HospitalInspections.org

Based on observation, the facility does not maintain the physical plant to assure a safe and suitable environment for patients.

Findings include:

Observation during facility tour on 7/19/10 between 10:30 AM and 3:30 PM revealed the following deficiencies in the facility's building maintenance:
- The door-latching mechanism on the right side exit door to the old ambulance entrance is broken and missing parts, thereby restricting proper operation of the door.
- The wall surface of the shipping receiving corridor along the boiler room is deteriorated. Approximately 8 x 15 feet of wall surface has paint and plaster peeled away from the wall due to exposure of moisture and heat on the interior side of the boiler room wall.
- One of 2 circulation pumps for Boiler #2 is leaking large quantities of hot water to the floor of the boiler room. Review of repair documents revealed the pump has been leaking since the beginning of May 2010.
- The hot water tank in the boiler room is leaking from a broken valve onto the floor creating a safety hazard.
- The wall surface under the dishwashing line behind the garbage disposal is deteriorated and not easily cleanable.
- Drinking fountains on the first floor adjacent to the radiology department and in the basement by the purchasing office did not operate.

These findings were verified with Staff #25 on 7/22/10.

Based on document review and interview, the facility does not ensure the delineation of clinical privileges for 2 of 3 established medical staff. (Staff #9 and 11)

Findings include:

Review on 7/20/10 of the credential file for Staff #9 revealed a delineation of privileges form from the facility dated 6/30/07. No evidence of current privilege delineation was found.

Review on 7/20/10 of the credential file for Staff #11 revealed a delineation of privileges form from the facility dated 9/15/99. No evidence of current privilege delineation was found.

These findings were verified with Staff #1 on 7/22/10 at 11:20 AM.

Based on observation, the facility does not ensure that outdated, mislabeled, or otherwise unusable drugs and biologicals are not available for patient use.

Findings include:

A tour of the Medical Care Unit (MCU) was conducted on 7/19/10.
-Observation of the 3rd floor medication room upper cabinet blood draw box at 11:35 AM revealed the following:
- 3 dark green blood tubes expired 1/2010.
- 3 teal green blood tubes expired 5/2010.
- 1 teal green blood tube expired 1/2010.
- 2 blue blood tubes expired 4/2010.
- 2 tan blood tubes expired 3/2010.
-Observation of the narcotics box at 11:40 AM revealed the following:
1- 1.0cc syringe was found opened and placed on a paper towel inside the locked narcotics box.
THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 4/11/08.


Based on observation and interview, the Dental Clinic does not ensure all drugs and biologicals are stored in locked storage areas.

Findings include:

Observation during tour of the Dental Clinic on 7/20/10 from 2:45 PM through 3:45 PM revealed the following unsecured items:

Sterilization room:
- 1 box of Carbocaine injectable carpojets in an unsecured/unlocked cabinet.

Dental Operatory room for Staff #21 contained the following in unlocked cabinets or unsecured areas:
- 25 carpojets of Septocaine with Epinephrine
- 13 carpojets of Citanest Plain Dental
- 27 carpojets of Lidocaine with Epinephrine
- 22 carpojets of Carpocaine

Both Dental Operatories contained the syringes of the following medications/biologicals in unlocked cabinets:
- Benco Etch Gel
- Flowable Composite
- FlowTec
- LimeLite
- Seek
- Quick Stat FS

These findings were verified with Staff #21 on 7/20/10 at 3:40 PM.

Based on observation and interview, the facility does not maintain the facility in a manner to ensure the safety and well being of patients.

Findings include:

Observation during facility tour on 7/20/10 at 3:00 PM revealed that the floor in Operatory #5 is carpeted. Interview with Staff #21 revealed the room was formerly office space and has been converted to a dental operatory. It is required that floors are comprised of easily cleanable material.


Based on observation, interview and document review, the Dental Clinic does not ensure that effective infection control practices, safe for patients and consistent with acceptable standards of professional practice, are utilized to avoid sources and transmissions of infections and communicable diseases.

Findings include:

Observation in the dental operatories on 7/20/10 from 2:25 to 3:45 PM revealed syringes of Benco etch gel, Flowable Composite, Flow-Tec, Lime-Lite, Seek and Quick Stat FS that were open and undated. The syringes had applicators applied for patient use, but were uncapped and left open to air.

Interview with Staff #21 on 7/20/10 at 3:40 PM revealed that it is facility practice to utilize the dental syringes for multiple patients. After use with a patient, the applicator tip is placed in the sharps container and the entire barrel of the syringe is wiped down with Caviwipes. It is left to air dry for the next patient. Staff #21 also confirmed that the syringes that had applicators already in place with no caps were to be used for the next patient. In addition, Staff #21 verified that Caviwipes are used to clean the curing lights in between patients.

Review on 726/10 of the Material Data Safety Sheet for Caviwipes revealed precautions not to ingest and to utilize respiratory control measures that include the recommendation to use in a well-ventilated area. This calls into question whether Caviwipes are appropriate to use with dental equipment for oral use.

