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Based on staff interview, and review of the facility's Complaint Log for the month of May 2014 & June 2014, Patients' Grievance files, Patient Safety/Risk Management Council minutes and Grievance/Appeals Committee minutes, it was determined that the facility failed to ensure that it has an effective grievance process which included prompt resolution of all grievances that the facility received. This was evident in nine (9) of ten (10) Grievance Files reviewed (Files #1, #2, #3, #4, #5, #6, #7, #8 & #9)

Findings:

Staff # 17 was interviewed on 7/10/2014. This staff stated that the facility's Grievance and Safety Committees review and resolve patients' complaints.

Ten Patients' grievances files were selected, from the complaint log for the months May and June 2014, and these files were reviewed. It was noted that nine of the ten patients' grievance files reviewed lacked timely written responses, as required.

For example:

Grievance file #1 was reviewed on 7/10/2014. It was noted that this grievance was regarding care rendered and discharge instructions in the facility's ED (Emergency Department) on 4/25/2014. It was noted that the facility received the grievance on 4/28/2014. The written response to the complainant was dated June 16, 2014.

Grievance file # 2 was reviewed on 7/10/2014. This grievance was regarding an occurrence dated 4/3/2014. In this complaint, the patient alleged that although he did not consented for HIV test, his blood was still tested and found positive. It was noted that an acknowledgement dated 4/3/2014 was located in the file. However, the written letter to the complainant was dated May 12, 2014, over 30 days after the grievance was filed.

Grievance file #3 was reviewed on 7/10/2014. It was noted that the patient's father filed a grievance with the facility on 5/13/14 alleging that the child's front teeth came loose during a surgical procedure. It was noted that the facility investigated the complaint. It was determined that the parent's family would be provided information of a dentist to schedule an appointment with and the evaluation would be at the facility's expense. However, the patient's family member was not provided a written response of the outcome of the investigation.

Grievance file # 4 was reviewed on 7/10/2014. It was noted that the facility received a grievance from a patient from the Reproductive Center dated June 09, 2014. In this complaint, the patient alleged that she was unable to gain access to her medical records and embryos. The grievance file indicated that the facility received the complaint on 6/17/2014. It was noted that an acknowledgement letter dated 6/17/14 was located in the file. A draft letter with a document in the file indicating that Patient Relations staff was "waiting for closure letter draft to be approved". At the time of this review on 7/10/14, this complainant has not been provided a written response of the outcome of the investigation.

Grievance file # 5 was reviewed on 7/10/2014. It was noted that the complaint was from a parent of a five (5) week baby seen in the ED on 6/23/2014. The parent alleged that the baby was placed on a stretcher with blood on the sheet. The final letter to the complainant was dated 7/10/2014.

Similar findings regarding delay of a written response to complainants were noted for files #6, #7, # 8, and #9.

The facility's Grievance /Appeals Committee meetings for 5/21/2014 and 6/4/2014 were reviewed on 7/10/2014. It was noted that four patient's complaints were discussed during the 5/21/2014 meeting and two patient complaints were discussed in the 6/4/2014 meeting. It was noted only the complaints and the status of the complaints were discussed in those meetings.

The facility's Patient Complaints and Grievance policy No. A3-106 revised 6/14 was reviewed on 7/10/2014. This policy indicated that "in accordance with Governing Body, the responsibility to review, and if needed resolve grievances, rests with the Patient Safety Committee.

The Patient Safety/Risk Management Council Meetings for the May 13, 2014 and June 10, 2014 were reviewed on 7/10/2014. It was noted that the facility's Patient Safety/ Risk Management Council was not resolving and reviewing all patients' grievance. It was noted that the issues such as timely responses to complainant and content of the responses were not addressed either in the Grievance Committee/Appeals Committee or the Patient Safety/Risk Management Council.

Based on staff interview and the review of Patients' Grievance files, it was determined that the facility failed to ensure that in its resolution of grievances that its decision contained all the required elements. This finding was evident in 2 of 10 grievance files reviewed (files #5 & #6)

Findings include:

Grievance file # 6 was reviewed on 7/10/2014. It was noted that the facility received a complaint from the patient who had a colonoscopy on 5/27/2014. The patient alleged that he was not properly sedated during the procedure. It was unclear when the facility received the grievance. However, it was noted that the facility received a second telephone call from the patient on 6/18/14 regarding this issue. It was documented that the patient was very upset. A copy of an acknowledgment letter dated 6/23/2014 and the final letter dated 6/26/2014 were located in the file. The final letter on the outcome of the investigation did not include the steps taken to resolve this grievance.

Similar findings was noted in grievance file #5; the response letter to the patient lacked the steps taken to resolve the grievance.

Based on interviews, the review of medical records and other documents, it was determined that the facility failed to determine a patient wishes concerning designation of a representative to exercise patient's right to participate in the development and implementation of patient's plan of care. This finding was noted in 1 of 5 applicable records reviewed (Patient #1).

