HospitalInspections.org

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Based on record review and staff interview during the Federal Recertification Survey it was determined the facility failed to ensure that the practitioner promptly authenticated verbal orders for three (3) out of ten (10) Physicians reviewed (Physicians #1, #2 and #3).

Findings:

Review of ten (10) Physicians' Electronic "In-Baskets" revealed that three (3) Physicians had verbal orders which had not been authenticated within the forty-eight (48) hour State Regulatory Requirement. These Physicians' "In-Baskets" revealed that Physician #1 had numerous unsigned verbal orders for multiple patients dating back to August of 2012 and Physicians #2 and #3 each had two (2) unauthenticated verbal orders for different patients.

An interview with Staff Member #11 during the morning of 01/08/14 revealed that the Physicians are sent notifications to their "In-Baskets" automatically reminding them of outstanding documentation that needs to be completed in the Electronic Medical Record System which includes authenticating verbal orders.

Review of the Medical Record for Patient #33 revealed that the Nurse obtained a telephone order on 08/13/13 at 10:43AM for Humalog Insulin 6 Units by injection three (3) times a day from Physician #1, which was not authenticated by the practitioner as of review on 01/10/14 (one hundred fifty (150) days later).

Review of the Medical Record for Patient #32 revealed that the Nurse obtained a telephone order on 12/27/13 at 8:07PM for a Regular Insulin drip rate from Physician #1, which was not authenticated by the practitioner as of review on 01/10/14 (fourteen (14) days later).

Review of the Medical Record for Patient #34 revealed that the Nurse obtained a telephone order on 01/04/14 at 10:42AM for Hydrodiuril 25mg oral daily from Physician #3, which was not authenticated by the practitioner as of review on 01/10/14 (six (6) days later).

Review of the Medical Record for Patient #36 revealed that the Nurse obtained a verbal order on 01/07/14 at 9:52AM for Dulcolax 5mg orally twice daily as needed from Physician #2, which was not authenticated by the practitioner as of review on 01/10/14 (three (3) days later).

Review of the policy titled "Telephone / Verbal Orders" dated 06/2012 documents that telephone / verbal orders must be authenticated by the ordering practitioner as soon as possible but in no case longer than thirty (30) days which is not consistent with New York State's Regulatory Requirement of forty-eight (48) hours.

An interview with Staff Members #9 and #10 on 01/08/14 at 11:30AM revealed that there is no current auditing of verbal / telephone orders or review of the Physicians' "In-Baskets" to ensure that the orders are authenticated by Nursing Performance Improvement or the Medical Record staff.
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1. Based on observation and staff interview during the Federal Recertification Survey, the facility failed to ensure that: 1) all ceiling and wall finishes in the hospital building were maintained in good repair, and 2) that the grounds of the building were maintained in a clean condition.

Findings:

1) On 01/06/14 at 11:28AM, a stained ceiling tile that exhibited what appeared to be a black colored substance on it was found in a Clean Utility Room (vicinity of Room 329 on the 3 North Unit). As per concurrent interview with the facility's Director of Engineering, this damaged ceiling tile will be replaced immediately.

On 01/06/14 at 12:15PM, some water damage was noted to a wall in the vicinity of the HVAC (Heating, Ventilation, and Air Conditioning) Unit in Room 205.

On 01/06/14 at 1:58PM, an approximately 2-inch diameter hole was noted in a wall in the 1st Floor 64-slice CT Scanner Suite.

On 01/07/14 at 11:05AM, two (2) water stained ceiling tiles were noted in the Lower Level Housekeeping Clean Linen Storage.

On 01/07/14 at 1:43PM, a small (approximately 4-inch diameter) section of painted surface on a monolithic ceiling in the Lower Level Central Sterile Department Sterilizer Room was noted to be chipped/in disrepair.

42 CFR 482.41(a)

2. On 01/06/14 at 1:30PM, numerous, approximately fifty (50), cigarette butts were noted to liter the ground in the vicinity of the 1 North Behavioral Health Unit outdoor patient smoking area. As per concurrent interview with the facility's Director of Plant Engineering, he would have the cigarette butts cleaned up as soon as possible.