Based on policy and procedure and medical record review, the speech therapist does not document assessment of the patient's progress and response to treatment in accordance with hospital policies and procedures for 2 of 2 patients. (Patients #9 and 43)

Findings include:

Review on 7/21/10 of the Rehabilitation Progress notes policy and procedure revealed that a weekly progress note will be written for all patients receiving PT, OT and speech therapy. These notes will include a summary of consultation with ancillary staff, family, physician, patient education, progression toward short and long term goals, new or revised goals, plan of care and discharge plans.

Medical record review on 7/21/10 for Patient #9 revealed the patient had a Speech-Language Evaluation performed on 6/23/10. Speech Therapy recommended the patient receive therapy 2-3 times a week for 30 days for restorative purposes. The progress notes written by the speech therapist did not contain any documentation describing progression toward short/long term goals and/or discharge plans. The patient was discharged to home on 7/3/10. No documentation was found regarding the status of Speech Therapy when the patient was discharged, whether goals had been met or if additional home Speech Therapy was needed.

Medical record review on 7/22/10 for Patient #43 revealed the patient had a swallow evaluation on 6/17/10. The speech therapist recommended the patient receive therapy 2-4 times per week for 30 days for restorative purposes. The short term goals included improving oral motor skills with oral motor exercises. Long term goals included maximizing swallowing safety. The therapist documented the patient's ongoing refusal to eat or drink, yet no alternative plan was made to address the refusal of eating or drinking. In addition, the notes through the discharge date of 6/24/10 did not describe progression toward short/ long term goals, new or revised goals and/or discharge plans.

Based on observation and interview, the facility does not ensure secured storage of medical records.

Findings include:

Observation during facililty tour on 7/19/10 at 12:30 PM of the detached maintenance garage revealed the two overhead doors were opened with no staff present in the area. On 7/20/10 at 12:30 PM, tour of the garage revealed approximately 200 boxes of medical records in storage. Interview with Staff #25 revealed the building is locked most of the time.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 4/11/08.

Based on policy and procedure review, medical record review, document review and interview, the Dental Clinic does not ensure that dental medical records are complete and accurately documented for 2 of 11 dental patients. (Patients #30 and 42)

Findings include:

Review on 7/21/10 of the Medical Records policy and procedure for Documentation Standards for Patient Care Areas revealed all care and services provided are documented for each individual patient, whether the patient is or is not billed for these services. All patients are registered and given a medical record and an account number. All documentation must include the patient's name, medical record number and date. The person making the entry must sign their name as it is listed on their license and date the entry.

Medical record review on 7/21/10 for Patient #30 revealed a care note describing a tooth extraction that occurred on 6/25/10 at 9:00 AM. The Dental Assistant initialed the entry and the Dentist signed the entry. However, further investigation on 7/21/10 by the NYS surveyor revealed the patient had not had the documented tooth extraction.

Medical record review on 7/21/10 for Patient #42 revealed a progress note dated 6/26/10 stating the patient had an extraction on 6/25/10.

Review of the Unit Secretary's monthly calendar schedule dated 6/10 revealed documentation that Patient #42 had a scheduled appointment at the Dental Clinic on 6/25/10. Patient #30's name was not listed on the schedule.

Interview with Staff #21 on 7/21/10 revealed the wrong patient identification number had been stamped on the care note indicating Patient #30 had an extraction, when in fact Patient #42 had the extraction. This issue was discovered during the survey process on 7/21/10. The staff at the Dental Clinic were unaware that the error had occurred until interviewed by the NYS surveyor.


Based on policy and procedure review, medical record review and interview, the Dental Clinic does not ensure the dental medical records are complete with an allergy sticker affixed in the chart for 3 of 11 patients. (Patients #31, 33 and 42)

Findings include:

Review on 7/21/10 of Dental Clinic policy and procedure for Patient Charts revealed whenever a patient has allergies it will be noted with an "ALLERGY" sticker, listing all allergens, affixed in the chart.

Medical record review on 7/21/10 for Patient #31 revealed the History and Physical exam dated 4/20/10 indicated an allergy to nickel. The medical record did not contain an allergy sticker.

Medical record review on 7/21/10 for Patient #33 revealed the History and Physical exam dated 10/23/08 indicated allergies to Librium and Exelon. The medical record did not contain an allergy sticker.

Medical record review on 7/21/10 for Patient #42 revealed the History and Physical dated 3/9/10 indicated allergies to peanut butter and bananas. The medical record did not contain an allergy sticker.

These findings were verified with Staff #21 on 7/21/10 at 10:00 AM.

