HospitalInspections.org

Based on findings from document reviews and interviews, in 2 of 2 Emergency Department (ED) medical records (MRs) reviewed (Patients HH and II), the patients signed a form indicating they had received a copy of the "Your Rights as a Hospital Patient" booklet which contains the New York State Patients' Bill of Rights statement even though they did not.

Findings include:

-- Per review of Patient HH's MR he/she signed a form titled "Patient Consent Record" on 12/02/14. The form indicates that Patient HH received a copy of the Patients' Bill of Rights.

-- Per review of Patient II's MR, he/she signed a form titled "Patient Consent Record" on 12/02/14. The form indicates that Patient II received a copy of the Patients' Bill of Rights.

-- Per interview with Registration Specialist #1 on 12/02/14 at 10:10 am, patients are provided the "Your Rights as a Hospital Patient" booklet and then he/she has them sign a patient consent record. When asked to show what is given to the patients, he/she only showed the surveyor a consent record. He/she did not have any copies of the Patients' Rights booklet.

-- During interviews on 12/02/14 with Patient HH at 10:20 am and Patient II and spouse at 10:40 am, they stated they signed a Patient Consent Record but they did not receive a copy of the booklet titled "Your Rights as a Hospital Patient."

-- The hospital Policy and Procedure (P&P) titled "Patient Rights and Responsibilities,"last reviewed 11/2014, stated "Each patient presenting to the Emergency Department, admitted for inpatient treatment or receiving outpatient services, will be given by Patient Registration a copy of 'The New York State Patients' Bill of Rights Statement' contained in the booklet 'Your Rights as a Hospital Patient.'"

-- The above findings were acknowledged by the Emergency Department Nurse Manager on 12/02/14 at 11:00 am.

Based on findings from observations, document review, and interview, the hospital's protocols for documenting and authorizing preprinted provider orders using both hardcopy and electronic provider order entry processes were contradictory. Also, in 4 of 4 hardcopy medical records (MRs) reviewed in the neonatal intensive care unit (NICU) for Patients D, JJ, KK, and LL, nursing staff had implemented preprinted provider orders for newborn care prior to a provider authorizing those orders for the particular patient. Written policy and procedure (P&P) allowed this practice.

Findings include:

--The hospital's P&P titled "NEWBORN PROTOCOL," last revised 4/2013, contained the following statement: "The attending provider will be noted on the order set and he/she or his/her appropriate designee will sign the protocol orders on rounds or within 24 hours."

--In contrast, per interview with the Informatics Information Technology Specialist #1 on 12/2/14 at 9:40 am, the Obstetrician who is present at the time of delivery orders and triggers the "NEWBORN PROTOCOL-PHARMACY ORDER SET-NAO" into the electronic health record (EHR) computerized provider order entry (CPOE) system which signs the Provider's signature electronically. There is no paper order in the electronic system.

--Per review of hardcopy MRs for Patients D, KK, JJ, and LL, they each contained a hardcopy provider order form titled "NEWBORN PROTOCOL-PHARMACY ORDER SET-NAO" that listed orders for newborn care, e.g., administration of Vitamin K and Erythromycin opthalmic ointment. The hardcopy order forms did not contain a provider's signature or indication the orders were verbally authorized by a provider. Regardless, review of nursing documentation in the MRs revealed these orders had been implemented. (NOTE: The preprinted orders in the electronic component of these MRs also were not authorized prior to nursing implementation.)

During interview with Registered Nurse (RN) #1 on 12/1/14 at 4:00 pm, he/she acknowledged the orders were not signed by a provider prior to implementation.


--The P&P titled "NEWBORN PROTOCOL," referenced above, inappropriately allowed nursing to implement provider orders prior to authorization for an individual patient.

Based on findings from observation, medical record (MR) review and interview, one of 6 MRs of Progressive Care Unit patients which were reviewed for fall risk assessments and interventions (Patient M) lacked a completed fall risk assessment. Also 3 of 6 MRs reviewed for patients who were assessed to be at risk for falls (Patients K, C and L) lacked indication that interventions warranted to prevent falls (based on their fall risk assessments) were implemented.

Findings include:

--Per review of hospital's policy and procedure (P&P) titled "Fall Prevention Program," implemented 6/26/13, it indicates that the RN (Registered Nurse) is to assess every inpatient upon admission to determine the risk for falls. It also indicates a falling star sign is to be placed at the entry to the patient's room if assessed to be at medium or high risk for falls.

--Per review of Patient M's MR on 12/2/14 at 9:45 am, it did not contain documentation of a fall risk assessment being performed since admission on 12/1/14.

--Also, per observation on 12/2/14 at 9:45 am, there was no fall risk sign placed at the entries to patient rooms for Patients K, C and L, who were all identified in their MRs as being at risk for falls.

