42%).

- During tour of the kitchen at NYU it was observed that the Isolation Trays were packed in paper and loaded into a non- thermal truck. These trays cannot hold standard hot/cold food temperature with no temperature control. The count for Isolation Trays that day was 30+.

19 - The food service division of the Food and Nutrition Department in both facilities had no quality assurance program. The nutrition division had clinical nutrition indicators for their quality assurance program yet the food service division had no approved plan or indicators to report to the hospital-wide quality assurance program.
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Based on staff interview, review of master menus and nutrient analysis of menus, it was determined that that the Food and Nutrition Department failed to ensure physician prescribed diets met the therapeutic nutritional needs of patients. This finding was noted in 7 of 10 diets reviewed.

Findings include:

An interview was conducted with the Director of Patient Services and Clinical Nutrition pertaining to hospital menus and nutrient analysis. A review of menus and nutrient analysis was conducted on 2/18/14 at approximately 1: 00 PM. The surveyor was informed that the hospital has a one week cycle menu and a diet formulary consisting of 40 different diets available to the physician for diet ordering.

Listed below are the findings identified in a sample of menus and the nutrient analysis of prescribed diets: There were only 5 diets out of 40 diets (13%) that had a nutrient analysis. Menu items did not match food items listed on the nutrient analysis. Examples include:

1- Wednesday- Lunch Nutrient Analysis for Heart Healthy Diet states 4 oz. Polenta; however, Wednesday Menu for Heart Healthy did not have Polenta on the menu.

2- Low sodium (2 grams) menu did not have 1 pint (16 oz.) of milk/day for adults. The menu had only 12 oz. of milk/day allocated to this diet.

3- Heart Healthy Menu makes no mention of its dietary restriction such as amount of cholesterol, sodium or fiber. The same was noted on the Renal and Diabetic diet, the amount of the restriction and the type of restriction was not present.

4- Lactation menu contained only 12 oz. milk/day. Thursday menu only had 8 oz. milk/day.

5- There were no age specific menus for Pediatric except for adolescent. A toddler diet nutrient analysis was done but there was no menu. Menus for Infant and the School- Age child was absent and hence there was no nutrient analysis.

6- Toddler's diet nutrient analysis ranged from 1089-1500 calories and the protein ranged from 53- 77 grams of protein. Both calories and protein for this age group was excessive.

7- Toddler nutrient analysis contained food items such as Yankee Pot Roast, Bean Chili, Stir fry Chicken Chow Mein, Veal Stew, Broiled Grouper and Chicken Picatta. Not all these food items are appropriate for toddlers.
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Based on staff interview, review of hospital's menus, and the physician diet prescription formulary, it was determined that the prescribed physician diet orders were not being accurately transcribed on patients menus. Findings were noted in 5 of 5 physician prescribed diets and corresponding menus reviewed.

Findings include:

An interview was conducted with the Director of Patient and Clinical Nutrition Services and the Clinical Nutrition Manager on 1/18/14 at approximately
3:00 PM concerning diets printed on the patient menus.It was observed that the Physicians' diet orders were abbreviated on menus and did not match the physician's prescribed diet orders.
Consequently diet orders do not correspond or match with the menus. The menu is required to correspond with the prescribed diet. The menu is placed on the patient tray to identify the diet, portion allowed and food item allowed on the diet. The menu is also an education tool for parents, staff and patients concerning the prescribed diet by the physician.

Examples of abbreviation of prescribed diet on the menu are:

The Physician order for "No added salt- High calorie/High Protein Diet" was represented on the menu as " NAS HPHC".

The Physician order for "Clear Liquid - 2 gm sodium diet" was represented on the menu as "Clearliquid, NA2".

The Physician order for "Low Residue Diet" was represented on the menu as "Low residuebr, Diet"

The Physician order for "Dysphagia-Soft- thin Liquids Diet" was noted as "Dyssoft, Thinliq, Diet" on the menu.

The Physician order for Low Sodium- 2 grams, Low Potassium Diet was noted on the menu as "NA2, K2, Diet".
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Based upon observations, interviews and review of the facility's policy and procedures and other facility documents, it was determined that the facility failed to be constructed, arranged and maintained to ensure the safety of patients. Therefore the accumulative effect of the Hospital Regulation standard level deficiencies as well as the Life Safety Code deficiencies is that the Condition of Participation for Physical Environment is not met as evidenced by:

Findings are:

The facility failed to maintain a safe, sanitary, and comfortable environment to ensure the safety and well-being of patients. (See tag A701)

The facility failed to meet Life Safety Code standards (See A710).

