HospitalInspections.org

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Based on staff interview and review of medical records (MR) and hospital policy, it was determined that the hospital failed to ensure that: a) all Medicare Beneficiary patients / patients' representatives were provided with the standardized notice "An Important Message from Medicare" (IM), within two (2) days of admission as an inpatient, and b) that the hospital presented a copy of the signed IM in advance of the patient's discharge to the patient / patient's representative, but not more than two (2) calendar days before the patient's discharge. This was evident in seven (7) of eleven (11) inpatient Medical Records reviewed (Patients #3, #4, #5, #6, #7, #8 and #9) for patients who were Medicare beneficiaries.

Findings include:

a) During the tour of the unit (13th Floor, Medicine) on 01/08/14 at approximately 10:45AM, a sample of inpatient medical records, for Patient #3, Patient #4, Patient #5, Patient #6 and Patient #7 who were Medicare beneficiaries, were reviewed. It was noted that these patients' medical records did not have copies of "An Important Message from Medicare about Your Rights" (IM) forms.

Staff #1 was interviewed in the unit on 01/08/14. This staff stated that the IM forms are given to the patients by the Social Workers.

Staff # 2, a Social Worker, stated that IM forms are given to patients by the Physicians.

Staff #3 & Staff #4 were interviewed in the Conference Room on 01/08/14. Staff #3 stated that the IM is given to the patients by the Hospital Care Investigators (HCI) on admission. Staff #4 stated that the second IM is given to the patient by the Physicians, as the Physicians are the ones who provide the patients with the twenty-four (24) hour notices, and discuss the patients' discharges.

The policy, Medicare Discharge Notice/Appeals Process - ADM 0470: effective 01/14 was reviewed on 01/08/14. This policy indicated that the Hospital Care Investigator (HCI) presents the "Important Message from Medicare Notice" and obtains the signature of beneficiary or representative; provides a copy of the signed notice to the patient; scans in EDM (Enterprise Document Management). It was determined that the staff on the unit were not aware of this process.

During the interview with Staff #3 on 01/08/14, she stated that the staff on the unit were unable to review the scanned copy of the IM in the EDM because the Financial Department has a different system from Health Information Management.

A request was made from Staff #3 for the signed and dated IM forms for these patients (Patient s #3, #4, #5, #6 and #7). The Financial Department was contacted and IM forms were presented.

Review of Patient #7's MR documented that the patient was admitted on 12/31/13 but the signed copy of the IM was dated 01/05/14, five (5) days later.

Review of Patient #3's MR documented that an IM form dated 12/22/13 was in the record but it was written on the form that the patient was unable to sign. There was no documentation on the form for the reason why the patient was unable to sign.

The facility was unable to produce signed and dated copies of IM forms for Patient #4 and Patient #5.

b) Five (5) closed in-patient medical records for Medicare beneficiaries were reviewed on 01/09/14. It was noted that these records contained copies of the facility's twenty-four (24) hour discharge notices. However, these medical records did not contain copies of IM forms. The Financial Department was contacted on 01/10/14 in order to obtain the signed and dated copies for these patients. It was noted that the facility was unable to locate copies of IM forms for Patient #8 and Patient #9.

Patient #5 and Patient #7 were discharged on 01/09/14 and their medical records were reviewed on 01/10/14. It was noted that the patients / patients' representatives, in these medical records, were not presented with copies of the IM forms before discharge.

Review of the policy, Medicare Discharge Notice/Appeals Process (ADM 0470) indicated that the Physician / Provider obtains the original signed "Important Message from Medicare Notice" in the chart, discusses the IM and obtains the patient's signature on the 2nd Page of the IM within forty-eight (48) hours of discharge and places the signed copy in the chart.

It was noted that although the hospital has a policy and procedure in the management of the Medicare Discharge Notice / Appeals Process, the facility failed to effectively implement this policy to ensure that patients and/or their representatives have the information necessary to exercise their rights.
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Based on patient interview and record review, it was determined that the facility failed to provide an assessment of the patients' response to treatment. Specifically, staff failed to comply with the policy to reassess and document the patients' pain level after the administration of pain medication. This was found in two (2) of two (2) medical records that were reviewed on the Surgical Unit (Patients #1 and #2).

Findings include:

During a tour of the Surgical Unit on 01/07/14 at 1:50PM, Patient #1 was interviewed. The patient stated he had pain in his left leg and the pain medication that he is now taking is not helping. The patient stated the medication through the pump was better and he never had pain like this before. When asked if this was told to the staff, the patient stated no one had come in to see him. The head Nurse, who was present during the tour, informed the patient that she would have the Doctor come in to see the patient.