--During interview of RN #2 on 12/2/14 at 9:45 am, he/she acknowledged the above findings.

Based on findings from observations, interviews, and facility document reviews, the Director of Dietary Services did not ensure staff compliance with Hazard Analysis & Critical Control Points (HACCP) industry standards addressing safe food handling practices.

Findings include:

-- Per observation during tour of the cafeteria serving line on 12/2/14 at 8:50 am, two food service workers were wearing hair restraints that only partially covered their head of hair (e.g., one hair restraint only covered the hair "bun" at the back of the worker's head). This practice does not provide the required protection from potential hand to hair contact.

-- During interview of Food Service Worker #1 on 12/2/14 at 9:00 am, in response to an inquiry about probe thermometer use (metal stem or digital) for food temperatures, he/she produced a small test-strip product called T-Sticks manufactured by EcoLab. This product provides a qualitative test result (color change when a certain temperature is reached) versus a quantitative test result. As such it does not meet the New York State hospital code addressing food service thermometers, which requires the use of standard metal stem thermometers to verify safe food temperatures (Part 14 State Sanitary Code, 14-1.85 states "Metal stem-type, numerically scaled, indicating thermometers accurate to plus or minus two degrees Fahrenheit (1.1 degrees Celsius) are to be provided and used to determine that proper internal cooking, holding or refrigeration temperatures of all potentially hazardous foods are obtained and maintained").

-- Per observations in the walk-in cooler and review of the Hazard Analysis & Critical Control Points (HACCP) Cooling Temperature logs during a tour of the kitchen on 12/2/14 at 9:20 am, there was a tray of turkey product labeled with a date that did not match the HACCP food logs (which contained two different log entries/dates for turkey products that were recently cooled).

-- Per interview of Cook #1 (in the presence of the Director of Dietary Services and the Manager of Dietary Services) on 12/2/14 at 9:25 am, he/she prepared the turkey and the HACCP cooling logs for that turkey. Cook #1 indicated the turkey product in the walk-in cooler was partially used after cooling. At that time, the original date on the food label (i.e., the food label that matched the documented HACCP log date) was removed/revised to a more current date.

-- This practice of changing the food label date which matches the original HACCP log date does not allow effective tracking and assurance that the cooling method described in the logs is matched to the cooled food products in the coolers and freezers. It also does not ensure proper tracking of potentially hazardous foods if an adverse event or suspect food-borne illness outbreak is identified.

Based on findings from observation, the hospital preventive maintenance and infection control program did not identify and correct an issue of physical plant disrepair in the surgical suite.

Findings include:

-- Per observation on 12/1/14 at 3:00 pm during a tour of the 2nd floor Pavilion building surgical suite, the floor in OR #8 under the operating table had a large separation (seam) exposing the subfloor. This condition creates an infection control risk since proper cleaning and disinfection of the floor is not possible as required in an operating room environment.

Based on findings from observation, document review, and interview, the staff working on the hospital's postpartum unit did not alert the Biomedical Department that the blanket warmer was not functioning as required.


Findings include:

--Per observation on 12/1/14 at 11:55 am, the blanket warmer on the postpartum unit contained patient blankets, gowns and newborn knit hats.

--Per review of document titled "Blanket Warmer Temperature Log," the recommended temperature is 130 degrees Fahrenheit. However on 19 of 30 days in the month of November 2014 the blanket warmer temperatures documented on the log were greater than 130 degrees. There was no documentation by nursing personnel indicating the out of range temperature was reported to Biomed.

--During interview with the Nurse Manager for Maternal/Child Health and Nursing Assistant #1 on 12/1/14 at 11:55 am, these findings were acknowledged.

Based on findings from observations, interviews, and facility document review, the hospital did not maintain proper ventilation in soiled areas or proper temperature controls in food storage areas, and did not take and/or document immediate and sufficient corrective actions when food storage equipment malfunction was identified.

Findings include:

-- Per observation during tour of the 4th floor Alternative Level Care (ALC) Unit on 12/2/14 at 1:45 pm, the trash room across from room 4143 did not have an exhaust vent in the drop down ceiling to provide required negative pressure.

-- Per observations during tour of the same ALC Unit on 12/2/14 at 2:00 pm, the room labeled "Linen Only" which was storing multiple 40 gallon soiled linen bags in carts, lacked the required negative air pressure. Although the room had a vent grill in the ceiling, there was no apparent exhaust. The Director of Facilities and the Director of Infection Control also observed and verified this finding during interview.

--Per observations during tour of the cafeteria dessert cooler behind the service line on 12/2/14 at 8:55 am, the digital air temperature reading on the unit indicated 82 degrees F, the small metal refrigerator thermometer inside the unit was reading in the red zone around 60 degrees F, and the inside of the unit was blowing warm air on approximately 30 plates of sliced apple and pumpkin pies, and approximately 10 whole pre-made uncooked pizzas. Regardless, staff had not acted to remove the food, identify it as "no use" (sign), or discard it to ensure it was not served.

