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Based on tour of the unit, medical record review and interviews with staff and patients/ representatives, it was determined that the facility was not effectively informing and explaining patient's rights information to patients/representatives.

Findings include:

During the tour of the surgical unit on 8/13/12 and medical unit on 8/14/12, patients and their families were interviewed regarding the distribution of patient rights information.

1. The patient in room 3C19 was interviewed on 8/13/12 at approximately 11:45 AM. The patient reported that he was not given patient's rights package nor was the information contained in the patient ' s rights package furnished by any staff member.

2. The patient in room 3C20 (MR # 10) was interviewed on 8/13/12 at approximately 12:15 PM. The patient reported that she was legally blind. She stated that staff communicates the information in the consents and patient rights documents to her verbally and if there are any documents to be signed, she is able to initial the document with guidance by the staff. The patient reported that the information contained in the patient's rights package was not discussed with her.

3. The patient in 3C03 was hard of hearing and was interviewed on 8/13/12 with her husband at approximately 12:00 PM. The patient arrived in the unit on 8/12/12. The patient and her spouse reported they were not provided furnished with the patient's rights booklet or any other information.

4. The patient in 4A43A was interviewed on 8/14/12. This patient reported that the patient rights information were not explained or given.

It was noted that 3 of 3 patients interviewed in the unit SE31 and 1 of 2 in the SLB4 unit reported they were not provided with the required Patient's Rights information.

At interview with staff members they stated that patient rights information is given to the patient at admission and in the Emergency room.

Review of MR # 10 in the unit on 8/13/12 at approximately 12:25 PM noted the patient was scheduled for discharge the same day of the review. The patient was admitted to the facility on 8/10/12 and was status post modified radical mastectomy. It was noted that two copies of "An Important Message from Medicare about Your Rights" (IM) dated 8/11/12 was in the record and were not signed. Staff documented "Pt unable to sign, IM explained and copy left at bedside". This patient at interview reported that she usually prints her initials on documents presented to her.

MR # 11 was reviewed at approximately 3:30 PM during a tour of the medical unit on 8/14/12. The patient was discharged and had left the unit at the time of the review. It was noted that there was no IM form located for this Medicare Beneficiary.