Findings include:

Patient #1 is a 61 year-old male who initially presented to the Emergency Department of another facility for medical evaluation and was transferred after medical treatment to St. Luke's Hospital on 6/24/14 for psychiatric stabilization. The patient was admitted to the psychiatric unit involuntarily with certification by two physicians.

During record review on 7/11/14, it was observed that the initial inpatient treatment team on 6/25/14 noted a list of problems that includes paranoid ideations, somatic preoccupation, anxiety and non-compliance with medication regimen for which short-term goals and interventions were developed. Although the planned intervention by the social worker on 6/25/24 included "supportive contact, coordination of care and discharge", there was no indication the patient's family member or representative had been contacted regarding the patient's admission and encourage their participation in the patient's treatment plan. The "Inpatient treatment Team Updates" on 7/3/14 and 7/9/14 also lacked patient's representative involvement.

The Admission Database listed the patient's daughter as the next of kin and emergency contact.

At interview with Staff #5 on 7/11/14 at 11:30 AM, she stated the patient's case manager at a residential home where the patient resides was visiting today and had reported the patient missing for up two weeks, but was recently aware of his admission to the inpatient psychiatric unit.

Staff #6 on 7/11/14 at 11:35 AM stated the patient's daughter called the facility on 7/8/14 and visited on 7/9/14. However, notes written by the social worker on 7/11/14 at 6:52 PM (after the interview) indicated she attempted to contact the patient's daughter using the listed phone numbers, but was unsuccessful. Social worker added that she would follow up with patient's case manager.

It was noted that there was no previous attempt to contact the patient's family since his admission on 6/24/14 until seventeen days later, on 7/11/14.

16790

Based on staff interviews, review of medical record and observations, it was determined that the facility failed to ensure that Patient #19 was properly monitored for safety and the patients' environment/equipment were safe. This was evident in 1 of 1 applicable medical record reviewed.

Findings include:

During the unit tour (9B), it was observed that Patient #19, housed in room 31 bed A, was on 1:1 observation. The staff assigned to the patient was interviewed. The staff stated that the patient had been on 1:1 observation since 7/7/14 for safety. The staff stated the patient was assigned to her today, 7/9/14 at 7:30 AM.

The Observation Accountability Record form dated 7/7/14 - time: 23:30, and its accompanying Observation Monitoring form dated 7/8/14 were reviewed. It was noted that the section on the form indicating the reasons why this patent was placed on 1:1 observation was not checked. In addition, the period of observation and the frequency of observation section of the Observation Monitoring form was not filled out.

The Observation Accountability Record Form for 7/8/14 - time: 3:45 PM, and the Observation monitoring form dated 7/8/14 were reviewed. It was noted that the Observation Monitoring form indicated that the patient was on constant observation for suicidal ideation & the patient was also on special observation for safety. The staff who did the monitoring on 7/18/14 at 5:45 PM did not include his/her initials on the form, as required.

The charge nurse indicated that the patient was agitated and she was placed on 1:1 observation for safety. She also stated that at no time was the patient on special monitoring due to suicidal ideation.

Also, during a tour conducted on unit 9B on 7/9/14 at approximately 11:00 AM loose shower seats were noted in rooms, 9B-33, 9B-32 and 9B-31. This was brought to the attention of Staff #10 and staff #11.

Based on interviews, the review of personnel files and staff development activities, it was determined that the facility failed to ensure that all staff who apply restraint received education and training in the use of First Aid techniques and certification in the use of cardiopulmonary resuscitation. This finding was noted in 4 of 13 applicable files reviewed (Staff # 5, 6, 7, and 8).

Findings include:

The review of personnel files for Staff #5, 6, 7, and 8 noted these Security Officers had no training in First Aid and certification in the use of cardiopulmonary Resuscitation as mandated for all staff members who apply restraint or seclusion to patients.

At interview with the Assistant Director of Security, Staff #9 on 7/15/14 at 1:20 PM, he stated Security officers do not apply physical restraints on patients, but under the direction of appropriate clinical staff, security officers are permitted to assist clinical staff in restraining patients and can physically hold a patient's arms or legs for therapeutic intervention or to assure safety. Staff #5 further stated that security officers are not involved in the application and monitoring of physical restraints and therefore are not required to have first aid training or certification in the use of cardiopulmonary resuscitation.

The review of the facility's policy and procedure on Restraint and Seclusion last revised June 2014 defines restraint as "any manual method, physical or mechanical device, material, or equipment that immobilizes or reduce the ability of the patient to move his or her arms, legs, body, or head freely . . ."