Review of the medical record for Patient #1 documented that this 47 y/o male presented to the ED (Emergency Department) on 01/03/14 after being struck by an automobile while intoxicated. Patient complained of pain, right leg and an x-ray revealed Closed Oblique Displaced Fracture of the Right Tibia and Fibula. Patient was admitted to Trauma for observation and Orthopedic consult. The patient's pain at the time of admission was nine (9) on a zero to ten (0-10) scale.

Review of the Pain Level and Medication Administration Report documented that on 01/07/14 at 0300 (3:00AM), the patient was given an oral analgesic (Oxycodone HCL 5mg and Acetaminophen 325mg - 2 tabs). There was no documentation of the pain level at the time of administration and the reassessment of the patient's pain level was documented at 10:45AM, approximately seven (7) hours after administration of the medication.

The dose was repeated at 10:50AM and the patient's pain level reassessment was documented at 1335 (1:35PM), approximately two and one-half (2.5) hours after administration.

Review of the facility's policy for Pain Management, states "pain level will be noted prior to intervention and after administration of pain medication (e.g. thirty (30) minutes for IV and IM, one (1) hour for oral)".

The medical record further documented that the patient received IV pain medications on 01/03/14 and 01/04/14. There was no consistent documentation of the pain level prior to each administration of the medication and the thirty (30) minutes reassessment and documentation after administration was not maintained. The frequency of pain level documentation after administration was noted to be one (1) hour.

Review of the medical record for Patient #2 documented that this 51 y/o male was admitted on 12/20/13 with a complaint of chest congestion, malaise, and unspecified abdominal pain, and was diagnosed with Recurrent Transverse Colon Volvulus, which required surgical intervention.

Medical record review documented that the patient had surgical procedures on 12/26/13 and on 01/02/14 and the patient was prescribed IV push and Patient Controlled Analgesia (PCA) Pump for pain management.

Review of the Pain Level and Medication Administration Report documented that the patient received IV push pain medication on 12/21/13 at 0645, 0959, 1740, 2133 and the pain level was not documented thirty (30) minutes after administration. A similar pattern of non-compliance was noted for 12/22/13 and 12/30/13.

Oral analgesic medication regimen was prescribed on 01/05/14, 01/06/14 and 01/07/14, and the patient's pain level was not consistently documented one (1) hour after administration.

Staff failed to comply with the policy that pain level will be noted prior to intervention and after administration of pain medication (e.g. thirty (30) minutes for IV and IM, one (1) hour for oral)".

During interview on 01/13/14, this finding was confirmed with the Chief Nursing Executive.
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Based on staff interview and review of medical records and hospital policy, it was determined that the facility failed to assure that: a) all inpatient medical records for Medicare beneficiaries contained signed and dated IM (An Important Message from Medicare) forms, within two (2) days of these patients' admission. This was evident in medical records for the following Patients: #3, #4, #5, #6, #7, #8, #9, #10 and #11, and b) all medical records contained all pertinent clinical information. This deficiency was noted for two (2) of five (5) applicable medical records (MR) (MRs #7 and #13).

Findings include:

a) During the unit tour on 01/08/14 at approximately 10:45AM, six (6) inpatient medical records for Medicare beneficiary's records were reviewed. It was noted that five (5) of six (6) medical records lacked copies of the IM forms in the paper sections of these medical records.

Staff #1 who was assisting with reviewing the electronic record was unable to locate this document in the patients' medical records.

Staff #5 was interviewed in the Conference Room on 01/09/14. This staff stated that the Important Message from Medicare (IM) forms are kept in the Financial Department Electronic System which is not part of the electronic medical record. She stated that the IM only gets into the patient's medical record if the Financial Department faxes them to Health Information Management (HIM). She also stated that if HIM receives the scanned copy of the IM forms they are kept in the paper section of the medical record.

Medicare Discharge Notice / Appeals Process: ADM 0470 - effective: 01/14 was reviewed on 01/08/14. This policy indicated that the Hospital Care Investigator (HCI) presents the "Important Message from Medicare Notice" and obtains the signature of the beneficiary or representative; provides a copy of signed notice to patient; scans in EDM (Enterprise Document Management), and places copy in chart. It's unclear if this chart is referring to the patient's medical record as all medical records reviewed lacked this document.

b) The medical record (MR) for Patient #7 was reviewed on 01/08/14. It was noted that this 81-year-old patient with a history of Hypertension was admitted to the facility after she refused to let her Home Health Aide into her home.

While on the unit (13th Floor) on 01/08/13 it was observed that this patient was placed on close observation. The staff assigned to monitor this patient reported that the patient was on close observation for safety.