42 CFR 482.41(a)
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Based on observation and staff interview during the Federal Rectification Survey, the facility failed to ensure that: 1) accessible facilities were designed and maintained in accordance with Federal, State and Local Laws, Regulations and Guidelines, 2) that hand wash sinks were installed in compliance with all requirements, and 3) that Emergency Department treatment cubicles were designed and maintained in accordance with Federal, State and Local Laws, Regulations, and Guidelines.

Findings:

1) On 01/06/14 at 1:35PM, door identification signage was improperly installed directly on doors to two (2) of two (2) unisex accessible Toilet Rooms in the 1st Floor Waiting Area. Accessible signage is not permitted to be installed directly on doors because there is a danger that a person attempting to read the sign may, depending on the swing of the door, be knocked backwards or pitched forwards. In addition, this sign lacked required Braille characters.

As per concurrent interview with the facility's Director of Plant Engineering, he will have accessible room identification signage installed as soon as possible.

42 CFR 482.41(c)

2) On 01/06/14 at 2:31PM, a hand wash sink in the 1st Floor Cardiac Catheterization Suite (vicinity of Station #2) was noted to have a water faucet that was not of the required "gooseneck" design that would provide a minimum 10-inch gap between the discharge point of the faucet and the bottom of the sink basin. As per concurrent interview with the Director of Plant Engineering, he will have the appropriate "gooseneck" type faucet installed on this sink as soon as possible.

42 CFR 482.41(c)

3) The hospital's Emergency Department was constructed in 2003 under New York State Department of Health Certificate of Need Project #AEP3361r1. New York State Department of Health Regulations (i.e., 10NYCCR) that were in effect at the time of construction required that Emergency Departments be constructed in accordance with the requirements found in the 1996-1997 Edition of the American Institute of Architects' Guidelines for Design and Construction of Hospital and Health Care Facilities. Section 7.9.D7 of these Guidelines require that Emergency Department Examination and Treatment Rooms have a minimum floor area of one hundred twenty (120) square feet and that when treatment cubicles are in open multiple-bed areas that each cubicle be provided with at least eighty (80) square feet of space.

On 01/10/14 at 8:36AM, it was noted that in the Emergency Department's (ED) Main Treatment Area located on the Main Floor of the ED Wing Building that several treatment cubicles (e.g., Cubicle #11, Cubicle #14, Cubicle #19) that had been constructed in 2003 to be multiple bed cubicles with at least eighty (80) square feet of space per bed had been subdivided into double bed cubicles with only approximately forty (40) square feet per bed. As per concurrent interviews with the facility's Director of Plant Engineering and the facility's Nurse Manger, the hospital had to subdivide these single bed cubicles due to the very heavy volume of patients that their Emergency Department sees on a daily basis. They added that the volume of patients that they are seeing was much higher than what had been anticipated and planned for when their Emergency Department expansion project had originally been approved. They said that the facility will submit a Waiver Request concerning this issue.

It was noted that each of the beds in the single bed cubicles that had been converted into two-bedded cubicles has all of the required electrical receptacles, Nurse emergency calling capabilities, and piped in medical vacuum and oxygen outlets as would be required by the Guidelines for multiple bedded construction and that the primary issue is that these cubicles are undersized and do not meet requirements.

42 CFR 482.41(c)
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Based on observation, record review, and interview during the Federal Recertification Survey, it was determined that the facility failed to ensure that: 1) staff followed Standard Infection Control Guidelines, and 2) staff access to hand wash sinks was not hampered.

Findings:

1) Observations on 01/07/14 between 10:15AM - 12:00Noon in the Intensive Care Unit (ICU) revealed the following:

Physician #4 entered Room #8, which housed Patient #38, who was on Contact Isolation and donned PPE (Personnel Protective Equipment). The gown's ties (neck and waist) were not tied. As the Physician auscultated the patient's lungs, the gown fell onto the patient's bed. The Physician then removed his gloves, performed hand hygiene, removed his gown, and without performing hand hygiene again, exited the room.