In a document reviewed on 7/15/14 titled "Position Description/Performance Appraisal", the responsibilities of a Security Officer includes the provision of restraints of psychiatric patients as needed. The educational/professional development requirements for a Security Officer as noted in the document in bold letters includes "Meets yearly minimum training time - sixteen (16) hours on the job training, and eight (8) hours training yearly," including C.P.R. (Cardiopulmonary Resuscitation) certification.

The facility did not adhere to its educational/professional development standards developed for Security Officers.

32522

Based on observation, review of documents and staff interviews, it was determined that the facility failed to have an ongoing Quality Assessment and Performance Improvement Program that includes all services and departments.

Findings include:

1. An interview with the Director of Medical Records was conducted on 7/11/14 at approximately 10:00 AM. The surveyor asked to see the annual Quality Improvement Plan submitted to the hospital wide Quality Improvement Committee. The Director provided the surveyor two packs of papers with dates of 2013 and 2014. Both packs contained pages of repeated statistics with no analysis or interpretation of the statistics. When the Director of Medical Records was asked for the department's annual plan for quality improvement, he responded there was no plan to interpret the data provided. There was no evidence that the Department of Medical Records had implemented a formal Performance Improvement Program to promote compliance to federal regulation.

Review of the Minutes of the Executive Committee of The Medical Board, 2013 and January to June 2014, and Minutes of the Quality Committee Board of Trustees, January to June 2014, which was completed on 7/11/14, revealed:
The Medical Records Department reports to the Medical Board, but there is no
evidence that this department is included in the hospital's report to the Quality
Committee Board of Trustees. It was also noted that the reports submitted to the
Medical Board relates only to delinquent medical records, and there is no evidence
that this department has selected other relevant, data driven measures to monitor
the performance of the department and to identify areas for improvement.

These findings were verified by Staff #3 and Staff #4. At interview, on 07/14/14 at 2:00PM, Staff #4 stated, "Historically, Medical Records does not present to QPIC (Quality Assessment and Performance Improvement Committee)."

2. Contracted Services reports to the Medical Board, but there is no evidence that
relevant, data driven measures are collected, aggregated and analyzed to monitor the
performance of each contracted service and to determine areas for improvement.
Review of the Minutes of the Quality Committee Board of Trustees, January to June
2014 showed no evidence that Contracted Services are included in the hospital's
QAPI Program.

At interview, on 07/14/14 at 2:00PM, Staff #4 stated there is no presentation of data to QPIC for Contracted Services.

3. On 7/15/14 at approximately 2:00 PM an interview was conducted with Staff #4 concerning the program of Organ, Tissue and Eye Procurement. Staff #4 presented the hospital's report for the year 2012, and later, the 2013 data. The VP explained that the Organ, Tissue and Eye Procurement Reports for 2014 were not available for review. There was no evidence that the Organ, Tissue and Eye Procurement Program was integrated into the hospital's Quality Assessment and Performance Improvement Program for 2013 or 2014.

Based on interview and review of the medical record, it was determined that the physician and or other licensed health care practitioners failed to appropriately assess the patient's condition and provide adequate course of treatment.
Findings include:
Review of MR #9 on 7/9/14 noted this 78 year old patient was admitted on 7/1/14 with a chief complaint of generalized weakness. On admission the patient is noted with a necrotic pressure ulcer to the right scapula (shoulder blade) measuring 1.2 cm x 1.0 cm. There was no physician's order located in the medical record for treatment of this pressure ulcer. This was brought to the attention of Staff #10 and Staff #11.

Based on review of medical record and hospital policy it was determined that the facility failed to ensure that each patient's care plan was kept current in regards to pressure ulcers evaluation and management. This was noted in 3 of 4 applicable records reviewed.

Findings include:

Review of medical record for Patient #8 on 7/9/14 noted this 91 year-old patient was admitted on 7/3/14 with a chief complaint of blood in stool. On admission the patient is noted with multiple pressure ulcers: a stage III left sacral ulcer measuring 3 cm x 7 cm x 0.3 cm, moist, yellow slough and a 3 cm tunneling; the right sacral ulcer is unstageable measuring 2.5 cm x 2.5 cm x 0.3 cm; stage I ulcer to the left and right heels and a right medial knee stage I.

On 7/4/14 at 9:28 AM the physician's order for calcium alginate for buttock daily and PRN is noted. However, there is no documentation on the Skin Scale/Pressure Ulcer Flow sheet for 7/5, 7/6, 7/7 and 7/8 to indicate that dressing changes are being performed as per physician's orders. This was brought to the attention of Staff #10 and Staff #11.

Review of medical record for Patient #9 on 7/9/14 noted this 78 year-old patient was admitted on 7/1/14 with a chief complaint of generalized weakness. On admission the patient is noted with a necrotic pressure ulcer to the right scapula measuring 1.2 cm x 1.0 cm. There was no physician's order for treatment of this pressure ulcer and there was no documentation by nursing that this pressure ulcer was being treated. This was brought to the attention of Staff #10 and Staff #11.