The patient was discharged on 01/09/14. The MR for Patient #7 was reviewed on 01/10/14. It was noted that the "Special Observation Flow Sheet" was not in the record submitted for review. This document was requested from Staff #7 but this document was never received.

The medical record for Patient #13 was reviewed on 01/09/14. It was noted that the patient, a 77 y/o female with a medical history of Dementia, was admitted to the hospital on 09/25/13. The presenting problem was that the patient was brought to the hospital by ambulance for evaluation of a bruise around her left eye.

The medical record noted that the patient was placed on close observation for safety. On 09/28/13, the Nurse noted that the patient was on close observation to optimize safety and prevent elopement. The Nurse noted that at 11:15AM the patient entered the elevator with the co staff following the patient and standing by the elevator to stop the patient from leaving. On 09/29/13, the Nurse noted that the patient was oriented to person and place but not to time. The Nurse noted the patient is on close observation to prevent elopement. On 09/30/13 at 1620, the Nurse noted "remains on 1:1 observation for safety and to prevent elopement".

The Physician's orders were reviewed. It was noted there was a Physician's order for close observation on 09/25/13 at 11:26PM. There was a Physician's order for one to one (1:1) Arm's Length dated October 3, 2013 at 10:40PM which documented the reason for the order as agitation.

The Flow Sheet Monitoring was not located in the paper section of the medical record. This document was requested from Staff #7 on 01/09/14. This staff reported that she checked with medical records and they were unable to locate this document. It was noted that the patient attempted to leave the unit on 09/28/13. However, it could not be determined if this patient was properly monitored or when the level of monitoring was changed from close observation to 1:1 monitoring.

The policy, Special Observation Constant (1:1) Observation and Close Observation: NP S 19.2 effective 03/13 was reviewed on 01/09/14. This policy indicated that ancillary staff will document the patient's behavior / activities every thirty (30) minutes on the "Special Observation Flow Sheet" and for patients on one to one (1:1). On patients on Close Observation, it will be documented on this form and every hour. However, these forms were not always located in the patients' medical records.
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Based on staff interview, review of menus, and the nutrient analysis of menus, it was determined that the Food and Nutrition Department did not ensure that Physician prescribed diets met the therapeutic needs of patients.

Findings include:

A review of the nutrient analysis of the hospital menus was conducted on 01/08/14 - 01/13/14. There was no nutrient analysis calculated for eight (8) consistent carbohydrate diets available in the electronic medical records for Physicians to prescribe. These diets were not analyzed to assess compliance to the national standard titled "Recommended Daily Intakes".

Therefore the nutrition adequacy and dietary restrictions on the menu is unknown. Due to lack of nutrient analysis calculated for these menus, there is no way to verify that the diet orders are provided as prescribed by the practitioner(s) responsible for the care of the patient.

During interview on 01/13/14, these findings were confirmed with the Clinical Nutrition Manager.
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Based upon observations, interviews, and review of the facility's policy and procedures and other facility documents, it was determined that the facility was not arranged and maintained to ensure the safety of patients. Furthermore, the facility did not perform corrective actions of all issues cited in the previous Federal Survey of 2010. Therefore the accumulative effect of the Hospital Regulation Standard Level Deficiencies as well as the Life Safety Code (LSC) Deficiencies is that the Condition of Participation for Physical Environment is not met as evidenced by:

1) Failing to meet LSC standards. (See K 012, K 050, K 062, K 064, K 067, K 073, K 104, K 106, K 130, K 145 and K 147).

The most important LSC issue relates to the facility not having the three (3) branches of Type I EES.

THIS IS A REPEAT CITATION FROM THE FULL FEDERAL SURVEY OF 2010.

The facility was cited for this same issue and facility had responded that "In accordance with new LSC standards for electrical distribution, as specified by NFPA 99 and NFPA 70, the existing TYPE 1 EES will be modified. The physical plant modernization project will ensure that all components in the plan are in accordance with NFPA 99. Facilities Management and Modernization Department will ensure that all components are incorporated into the plan according to NFPA 99 standards. The estimated completion date for the project is 2/2012".

As per Director of Facilities, the facility started doing the project and managed to separate six (6) out of ten (10) transfer switches (those new six (6) are dedicated to elevator). However the rest four (4) still have mixed wiring. As per the Director of Facilities, the reason why the project could not be completed in a timely manner was lack of resources / funds.

No information prior to the survey was ever provided to DOH or CMS regarding the facility's intention of extending the project due to circumstances and not completing as promised and indicated by their response in 2010.

Furthermore, the facility also did not ensure to fix the previous citation of five (5) year sprinkler test.