The facility did not ensure that supplies and equipment were maintained to ensure an acceptable level of safety and quality. (See tag A724)

27522

Based on observations, and staff interview, it was determined that the facility failed to maintain a safe, sanitary, and comfortable environment to ensure the safety and well-being of patients.

A. The findings at the Hospital for Joint Diseases include:

On 2/18/14 at 10:23 AM observation in Inpatient Pediatrics revealed that the ceiling vent within the Soiled Utility Room was dust laden.

On 2/18/14 at 12:20 PM observation in Ambulatory Surgery revealed that there seventeen biohazard sharps containers being stored in a non-functioning dumbwaiter located within the Soiled Utility Room.

On the afternoon of 2/18/14 observation in the Central Sterile Area revealed that:

- On 2/18/14 at 2:05 PM observation in the Central Sterile Area revealed that there were two dangling light bulbs found in the Autoclave Room.

- On 2/18/14 at 2:24 PM observation in the Central Sterile Area revealed that inside the Decontamination Area there was one stained ceiling tile and one stained light cover.

On 2/18/14 at 3:10 PM observation in Eye Care revealed that between the Men's Bathroom and the Women ' s Bathroom there were two unsealed pipe penetrations.

On 2/18/14 at 3:23 PM observation in Outpatient Pediatrics revealed that a nurse call cord was wrapped around a pole in the ADA (Americans with Disabilities Act) Patient Bathroom.

On 2/19/14 at 10:10 AM observation in the Kitchen revealed that the Pot Area exhaust vent had a layer of grime on it.

On 2/19/14 at 12:00 PM observation revealed that there were two stained ceiling tiles in Radiology X-Ray Room #1.

On the afternoon of 2/19/14 observation in Adult Acute Care revealed that:

- On 2/19/14 at 2:30 PM observation in Adult Acute Care revealed that there were two stained ceiling tiles in the ADA Patient Bathroom.

- On 2/19/14 at 2:36 PM observation in Adult Acute Care revealed that within the Soiled Utility Room the wires of two Accu-Check Glucometers were bundled together with medical tape.

All of the above findings were concurrently verified by Staff #4 during tour of the Hospital for Joint Diseases on 2/18/14 and 2/19/14 between 10:00 AM and 3:30 PM.

B. During the tour of the Tisch and HCC building from 02/18/14 to 02/21/14 between 11:00 AM to 4:00 PM, following issues were noted.

On 02/18/14 during the tour of the Post Anesthesia Care Unit/Post Op (6th floor) it was noted that when the nurse call bell was elicited from Bay #s 28, 29, and 30 it did not register an audible sound at the nurse's station. When the staff tried to find the issue, it was noted that the volume of the alarm was set low so that it was in-audible.

Furthermore, bay #29 was missing a dome for the visual light of the nurse call bell at the bay.

The issue of audible nurse call bell not registering at the nurse's station was noted on 02/18/14 at 3:00 PM, on the 15th Floor-west (Tisch). A nurse call bell from room #33 was elicited and no audible alarm was heard.

Similar issue was noted in the PICU unit on 02/20/14 at 1:30 PM.

C. On 02/19/14 at 11:00 AM during the tour of the Psych Unit in HCC 10th floor it was noted that:

The Laundry room was not closed and secured from unauthorized access. The laundry room has metal pipe going through the wall, electrical plugs for the machines and other similar risk of hazard that may put patient safety at risk.

All the patient rooms including but not limited to room #10-17 had cupboards/closets that have doors providing the potential space/area for patients to hide.

D. On 02/19/14 at 2:00 PM, during the tour of the 13 Floor-West OB/Post Partum floor (Tisch), it was noted that some of the rooms including but not limited to private room 1317 had their wall bumpers broken and missing revealing thus the underneath sticky residue.

E. On 02/19/14 at 3:00 PM, during the tour of the 13th floor- Cardiovascular Center (HCC) it was noted that the emergency patient call bells in the patient toilets were high above the floor and thus would not be readily accessible for a patient who might collapse on the floor and need assistance as per AIA 1996-97 7.32.G2.