Review of medical record for patient #10 on 7/15/14 noted this 69 year-old patient was admitted on 4/16/14 and the initial skin assessment noted the patient's skin to be intact. On 4/17/14 at 12:27 PM, a stage II pressure ulcer is noted to the sacrum measuring 1.5 cm x 1.5 cm with no exudate. This was identified as a new in house pressure ulcer. there was no treatment plan documented for the sacral ulcer. This was brought to the attention of Staff #12.

Based on staff interview, policy and procedure and other documents, it was determined that the facility failed to ensure that patient's medical records are completed in a timely manner. This finding was noted in 5 of 5 delinquent records reviewed (Patient #2, 3, 4, 5, and 6).

Findings include:

On 7/11/14 at approximately 11:45 AM the Director of Medical Records was interviewed concerning delinquent medical records that were not completed within 30 days. The hospital policy titled "Medical Records: Suspension for Delinquency" noted that medical records are to be completed upon discharge of the patient, and no later than 30 days after the patient's discharge from the Hospital Center.
Five delinquent medical records were selected randomly. A review of the medical records noted the following:

Patient # 2 is a sixty nine year old female who was admitted on 10/19/13 with a diagnosis of Choledocholitiasis (the presence of gallstones in the common bile duct). The patient expired on 10/24/13. Review of the medical record shows the absence of an Emergency Department Record and a Discharge Summary that was not signed or dated by the Attending Physician.

Patient #3 is a sixty one year old male patient who was admitted too the hospital on 5/2/14 with an admitting diagnosis of renal disease and was discharged on 5/10/14. Review of the medical record noted the absence of an Emergency Department Report, missing Operative Report and the lack of an Attending Physician signature on the Discharge Summary.

Patient #4 is a forty two year old male patient who was admitted to the hospital on 11/21/12 and discharged on 11/24/12. The review of medical record showed no evidence of an Emergency Department Report, there was no operative report only a brief written note on the progress note, and the discharge summary was missing the Attending Physician signature and date.

Patient #5 is a 51 year-old male patient who was admitted to the hospital on 3/28/14 with diagnosis of drug induced mental disorder. The patient was discharged on 3/31/14. Review of the medical record showed that the discharge summary was not signed and dated by the Attending Physician.

Patient #6 is a 1 year old male patient who was admitted to the hospital on 1/4/14. The patient was admitted with a diagnosis of Respiratory Syncytial Virus (RSV - a virus that causes respiratory tract infections) and Bronchialitis (inflammation of the small airways in the lung). He was discharged on 1/5/14. Review of the medical record showed the discharge summary was missing both the House Staff Physician and Attending Physician signature and date.

The Director of Medical Records provided the surveyor a list of delinquent records for the past 6 months (1/1/14 - 6/1/14) titled "Delinquent Records - Suspension. Review of these documents dated 6/1/14, showed that thirty-one (31) Attending Physicians had delinquent records. There were 275 medical records that were delinquent for 30 days or more and there were 203 medical records that were delinquent for over 60 days. The total number of delinquent records for the month of June 2014 was 478.
It was evident that the hospital policy on completion of medical record has not been implemented.

Based on observation and staff interview, the facility's physical plant and the overall hospital development was not maintained in such a manner that the safety and well-being of patients are assured.

The findings are:

1. On the morning of 7/9/2014 observation of the Post-Anesthesia Care Unit revealed that there was a dusty ceiling vent in Bay #19.

2. On the afternoon of 7/9/2014 observation of the Post Partum/Neonatal Intensive Care Unit revealed that:
a) Room 12B-40, the Locker Room, had a ceiling vent that was covered with plastic wrap.

b) Room 12B-39, the Storage Room, had a dusty ceiling vent.

3. On the afternoon of 7/9/2014 observation of the Labor and Delivery Unit revealed that there was a dusty ceiling vent in Room 12A-15, the Soiled Linen Room.

4. On the afternoon of 7/9/2014 observation of the Emergency Department revealed that:
a) Room GE20B, a Restroom, had a sink that was not flush with the wall.

b) the Comprehensive Psychiatric Emergency Program Seclusion Room had a dusty ceiling vent.

c) the Soiled Utility Room had a dusty ceiling vent.

5. On the morning of 7/10/2014 observation of the Pediatric Intensive Care Unit revealed that Room R8A-43 had a dusty ceiling vent.

6. On the morning of 7/10/2014 observation of 8th. Floor Medical/Surgical Unit:
a) one of the Clean Linen Room walls had a hole in it. Within this room it was also observed that the cove base was taped onto the bottom of the wall.

b) Room 8B-23, a Bathroom had a dusty ceiling vent.