THIS IS A REPEAT CITATION FROM THE FULL FEDERAL SURVEY OF THE FACILITY DATED 2010.

The facility was cited for the same issue and had responded in its plan of correction " The facility has reviewed all the requirements in NFPA 25 for the inspection, testing and maintenance of water based fire protection systems. The facility ' s Management Department has modified their desisting monthly / quarterly / semi-annual / annual preventive maintenance programs for water based protection systems to include all of the appropriate elements of NFPA 25. This includes the preventive maintenance of the sprinkler water storage tank, the O S and Y valves and five (5) year inspection and testing for the sprinkler piping alarm valves and associated trim " .

No such information was present at the time of survey for the five (5) year inspection.

2) Failing to maintain the physical plant to assure patient safety and well-being. (See A 701).
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Based on observation and staff interview, the hospital environment was not maintained in such a manner that the safety and well-being of patients was assured.

Findings include:

1) On 01/10/14 at 3:30PM, during tour of the Newborn and Post-Partum Units at Martin Luther King Pavilion-4th Floor, it was stated by staff representing Security and Nursing Administration that an electronic tag system is used to augment safety and tracking of newborn infants on the units. There is hospital Police on the floor monitoring the elevators and letting the visitors in. The exit stairwell doors in the unit are on emergency lock and hence will unlock but give a loud alarm for anyone who tries to depart using the stairwell of the unit.

The Director of Hospital Police stated that this system manufactured by "Accutech" operates when an electronic transponder tag is attached to a band placed around the ankle of all newborns. This device is linked electronically to a computer tracking system which activates a visual and audible electronic alarm during the following contingencies:

-The doors to the unit lock when the infant wearing the device approaches the proximity of the exit doors to the unit; this feature includes a ten (10) second lapse when the infant wearing the tag loiters around the exit doors.

-The visual and audible alarms are to immediately activate when the band is cut.

-The elevators are recalled to the 1st Floor in case it is determined it is a Code Pink.

As per the Director of Hospital Police the time lapse between the band cut and the alarm at the Nurses' Station will be approximately a few seconds.

At 4:02PM, a test was conducted of the infant protection system. After the band was cut, it took approximately two (2) minutes for the alarm to annunciate at the Nursing Station. The audible and visual alarms were not distinctly noticeable following the cutting of the band. The visual flashing is not readily visible unless staff is present in close proximity to the computer display. In addition, the audible alarm was weak and barely detectable.

It took another approximately four to five (4-5) minutes for the " CODE PINK " announcement to occur overhead and the Police activity along with elevator recall to happen.

Therefore performing this test determined that the second component of the system failed to activate the alarms immediately as required when the band was cut. Facility was requested to conduct an investigation and provide the reason why the system did not work as designed.

On 01/13/14 at 11:00AM , Director of Hospital Police, Chief Operating Officer, Accutech Vendor, and the Staff who are a part of group conducting Code Pink provided the Surveyor with a drill critique and investigation for the reason the system did not work as designed. A big binder was provided.

Facility acknowledged the delay in alarm and delay in Security / Police response. The reason as told by the staff was more of a " software " issue rather than a " hardware " issue. As per the vendor the " Accutech " program had a database issue that required " purging " . After the purge, the system worked as designed and the response times were accurate.

During review of the documents it was noted that the system had its last preventive maintenance on 12/05/13 in which everything functioned as required. Furthermore, the facility conducted a CODE PINK drill on 12/17/13 ensuring all parameters were met.

Therefore, it could not be ascertained that what caused the database to be purged within the gap of the past few weeks that elapsed.

Another confirmatory infant protection system test was conducted on 01/13/14 at 11:45AM. The response after the band cut was within few seconds. All the components worked.

2) During the tour of the different buildings of the facility from 01/07/14 to 01/13/14 between 11:00AM to 4:00PM, the following issues were noted which were verified with the staff accompanying the Surveyor.

OR / SURGICAL UNIT-MURAL Pavilion 3RD FLOOR

i. Ambu bags and other similar items were noted hung on the oxygen flow meter which may result in the oxygen flow meter getting loose leading to leaks and other disrepair with the medical gas equipment.

Similar findings were noted in many other units of the facility including but not limited to the Trauma Room in the Emergency Department.

ii. The Blanket Warmer in the sub-sterile core was noted higher than the limit of 110*F. The alarm of being " HI " was visibly blinking; however there was no audible sound.

iii. The door of the Air-Borne Isolation Room in the Recovery Area was noted to be jammed and was not easily operable.

