HospitalInspections.org

Based on interview and the review of documents, it was determined the facility's Board of trusties failed to demonstrate accountability for services provided under contracts. Specifically, the Board of Trustees has not been privileged to reports of reviews and recommendations of clinical and non clinical contracts. This finding was noted in 10 of 10 clinical and non-clinical contracts reviewed.

Findings included:

1. The review of Board of Trustee monthly minutes on 11/21/13 noted the evaluation of contracted services were not furnished to the Board of Trustees in the January to October 2013 minutes submitted for review.

At interview with Staff #9 on 11/21/13 at 9:40 AM, she stated that the report of evaluation of clinical and non-clinical contracts have not been reported to the Board of trustees in previous years. She added that the facility began evaluating contracts in January 2013 which would be reported to the Board of Trustees by December 2013 and annually thereafter.

2. The review of 10 randomly selected clinical and non clinical contract evaluations failed to reveal an established procedure for the review of contracts. The members involved in the review of contracts were not indicated and the criteria used for the review of each contract were generic for all contracts; there were no specific indicators established to evaluate the diverse services provided by contractors.

a. For example, the contract with Cardinal Health, the supplier of pharmaceuticals was evaluated on 6/3/13 by the Director of Pharmacy and a recommendation was made for contract renewal; there was no indication of other participants in this review. The generic form titled Evaluation of Contracted Clinical Service was used by pharmacy for the evaluation of Cardinal Health with no selected criteria by the Department of Pharmacy.

b. The evaluation Virtual Radiology performed by the Clinical Director on 5/16/13 reveals the services provided by the contractor are acceptable; however, there were no quantitative measures to identify areas of performance improvement.

c. Similarly, Allied Urology Services was recommended for renewal based on evaluation of clinical services by the Clinical Director on 9/30/13. The Clinical Director indicated that the contractor does not participate in Performance Improvement Programs. There was no indication of how the performance of this contractor is measured and reviewed for quality improvement purposes.

At interview with Staff #9 on 11/21/13 at 9:45 AM, she stated a group of staff members including the Chief Medical Officer and the Chief Operating Officer evaluates all clinical contracts and the Legal Department evaluates all non-clinical contracts. There was no indication of a group involvement in the ten contracts selected for review.
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Based on patient interview and the review of medical record, it was determined that the hospital failed to consistently inform each patient of his/her patient rights.
Findings include:
The review of medical record for Patient # 38 on 11/18/13 noted that this 76- year-old Spanish speaking, patient was admitted on 11/15/13 with diagnosis of Diabetes Mellitus type 2- newly diagnosed. It was documented on the Acknowledgement form that the patient was informed of Patient's Rights but was unable to sign. The information on the form was written in English.

The patient was interviewed at bedside (Room 304-A) on 11/18/13, at approximately 1:00 PM, with the assistance of an interpreter. The patient stated that he is able to write and reported that he never saw the acknowledgement form before it was presented to him by the surveyor. The patient stated that the patient rights booklet and any other information were not given to him.
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Based on staff interview, review of medical record, patients grievance files and review of Board of Trustees Minutes, it was determined that the governing body failed to establish a procedure for prompt resolution of patient grievances.

Findings include:
The Board of Trustees Minutes for meetings held in September 12, 2013 and October 10, 2013 were reviewed on 11/19/2013. There were no discussions regarding grievances in the September 12, 2013 Board of Trustees minutes. The minutes only addressed the Federal survey findings. In the October 10, 2013 minutes, discussions were held regarding the need for timely response to patients ' complaints and the total number of complaints received in the months of July, August and September. The Board of Trustees Minutes for October 10, 2013 discussed that the total number of complaints received in September was 13 and that all complaints have been closed after the revision of policy and staff education.

The review of Grievance # 6 on 11/19/13 noted that the facility receive this grievance from the patient on 9/11/13. The Grievance file was closed on 9/18/13 without a written response to the patient. The patient alleged he received care in the facility's ED and there was a discrepancy in his medical record. The Board of Trustees Minutes failed to resolve this grievance.

The Board of Trustees failed in its responsibility to resolve grievances or delegate the responsibility to Grievance Committee. At interview with Staff # 27 on 11/19/13, she stated the facility does not have a Grievance Committee. This information was confirmed by Staff #9 on 11/20/13. They both stated that going forward, the Patient Advocate Department will report to OPEC ( ) monthly and OPEC will report to the Board of Trustees.
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Based on staff interview, the review of patients' grievance files and hospital's policy, it was determined that the facility failed to ensure that response to grievances made by patients and patients' representatives contained the regulatory required elements. This deficiency was noted in five of seven grievance files reviewed (files #1, #2, #3, # 4 & #5)

Findings include:
Grievance file #1 was reviewed on 11/19/13. It was noted the facility received this grievance from a 38 year pregnant patient on 9/11/13 regarding allegation of inappropriate gynecological care in the facility's Emergency Department (ED) on 9/7/13. The facility response to the complainant on 9/26/2013 did not includes the steps taken to investigate the grievance and the results of the grievance.