Per interview of Food Service Worker #1 (in the presence of the Dietary Service Manager) on 12/2/14 at 9:05 am, maintenance was notified of the problem.

Per review of the equipment temperature log entries for that morning, the dessert cooler unit temperature was logged at 34 degrees at 5:00 am. However, documentation describing the temperature problem that followed, including documentation indicating that maintenance was notified of the problem to come repair it, was lacking.

Based on findings from observations and interview, several lapses in acceptable infection control practices were identified at the hospital's outpatient and inpatient settings.

Findings include:

--During a tour of the hospital's Samaritan Medical Plaza extension clinic on 12/1/14 at 1:15 pm, a white round machine was observed on the floor in the public bathroom in the chemical dependence clinic area. In response to questions during interview of Case Educator #1 at this time, he/she indicated the machine was a noise machine used in that bathroom and acknowledged it was always kept on the floor.

Per additional observations in the bathroom noted above, an unsecured refrigerator in the corner of the bathroom held several (>7) Fed Ex bags, each containing urine specimens in hazardous bags.

Per continuing interview with Case Educator #1, the urine specimens were obtained from patients and placed in the unlocked refrigerator until pick up by Fed Ex later in the week. The urines were being sent out for drug testing.

--Per observations during tour of the 4th floor medical surgical unit in the Pavilion building on 12/1/14 at 3:00 pm, both soiled utility rooms contained boxes of archived patient file folders and storage racks with five (5) shelves of blank patient forms for eventual use. These clean items should not have been stored in the soiled utility rooms.

Per interview of this unit's Assistant Nurse Manager on 12/1/14 at 3:15 pm, they have routinely stored the files and forms there due to lack of space on the unit.

--Per interview with the Director of Rehabilitation Services on 12/3/14 at 9:10 am, the outpatient rehabilitation unit lacked a policy and procedure for cleaning and disinfecting the water tank storing hot packs used for patient care. Additionally, the unit lacked a log to document the cleaning and disinfecting of the tank.

Based on findings from document review and interview, the hospital's policy and procedure (P&P) governing the use of alcohol based skin preparations for antisepsis in the operating room (OR) did not require documentation in the MR of measures undertaken by staff at the time of use to reduce the risk of associated fire.

Findings include:

--The hospital's P&P titled "Skin Prep, Pre-op," last revised 08/2014, outlines OR fire risk reduction measures that should be undertaken to prevent surgery related fires when alcohol based skin preparations are used for skin antisepsis, e.g., allowing to dry before draping, use of packaged applicators to ensure controlled delivery, etc. However, the P&P does not require that staff document the measures taken to reduce the risk of fire associated with use.

--During interview with the Interim OR Director on 12/02/14 at 11:30 am, he/she acknowledged that OR staff do not document interventions that are undertaken in the OR to reduce the risk of associated fire when alcohol based skin preparations are used.

Based on findings from document review and interview, 2 of the hospital's policies and procedures (P&P) addressing consent for blood transfusions were not consistent in regard to the requirement for written patient consent for the administration of blood.

Findings include:

--The hospital's P&P titled "Consent," last revised 4/2010, indicated that a specific consent is required for invasive procedures or treatments, including specific consent for blood transfusions. The P&P also stated that physicians may alternatively document in progress notes that they obtained informed consent for the administration of blood and blood products.

--The hospital P&P titled "Blood PRBC (Packed Red Blood Cell) Administration," last revised 08/2013, indicated that except in emergency situations, written consent should be obtained prior to blood transfusions.

--During interview with Quality Improvement Practitioner #1 on 12/2/14 at 12:30 pm, the above findings were acknowledged.

Based on findings from medical record (MR) review and interview, in 1 of 1 medical record reviewed for outpatient surgery patients receiving anesthesia services (Patient I), the MR lacked documentation that a post-anesthesia evaluation was performed. Also, the hospital did not have a policy that addressed the requirements for and elements of a post-anesthesia evaluation.

Findings include:

--Per MR review, on 12/01/14 at approximately 8:00 am Patient I underwent a laparoscopic tubal ligation and drainage of peritubal cyst while receiving intravenous (IV) general anesthesia. However, Patient I's MR lacked a post anesthesia evaluation prior to her discharge.

--Per interview with Registered Nurse #3 on 12/01/14 at 12:00 pm, anesthesia personnel do not routinely document post-anesthesia evaluations for patients undergoing outpatient surgery.

--During interview with the Interim Operating Room Director on 12/2/14 at 12:00 pm, the above findings were acknowledged.