MEDICAL UNIT - MARTIN LUTHER KING (MLK)-13TH FLOOR

i. The multi-corridor light was not registering a signal when elicited from Patient Room 138.

ii. The Nursing staff did not know how to open the bathroom door to rescue a patient in need if the door is locked from inside and the patient has collapses.

COMPREHENSIVE PSYCHIATRIC EMERGENCY PROGRAM - MLK-1ST FLOOR

i. An oxygen cylinder was noted stored on the floor by Nurses' Station in an unsecured condition.

MAIN BIO-HAZARD STORAGE ROOM AND LOADING DOCK

i. The Bio-Hazard Room and the main bio-hazard containers in the Loading Dock were not locked and secured from unauthorized access.

PSYCHIATRY SERVICES - MLK BUILDING-10TH FLOOR

i. During the tour of the Psychiatric Unit it was noted that the patient rooms have cupboards with doors. The shelves inside are installed / spaced as such that there is plenty of space for a patient to hide which can make it difficult for the staff to rescue and count the patients safely in case of emergency.

ii. The night lights in some patient rooms (including but not limited to Room #10143) was is such that the grills pose a looping hazard.

MECHANICAL SPACE - MLK-BASEMENT

i. The transfer switch (ATS) Room was noted having a big pool of water on the ground.

ii There were combustibles such as cardboard, gloves and trash noted in the transfer switch for the Elevator Room.

FAMILY HIV CLINIC-KP BUILDING-2ND FLOOR

i. The Outpatient HIV Clinic does not have the height of the registration window in compliance with ADA 4.32.4 Code. The window was more than the required twenty-eight to thirty-four (28-34) inches.

All of the above findings were verified with the Director of Facilities, Chief of Operations and the respective staff on the floor.
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Based on observations during tours of the facility and staff interview, it was determined that the facility failed to monitor and implement Infection Control practices related to the environmental design of the facility, in order to prevent the potential for cross contamination and spread of infections and the facility failed to ensure a safe environment consistent with recognized Infection Control Practices and prevention of cross contamination.

Findings include:

1(i). On 01/08/14 at 10:55AM during the survey of the Emergency Department (ED) in the Martin Luther King Building, 1st Floor, it was noted that there are no Air-Borne Isolation Rooms in the Department. The Nursing Director and Medical Director of the Emergency Services indicated that if required any room/bay (with doors) of the Department can be used for an Air-Borne Isolation Room by providing HEPA filters.

It was noted that none of the rooms in the ED has the architectural structure to be effective for air-borne isolation and infection control purposes. The rooms to be converted for Isolation Room did not comply with the requirements of AIA 1996-97 Section 7.2.C4 for Isolation Rooms.

The requirement states that "Air Borne Infection Isolation Room shall have self-closing devices on all room exit doors". The Isolation Room in the unit did not have self-closure or self-closure mechanism installed at the exit door. Similar issue was noted in the Isolation Room of Pediatric ICU.

It is also to be noted that any patient room that is converted for the use of isolation room should have all perimeters / gaps and penetrations tightly sealed so that the outside air does not infiltrate the environment and vice versa (AIA 7.2.C3).

Furthermore the ceiling tiles in the room to be used for isolation were noted to be of regular kind and were not the cleanable and non-porous used for specifically for isolation rooms. Therefore the tiles were not as per AIA 7.28.B8. These tiles may retain dirt and germs and pose an infection control issue.

(ii) At the time of observation the facility was asked to provide a policy and procedure and records on how the rooms that are converted to negative pressure air-borne isolation room are monitored. The Director of Facilities stated that the dedicated air-borne isolation rooms in the facility were monitored for negative air-pressure but the rooms that are converted to negative isolation via HEPA filter are not monitored for its negative air-pressure.

On 01/09/14 at 11:00AM, the Director of Infection Control provided the Surveyor with manufacturer ' s specification on HEPA filters. Facility utilizes the " Abatement Technologies HEPA-CARE In-Room Air Purification Systems " which as per the manufacture "can provide or supplement negative pressure conditions " . Furthermore the manufacturer ' s specification indicates that to comply with CDC recommendation of monitoring the negative air pressure, the provider may use one (1) of three (3) model / ways to track / monitor or measure the negative air-borne pressure and contamination sources.

Therefore, not only Emergency Department but all other units (including but not limited to Newborn NICU) when converted to air-borne isolation via HEPA filter are not monitored for negative air-pressure and some patient rooms/areas are not structurally in compliance for isolation rooms and infection control.

2. During the survey of the OR/Surgical 3rd Floor of the Mural Pavilion on 01/07/14 between 11:45AM to 3:00PM, following issues were noted:

i. The perimeter of the Isolation Room in the OR Suite Pre-Op Area was noted to be dusty and dirty.

ii. A used IV bag was noted being drained in one of the hand washing sink in the Recovery Area.