Review of MR # 12 on 8/15/12 noted that this is 70 year old patient was admitted on 7/19/12 and discharged on 7/23/12. The IM form was dated 7/23/12. The patient was discharged on 7/29/12. The facility did not provide this patient with another copy of the IM which is required prior discharge. Similar finding was noted for MR# 13, an 88 year old patient who was admitted on 06/29/2012 with cellulitis on the right leg and discharged on 7/15/12.
Review of MR # 14, a 75 year old Spanish speaking patient with perforated Duodenal Ulcer was admitted on 8/6/12 consented for exploratory laparotomy on 8/7/12. It was noted that all consent forms were written in English but not all the consent for treatment forms indicated that an interpreter was used. The reason for not utilizing an interpreter was not documented.
Similar finding noted for this Spanish speaking patient in MR # 16. This patient consented for possible C-section on 6/22/12. It was noted that consent form was written in English. There was no documentation that an interpreter was used to obtain the consent or the reason why this was not necessary.
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Based on the review of the grievance policy, complaint log for twelve months and facility ' s complaint process, it was determined that the hospital was not reviewing , investigating , and resolving each patient's grievance within a reasonable time frame. In addition, there was no evidence that the facility was responding to patients/patients ' representatives on the outcome of the investigations of the grievances.
Findings include:
Review of Grievance #1 on 8/15/12 noted the facility's Patient Relations Department received a written complaint from the patient regarding care rendered in the Emergency Department (ED). The complaint letter was dated August 28, 2011 and the Patient Relations Department Patient/Family Feedback Report was dated 9/26/12. It could not be determined when the facility received this complaint. It was noted that the investigation was completed 10/12/11 but the letter to the complainant regarding the outcome of the investigation was dated 10/31/11.
In Grievance # 3, dated 1/9/12, the patient filed a grievance with the Patient Relations Department regarding an appointment with the orthopedic clinic on 1/9/12. The patient was dissatisfied with the physician's treatment plan for his knee and was unhappy with the overall attitude of the hospital Security Guard. The documents reviewed indicated that the facility investigated the complaint. There was no evidence that the complainant received an acknowledgement that the facility was investigating the issues. The Security Department responded to the Patient Relations on 3/2/12 and the physician ' s response was dated 1/12/12. There was no evidence that the complainant received a written response on the outcome of the investigation.
In Grievance # 4, dated 1/12/12, the complainant, the patient's health aide complained to the Patient Relations Department on 1/12/12 regarding issues in the Endoscopy Department. The Patient Relations Department documentation indicated that the complaint was forward to the Chairman of Medicine, the Nurse Manger of Endoscopy and Directory of Radiology for further review and investigation. There was no evidence that the complainant was informed of the outcome of the investigation or the reason why this was not necessary.
In Grievance # 5, dated 1/17/12, the patient's Health Care Proxy Agent filed a complaint with the Patient Relations Department on 1/17/12 regarding the facility ' s failure to properly execute the patient's Advance Directive. It was noted the complainant was forwarded to the Chairman of Medicine and Nurse Manger of the Emergency for further investigation. The response to the complainant was dated 2/8/12. However, the document reviewed indicated that the response from the Nursing Department was on 4/26/12, two months after the response to the complainant.
Review of Grievance # 6 noted that the patient contacted the Patient Relations Department on 1/20/12 regarding a surgical procedure and overall care. It was noted the Patient Relations Department forwarded the complaint to the Chairman of surgery and the nurse manager of SLB6. The Surgical Department response was dated 1/26/12 and the Departmental Action/Resolution from SLB6 was dated 7/5/12. The investigation was completed on 7/5/12 There was evidence that the complaint was informed of the outcome of investigation.
In Grievance # 7, the patient was discharged from the facility on 12/18/11. The patient contacted Patient Relations Department on 1/20/12 because she felt that she was inappropriately discharged. It was noted that the initial written response to the complainant was dated 2/16/12, almost 30 days after the complaint was filed. There was no evidence that the complainant was informed that she may file a grievance with the State Department if she is not satisfied with the outcome of the investigation.
In Grievance # 8, dated 3/2/12, the patient's daughter filed a grievance with Patient Relations Department regarding the care rendered in the Wound Care clinic on 2/7/12. The complainant alleged that the patient with dementia and an open sore on the hip was brought the patient for wound care but the physician was not present. The complainant alleged that if the physician had examined the patient he would have noticed the infection. The response to the complaint dated 3/7/12 did not address the patient's representative concerns.
In Grievance # 9, dated 3/21/12, the complainant's brother contacted the Patient Relations Department alleging that security used excessive force while attempting to restraint his brother. The directory of security investigated the complaint. There was no acknowledgement or written response of the outcome of the investigation.
In Grievance # 10, dated 3/27/12, the patient's mother was dissatisfied with care rendered to her son in the orthopedic clinic. The grievance was forwarded to Interim Chairman of Surgery for further review. The response to the Department of Patient relations was dated 4/1/12. There was no evidence that the complainant was informed of the outcome of the investigation.
This patient filed two grievances with the facility (a verbal Grievance # 11 and a written Grievance # 2). In Grievance # 11, the patient contacted the Patient Relations Department on 3/28/12 regarding care in the ED on 3/13/12. The Patient Relations staff forwarded the complaint to the Chairman of Emergency Medicine and the Nurse Manager of the Emergency Department. The response was dated 3/29/12. There was no evidence that the complainant was informed of the outcome of the investigation. This patient then filed a second written complaint regarding the same issues. It was noted that the Patient Relations Department received the second complaint on 4/26/12. The written response to the patient was dated 6/13/12, three months after the original grievance was filed.
In Grievance # 12, dated 7/30/12, the complainant who is the patient's sister contacted the Patient Relations Department regarding the patient development of multiple bed sores for the admission of 02/20/12. The case was forwarded to the Nurse Manager of Seton 3-2 for investigation. The documents reviewed indicated that the investigation was completed on 8/15/12. There was no evidence that the patient's representative received a written acknowledgement or the outcome of the investigation.
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Based on observation, it was determined that the facility did not effectively ensure a safe and sanitary environment for all patients
Findings include:
During the tour of surgical unit on 8/13/12 at approximately at 11: 25 AM - the patient's bathroom in room 3C19 was inspected. It was observed that the shower stall was dirty; toilet bowl was soiled/ stained; vent was laden with dust and ceiling tiles were stained.
During the tour of the Inpatient psych unit Bayley Seton-3rd floor on 8/16/12 at approximately 12:30 PM, it was observed that in the TV room- 14 chairs were in disrepair, material on the seat and back of chairs were torn.

In Room 376, the soap dispenser was off the wall.
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Based on the review of medical record, it was determined that the facility did not ensure that the patient in MR # 17 had a complete nursing assessment.