During an interview with RN #1 at that time she confirmed the findings.

RN #2 entered Patient #38's room with the WOW (Workstation on Wheels) to administer medications to the patient. When the task was completed RN #2 removed the PPE and exited the room with the WOW. In the hallway in front of the patient's room, not in the patient's room, and without donning appropriate PPE, the RN proceeded to disinfect the WOW. The RN did not disinfect the sides of the WOW, the stethoscope that hung on the monitor, and the monitor.

During an interview with RN #2 at that time, he stated the cart was cleaned and ready for the next patient. He confirmed the above findings and stated he was taught to clean only the areas he touched on the WOW. He also stated he did not have to wear PPE when cleaning the WOW and it was okay to clean the WOW in the hallway.

With the WOW, RN #3 entered Room #4, which housed Patient #39, who was on Contact Isolation. When the task was completed RN #3 removed the PPE and exited the room with the WOW. In the hallway in front of the patient's room and without donning appropriate PPE, she disinfected the WOW. The RN did not disinfect the sides of the WOW, pole, and monitor.

During an interview with RN #3 at that time she stated she completed cleaning the WOW. She stated she was taught to clean where she touched the cart. She confirmed the above findings.

During an interview with RN #4 at that time the Surveyor reviewed the disinfection observations and interviews. She stated the Nurses cleaned the WOWs appropriately as per Infection Control Guidelines.

At 1:00PM a review of the policy titled "Computer Etiquette" dated 01/13, revealed "when computers are brought into Isolation Rooms, they must be decontaminated prior to removal from room. Gloves may be used as they are part of the protection that is indicated for isolation. Users will decontaminate all surfaces of he cart along with the keyboard. Screens may be cleaned with water dampened wash cloth and buffed dry."

During another interview with RN #4 at 1:30PM the Surveyor reviewed the observations and the "Computer Etiquette" Policy. RN #4 stated she taught the staff to clean the top of the WOW cart, mouse, scanner, and keyboard. Anything they touched while in the Isolation Room. She stated she wrote the policy. CDC (Center for Disease Control) rules are whatever your policy says. The policy needs to be reworded. The wording in the policy is wrong. It is okay to clean the WOW cart in the hallway.

Observations on 01/07/14 between 1:30PM - 3:00PM in the Acute Dialysis Unit revealed the following:

At 2:10PM RN #6 at Station #2 touched the functioning hemodialysis machine's dialyzer and tubing with an ungloved hand.

During an interview with RN #6 at that time she agreed she should have worn gloves to touch the functioning machine.

At 1:40PM PCT #1(Patient Care Technician) used the PH/Conductivity Meter at Station #2 and without cleaning the meter, it was placed back in its box.

During interview at 2:50PM RN #7 was notified of this finding.

At 2:00PM, RN #8 at Station #2, while accessing the AVF (Ateriovenous Fistula) for the initiation of hemodialysis, did not wear eye protection. After applying antiseptic to the skin over the cannulation site she palpated the site again and without repeating skin antisepsis she cannulated the site.

During an interview with RN #8 at 2:08PM she stated she forgot her glasses were on her head and she was not aware she palpated the site again after she applied the antiseptic.

On 1/7/14 at 1:40PM PCT #1 used the PH/Conductivity Meter at Station #2 and disposed of the meter fluid in the utility sink in the Soiled Utility Room (Room 212).

At 1:43PM and 12:04PM RN #8 was observed performing hand hygiene at the same sink.

On 01/10/14 at 8:25AM, the Soiled Utility Room in the 2 South Acute Dialysis Unit (Room 212) was noted to lack a room identification sign.

On 01/10/14 at 8:26AM the Department of Health Principal Sanitarian notified the Director of Engineering of this finding.

2) On 01/10/14 at 8:26AM, a "red bag" infectious medical waste receptacle was improperly stored directly in front of and hampering access to a hand wash sink in the in the 2 South Acute Dialysis Unit (Room 212) Treatment Room.

During concurrent interview with the facility's Director of Engineering, he stated that the waste container should not be stored in front of the sink.



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