3. On 01/08/14 during the tour of the CPEP (Comprehensive Psychiatric Emergency Program) Unit in the Martin Luther King Building at 12:15PM, following issues were noted:

i. The holding area / patient waiting area chairs were noted dusty dirty with stains on the sides. The perimeter of the holding / patient waiting area was also very dirty and dusty.

ii. There were gaps in the corners of the bed frame of the CPEP Unit (once the mattress was removed) that were not sealed with approved tamper proof caulk / security sealant and therefore had accumulation of dust and dirt.

iii. The mechanical vents of the CPEP were noted laden with dust and dirt inside the grills.

4. On 01/08/14 at 2:30PM during the tour of the Medical Unit on 13th Floor in the Martin Luther King Building it was noted that the mechanical vents in patient bathrooms were laden with dust and dirt in side the grills. Furthermore, many Nurse call bell cords in the patient bathrooms were noted either short or wrapped to the grab bar thus preventing it to be accessible to a patient who may be collapsed on the floor.

5. On 01/10/14 during the tour of Psychiatric Unit on Martin Luther King building 10th Floor from 11:45AM to 1:00PM, it was noted that the perimeters of the patient rooms inside and around the corners and doors were very dusty and dirty.

6. On 01/13/14 at 3:15PM, during the tour of the Family HIV clinic on 2nd Floor of the Kountz Pavilion it was noted that the Waiting Room walls were dirty and dusty and had streaks of stains.

7. During the survey of the Ron Brown Building (RB), Kountz Building (KP) and Women's Pavilion (WP) on 01/13/14 between 2:00PM to 3:45PM, some areas of the different buildings were noted not exhibiting the correct air-flow. The examples include the following but are not limited to:

i. 4th Floor RB Building-ENT Clinic-Soiled Utility Room exhibited neutral air flow instead of negative air flow.

ii. 1st Floor RB Building-Pediatric Clinic-Soiled Utility Room exhibited positive air flow instead of negative air flow.

iii. 3rd Floor WP Building-Community Support Services / Psych OP-Housekeeping Closet was neutral instead of negative and did not have a self closure installed at the door.

iv. 2nd floor KP Building-Family HIV Clinic - Soiled Utility Room and Clean Utility Room exhibited neutral air pressure.

8. During the survey of the Ron Brown Building (RB) and Women's Pavilion (WP) on 01/13/14 between 2:00PM to 3:45PM, it was noted that the areas / rooms housing sterilized equipment for patient use did not have any humidity monitoring mechanisms. Examples include but not limited to area:

i. Clean Utility Room on 4th Floor RB Building-ENT Clinic- Sterilized item from the Central Sterilize Area were noted stored in this room.

ii. Sterilized Supply Storage / Clean Room on 2nd Floor WP Building-Dental- Sterilized item from the Central Sterilize Area were noted stored in this room.

9. During the survey of the Ron Brown Building (RB), Kountz Building (KP) and Women's Pavilion (WP) on 01/13/14 between 2:00PM to 3:45PM, it was noted that clean supplies were present in dirty area and under the sink thus posing a risk of cross-contamination. Examples including but not limited to are:

i. 4th Floor RB Building-ENT Clinic - 1 gallon and 32oz bottle of Distilled Vinegar was stored under the sink in Room #4104 / Patient Exam Room. As per Nursing staff the vinegar is for use in patient treatment by the Physician.

ii. 2nd Floor WP Building-Dental- Clean rolls of toilet tissue papers were noted stored in the Housekeeping Closet (near the entrance by the medical gas manifold).

iii. 2nd Floor KP Building- Family HIV Clinic - The covering of the clean microscope lighting source stored in the Clean Utility Room was noted very dirty. On using the alcohol wipe the dirt came off indicating that it was not a stain but dirt.

10. During the survey of the Main Linen Storage Room on 01/07/14 at 4:00PM in the Martin Luther King Building Basement, it was noted that the room was dusty and dirty around its perimeters.

All of the above findings were verified with Director of Director of Facilities, Chief Operating Officer, and the various unit Nurse Managers and staff escorting the Surveyor at the time of observation / survey.
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Based on staff interview, patient and patient's representative's interviews and review of medical records, it was determine the hospital failed to ensure that the qualified staff who developed the patients' discharge plan ensured that the discharge planning evaluation entailed all of the individual patients' post-discharge needs. This deficiency was found in two (2) of ten (10) patients' medical records reviewed (Patients # 5 and #7).