Grievance file # 2 was reviewed on 11/19/13; the grievance was received by the facility on 9/16/13 and the written response to the complainant was dated 10/4/13. The complainant alleged that she did not have a nurse during her visit to the Emergency Department on 9/12/13. The Grievance file did not contain the name of the investigator and the date the investigation was completed. It was also noted that the complaint response was sent to the Patient Advocate on 10/4/13, two weeks after the receipt of the complaint. In addition, the result of the investigation pertinent to this grievance was not included in the response letter to the complainant.

Grievance file # 3 was reviewed on 11/19/13. The facility received a grievance from the spouse of the Patient referenced in Log #3 on 10/16/13 regarding long waits in the ED for care. The facility's response to the complainant lacked the steps taken to resolve the grievance and the date the investigation was completed.

The review of Grievance file #4 revealed a complaint received by the facility on 10/9/13 from a patient who alleges inappropriate medical care rendered by a urologist while an inpatient. The hospital investigated the allegations and responded to the complainant on 10/22/13. The response lacked the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion, as required.

The review on 11/19/13 of the policy titled "Patient Grievance Mechanism Code 7.10" effective September 2013 noted that this policy listed the regulatory elements that the written response must include; however, the facility has not implemented this policy in its written response to patients' grievances.
This finding was discussed with Staff #26 and #27 on 11/19/13.
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Based on interviews and review of medical record, it was determined that the facility failed to respond to patients / patient ' s representative request for services customarily rendered by the hospital as required by the patient's medical condition. This deficiency was noted in one medical record reviewed (MR # 39).

Findings include:
During the unit tour on 11/21/13 at approximately 3:00 PM, the patient's representative in Room 601-A stated that the patient was to have surgery today but this procedure was not done and no one has explained why the procedure was not done. The family member stated that the patient was uncomfortable and in pain.

The surveyor observed that the dressing on the patient's shoulder was covered with blood.

At interview with the patient's nurse on 11/21/13 at approximately 3:15 PM, the nurse stated that the patient arrived in the unit from the Emergency Department (ED) today and her dressing was recently changed but it kept "oozing" and the physician has been paged. The nursing staff later stated that the surgeon responded to the call and would be in the unit in 20 minutes to see the patient. It was noted that this surveyor left the unit approximately 4:50 PM and the patient had not been evaluated by the surgeon.
The case was discussed with Staff # 26 on 11/22/13 who followed-up with the patient. The staff stated that she was informed by a Resident Physician that the patient's procedure was canceled on 11/21/13 at 5:00 PM and rebooked for 11/22/13. She added that the patient had been updated.

Review of medical record for Patient # 39 on 11/22/13 noted that the patient, 46 year old patient with history of diabetes Mellitus type 2, hypertension and cellulitis and abscess, was admitted on 11/21/13. The presenting problems were carbuncle of upper back and furuncle on neck region. The patient was admitted with diagnosis of cellulitis to the left shoulder and diabetes. The patient underwent incision and drainage on left shoulder abscess in the ED on 11/21/13 at 0537 AM and was transferred from the ER on 11/21/13 at 1230 PM.
On 11/21/13 at 2:32 PM, the nurse noted that the patient was for OR today. On 11/21/13 at 6:09 PM, the nurse noted that the OR was canceled.
The procedure form dated 11/22/12 at 0924 indicted that the patient had infected, necrotic left posterior shoulder abscess and infected anterior shoulder abscess for which she underwent sharp excision and debridement. There was no documentation that the physician responded to the patient and her family concerns on 11/21/13 as there was no documentation of an assessment and treatment of the patient in the medical record. There were no inpatient physician's progress notes for 11/21/13.
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Based on observation, interview and record review during the Federal Recertification Survey, it was determined that the facility did not ensure staff maintain patient privacy.

Findings:

1 - Observations on 11/18/13 in the Ambulatory Surgery unit revealed the following:

In the Pre Admit Room at 11:33 AM Patient #10, Patient #10's aide, Patient #8, and one visitor were sitting within inches of each other in a semicircle. Two other patients were sitting about two feet to the right of Patient #8. Staff member #11 confirmed Patient #10's identifying information and administered eye drops to the patient without drawing curtains.