During the survey of the different units, many mechanical closets and electrical panels were noted blocked by stretchers or carts, thus not allowing easy access in case of emergency. This situation was noted specifically during the tour of the OR suite and NICU.

Furthermore in many areas the electrical panels were not locked/secured from unauthorized access. Example including to but no limited to was the Outpatient Lab.

All above findings were verified with Manager of Facilities Management, the Environmental Specialist Staff and the Nursing Managers of the units from 02/18/14 to 02/21/14 between 11:00 AM and 4:00 PM.
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The hospital did not ensure that the life safety from fire requirements was met. (For the NYU Hospital Center see Life Safety Code survey, K17, K18, K20, K23, K25, K29, K33, K34, K38, K45, K46, K56, K62, K69, K71, K76, K106, K130, and K147) and for the NYU Hospital for Joint Diseases see Life Safety Code survey, K17, K18, K20, K25, K29, K33, K34, K38, K56, K62, K106, K130, and K147).
42 CFR 482.41(b)

Based on observations and staff interview, the facility did not ensure that supplies and equipment were maintained to ensure an acceptable level of safety and quality.

Findings include:

1. During observations tour of the facility-Tisch and HCC on 02/21//14 between 11:45 AM and 3:30 PM, it was observed facility did not ensure that the preventive maintenance and electrical checks were conducted in a timely on all equipment.
For example:

(a). The centrifuge machine with asset number #TH30811038 in the Biochemistry lab was noted having a due date of inspection of 12/13. The Director of Clinical Engineering acknowledged that the equipment was past due for its electrical and safety check.

(b). The pediatric scale in 8W with asset number #TH41798, indicated that it was due for a PM/safety check on 01/14, however not information was provided if it was done or not.

2. During the tour of the facility-Tisch from 02/18/14 to 02/21/14, it was told to the surveyor by the nursing staff that the monitoring of the medication refrigerator is not done by writing the temperature down. The staff relies on a built in 'alarm' that will go off if the temperature of the refrigerator goes out of range.

On 02/21/14 during the tour of 8W it was noted that the medication refrigerator sticker had a blank annual safety check tag with no other information of any preventive maintenance or checks. Furthermore, no information was provided regarding how does the facility checks and ensures the alarms are calibrated and working in their optimum condition.

All above findings were verified with Manager of Facilities Management and the Administrators/nurse managers of the units.

3. On 02/21/14 at 3:00 PM, during survey of the Dialysis unit (18 th floor-Tisch), it was noted that a patient was receiving treatment on machine #4183. The conductivity of the machine was reading 14.1. The nursing staff was asked to show the theoretical conductivity (TCD) of the machine, which indicates the parameters of the actual conductivity to be given to the patient. The TCD for the dialysate prescription of 2K 2.5 Ca and 142 Sodium /35 Bicarbonate, was reading as 13.9 and the alarm range for the high and low conductivity was set at 13.6 to 14.6.

As per the Fresenius manual, the alarm range for the conductivity of the dialysate being given to the patient is set by default, +/- 0.5 of the TCD. With this manufacture's requirement the alarm range should have been 13.4 to 14.4. Thus for this particular machine. if the conductivity of the dialysate will go to 14.6 only then it will alarm unlike alarming at 14.4 which is a default high level of conductivity based on TCD.

The Bio-Med Technician acknowledged that the alarm parameters should not be altered and staff should be aware of the relationship between TCD and actual alarm limits.

Above findings were verified with Bio-Med Technician and Director of Critical Care.

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27522

Based on observations and staff interview, the Infection Control Officer failed to ensure (1)the facility is maintained in a sanitary condition to prevent the spread of infections, (2) maintain medical records for all personnel to include records of immunization status.

The findings at the Hospital for Joint Diseases include:

1. Tour of the facility conducted on 2/18/14 and 2/19/14 revealed:

(a) On 2/18/14 at 11:15 AM observation at Ambulatory Surgery revealed that there were two stacks of universal Operating Room table protection system sheets found in the Janitor's Closet.

(b) On 2/18/14 at 2:00 PM observation at Central Supply revealed that there was a broken ceiling tile in the Sterile Area.