Findings include:

The medical record for Patient #7 was reviewed on 01/08/14 at approximately 11:05AM. It was noted that this 81-year-old patient with a medical history of Hypertension and Arrhythmias was brought in into the facility's ED (Emergency Department) on 12/31/13. The patient refused to let her Home Health Aide into her home who she felt was stealing from her.

The Social Worker (SW) progress notes indicted that the patient was seen in the ED. The SW contacted the patient's home aide agency who stated that they did not feel that the patient was safe at home as she was always "paranoid".

The Social Work update note dated 01/07/14 1252 was reviewed. The SW noted "covering worker had spoken to patient who reports that patient desires to go home and agreed to referral for home care services". This assessment did not address the issue with the patient and her not wanting any home aide in her home.

The Physician's discharge summary dated 01/02/14 at 0956 indicated that the patient was seen by Psychiatry and Rehab Medicine that cleared the patient to be discharged. It was noted that there was a twenty-four (24) hour discharge notice and discharge order dated, today, 01/08/14 in the medical record.

Patient #7 was interviewed at bedside (RM 13138C) on 01/08/14 at approximately 11:20AM. The patient stated that she had not seen the Social Worker. She also stated that she was waiting on the Social Worker to discuss her discharge plan.

Staff # 2 was interviewed in the unit on 01/08/14. She stated that the patient had discussed her discharge plan with the covering Social Worker. Staff #2 stated that she plans to discuss the patient's discharge with the patient's family. Staff #2 also stated that the patient was evaluated by Psychiatry and that the patient was competent to make decisions regarding her discharge plan. It was noted that the patient was discharged but the discharge planner had not discussed the discharge plan with the patient who was competent to make discharge decisions.

The medical record for Patient #7 was re-reviewed on 01/10/14. The SW discharge summary dated 01/08/14 at 1710s indicated that the disposition was home with services from preferred home care services. It was noted that the home care service that the patient would require was not included in the assessment. It was noted that the date and time that the services will be implemented was not located in the assessment. In addition, it was noted that on 01/08/14 it was documented that abuse was not suspected. However, it was documented on 01/07/14 that a referral was made to APS (Adult Protective Services). This inconsistency was not clarified before the patient was discharged.

The patient's son and patient's (#5) Health Care Proxy was interviewed, on 01/08/14 at approximate 11:30AM, at patient's bedside. The patient's son stated that he was not aware that the patient was to be discharged today, 01/08/14. According to the patient's son, the patient could not be discharged until there is a meeting with the medical staff.

During the unit tour (13th Floor on 01/08/14 11:45AM, the medical record for Patient #5 was reviewed. It was noted that the patient, 76-year-old with a history of CVA, DM, HTN and Stage 3 Breast Cancer (recently diagnosed), was admitted to the hospital on 12/31/13. The admitting diagnosis was Hyperkalemia. The patient had a discharge planning evaluation on 12/31/13. The discharge planner noted that the discharge plan was home with re-activated pending MD evaluation, procedures and recommendations. It was noted that there was no documentation that the discharge plan was discussed with the patient / patient representative before the decision was made on the discharge plan. There was no other Social Work discharge planning note in the record. However, there was a Physician's discharge summary located in the record. This discharge summary indicated that the patient was to be discharged today, 01/08/14.

Palliative F/U note dated 01/02/14 at 1356 was reviewed. It was noted that this provider wrote "there are concerns regarding her social situation as she currently lives alone has HHA 5/7 days per week". She would likely benefit from having more. It was noted that this issue was not addressed in the discharge planning evaluation.

The Social Work follow up note dated 01/08/14 at 1715 was reviewed on 01/10/14. It was noted that on 01/08/14 at 1715 (5:15PM), the SW noted worker met with patient and patient's son and discharge options were discussed. Per patient's son requests services, worker refer patient back to HHC (Health Hospital Corporation) for CHHA (Certified Health Home Agency) services. It was noted that the concerns that the patient may need increase in home health aide services was not addressed. There was no documentation if this was provided.

I was noted that the patient had rehab evaluation on 01/03/14 and the recommendation was bedside occupational and physical therapy (OT/PT). It was noted that this patient was followed by OT and PT while as an inpatient. It was noted that the patient had a PT evaluation on 01/08/14 and OT evaluation on 01/09/14. This patient was discharged on 01/09/14. It was noted that there was no recommendation for OT /PT at discharge or if this was necessary. It was noted that there was no final discharge notes from both disciplines

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Based on staff interview, patient and patient's representative's interviews and review of medical records, it was determine the hospital failed to ensure that the qualified staff who developed the patients' discharge plan ensured that the discharge planning evaluation entailed all of the individual patients' post-discharge needs. This deficiency was found in two (2) of ten (10) patients' medical records reviewed (Patients # 5 and #7).