At 11:36 am and 11:49 am Staff Member #1 was observed entering the same room. She confirmed Patient #8's identifying information and administered eye drops to the patient in the presence of 3 patients and 2 visitors.

During another observation in the Pre Admit Room at 12:15 PM and 12:26 PM Staff Member #2 confirmed Patient #1's identifying information and administered eye drops to her in the presence of Patient #2 and a visitor.

At 11:40 am Staff Member #11 wheeled Patient #10 into the waiting rooming which did not have privacy curtains or screens. He confirmed Patient #10's identifying information and administered eye drops to the patient in the presence of another patient and 3 visitors.

At 12:00 noon in the same waiting room, that lacked privacy curtains and screens, in the presence of 5 visitors and 3 patients, Staff Members #3 and #4 confirmed Patient #15's identifying information and repeatedly explained they were going to move him to the stretcher. Attempts to move the patient to the stretcher, in full view of everyone in the room, was unsuccessful. Staff Member #2 then intervened and placed the patient in another room.

On 11/19/13 in the morning Staff Member #9 was notified of the these findings.

2 - During the unit tour (6 S) on 11/21/13 at approximately 3:00 PM, it was observed that the curtains for patient in Room 601-A was open; the patient was observed lying in bed with his gown open at the back exposing his body. The patient's upper left shoulder had a wound dressing that was covered in blood.
The lack of privacy for this patient was discussed with staff # 26 on 11/22/13.
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16790

Based on observation, staff interview and the review of performance improvement plan, it was determined the facility failed to ensure that Outpatient Services have an ongoing quality assurance program that would improve health outcome. Specifically, the facility failed to address long wait times in the Orthopedic Clinic.
Finding includes:
A tour was conducted in the hospital's outpatient clinics on 11/20/13 at approximately 3:00PM with the Assistant Vice President for Ambulatory Care. The hospital's ambulatory services have approximately 36 clinics. During the tour, Staff #28 was interviewed at 3:15 PM regarding the lack of indicators specific to the scope of services provided. The staff member stated the Performance Improvement Plan for 2013 has two generic indicators and one indicator that is specific to Woman's Health Clinic.
During the tour it was observed that the Orthopedic Clinic was crowded. Staff #28 stated the clinic provides services to adult and pediatric patients and is open only two days weekly from 8 AM to 12:00 PM. She added that appointments are scheduled; however they have experienced a large volume of walk- in patients. She stated that due to the large volume of walk-ins the wait time to see an orthopedic physician is approximately 3 hours.
Further interview with Staff #28 regarding the monitoring and assessment of wait- time in the clinic, she stated that in the past, ambulatory service had an indicator on wait time in the clinic but due to improvement in wait time the indicator was deleted.
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Based on interviews, observations and the review of medical records and other documents, it was determined that nursing staff failed to identify patient care needs and implement interventions to assure the prevention of pressure ulcers. These findings were noted in 7 of 10 patient records reviewed (Patient #s 22, 23 and 24, 40, 41, 42, 43).

Findings include:

1. Patient #22 is a 48-year-old paraplegic male admitted to the facility on 11/15/13. The initial nursing assessment failed to identify the patient as a high risk for developing pressure ulcers and implement measures to reduce the risk.

The initial nursing assessment on 11/16/13 placed the patient at a low risk for pressure ulcer based on a Braden score of 17 that did not include accurate assessment of the patient's sensory perception and the degree to which the patient's skin is exposed to moisture. Although the patient was paraplegic, the nurse noted his sensory perception was not impaired. The patient was noted to be rarely moist even though he was incontinent of bowel and bladder.

The initial skin assessment on 11/16/13 revealed no pressure ulcers but a healed ulcer in the right buttocks and multiple old scars in the abdomen and back.

A hospital acquired pressure ulcer was identified on the third day of admission on 11/18/13; a stage II, 1 cm x 0.5 cm on the left buttock.
Two more pressure ulcers were noted on 11/19/13, a left buttock, stage II, 1 cm x 1 cm and a left hip, stage II, 2 cm x 2 cm.

There was no early detection of the pressure areas until they were stage II ulcers. The patient's care plan was not revised to include treatment and intervention for the pressure ulcers.

At interview with Staff #16 on 11/20/13 at 11:58 AM, she stated the patient is repositioned every two hours to prevent pressure ulcers; however upon patient interview at 11:59 AM, he stated he would need an assistive device to increase his bed mobility.