Findings include:
MR # 17, a 48 year old female with past medical history of type II diabetes was found to have glucose level of 1419 and was admitted on 8/10/12. The initial nursing Adult Admission Assessment dated 8/10/12 did not identify the patient's need for nutritional consultation. The staff interviewed reported that the patient did not meet the criteria for nutritional trigger and therefore, a nutrition consult was not done.
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Based on review of medical records, it was determined that the facility failed to ensure that each patient's care plan was kept current in regards to pressure ulcers. This finding was noted in 2 of 10 applicable medical records reviewed.
Findings include:
Review of MR #1 on 8/15/12, noted that the patient was admitted on 8/7/12 for Urinary Tract Infection. An initial nursing assessment on 8/8/12 noted pressure ulcer, but no description as to size, stage or color. On 8/14/12, nursing documentation noted a stage II sacral ulcer measuring 4 cm x 4 cm and hydrocolloid dressing placed. There was no documentation that the pressure ulcer was treated from 8/8/12 through 8/13/12. In this time period, there was no physician order for the treatment of the pressure ulcer.



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Based on medical record review and staff interview, it was determined that the facility failed to implement an interdepartmental protocol for the prevention of pressure ulcers.
Findings include:
MR #2, an elderly patient was admitted to the hospital on 5/9/12 due to a urinary tract infection, congestive heart failure and to rule out sepsis. The patient skin assessment upon admission was noted as intact- no skin breakdown. The patient developed a stage II pressure ulcer at the left heel on 5/13/12. The patient also developed a stage II pressure ulcer at the sacrum and an unstageable pressure ulcer on the left calf. There was no evidence of a request for a nutrition consult/referral upon nursing identification of a hospital acquired pressure ulcer. There was no evidence of an interdepartmental protocol by nursing and the nutrition department for the timely referral of patients with hospital acquired pressure ulcers.
Similar findings regarding the lack of nutrition referral for patients with pressure ulcers were noted in MR #3, 4 and 5.
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Based on the review of medical and staff interview, it was determined that the facility did not effectively ensure that medical records were accurate and complete.
Findings include:
During unit tour on 8/14/12 MR # 17 was reviewed on 8/14/12 at approximately 3:30 PM. The surveyor was informed that the patient was discharged on 8/14/12. The patient had already left the unit and could not be interviewed.
The record revealed a 68 year- old patient brought by ambulance on 8/09/12 with a chief complaint of shortness of breath and a medical history that included COPD, anxiety and asthma. The patient was admitted for further evaluation and treatment. It was noted that on 8/13/12 at 1200, the attending noted " discharge patient today " . There were no other progress notes in the record. The discharge order to home was dated 8/14/12 at 9:30 AM. There was no documentation why the patient remained in the hospital an extra day. The discharge instructions indicated that the diagnosis was COPD and chest pain. The discharge instructions signed by the physician was dated on 8/13/12, the day before discharge.

Patient in MR # 20, a 71 year old patient with past medical history of diabetes type II, hypertension and a left total knee replacement was admitted to the facility for an elective surgery of the (R) knee on 8/8/12. Review of the History & Physical form noted that pages 1 and 3 were dated 7/26/12. Pages 4, 5 and 6 were dated 8/8/12. The Consent and Authorization form signed by the patient was dated 7/26/12. There was no explanation for the different dates on the History and Physical form.

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Based on interview, the review of medical record and other documents, it was determined that the facility failed to ensure that medical records are complete within 30 days following discharge. This finding was noted in 4 of 28 applicable records.

Findings include:

The review of the four delinquent records on 8/16/12 noted they were tagged incomplete for various reasons.
MR #6 who was discharged on 5/15/12 did not have a discharge summary.
MR # 7, discharged on 6/7/12 did not have a discharge summary and the Physician Assistant medication orders was not co-signed by the attending physician.
For MR #8, the discharge summary had not been dictated, a consultation request did not indicate the reason for consultation, and there was no discharge order. The patient was discharged on 5/17/12.
MR #9 who was discharged on 6/12/12 had a dictated discharge summary that had not been approved by the patient's attending physician.

At interview with the Administrative Director of Medical Records (HIMS) on 08/17/12, she stated she has about 600 delinquent records in the Medical Record Department that are at different stages of completion.
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Based on interviews and the inspection of drug storage areas, it was determined that outdated drugs were available for patient use.