(c) On 2/18/14 at 2:56 PM observation at Eye Care Soiled Utility Room revealed that there was a RCA hazardous waste container and two specimen bags located on the dedicated "clean" sink countertop.

(d) On 2/19/14 at 3:00 PM observation at 11 th. Floor Patient Care Area revealed that three isolation rooms (HJ1108, HJ1109, and HJ1102) did not have scrubbable ceiling tiles which are required for this type of room as per AIA Guidelines.

(e) On 2/19/14 at 3:15 PM observation at Special Care Unit revealed that a Hoyer lift, a fake plant, and an umbrella were being stored in the ADA9 Patient Bathroom.

All of the above findings were concurrently verified by Staff #4

(f). The following Infection Control issues were noted during the survey of TISCH and HCC buildings from 02/18/14 to 02/21/14 from 11:00 AM to 4:00 PM.

On 02/18/14 between 2:00 PM to 3:00 PM during survey of the Central Sterile Processing Department (CSPD), the following were observed:

(i). In the sterilizer work area no audible and visual alarm was noted for exhaust system which is intended to alert the staff for the loss of air-flow as required by AIA 1996 7.31.D19.

(ii). The pass through windows from the decontamination side to the clean side were not closed /separated. Leaving the pass though windows open between the two areas may lead to cross-contamination in case of loss of air-flow or any other issue with HVAC.

(iii). The facility did not have a dedicated Endoscopy Processing room as required by AIA 1996 97 9. 9.B. The facility provides the services of Endoscopy and is utilizing the main decontamination room as the area to install and utilize instruments used for decontamination of endoscopes. This may lead to environmental cross contamination.

(iv). Furthermore, the flow of instruments/endoscopes for cleaning was not from dirty to clean and then to storage. After being fully disinfected, the cleaned scopes/instruments pass through the dirty area/zone before going to storage.

(v). The housekeeping closet near the Central Sterile department was noted housing clean supplies such as toilet tissue rolls and paper towels. Storing clean items in a dirty room may lead to cross contamination.

(g). On 02/18/14 at 12:30 PM, during the tour of the Respiratory Care Department on 7 th floor- Tisch it was noted that the main storage room had stain ceiling tiles and the perimeters of the room were very dusty and dirty.

(h). During the tour of the ICU on 15 th floor -West (Tisch) it was noted that:

(i). The walls of the room #1514 and 1533 were dirty and had light orange color stains.

(ii). The clean utility room opposite room #1526 exhibited negative air-pressure instead of positive air pressure.

(h). During observation of the Isolation Room on the 12 floor West-NSICU/Surgery on 02/19/14 at 12:30 PM, it was noted that the ceiling tiles in the Isolation Room were porous/had holes that may retain dirt (they were not monolithic) and thus were not as per AIA 7.28.B8

(i) During the survey of the NICU-9th Floor West (Tisch) and Newborn Nursery-13 th Floor west on 02/19/14 and 02/20/14 between 11:00 AM to 2:15 PM, it was noted that the facility does not have any Isolation Room provision for the newborns at any level of Nursery care (as per AIA 7.3.E9) .

Similarly no isolation room was present on Pediatric Floor 9 East-Tisch as required by AIA 1996-97 section 7.5.F6.

(j). During the tour of the Pediatric Floor 9 East-Tisch on 02/19/14 at 3:00 PM it was noted that there was dirty toilet bowl plunger and a used dusty brush stored on the floor of the clean storage room.

(k). During the tour of the Cardiovascular Center 13 th floor HCC building on 01/20/14 at 2:45 PM, it was noted that a construction on the floor was going on for the fire alarm system. The construction area was blocked off from the patient care area by a door with plastic cover. It was noted that the bottom edge of the door was not sealed/blocked with any plastic cover. Therefore environmental contamination from the construction area to the patient care area may occur.

(l). During the tour of the PACU 6 th floor-Tisch on 01/18/14 it was noted that one of the clean red recliners used for patients had dirt and dust in its cervices and folds.

Similar issue of dirty recliner was noted in the Urgent Care 1st floor HCC on 01/20/18. The chair was considered clean by the staff however it had blackish residues/dirt in its fold and cervices. Furthermore, the hand rest of the recliner was noted chipped which does not allow for thorough cleaning.