7. On the morning on 7/10/2014 observation of the 9th. Floor Medical/Surgical Unit revealed that:
a) Room 9A-20, an Equipment Room, had a clean linen cart, spare wheelchair, a hoyer lift, and a warmer in it.

b) Room 9A-15, a Housekeeping Closet, had one stained ceiling tile.

c) one of the medical refrigerators in this medical/surgical unit had ice build-up in it.

8. On the afternoon of 7/10/2014 observation of the AINY Rehabilitation Inpatient Unit revealed that:
a) two of the Patient Shower Rooms, had dusty ceiling vents and peeling paint coming off the ceiling.

b) in the vicinity of Winston Elevator there was one stained ceiling tile.

9. On the afternoon of 7/11/2014 observation of the 9th. Floor Medical/Surgical Unit revealed that Patient Rooms 9B-32, 9B-33, and 9A-32 had loose wooden shower seats.

10. On the morning of 7/14/2014 observation on the 6th. Floor Ambulatory Psychiatric Center Extension Clinic, the Primary Care Clinic, revealed that:
a) the Women Bathroom had missing floor tiles that exposed a hole around a steam riser.

b) the Men Bathroom had a sink that was loose and not flush with the wall.

11. On the morning of 7/14/2014 observation on the 3rd. Floor Ambulatory Psychiatric Center Extension Clinic, the Outpatient Psychiatry Clinic, revealed that the nurse call bell was not working in the Men Room.

12. On the morning of 7/14/2014 observation on the 2nd. Floor Ambulatory Psychiatric Center Extension Clinic, the Crime Victims Unit, revealed that one of the offices had one stained ceiling tile, and one stained light cover.

13. On the morning of 7/14/2014 observation on the 1st. Floor Ambulatory Psychiatric Center Extension Clinic, the Child and Family Institute Outpatient Clinic, revealed that:
a) one of the Bathrooms had three stained ceiling tiles.

b) there was one live cockroach on the floor of the Electrical Closet.

These findings were concurrently verified by Staff #1, the Vice President of Administration.

Based on observations and staff interviews, it was determined that the facility failed to meet the applicable provisions of the Life Safety Code, NFPA 101, 2000 Edition.

Findings include:

During the survey of the facility from 7/9/2014 - 7/14/2014, Life Safety Code deficiencies were noted in multiple areas of the Code requirements and were cited under the following Fire/Life Safety Code K-Tags:

K17 (Corridors are separated from use areas by walls constructed with at least ½ hour fire resistance rating. 19.3.6.1, 19.3.6.2.1, 19.3.6.5)

K18 (Door frames shall be labeled and made of steel or other materials in compliance with 8.2.3.2.1)

K33 (Exit components (such as stairways) are enclosed with construction having a fire resistance rating of at least one hour, are arranged to provide a continuous path of escape, and provide protection against fire or smoke from other parts of the building. 8.2.5.2, 19.3.1.1)

K46 (Emergency lighting of at least 1½ hour duration is provided in accordance with 7.9. 19.2.9.1.)

K56 (The system is properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. It is fully supervised. There is a reliable, adequate water supply for the system. Required sprinkler systems are equipped with water flow and tamper switches, which are electrically connected to the building fire alarm system. 19.3.5)

K62 (Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5)

K72 (Means of egress are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10)

K140 (Master alarm panels are in two separate locations and have audible and visible signals. There are high/low alarms for +/- 20% operating pressure. NFPA 99, 4.3.1.2.2)

K145 (The Type I EES is divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. 3.4.2.2.2.)

K147 (Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2)

Based on observation and staff interview, the facility failed to develop a system for identifying and controlling inspections and communicable diseases of patients and personnel.

The findings include:

1. On the morning of 7/9/2014 observation of the Central Sterile Supply Unit revealed that a Steris V-160H Prevac Steam Sterilizer was not flush with the wall.

2. On the afternoon of 7/9/2014 observation of the Emergency Department revealed that:

a) In the vicinity of the Pantry there were two jars of Concord Grape Jelly, a container of Cranberry Juice Cocktail, boxes of Suncup Juice Cups, etc. being stored under the sink.

b) Isolation Room #25 had positive pressure airflow to the outside hallway. This room is required to have negative pressure air flow.

These findings were concurrently verified by Staff #1, the Vice President of Administration.

Based on staff and patient interview, the review of medical records and hospital policy, it was determined that the facility failed to ensure that it has an effective discharge planning process that identifies all patients who needs discharge planning at an early stage of patients' hospitalization. This finding was noted in 4 of 8 applicable records reviewed (Patient #11, #12, #13 and #14).

Findings include:

Staff #13 was interviewed, in the unit (9B,) on 7/9/2014 at approximately 11:00 AM. This staff reported that she screens all inpatients to determine which ones are in need of discharge planning and the social worker does the discharge planning evaluations. This staff was unable to give a time frame when the initial discharge planning screening should be completed.