Findings include:

An inspection of the Night Cabinet located at the Baley Seton Campus found two medications that expired in July, 2012. The Night Cabinet provides immediate access to medications during off hours when the satellite pharmacy is closed. At interview with the Administrator Director of Pharmacy, she stated that the system in place was to conduct periodic checks and mark cassettes for easy identification and timely removal of soon to expire medications. The cassettes from which the expired medications were pulled were not marked as described.
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Based on observation and staff interview, it was determined that the facility failed to maintain the cleanliness of the kitchen and food storage area to ensure food safety.
Findings include:
A tour of the kitchen and store room was conducted on 8/15 and 8/16/12 accompanied by the Interim Food Service Director and the Food Service Administrator. The walls throughout the kitchen were dirty and had paint peeling off the wall. Baseboards throughout the kitchen were detached from the walls and had accumulated dust and grime. Baseboards outside of freezers were broken and detached with dirt on the inside of them. The window behind the tray line was opened and dusty. This open window had no screen to prevent flies from entering the kitchen. An uncovered meat slicer was placed on top of a table and was dusty. When the Director was asked if the slicer is used in the kitchen, she replied the equipment is not in use. Many large garbage cans were found throughout the kitchen, one of the large garbage cans was used to dispose of paper towels after hand washing.
A cook was observed panning chicken on a table next to a large dirty garbage can and in front of the garbage can was a dusty window with a plastic screen that was very dirty. There was no visibility through the screen. This area was unsanitary. It was observed that at the end of the tray line there was silver duct tape attached from side to side covering about 12" of the tray line. The duct tape was detached, raised and shredding. When asked what the tape was used for, the surveyor was informed that the tape prevent the tray from falling from the end of the tray line. This was a manual tray line and the checker at the end of the tray line was responsible for checking the tray for accuracy and holding a tray until it is ready to be placed on a cart. The tape is raised off the base of the tray line and prevents a thorough cleaning and disinfection of the tray line.
The cabinet lock was broken and it had a makeshift cord to close the cabinet. It was observed that a rack containing 3 shelves of clean pots and pans was located behind the tray line next to the cabinet that stores clean and dirty aprons. This rack is located in a traffic area where employees are picking and dropping off dirty aprons. The rack was not covered to prevent dust and unwanted handling of pots and pans. There was another rack beside this rack that had 3 shelves of clean ladles, slotted spoons and other small equipment used in the preparation of food. This rack was also uncovered and open to dust.
The storeroom where canned goods are stored was observed to be dusty and dirty. The floor was dirty and full of obsolete equipment. Upon entering the storeroom there was a large gray garbage container that had dry food grime at the bottom of the garbage container. The storeroom was disorganized and unsanitary.