(m). During the tour of the Main Clean Linen storage room on 5 th floor Tisch on 02/21/14 at 11:45 AM following issues were noted:

(i). The heating unit/radiator cover was missing. The perimeter of the unit was dirty and dusty. Furthermore, trash and some linen were noted inside and under the gap of the heating unit.

(ii). One of the ceiling tiles in the corner of the room was missing.

(iii). The corners and perimeters of the room was noted dusty and dirty.


(n). During the tour of the Labor & Delivery unit on 8 West-Tisch on 02/21/14 at 2:30 PM, following issues were noted in the unit:

(i). The clean supply storage room had some sterilized instruments stored in packs. This room does not have any mechanism to monitor/ensure that the temperature and humidity of the room is in compliance with AIA 1996-97 Table 2.

(ii). The nourishment room/pantry room had no wrist blades at the hand washing sink.

(o). During the tour of the Hemodialysis unit on 18 th floor Tisch it was noted that the facility did not keep all the equipment/instruments that are used on Hep B+ exclusive for the Hep B + patient and inside the isolation room. There were no separate rinsing and calibrating liquids kept exclusive for the use of conductivity meter used on Hep B + patient's machine. Facility had only one station of the rinsing and calibration liquid used for rinsing of all conductivity meters used in the unit.


(p). During the tour of the Outpatient Lab on 1st floor HCC, following issues were noted:

(i). A urine sample from a patient was left unattended in room #1. The door was open and this room is near the waiting room.

(ii). The upholstery of the patient/examination table in room #7 was noted torn and in disrepair.

(iii). The hand wash/clean sink in the lab did not have wrist blades.

(vi) Facility utilizes a regular sink to dispose off urine. It was noted that this is not a clinical sink. As per facility's policy titled 'Disposal of urine and stool' under bullet (II b) states that 'Only a toilet sprayer or dirty utility room sink may be used to rinse out a device which contained urine'. This lab did not have any soiled utility room and the sink utilized for disposing the urine is in the middle of the working area. Such arrangement may lead to environmental contamination.

(v) Furthermore, during survey dry ice was noted thrown in this sink.

(vi) The sink was also noted to be corroded and in disrepair.

(vii). The clean hand wash sink in the Virology lab was noted very dirty with white precipitates around the perimeters. Portion of the sink was corroded also. This sink also had items/supplies used for clean work stored under the sink.

(q). During the tour of the Clinical Lab on 3rd floor Tisch building the following issues were noted:

(i). The Diagnostic Immunology/serology lab was noted to be in the same vicinity/compartment as microbiology. It is to be noted that as per AIA 1996 97 Table 2, the microbiology is a dirty lab with negative air pressure and Serology is positive air pressure. The diagnostic immunology/serology lab did not exhibit positive air-pressure and the rear door had an open communication with the microbiology lab.

(ii). At least two mechanical exhaust/vents were noted closed in the microbiology lab area including the diagnostic immunology lab. The vents were closed with tape/paper/cardboard.

(iii). The Biochemistry lab was noted very negative oppose to being positive as required by AIA 1996 97 Table 2. One of the doors of the lab did not latch positively separating it from the corridor.

(iv). Two ceiling tiles were noted stained in the Hematology lab.

All above findings in Tisch and HCC were verified with Manager of Facilities Management, the Environmental Specialist staff and the Nurse Managers/Administrators of the areas surveyed.

(r). The Respiratory Care Department at the Hospital for Joint Diseases lacked a clean holding area for the storage and distribution of clean and sterile supplies and materials.

During a tour of the facility on 2/19/14 at approximately 13:40, it was noted the Respiratory Care Room located in the step down unit was used as a multipurpose room. The room is an office for respiratory care staff and also was used for the storage of clean equipment like ventilators, BiPAP (Bi-Level Positive Airway Pressure) machines, bronchoscopy cart, and several other sterile supplies and materials. The failure to store clean equipment and supplies in a designated room can result in cross contamination.

At interview with Staff # 6 on 2/19/14 at 13:50, he acknowledged findings and stated the facility is working on a plan to remodel the room to include a separate storage area for equipment and supplies.



2. Review of Personnel Files on 2/20/14 revealed there was no documented evidence of immunity for Hepatitis B or Varicella in five (5) of ten (10) Personnel Files.

At interview with Staff #5 on 2/21/14, these findings were verified and Staff #5 stated the employees were old employees but this examination is now required for new employees.

