HospitalInspections.org

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Based on document review, and interview, in two (2) of eight (8) personnel files reviewed, the facility failed to maintain a safe environment for patients by ensuring their policies and procedures regarding verification of new hires were implemented (Staff As and K).

Findings include:

Review of the facility's Policy titled "Operation Procedure 20-53 - Background Investigation of New York City Health and Hospitals" dated May 6, 2016 states: "Background investigations are to be conducted for each category of employee set forth in Section III. As a condition of employment or continued employment by the NYC Health and Hospitals, background clearance is required ...Digital fingerprinting by NYC Health and Hospitals of any candidate who has not been previously fingerprinted by the System in connection with his/her employment ... When a candidate's foreign education is required to meet the minimum qualification requirements (MQRs) for a position, the candidate must be informed that he/she must obtain an evaluation of his/her education from one of the approved evaluation services listed ...Educational evaluation by any of the approved evaluation services does not require further verification by NYC Health + Hospitals background vendor as these services conducted a sufficiently thorough investigation of document authenticity and equivalency to United States education."

Review of the personnel file of Staff A, revealed a 64-year-old male hired on 6/29/15 as a Chaplain/Priest. The job description for the chaplain position last revised on 4/19/20 states: "Under direction conducts religious services and provides spiritual and moral guidance for members of the chaplain's faith; performs related work. Examples of Typical Tasks: Schedules and conducts religious services; Administers Rites and Sacraments; Counsel individuals and families on personal, moral, and spiritual problems.

There was no documented evidence of the following as required by the facility's policy, in his personnel file:
a) Seminary Ordination as a Priest. Staff A's diploma titled Bachelor of Sacred Theology dated 6/23/95 was translated from Latin to English by the facility contractor who noted on the diploma that they translated the document, but they did not verify the document.
b) Verification of previous employments
c) Ecclesiastical endorsement by an official endorsing agency of the candidate's faith or denomination, and by the Committee on Chaplaincies
d) Background check
e) Fingerprinting

Review of the personnel files of Staff K revealed a 74-year-old male who was hired by the hospital on 2/16/15 as a Chaplain/Rabbi.

There was no documented evidence of the following in Staff K's personnel file as required by facility's policy:
a) Translation (from Hebrew) or validation of diplomas
b) Validation of employment history
c) Background Investigation
d) Fingerprinting.

Staff C, Regional Director of Human Resources for Health + Hospitals and Staff B, Associate Director of Human Resource who were present during the personnel files review on 7/16/2021 at approximately 12:30 PM, acknowledged findings.
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Based on medical record review, document review and interview, in 1 (one) of 3 (three) medical records reviewed, the facility did not ensure nursing evaluations included accurate assessments of patient's skin condition in accordance with accepted standards of nursing practice (Patient #2).

Findings include:

Review of Patient #2's medical record identified the following information: A 62-year-old, male patient admitted on 3/28/2021 for chief complaint of respiratory distress with pulmonary edema and infiltrates. The patient was immediately worked-up in the emergency department and subsequently admitted to the Intensive Care Unit (ICU) for comprehensive management.

Review of the Nursing Flowsheets documented Braden Assessments (Assessment to determine patient's risk for developing pressure ulcer), including assessments for Integument were conducted not limited on the following dates:

On 3/28/2021 at 9:00 AM Braden Score=17 (At No Risk Score 15-18); Integument=Within Desired Limits (WDL, intact skin).
From 3/29/2021 to 4/1/2021 Braden assessments documented between Moderate Risk (Braden Score 13-14) to No Risk (Braden Score=15-18). Integument =WDL.

On 4/2/2021 at 8:00 AM Braden Score=14; at 8:00 PM Braden Score=15. Integument=Skin integrity not intact, and with bruise. No location documented.

On 4/3/2021 at 8:00 AM Braden Score=15; at 8:00 PM Braden Score=16; Integument=WDL.

On 4/4/2021 at 8:00 AM Braden Score =15; at 8:00 PM Braden Score=10 (High Risk Braden Score=10-12). Integument=appropriate for ethnicity, with bruise. No location documented.

On 4/5/2021 at 8:00 AM Braden Score=15; at 8:00 PM Braden Score=15. Integument=Not intact. Not specified.

On 4/6/2021 at 8:00 AM=Braden Score=16; at 8:00 PM Braden Score=16; Integument=Skin tear right buttock.

On 4/7/2021 at 10:00 AM, Pressure Injury was first identified; Location=posterior head; Stage 3; Full skin thickness Loss; Length=5 cm; Width=7 cm; Depth=0.1 cm.

The Physician's Wound Care Orders dated 4/7/2021 at 1:07 PM revealed orders were written for Stage 3 posterior head pressure injury: Cleanse wound with Dermal wound cleaner; Apply Hydrophilic paste; Cover with dry sterile dressing.

Nursing documentation revealed the patient was assessed daily with no pressure injury from 3/28/2021 until 4/7/2021. The pressure injury to the posterior head was first documented 10 days after the patient was admitted and it was identified as a Stage 3, a deep tissue injury.

During interview of Staff B, RN, Nurse Educator on 7/14/2021 at 3:00 PM, Staff B was asked of the role of and expectations from registered nurses regarding pressure injury prevention and management. Staff B reported the following: Registered nurses were educated in pressure injury prevention and management which included Braden assessments on admission, every shift and upon transfer, wound assessments, and implementation of preventive measures such as the use of special air mattress, turning and positioning, and referrals to physician and dietician. Once a pressure injury is identified, the nurses are to document in the medical record, notify the physician, and make referrals to the dietician and the wound care nurse.

This finding was acknowledged by Staff A, RN Head Nurse and Staff C, Interim Chief Nursing Officer who were present during the interview.