2- A tour of the kitchen at Bailey Seton on 8/16/12 found the kitchen and storeroom in disrepair. The electrical outlet does not work rendering the dishwashing machine unusable. The facility is using paper goods. There was a leak in a section of the dry storeroom and the acoustic tiles were damaged. There are missing and stained acoustic tiles in the dry storeroom. The cover (cracked) and hinge on the ice machine was broken. Two acoustic tiles above the ice machine were missing. Ceiling acoustic tiles above the prep area near the tray line was missing. A rack containing pots and pans was not covered. This rack was located where there is heavy traffic. Throughout the kitchen and the dry store room there was paint peeling from the walls. The receiving area had a television on the floor not in use and very dusty. The wall next to the receiving area was observed with large holes at the bottom of the wall. The wall is covered by a small metal sheet that is not fixed to the wall. Two hand sinks were observed not to have soap. Forty eight (48) florescent lights were not working in the kitchen.
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Based on Food Service Emergency Preparedness Manual, observation and staff interview, it was determined that the hospital food emergency preparedness program was ineffective and would not meet the needs should a disaster occur.
Findings include:
1. A tour of the kitchen and food storage was conducted on 8/15 and 8/16/12. The surveyor was accompanied by the Interim Food Service Director and Food Service Administrator. The department's Emergency Preparedness Manual was reviewed with all in attendance. The manual consisted of 2 sheets of paper. One sheet was a three day menu with portions assigned to food items and a list of food items with a number next to it. There was no other information available in the manual to make the process complete and efficient. The emergency preparedness manual was incomplete. There was no evidence that the menu was modified to include pureed diets. The location of water and how it would be distributed to the units was not defined. The manual did not have a process so that anyone from any department could follow through with food distribution to the units. The location of the food was not documented. When the Food Service Director was asked where is the food for this menu, he did not respond. Paper goods were not listed and food equipment such as can openers, gloves, and aprons were not listed. Menu food items were scattered throughout the department. The hospital program for Emergency food supplies does not meet the standard to deal with a disaster. There is no documented process in place for the distribution of food to patients, staff and visitors should a disaster occur.
2. A tour of the kitchen at Bayley Seton was done on 8/16/12 with the Interim Food Service Director and the Food Service Manager. The Food Service Manager was asked about her department's Emergency Preparedness Program to which she responded that she was unaware of an Emergency Preparedness Program at the site. The Food Service Manager informed the surveyor that the facility feeds approximately 75 patients. The facility has an impatient psychiatric unit, inpatient detoxification unit and multiple outpatient clinics. The facility is approximately 25 minutes away from the main hospital by car. Currently, this facility does not have a Food Emergency Preparedness Program should a disaster occur.
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Based on dietary menu review, physician's diet prescription and staff interview, it was determined that the physician diet orders were not documented as prescribed on the patient's menu.
Findings include:
A tour of the Clinical Nutrition area of the department was conducted on 8/14/12 with the Interim Food Service Director and Clinical Nutrition Manager. In reviewing the hospital menus and physician diabetic diet orders, the surveyor observed a patient's menu titled "CHO/ DIABETIC. " The surveyor inquired about this diet abbreviation on the menu. The Clinical Nutrition Manager informed the surveyor that the diet was an abbreviation for a diet titled "Consistent Carbohydrate Diet." This "Consistent Carbohydrate Diet " is the new version of a Diabetic diet that was approved by the hospital.
This diet was not ordered by its appropriate title "Consistent Carbohydrate Diet- and did not provide the number of grams of carbohydrate per day that the patient requires. The process of incorporating this new diet correctly in the food service system was not done. The diet was not ordered appropriately by the physician, it was ordered in calories instead of grams of carbohydrate. The menu is a tool used for teaching patients their prescribed diet and the diet order should be clear, non-abbreviated and written on the menu as prescribed.
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Based on medical record review and staff interview, it was determined that the facility failed to ensure that timely nutrition reassessments were performed on patient with pressure ulcers.
Findings include:
Review of MR # 21 on 8/13/12 noted that an elderly patient was admitted to the hospital on 5/9/12 due to a urinary tract infection, congestive heart failure and to rule out sepsis. The patient was initially nutritionally assessed on 5/10/12. The patient developed hospital acquired pressure ulcers on 5/13/12, a left heel stage II, sacral stage II and an unstagable ulcer on the left calf. Nutrition reassessment of the patient was untimely on 7 of the 14 occasions (50%). Reassessment intervals were inconsistent and were not in accordance with the hospital reassessment policy on high risk patients. The nutrition reassessments were done on 5/29 (8 days), 6/5 (7 days), 6/12 (7 days ), 6/28 (16 days), 7/23 (12 days), 7/29 (6 days) and 8/7 (9 days).
Similar findings were found in MR#22 and MR #23.
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Based on observation and staff interview, the facility did not maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured.

Findings include:

During tours of the different departments of the hospital with the Vice President of facilities, on various times in the period from 8/13/2012 to 8/17/2012, the following issues were identified in the presence of the facility staff who acknowledged them:

Operative Suite and the Ambulatory Surgical Unit:
1. The soiled utility room (room #2C-6) on the second floor of the Spellman building was found to have positive air flow instead of the required negative air flow for this type of room.
2. Many electric closets were observed to have very dirty floors and they were dust laden. Also, some of those electric closets were found to have penetrations in their fire rating walls. Examples included but were not limited to: electric closet by the OR suite, electric closet 2C-3, ground floor of Seton Building GC-4, electrical closet of the ED2,
3. The bathroom 2C-7 did not have a nursing call bell and the ceiling tile was missing.
4. The nursing call bell in the patient bathroom of room 2-16 was not working, and the door of that room did not have a working locker that ensures the privacy of the patients who use that bathroom.
5. The nursing call system of room 2C-1B was not working and the door of that bathroom needed a key to open it from outside.
6. The nursing call bells of many patient bathrooms were not working. Examples included but were not limited to: bathrooms of rooms 2C-1B, 2C-14, 2C-10 and 2C-12.