The Initial Physical Examination Form, Revised 12/09, lists the designated infectious diseases and also states the vaccinations that are available from the facility's Employee Health Services. However, there is no documentation that the "old employees " were encouraged or offered the vaccinations from the facility's Employee Health Services to evaluate the immunization status for these employees.
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32522

Based on review of records and staff interviews, it was determined that the facility failed to provide complete discharge referrals that fully addressed housing, financial issues, or post discharge mental health and substance abuse needs for homeless patients with mental illness. These findings were noted in 2 of 2 applicable concurrent medical records for homeless patients who were discharged from inpatient psychiatry ( Patient #6 and #11).

Findings include:

Two of two records (patient #6 and #11) for inpatient homeless patients treated for mental illness on inpatient psychiatry were reviewed on 2/14/14 and 2/18/14. Discharge records lacked documentation that discharge shelter arrangements were appropriate for patients with diagnosed mental illness and failed to ensure that all required information was provided in writing to patients, along with necessary staff contact information, to two homeless patients with mental illness who were discharged from the inpatient psychiatric unit. Discharge instructions provided were incomplete and did not include essential information or referrals for identified patient needs.
Written aftercare visit summaries given to patients lacked staff contacts at drop in shelters/programs, lacked arrangements for post discharge injections, and/or lacked referrals for substance abuse, mental health, or financial needs.The medical record for the patient referenced in MR # 6 was reviewed on 2/14 and 2/18/14. This 48 year old male was originally admitted to inpatient psychiatry on 1/24/14 for treatment following command auditory hallucinations that told him to kill himself and he was contemplating jumping in front of trains or in traffic. Patient reported significant history of depression, recent relapse of heroin substance abuse, and was homeless.

The initial social work assessment of 1/27/14 noted financial resources were noted as " other community resources " but this was not defined.

A social work note of 2/11/14 indicated Care management staff was to follow up on lack of insurance issues and the patient reported he would go to a shelter in Hoboken New Jersey which was near transportation and family.

On 2/16/14 the physician noted that he would be discharged on 2/18/14 pending resolution of reimbursement for lost belongings while in the hospital.

Review of physician ' s psychiatry discharge summary note documented at 9 AM on 2/18/14 found the patient was initially interested in inpatient substance abuse rehabilitation but the inpatient rehabilitation facility where he had resided in past did not wish to accept him back. It was noted however due to need for Percocet for chest pain he would not be candidate and instead chose to be discharged with follow up for outpatient substance rehabilitation treatment.

The patient was interviewed at approximately 11 AM on 2/18/14. He stated he was being discharged and planned to go to the shelter in New Jersey that day. He would follow up also with his cardiologist. He expressed that he needed to leave the hospital in order to visit Human Resources Agency in New York because all of his identification papers were lost in the hospital including driver license, non driver identification, and birth certificate. He explained he would need to address the lost documents and his financial issues before going to the shelter in New Jersey because he could not obtain reimbursement from the hospital.

Follow up interview of Staff #20 on 2/18/14 at approximately 11:30 AM., found that she had not called the shelter in New Jersey to validate a bed. She reported a shelter was called last week to confirm beds. The patient would go to a drop in shelter and the hospital staff would follow up in 30 days following discharge. As far as the lost documents, the hospital will pay for replacement of documents but will not provide the cash the patient wants.

After this interview the patient's record was reviewed again at approximately 1:30 PM on 2/18/14. A follow up social work note documented on 2/18/14 at 12 noon found the patient would see his cardiologist the next day (2/19/14), who would provide psychiatric medication management and the patient would be referred to a walk in clinic at the nearby municipal hospital (Bellevue) for psychiatric care. The intern called to confirm the New Jersey shelter lacked beds and the patient was agreeing to referral to a drop in shelter where the intern noted " it was confirmed space is available " . The note indicated the patient was advised he would be reimbursed for his lost documents when he presents a receipt to the Patient Advocacy Office and that two one way Metrocards were provided for public transportation.

Arrangements did not include validation of calendar appointments for mental health aftercare and did not include name(s) of shelter staff contact on discharge paperwork (After Visit Summary or " AVS " forms) given to patients upon release.