Based on medical record review and interview, the facility does not properly execute consent for treatment while patients are hospitalized for 7 of 47 patients. (Patients #11, 16, 18, 24, 39, 40 and 41)

Findings include:

Medical record review from 7/19/10 through 7/22/10 revealed the lack of documentation of consent for treatment from date of admission:
- Patient #11 and 16: 5 day lapse
- Patient #18: 8 day lapse
- Patient #24: no consent noted
- Patient #39: 4 day lapse
- Patient #40: 3 day lapse
- Patient #41: 7 day lapse

This finding was verified with Staff #1 on 7/21/10 at 3:30 PM.

Based on observation, document review and interview, the facility does not maintain the confidentiality of medical information and provide safeguards against unauthorized use.

Findings include:

Observation during tour on 7/19/10 of the Urgent care Center revealed two large size 3-ring binders in an unlocked cabinet in a patient care area:
--Binder #1 contained patient names and urine test results (over 20 pages with 10-15 patients' names on each page).
--Binder #2 contained patient names with ED triage diagnoses (over 20 pages with 10-15 names on each page).

This finding was verified with Staff #1 on 7/19/10 at 11:15 AM.

Based on policy and procedure review, the facility does not ensure policy and procedure manuals are reviewed and revised as necessary annually.

Findings include:

Review on 7/21/10 of the Medical Staff/Professional Staff policies and procedures manual revealed the last review and/or revision date of the manual was 4/18/05. Review of the policies contained in the manual such as "Reappointment Process" and "Physician Supervision" revealed review dates in 2007.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEYS COMPLETED 4/23/05 AND 4/11/08.

Based on policy and procedure review and medical record review, the facility does not ensure that patients receive all the information needed regarding advanced directives for 3 of 31 patients. (Patients #10, 37 and 44)

Findings include:

Review on 7/21/10 of Advanced Directives/Medical Orders for Life Sustaining Treatment(MOLST) form policy and procedure revealed, "All patients cared for at the facility should be encouraged to appoint a HCP and make their wishes known regarding life sustaining treatment."

Medical record review on 7/20/10 and 7/21/10 revealed no evidence in the files for Patients #10, 37 and 44 that discussions took place regarding completing a health care proxy form, living will, etc.

Based on record review, interview and observation, the facility does not provide activities designed to meet the overall well-being of 9 of 9 swing bed residents currently hospitalized. (Patients #6, 11, 39-41 and 46-49)

Findings include:

Document review of posted activity calendar and interview of Staff #49 on 7/20/10 and 7/21/10 revealed the "am" activity is scheduled for 10:00 AM. The residents in the swing bed capacity are in therapy sessions during all or most of these scheduled activity time.

During interview on 7/21/10 at 10:00 AM, Staff #49 verified that all activities are scheduled (date and time) according to the posted activities calendar on units.

Review on 7/21/10 of activity log sheets dated during the month of July 2010 revealed that participation by swing bed residents was documented as "R" (refused) or "O" (off unit) for activities as posted on the activity calendar. Yet, no evidence was found in activity log sheets to offer alternative or substitutions for planned activities; e.g., room visits, review of current events, etc.

Observation of the swing bed unit on 7/21/10 from 11:00 AM to 12:00 PM and 1:00 PM to 3:00 PM revealed no activity staff member observed on the swing bed unit to assist and/or invite residents to any of the scheduled activities as posted on the said activity calendar.

Review of the activity log sheet for Patients #12, 13 and 14 revealed documentation that the residents were off the unit "O", sleeping "S" or refusing "R" most activities offered. The only activity listed under 1:1 time was "5 minute mail". No evidence was found to indicate what individualized programing was offered, evaluation of resident responses to activity programing, and/or alternative activities presented to residents to meet residents' needs.

Based on medical record review and interview, the facility does not provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for 7 of 37 residents. (Patients #12-17 and 41)

Findings include:

Medical record review from 7/19/10 through 7/21/10 revealed that the social service section of the records for Patients #15-17 lacked individualized social work plans of care for the residents. Review of the narrative social work notes for Patients #15-17 revealed nearly identical narrative notes upon admission.

Medical record review on 7/21/10 for Patient #41 revealed a social work note that documented that the resident had had incidents of injurious behavior to self and others, and was transferred to a higher level of care in the emergency department for evaluation on two separate occasions while on the swing bed unit. The Nursing Care Plan revealed the patient had recently been released from incarceration, and had a life-long history of a troubled upbringing and crisis issues, yet social services did not assess and/or intervene on the resident's behalf. This finding was verified with Staff #4 on 7/20/10 at 11:00 AM.

During interview on 7/21/10, Staff #4, who is a social worker, verified his lack of participation with discharge planning. In addition, Staff #4 revealed he has no participation in the palliative care program.

Interview with Staff #19 on 7/20/10 revealed that Staff #4 does not actively participate in providing for the social care needs of the residents.

Medical record review on 7/21/10 of the social work care plan form for Patients #12, 13 (admit date 3/31/10) and #14 revealed the advanced directives section was completed, but the remainder of the care plan was left blank, lacking individualized goals, interventions and outcomes/evaluations, despite all three residents receiving palliative/end of life care.