Emergency Department (ED):
1. The entrance of the handicapped bathroom of the ED was found not to be even with the floor outside the room which makes it difficult for people using the wheelchair to use the room.
2. The water drains of the ADA bathroom under the hand washing sink were not insulated or otherwise configured to prevent abrasion or burn to wheelchair patients.
3. The clean supply room of the ED2 was found to have negative air pressure instead of the required positive air pressure for this type of room.
4. The high voltage electric wiring (460 volt) of the MRI trailer was observed to be hanging from the canopies of the ED entrance and was not secured which presented an electric and fire hazard. The hospital corrected this finding the next day after this issue was brought to the attention of the hospital staff.
5. The corridor between the urgi-center and the waiting room which is known as Gray Mile was uneven and presented a tripping hazard.
6. Dirt and grime were found at the periphery of the rooms and around furniture edges. The bathroom floor and the floor of the medication room in the Urgi-Care area were dirty. The base of furniture, intravenous poles, cabinets and other equipment were laden with dust and grime. Housekeeping equipment including a dust pan was stored in the hallway in the patient care area. Two feeding pumps on a desk beside the work station were dirty. At interview staff stated that the two pumps would be removed for cleaning. There was blood on the two equipment (Triage Metro Pro) used for point of care testing. The AVP of Nursing Services stated it was the responsibility of nurses to clean the equipment between each use.

Cooke Pavilion Psychiatry - children/adolescent psych unit:
1. A linen cart was observed being stored outside room 2 of the children/adolescent psych unit. This is a fire hazard and inappropriate storing of linen, especially in psych unit.
2. The nursing station of the children/adolescent psych unit was observed to be open. All of the mobile items/objects were accessible to the patients, and this presents potential risk for the staff and patients.
The door of the personal belongings closet at the children/adolescent psych unit was loose/ partly broken and was not secured.

Cooke Pavilion Psychiatry -Adult Psych Unit:
1. The toilet paper holders in many patient bathrooms were observed to have sharp edges and present a looping hazard. Examples included but were not limited to rooms #4, #11, #14, and #15.
2. The mirrors of the patient bathrooms were fixed to the frame by metal plates that had sharp edges and were mounted using non safety screws.
3. The closets of all of the patient bathrooms had regular hinges, and not piano hinges which presents a looping hazard.
4. The floor of the storage closet of the psych unit was observed to be very dirty.
5. The cushions and the surfaces of the chairs in the day room and lounge room were observed to be torn and broken.
6. The tub room was observed to have signs of water leak on the ceiling tiles.
7. The night stand in room #18 was noted to have a missing drawer, this makes it a looping hazard.
8. Almost all of the chairs in the dining room were observed to have cracked and broken surfaces that makes it difficult to clean and therefore presents an infection control problem.
9. The electric wiring of the coffee machine and water cooler in the dining room was exposed and not secure thereby presenting a looping hazard.

WIC program:
1. The breast feeding and the education rooms were observed to have stained ceiling tiles and signs of water leakage. During interview with the WIC program Administrator, she stated that the floor above them had water flooding which caused the problem.
2. There were some ceiling tiles that were missing in the education room and on the corridor of the WIC program.
3. Also, there were more than seven (7) ceiling tiles stained, along with signs of water leak in the waiting area.

Seton Building 2- ICU:
During a tour of the surgical ICU at approximately 10:20 am, the following were identified in the presence of the Vice President of facilities who acknowledged the findings.
1. The ceiling tiles of the airborne isolation rooms of the surgical and medical ICUs' #2C-33 and 2C-35 were of the regular type that present an infection control problem and not the washable tiles.
2. The floors of the surgical and medical ICU were observed to be dirty especially around the rooms perimeters.
3. There were two (2) broken floor tiles on room 2C-38. Additionally, the door of that room was not closing properly.
4. The medication room of the surgical ICU was found to have a negative air pressure instead of the required positive air pressure for this type of room.
5. There were penetrations around conduits on the fire rated wall above the fire and smoke doors between the medical ICU and the ambulatory surgical unit.
6. The smoke and fire damper on the corridor between the surgical ICU and the ambulatory surgical unit was noted to have multiple wiring passing through it which makes it difficult to close in the event of fire or smoke.

Catheterization Lab (Cath Lab):
1. No soiled utility room was provided for this unit.
2. No clean utility room was provided for this unit.
3. The fire rated wall of the electric closet 1C-5 on the first floor of Seton building was noted to be open to the corridor above the ceiling tiles and was not protected or sealed by the proper fire stops.

The Dialysis Unit- SLB Building:
During a tour of the dialysis unit on the third floor of SLB building at approximately 2:00pm, the following were identified and brought to the attention of the Dialysis medical Director and the Hospital Vice President of Facilities who acknowledged the deficiencies.
1. There were no pressure gauges provided at the sediment filter, softener or the carbon filters to help with monitoring of the water treatment system.
2. There was no water sample port provided at the second carbon filter to allow for testing for the chlorine and chloramines at this site.