The after visit summary form (AVS) dated 2/18/14 noted instructions to walk in a psychiatric clinic at a nearby hospital. The name address and phone were provided for the drop in center that is part of the Department of Homeless Services, but no staff contact was listed. The cardiology appointment was listed for the following day, 2/19/14. No referral information was listed on the AVS for referral to address substance abuse treatment or financial needs. In addition, medication list included a list of 17 medications, including need for a daily injection of Fondaparinux, 7.5 mg/0.6 ML injection. (This medicine is used to prevent deep vein thrombosis (a blood clot, usually in the leg), which could lead to pulmonary embolism (a blood clot in the lung)).The form indicated these medications could be obtained from any pharmacy, but the discharge plan did not address how this could be administered without insurance resources, financial resources, or supplies. No follow up was noted on previously noted plan to obtain insurance for lapsed Medicaid.

Follow up interview with the Director of Social Work on 2/18/14 at 4:15 PM determined no contact name is required when patients are placed in shelters that are not affiliated with New York City Department of Homeless Shelters.

The discharge plan changed on the discharge date to drop in shelter placement without evidence this plan for drop in shelter was reassessed as safe for the patient.

The discharge was incomplete because post-survey follow up contact with New York City Department of Homeless Services on 2/24/14, following the survey, found that referral forms must be submitted in advance to the City Department of Homeless Services (DHS) where clearance for suitability of shelter placement shall be obtained and approved in advance by DHS. The drop in center the patient was referred to is part of the New York City Department of Homeless Services facilities, but is not an authorized shelter for placement of new homeless patients. The 2/18/14 social work note in the medical record indicated care plan was faxed to post hospital service providers but lacked description of which providers were sent information and lacked evidence that the patient was formally accepted by Department of Homeless Services for placement in the correct location.

The mental health outpatient appointment lacked calendar dates and there was no evidence of any referral provided for financial and substance abuse needs. Moreover, the plan indicated the patient could follow up with Patient Advocacy for reimbursement of lost documents. This instruction noted in the record requiring that the patient present a receipt for reimbursement did not explain how the patient would be able to conform to this, given that the patient lacked the financial resources to pay for the document replacement.

There was no rationale documented to explain why supportive housing for mentally ill was never considered. The plan lacked sufficient justification for viability of discharge with a drop in center referral, given the patient ' s expressed recent history of command hallucinations.

Review of MR # 11 on 2/14/14 and 2/18/14 determined this 52 year old patient was admitted to inpatient psychiatry on 2/9/14 for suicidal plan to jump off a bridge. On 2/9/14, social work noted the patient became homeless following the death of his mother in June 2013 and had been residing in Penn Station. Patient reported he was known to Bellevue intake but refused to return due to an unsafe environment. Patient reported no insurance or income. The patient was admitted to inpatient psychiatry and treated for major depressive episode and substance use disorder, including alcohol use and cocaine use disorder.

Review of the treatment plan in the medical record found that on 2/14/14, the goal for the patient ' s homelessness shall include a referral to the DHS (Department of Homeless Services) shelter.

On 2/14/14 Social Work noted referrals were made to two facilities for inpatient treatment for mental health and substance abuse treatment, of which one agency (National Recovery Institute) had accepted the patient. A regular Medicaid application was filed for by the hospital as noted.

On 2/18/14 at 1:08 PM the social work discharge note indicated the patient was referred to this facility, care plan documents were sent, along with the address and phone number to " NRI " for substance abuse treatment, outpatient psychiatric care, and housing assistance. Review of the after visit summary form (AVS) provided to the patient on discharge on 2/18/14 found that this form included a medication grant card to cover outpatient medications.

However, this AVS form did not document the name(s) of contact staff at the referral center nor plan to address financial needs and the lack of income.

Interview with the patient was conducted on 1/18/14 at approximately 1:15 PM where it was stated that he wanted inpatient treatment but had no insurance. He stated he was advised that he will be referred for shelter once he arrives at the center.

Interview with Staff # 21 on 2/18/14 at approximately 1:20 PM determined the information for all his aftercare needs was faxed to the agency, NRI.

Follow up contact with National Recovery Institute (NRI) post survey on 2/25/14 determined that while substance abuse treatment and transitional shelter placement can be provided on arrival, no direct services are offered for mental health. Only outpatient referrals can be provided for mental health service needs when the patient has insurance. Therefore, the discharge planning referral provided for this patient was incomplete.

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