The facility's Skin Integrity Protocol revised June, 2012 notes that nurses are to institute measures to reduce/relieve shearing forces and friction.


2. Patient #23 is a 67-year-old female who was admitted on 10/15/13 with complaints of progressive weakness, dysuria and urinary retention. The initial nursing assessment on 10/15/13 noted the patient did not have a pressure ulcer on admission but was identified as a low risk of developing pressure ulcer. The daily nursing assessment failed to accurately document the patient's skin condition prior to the identification of all the pressure ulcers the patient developed in the facility. A stage II, right hip pressure ulcer, measuring 6 cm x 6 cm was first documented on 10/20/13; A sacral stage II, 10 cm x 15 cm was initially noted on 11/4/13 and a left buttock, stage II, 2 cm x 2 cm was identified on 11/18/13.

The nurse's notes on 10/20/13 revealed that Mepilex (Self-adherent Absorbent Dressing) was applied to the right hip ulcer and that "MD order for wound care consult" was obtained. However, there was no evidence of physician assessment of the wound and recommendations for treatment.

Interview with Staff #17 on 11/20/13 at 12:30 PM, she stated nurses are responsible for the management of stages I and II ulcers while the Wound Care Team is responsible for daily management of stages III and IV ulcers with the exception of Saturdays and Sundays. She added that nurses implement wound care protocol for the management of stages I and II ulcers.

Nursing daily assessment of the patient's right hip ulcer failed to describe the wound appearance, and timely confer with the responsible physician for the care of the pressure ulcer. A wound consultation obtained on 11/5/13 revealed a stage III, right hip ulcer with 80% necrotic tissue and also multiple lesions at the sacral and bilateral buttocks. The wound required surgical debridement and daily treatment with Collagenase (enzymatic debriding agent). Nursing follow up assessment on 11/5/13 notes a right hip stage III, pressure ulcer measuring 10 cm x 10 cm x 0.3 cm.


3. Review of medical record for Patient #24 on 11/19/13 about 12:30 PM noted this 68- year-old patient was admitted on 10/15/13 for exacerbation of Chronic Obstructive Pulmonary Disease and Pneumonia. On admission the skin is noted to be intact and Braden scale skin assessment identified the patient as low risk for pressure ulcer. Nursing documentation on 11/5/13 identified a stage II sacral ulcer measuring 2 cm x 2 cm; the wound had no drainage and no odor. The patient's sacral area went from being intact on 10/15/13 to a stage II pressure ulcer on 11/5/13, no skin breakdown was noted to the sacrum prior to 11/5/13. This finding was brought to the attention of Staff # 18.

4. Review of record for Patient #40 on 11/20/13 at approximately 10 AM noted an elderly female from a nursing home was admitted to the hospital on 11/14/13 for complaint of abdominal pain as per Emergency Medical Service. The patient was admitted with a diagnosis of renal failure. The patient's medical history included hypertension, diabetes mellitus, Alzheimer's disease and renal failure. An Initial Nursing Assessment was done on 11/15/13 which noted that patient had a Braden score 11 (at risk) and her skin was intact. The patient was identified with a stage II pressure ulcer on 11/16/13. All preventive measures were documented. Staff #29 at interview on 11/20/13 at 10:15 AM stated that patients are turned and position every two hour using a "Turning Clock" schedule which is posted on the wall of all patients identified as needing repositioning every two hours. However, the tour of the unit revealed that four patients that require turning and repositioning did not have the clock posted on the wall and one patient who had the Turning Clock was not positioned in accordance with the clock schedule.

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27378

Based on record review and interview during the Federal Recertification Survey, it was determined that the facility did not ensure that medication orders included only acceptable abbreviations and all of the required elements for 4 of 6 medical records reviewed (Patient #8, Patient #9, Patient #10, and Patient #11) as per hospital policy.

Findings:

1) Review of Patient #8's medical record revealed on 11/18/13 the patient was admitted to same day surgery for a left eye cataract extraction with lens implantation. The preoperative medication order sheet documented Vigamox, Mydriacyl 1%, Mydfrim, and Cyclogyl 1% one drop q(every) five ' (minutes) x (times) three to the left eye. These medication orders included abbreviations that were not approved by the hospital policy and did not include frequency or duration.

2) Review of Patient #9's medical record revealed on 11/18/13 the patient admitted for cataract surgery and the preoperative medication order sheet documented Vigamox, Mydriacyl 1%, Mydfrim, and Cyclogyl 1%. These same medication orders again included abbreviations that were not approved by hospital policy and did not include frequency and duration.

Similar findings were identified in Patient #10's and #11's medical records.