Staff #14 was also interviewed, in the unit (9B), on 7/9/2014. This staff reported that discharge planning evaluations are conducted based on the facility's high risk criteria. She also stated that discharge planning evaluations should be completed within 72 hours from admission. This staff stated she was not sure of the time frame for the initial discharge plan screening for all inpatients.

While on the unit (9B), on 7/9/2014, the staff reported that the patient in RM9B bed 22B was to be discharged today. The case manager stated that she went to see the patient, but he refused to speak to her.

Patient #11 was interviewed, at bedside, on 7/9/2014. The patient stated that prior to admission he resided at Time Square Hotel. The patient stated that he has issues at his residence. He was hoping that the social worker would help him to resolve these issues, but he just met the social worker a few minutes ago.

The review of patient's record on 7/9/2014 noted that the patient, 48 year-old male with a past history of heroin Abuse and CHF (congestive heart failure), aortic valve replacement in 2008 and renal artery embolism, was admitted on 7/4/2014. The patient was diagnosed with GI (Gastrointestinal) Bleed. It was noted that the patient was admitted on 7/4/2014, but the discharge plan notes was dated 7/7/2014 at 15:05 (3:05 PM). The discharge plan notes indicated that the patient resided at Time Square Hotel and that the patient was independent prior to admission. It was noted that there was a request for the discharge summary be faxed to Times Square Hotel and that the social services department be contacted prior to the patient's discharge. The case manager's initial screening notes indicating that the patient refused to see this staff was not located in the record. It was noted that date and time this staff attempted to speak to the patient was not documented.

The discharge summary and instructions form in the record were signed by the physician dated 7/8/2014. There was no documentation that the discharge summary was faxed to the social services at Times Square hotel, as requested. This patient was still in the hospital during the unit tour on 7/9/2014 at 12:30 PM. There was no documentation in the medical record to indicate the reasons the patient was still in the hospital.

Record for Patient #12 was reviewed in the unit (9B) on 7/9/14. It was noted that the patient, 91 year-old with history of CVA (Stroke), was admitted on 7/3/2014 at 21:31 (9:31 PM) with a diagnosis of GI (Gastrointestinal) bleed. This patient did not have an initial discharge plan screening until 7/7/2014 at 13:01 (1:01 PM). It was noted that the patient was placed on ALOC (Alternate Level of Care) on 7/8/14. However, the patient remained in the hospital during the unit tour on 7/9/14 at 12:00 PM.

While on the unit (10 A) on 7/14/14, the medical record for Patient #13 was reviewed. It was noted that this 69 year old patient with history of HTN (hypertension) and GERD (Gastroesophageal Reflux Disease) was admitted to the facility on 7/8/14 with diagnosis of acute cholecystitis (inflammation of the gall bladder with sharp acute right upper quadrant or epigastric pain). This patient underwent laparoscopic (minimally invasive surgery through small incisions utilizing a long fiber optic cable system which allows viewing of the affected area by snaking the cable from a more distant, but more easily accessible location)cholecystectomy (removal of the gall bladder) on 7/10/14 and the patient was discharged on 7/14/14. The discharge plan evaluation noted that the discharge planning evaluation was dated 7/14/14. The discharge planning evaluation was not completed within 48 hours of discharge, as the initial discharge planning evaluation was completed on the fifth day of admission which was the day of discharge.

Medical record for Patient #14 was reviewed on 7/14/14. It was noted that this 74 year-old patient with multiple comorbidities including cardiomyopathy (the measurable deterioration of the function of the heart muscle), CHF (Congestive Heart Failure), CKD (Chronic Kidney Disease) and morbid obesity, presented in the facility ' s Emergency Department (ED) with complaint of abdominal pain. The patient was admitted on 7/11/2014 with diagnosis of acute appendicitis. The patient was treated conservatively and he was discharged on 7/14//14. There was no evidence that this patient was screened to determine if discharge planning was needed.

The facility's Administration policy No: A2-102 - Discharge Implementing, revised on July 2014, was reviewed on 7/14/14. The policy notes the Department of Social Work is responsible for coordination and implementation and ongoing review of discharge planning; " For high-risk patients, screening is done within 72 hours, and thereafter re-assessment is to be done weekly". Based on CMS guidelines, screening in order to determine if an inpatients requires discharge planning should be done at the time of admission, or at least 48 hours prior to discharge. This facility has not met this guideline. In addition, this policy does not address discharge planning for patients whose length of stay is less than 48 hours.

Based on staff interview and the review of medical records, it was determined that the facility failed to ensure that all patients identified as needing discharge planning evaluations were provided with thorough and complete evaluations.
Specifically, the hospital failed to ensure: (1) that discharge assessment includes evaluation of all of patients' post hospitalization care needs and required services, an indication whether the discharge services are available immediately, and whether those needs would remain constant or lessen over time; and (2) that for patients unable to return to the setting in which they were living prior to admission, that stated are the reasons why these patients cannot return to the prior setting.