Findings include:

The medical record for Patient #7 was reviewed on 01/08/14 at approximately 11:05AM. It was noted that this 81-year-old patient with a medical history of Hypertension and Arrhythmias was brought in into the facility's ED (Emergency Department) on 12/31/13. The patient refused to let her Home Health Aide into her home who she felt was stealing from her.

The Social Worker (SW) progress notes indicted that the patient was seen in the ED. The SW contacted the patient's home aide agency who stated that they did not feel that the patient was safe at home as she was always "paranoid".

The Social Work update note dated 01/07/14 1252 was reviewed. The SW noted "covering worker had spoken to patient who reports that patient desires to go home and agreed to referral for home care services". This assessment did not address the issue with the patient and her not wanting any home aide in her home.

The Physician's discharge summary dated 01/02/14 at 0956 indicated that the patient was seen by Psychiatry and Rehab Medicine that cleared the patient to be discharged. It was noted that there was a twenty-four (24) hour discharge notice and discharge order dated, today, 01/08/14 in the medical record.

Patient #7 was interviewed at bedside (RM 13138C) on 01/08/14 at approximately 11:20AM. The patient stated that she had not seen the Social Worker. She also stated that she was waiting on the Social Worker to discuss her discharge plan.

Staff # 2 was interviewed in the unit on 01/08/14. She stated that the patient had discussed her discharge plan with the covering Social Worker. Staff #2 stated that she plans to discuss the patient's discharge with the patient's family. Staff #2 also stated that the patient was evaluated by Psychiatry and that the patient was competent to make decisions regarding her discharge plan. It was noted that the patient was discharged but the discharge planner had not discussed the discharge plan with the patient who was competent to make discharge decisions.

The medical record for Patient #7 was re-reviewed on 01/10/14. The SW discharge summary dated 01/08/14 at 1710s indicated that the disposition was home with services from preferred home care services. It was noted that the home care service that the patient would require was not included in the assessment. It was noted that the date and time that the services will be implemented was not located in the assessment. In addition, it was noted that on 01/08/14 it was documented that abuse was not suspected. However, it was documented on 01/07/14 that a referral was made to APS (Adult Protective Services). This inconsistency was not clarified before the patient was discharged.

The patient's son and patient's (#5) Health Care Proxy was interviewed, on 01/08/14 at approximate 11:30AM, at patient's bedside. The patient's son stated that he was not aware that the patient was to be discharged today, 01/08/14. According to the patient's son, the patient could not be discharged until there is a meeting with the medical staff.

During the unit tour (13th Floor on 01/08/14 11:45AM, the medical record for Patient #5 was reviewed. It was noted that the patient, 76-year-old with a history of CVA, DM, HTN and Stage 3 Breast Cancer (recently diagnosed), was admitted to the hospital on 12/31/13. The admitting diagnosis was Hyperkalemia. The patient had a discharge planning evaluation on 12/31/13. The discharge planner noted that the discharge plan was home with re-activated pending MD evaluation, procedures and recommendations. It was noted that there was no documentation that the discharge plan was discussed with the patient / patient representative before the decision was made on the discharge plan. There was no other Social Work discharge planning note in the record. However, there was a Physician's discharge summary located in the record. This discharge summary indicated that the patient was to be discharged today, 01/08/14.

Palliative F/U note dated 01/02/14 at 1356 was reviewed. It was noted that this provider wrote "there are concerns regarding her social situation as she currently lives alone has HHA 5/7 days per week". She would likely benefit from having more. It was noted that this issue was not addressed in the discharge planning evaluation.

The Social Work follow up note dated 01/08/14 at 1715 was reviewed on 01/10/14. It was noted that on 01/08/14 at 1715 (5:15PM), the SW noted worker met with patient and patient's son and discharge options were discussed. Per patient's son requests services, worker refer patient back to HHC (Health Hospital Corporation) for CHHA (Certified Health Home Agency) services. It was noted that the concerns that the patient may need increase in home health aide services was not addressed. There was no documentation if this was provided.

I was noted that the patient had rehab evaluation on 01/03/14 and the recommendation was bedside occupational and physical therapy (OT/PT). It was noted that this patient was followed by OT and PT while as an inpatient. It was noted that the patient had a PT evaluation on 01/08/14 and OT evaluation on 01/09/14. This patient was discharged on 01/09/14. It was noted that there was no recommendation for OT /PT at discharge or if this was necessary. It was noted that there was no final discharge notes from both disciplines