The Sleep Center:
The nursing call bell of the two rooms of the sleep center did not have audible alarm.

Bayley Seton campus RUMC:
During a tour of the Bayley Seton campus of RUMC on 8/16/2012, the following were identified in the presence of the Vice president of Facilities who acknowledged the findings.
1. The fire alarm next to room 6 on the first floor of the F wing- Extended Observation Bed (EOB) was mounted to the wall with a gap of 2 inches between it and the wall. This presents a looping hazard.

2. There were two portable ACs in the EOB unit that were not secured and their electric wiring was exposed and not secured. This presents a looping hazard.

3. The nursing station of the EOB unit was noted to be open, not secured and accessible to patients. This presents a risk for patients and staff.

4. The electric wiring of the air conditioner at the nursing station were assembled through a conduit and secured to the wall leaving a gap of 2 inches. That, in addition to the coiled cord of the phone and other items present looping and a security hazard to patients and to the staff.

5. The TV set in the activity room was not secured and its wiring was exposed and presented a looping hazard.

6. The storage cabinets in the activity room were mounted to the wall at a level of 4 feet from the floor with their handles presenting a looping hazard.

7. The sink and faucet of the activity room were the regular type and not the safety type required for the psych units in order to prevent a looping hazard.

8. The padlocks of the lockers in the activity room were protruded metal that present a looping hazard.

Main ER (CPEP):
All of the hardware of the patient bathroom (faucet, toilet's flushing, door handle, water pipes, etc.) were the regular type, not the safety type required for the psych units and presented a looping hazard.

EF3 - 25 inpatient Psychiatric beds:
1. All of the electric outlets of the occupational therapy room were not the safety type required for the psychiatric units.
2. The fire extinguishers of the unit were locked with pad locks that was a metal projection that could be used for self-harm to psychiatric patients.
3. The gasket of the refrigerator and the door handle were broken and glued by plaster that was stained and dirty. This presents an infection control problem.
4. In room 307 the metal plate used to affix the heat unit to the wall had regular screws not the safety screws and the wiring of this unit was exposed and presented a looping hazard.
5. The edge plate of the mirror was loose and was not secured properly and had a broken edge that was sharp and presented a risk of the patient safety.
6. Room 3-119 had a hole in the wall next to the door frame.
7. The TV of the lounge room was not secured and its electric wiring was exposed and presented a looping hazard. Also the wall behind the TV had multiple holes.
8. The shower head and the shower knob of the patient's shower room presented a looping hazard.
9. The patient closets in all of the patient rooms had regular hinges that present a looping hazard.
10. The cushions and the backs of the dinning chairs in the dining room were ripped and torn.
11. The fire alarm bell on the corridor of the unit was mounted to the wall with a three inch gap between it and the wall which presents a looping hazard.

Detox Unit:
1. The medication room 3-32 was found to have negative air pressure instead of the required positive air pressure for this type of room.
2. The temperature of the food refrigerator in the dining room was 48 Fahrenheit degrees exceeding the safe food refrigeration temperature (<40 F).

Spellman Building:
During a tour of the Spellman building on the morning of 8/17/2012, the following were identified in the presence of the Vice President of Facilities who was touring the hospital with the state surveyor:

Six (6) broken beds and five (5) huge plastic containers were observed being stored in the corridor of the sub-basement of the Spellman building outside elevator bank D.

Central Sterile Supply (CSS):
1. The sterile area of the CSS was found to have negative air pressure in relation to the area at the stairwell C outside the door of the sterile area of the CSS. This is a potential for an infection control issue.
2. The decontamination area was found to have positive air pressure to the corridor. This is a potential for an infection control issue.
3. The Janitor closet in the basement of Spellman building by elevator bank D was found to have missing all of its ceiling tiles and the electrical wiring was exposed, hanging from the ceiling and in disrepair. Also, the door of the room was broken and the room was in disrepair.

Radiology:
The door of the patient restroom in the waiting area was found to be broken at the locker site and the lock was not working. The door was not opening or closing easily.