This finding was evident in 4 of 10 applicable medical records review (Patient #15, #13, #16 and #17).

Findings include:

The medical record for Patient #15 was reviewed on 7/14/2014. It was noted that this, 77 year-old patient, with medical history of hypothyroidism (a disorder in which the thyroid gland does not produce enough thyroid hormone), iron deficiency anemia, hemorrhoid and chronic poor gait stability, was admitted to the facility on 7/7/2014. The discharge plan notes dated 7/10/2014 indicated that the patient was seen by PT (physical therapy), OT (occupational therapy) and assessed for SAR (Short-Term Acute Rehab). The social worker noted "I have requested a PRI (patient review instrument) and will give patient entire list of SARs and IMM (Important Message from Medicare) and will help him to find five places for rehab as per Medicare guidelines". There was no documentation that this discharge planner had a discussion with the patient or the reason this was not necessary.

It was noted that this patient was admitted from home. There was no documentation on why this patient could not return home with services. On 7/11/2014 at 14:20, it was documented that TCC (Terence Cardinal Cook) Health Care Facility accepted the patient. It was noted that the patient's choice of skilled nursing facilities and preferences was not documented. On 7/11/2014 at 16:43, it was documented that the patient was appealing the discharge. There was no documentation that the discharge planner met with the patient to discuss the reasons why the patient was appealing the discharge. On 7/14/14 at 09:59, the social worker noted "Pt spoke with me this morning. He said he never followed through with calling IPRO (Island Peer Review Organization) and he was willing to go to TCC as soon as possible". There was no documentation that there was a discussion with the patient on the reason why the patient wanted to remain in the hospital over the weekend.

Staff # 15 was interviewed, on the unit (8B) on 7/14/2014. This staff stated that the patient informed her that he was appealing the discharge and later changed his mind. The content of the discharge planning was discussed with this staff.

The medical record for Patient #13 was reviewed on 7/14/14. It was noted that the patient, a 69 year- old female, with history of HTN (hypertension) and GERD (Gastroesophageal Reflux Disease), was admitted to the facility on 7/8/2014 with diagnosis of acute cholecystitis. The discharge plan notes on 07/14/2014 at 11:17 AM indicated that the social worker (SW) spoke with the patient on the day of discharge. The SW noted that the patient would need home Physical Therapy and she requested VNS (Visiting Nurse Services). The SW noted that a referral was mate to VNS coordinator. The SW also noted "patient's son is here to take her home". The discharge planning evaluation did not include if the patient required any other home care services and if the home care service was approved. In addition, the discharge evaluation did not included the number of days and hours of services approved by the patient's insurance and the day and time services will be initiated. The SW assessment did not include who will assist the patient until the home care services are furnished.

The medical record for Patient #16 was reviewed on 7/15/14. It was noted that the patient, 75 year old male, went to the hospital on 2/20/2014 complaining of hip pain after a fall on ice. X-ray revealed a left femoral neck fracture. The patient underwent left hip ORIF (open reduction internal fixation) on 2/21/14. The patient was transferred to the facility's acute rehabilitation unit on 2/24/14. It was noted that this patient did not have a discharge planning assessment while he was in this inpatient unit. The patient was admitted to the Rehab unit on 2/24/14 and he was discharged to his home with home care services on 3/10/14. The initial discharge plan note dated 3/10/14 at 17:45 indicated that the patient was referred to VNS (Visiting Nurse Services of New York) for nursing and physical therapy evaluation as well as care by HHA (home health aide). The social worker noted that the patient reported that he will only take home care for one week as he planned to fly to Mexico on 3/18/14. The discharge assessment did not include if this was an appropriate discharge plan for this patient or if flying out of the country post-surgery was appropriate. In addition, the discharge planning evaluation did not indicate if the proposed home care services was approved and when the services would be initiated.

The medical record for Patient #17 was reviewed on 7/15/14. It was noted that this 72 year-old patient, with history of OA (osteoarthritis) and HTN (hypertension) was admitted to the facility's Acute Rehabilitation Unit on 3/4/14. The initial discharge planning notes consisted of the discharge planner communication (voice mail and faxing documents) with the patient's insurance on 3/6/2014, 3/7/2014 & 3/14/2014. It was noted that it was not until 3/17/2104 at 17:04 (5:04 PM) that a discharge planning evaluation was done. The discharge planning evaluation indicated that the tentative discharge date was 3/21/2014 and the discharge plan was home with services. A referral was made on 3/21/2014, the day of discharge to Visiting Nurse Services of New York for registered nurse, physical and occupational therapy evaluation and for care by HHA (home health aide). The discharge planning evaluation did not include the patient's level of functioning and if the proposed home care services would meet the patient's post-hospital needs. On 3 /21/2104, the SW noted "patient's sister expressed that if patient is approved for additional rehabilitation time she wants the patient to continue rehabilitation therapy to maximize her functioning prior to returning home". It was noted that the patient's sister's concerns were not addressed. There was no other discharge planning notes. The patient was discharged on 3/21/2014.

Based on staff interview and review of medical records, it was determined that the hospital personnel failed to ensure that evaluations are completed in order to avoid unnecessary delays in discharge. This was evident in 1 of 8 applicable medical records reviewed (Patient #14).

Findings include:

Staff # 14 was interviewed, on the unit (9B) on 7/9/14. This staff stated that Patient #12 was scheduled for discharge today. The staff stated that the clinical package was prepared and ready to be submitted to the patient's choice of skilled nursing facilities, but the patient was not ready for discharge as the patient had not been evaluated by the physical therapist. This staff stated that she spoke with the physician and the order was written. Once the physical therapy evaluation is completed, the clinical package will be sent out and the patient will be discharged to the facility that accepts her.

The patient's record was reviewed on 7/9/14. It was noted that the patient, a 91 year-old female was bedbound with a history of hypertension, Cerebral Vascular Accident (Stroke) with residual right-sided paralysis, presented from home for rectal bleeding. The patient was admitted on 7/4/14. It was noted that the patient was medically stable and she was placed on ALOC (Alternate Level of Care) on 7/8/14. The copy of the discharge summary located in the chart was dated 7/8/14. The disposition was to home. The Discharge information Form was signed by the provider dated 7/7/14.

The discharge planning evaluation notes were reviewed. It was noted the discharge planning evaluation was on 7/7/14 at 14:31 (2:41 PM). The patient wanted to return home and a referral was made to MJHS (Metropolitan Jewish Home Care Services) for skilled nursing and social work services. It was noted that on 7/8/14 at 10:32 AM , the social worker was contacted by the patient's husband who requested skilled nursing facility. On 7/9/14 12:47 PM, the social worker noted that the clinical packet will be prepared for submission to SAR facilities. It was noted that the physician's order for physical therapy evaluation was dated 7/9/14 at 1:02 PM. It was noted that although the patient was medically stable for discharge. The patient remained in the hospital due to inadequate discharge planning.

Based on staff interview and the review of medical record, it was determined that the facility failed to effectively implement patient's discharge plan. This finding was noted in 1 of 4 applicable records (Patient #18).

Findings include:

Medical record for Patient #18 was reviewed on 7/9/14. It was noted that the patient, a 26 year-old with history of asthma, SOB (shortness of breath) and wheezing was admitted on 7/8/14 at 4:45 AM due to asthma exacerbation. The physician noted that the patient ran out of his asthma medications due to insurance issues. The patient was discharged on 7/9/14.

Screening notes by the Case Manager on 7/8/2014 at 12:19 PM indicated the patient did not have a primary physician and was waiting on his insurance card from his job. The discharge plan notes on 7/9/2014 at 13:23 (1:23 PM) was reviewed. The social worker (SW) noted that the patient worked part-time and his insurance has not yet been activated, but will be activated next week. The SW noted "I gave the patient information about Bellevue Hospital outpatient pharmacy services and written information about obtaining medication". The SW noted that the patient agreed to follow up with Bellevue Hospital. It was noted that this staff did not make the initial referral and provide the patient with a contact name. The patient was not provided with a date and time of the appointment. The patient was not provided information on how much medication the patient would obtain at the pharmacy at Bellevue clinic

Staff # 13 was interviewed on 7/9/14. She stated she referred the patient because he did not have insurance.

Staff # 16 was interviewed on 7/9/14. He stated the patient's insurance was not active and he gave the patient information about the Bellevue Hospital pharmacy, which has a program that provides medications to patients.

A copy of the written documentation given to patient was presented for review. This document included how to register at Bellevue Clinic and Bellevue Psych Walk in Clinic. This information did not include information about the Bellevue Pharmacy program.

Based on review of the Organ, Tissue and Eye procurement Program Manual and staff interview, it was determined that the facility failed to ensure that the program is integrated into the hospital's Quality Assurance Performance Improvement Program.

Findings include:

On 7/15/14 at approximately 2:00 PM an interview was conducted with the Vice President (VP) of Quality Initiatives concerning the Organ, Tissue and Eye Procurement Program. The VP of Quality Initiative presented the Organ, Tissue and Eye Procurement reports for the year 2012,and later, the 2013 data. The VP explained that the first quarter reports for 2014 were not available for review.

The review of the hospital -wide Quality Assessment and Performance Improvement data revealed the activities of the Organ, Tissue and Eye Procurement Program was not integrated into the hospital-wide Quality Assurance and Performance Improvement program for 2013 or 2014.