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Based on the review of medical record and patient interview, it was determined that the facility did not consistently ensure that patient's discharge planning evaluations met all discharge plan requirements. This deficiency was noted in four of ten applicable medical records reviewed (MRs # 12, # 17, #18 & # 19).
Findings include:
During tour of the unit on 8/14/12 at approximately 1:30 PM, the patient housed in room 4A41A at interview reported that she was waiting for the MD to discharge her. This patient stated that her discharge plan was home with Visiting Nursing Services. The patient reported that she was instructed that the nurse will visit her tomorrow. However, the patient was unclear on the purpose of the home visit. The patient also did not know that she had a choice in home health care agency.
Review of MR # 17, in the unit on 8/14/12 at approximately 2:00 PM, noted that this 48 year old with history of HTN, DM, Afib, hypercholesterolemia went to the Emergency Department on 8/9/12 with chief complaint of genital pains. During the evaluation, laboratory work was done. The blood result came back with blood glucose of 1419. The patient was admitted for further evaluation and treatment. The patient was discharged on 8/14/12. The discharge planner noted on 8/13/2012 " agreeable with referral to visiting nurse on discharge." There was no documentation in the chart or the discharge documentations copied in the unit on 8/14/12 that there was discussion with the patient regarding the reason for the referral. In addition, there was no documentation that the patient was given a choice of home care agency. A copy of the chart presented to the surveyor on 8/15/12 noted that a copy of the Agency/Vendor referral form indicated that the patient had no preference of agency and Visiting Nursing Association of Staten Island was checked off. The patient signed the form on 8/13/12. The time that the form was completed was not indicated. There was no documentation that the patient was aware that she had a choice of agency.

Review of MR # 12 on 8/15/12 noted that this 70 year old patient was admitted on 7/19/12 with diagnosis of pneumonia and fluid overload. It was noted that the patient was alert and oriented. The Case Coordination Initial Assessment dated 7/23/12 was reviewed. This document indicated that prior to admission the patient required partial assist with ADLs. The Discharge plan was reviewed on 7/27/12. The discharge planer noted " patient febrile at present will follow to resume services with VNA upon discharge " . This patient was discharged on 7/29/12. There was no documentation when the home care services were reinstated. There was no documentation that there was a discussion with the patient in order to determine if the patient was still satisfy with this agency. The discharge instruction dated 7/29/12 was not signed by the patient. The nursing discharge indicated that the patient was discharge home accompany by self. There was no documentation in the record if the patient was discharge with home care services.

Review of MR # 18 on 8/15/12 noted that this 53 year patient with medical history of breast cancer with stage IV lung metastasis, hypertension and ascots was seen in the ER on 6/7/10 and the patient was admitted. The discharge plan dated 6/8/10 was reviewed. The discharge planner noted " the patient requested hospice care on discharge. VNS Hospice notified " . There was no documentation that the patient was given a choice of agency.

Review of MR # 19 on 8/15/12 noted that 68 year old patient brought from the adult home on 5/11/12 for evaluated due to blood sugar level of 491. The diagnosis was hyperkalemia and uncontrolled diabetes. -The discharge plan dated 5/12/2012 was reviewed. It was noted that the patient was alert and oriented. The patient resides at adult home and ambulates independently with a walker. The discharge planner noted will follow up for discharge needs. The discharge planning reassessment was not documented. There was no further discharge planning notes located in the record. The patient was discharge on 5/14/12. The discharge instructions dated 5/14/12 was reviewed noted that the patient was advised to check FS 2-3 times daily. The Care Coordination Initial Assessment documentation dated 5/12/12 indicated that the patient did not have a Glucose meter. There was no documentation if the patient had the ability to comply with the discharge instructions. The discharge instruction indicated that the patient was discharged on 5/14/12 at 0518. The patient ' s signature indicating that the patient understood the discharge instructions was not located on this form. In addition, the only signature was the physician signed who signed the form on 5/15/12, a day after discharge.
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Based on review of medical records and hospital's policy, it was determined the facility did not consistently ensure that all patients had properly executed inform consents and that the informed consents forms contained the required elements prior to the surgical procedure.
Finding including:
Review of MR# 15 on 8/15/12 noted that this 14 year old female signed a consent form on 6/22/12 for the delivery of her baby. It was noted that the name of the physician was not listed on the form. The operation and/or procedure on the form was not specific, it notes " Anesthesia and Delivery or C-Section with Spinal or General Anesthesia " . It was noted that on this form there was a section for the physician who explained the risks and benefits of this procedure but the name of physician was not provided. The patient signed the consent form on 6/22/12. The physician who signed the form did not include the date and time. Additionally, the signature was illegible. The anesthesiologist signed the form on 6/23/12. The name was not printed and the signature was illegible
Similar findings were noted for patient in MR # 16. The consent was signed by a Spanish speaking patient and there was documentation that an interpreter was used to provide the information contained in the consent form. Additionally, the witness, physician and anesthesiologist signatures were illegible.