On 11/19/13 at 2:30 PM the above order was reviewed with Staff Member #1 . She explained the "q" indicates every, the hyphen after five indicates minutes, the "x" indicates times and the order should include doses after the 3.

3) Review of Patients #10's and #11's medical records revealed on 11/18/13 the patients were admitted for cataract surgery and the Post-Operative Instructions sheets documented Pred 5 x(times) 1 d(day) and Vigamox 4 x (times) 1 d(day) to the eye. The medication orders included abbreviations that were not approved by hospital policy and did not include the complete name of the medication, dosage, route, frequency and duration.

On 11/19/13 at 2:30 PM the above order was reviewed with Staff Member #1 . She explained the "Pred" indicates Predforte, "5" indicates 5 times a day and "d" indicates for one day. She stated the order should be written Predforte one drop to the affected eye five times a day for one day.

Similar findings were identified in Patient #8's and #9's medical records.

Review of hospital policy's entitled "Abbreviations-Approved/Unacceptable Abbreviations and Symbols" dated 01/03/2011 and Prescribing/Ordering" dated 03/15/2011, respectively, documented unacceptable abbreviations are not to be used, medication orders shall contain only abbreviations and symbols which have been approved by the medical staff and complete medication orders include drug name, dosage, strength, duration, route and frequency.
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Based on review of medical record and staff interview, it was determined that the facility failed to ensure (1) that all patients have accurate documentation in the medical record. This deficiency was noted in one of eleven applicable medical records. (Patient # 30); and (2) ensure medical information such as patient assessment are promptly completed and filed in the medical record. Findings were noted in Patient #s 45, 46, 47 and 48.

Findings include:
1. The review of medical record Patient #30 on 11/18/13 noted an 81 year old patient, with multiple co-morbidities. The patient was admitted to the facility on 11/8/13 and remained in the hospital on 11/18/13 awaiting nursing home placement.
On 11/12/13 4:41 PM, the physician noted that the patient was on medical one to one for confusion and disorientation.
The review of the Criteria for One-One Management of the Patient located in the record revealed the form was not complete and accurate. For example, it was noted that on 11/16/13 at 4:30 PM, under Psychiatric One-to-One, physician checked the box that indicates the patient has exhibited violent behavior as evident by risk for falls. The Risk for fall is not considered a violent behavior.
This form indicted that for patient on " Medical One to One management: the patient must score at least two (2) points for order to be justified. This must be reordered every eight (8) hours " .
It was noted that on 11/14/13 at 3:00 AM and on 11/15/13 at 12:30 PM, the physicians who completed the form did not document the justification for the one-to-one monitoring.
The form indicated that patient scores 1 (one) point if the "patient wanders and/or is confused/disoriented". However, on 11/17/13 at 8:30 AM and 8:30 PM, the physician checked that the patient was confused and disoriented; total of 2 (two) points instead of 1 (one) point as indicated on the form.

This form was not always recorded every 8 hours as in 11/13/13 when the form was completed on 11/13/13 at 4:00 AM and the next form was dated on 11/13/13 at 7:00PM.

The physician's order for the monitoring was requested from staff # 31. This staff stated that the Criteria for one-to-one was the order. The inconsistent documentation on physician's order was brought to the attention of staff #31.

2. Review of 4 medical records which included 10 clinic visits to the " Woman Health Clinic " was done on 11/21/13 at approximately 1:00PM. Present during the review of medical records was the Assistant Vice President (AVP) of Ambulatory Services. Patient # 45 is a 21 year old female, 32 weeks gestation, Gravida 2, Para 1, who was seen at the Woman Health Clinic on 11/1/13 for a follow-up visit. The patient's medical history included abnormal Pap smear, seasonal allergies and a cesarean section in 2010. There was no physician assessment of the patient during the 11/1/13 follow-up visit at the clinic; instead, a diagnosis related group number 765.26 was indicated. In another follow-up visit to clinic on 11/15/13, it was noted that patient stopped smoking prior to the present pregnancy. Again, Diagnosis- related group codes were noted. There was no documentation of a physician assessment of the patient.





27378

Based on observation and staff interview, it was determined that the facility failed to consistently ensure the confidentiality of patient's medical record.
During the tour of the unit (3 South) on 11/18/13 at approximately 1:13 PM, the patient's medical record (# 32) was left unattended on the counter of the nursing station and was accessible to non-clinical staff, patients and visitors. It was noted that although this facility maintains its medical records in electronic format, it still maintains pertinent patient information in paper form.

This finding was brought to the attention of Staff # 18 who discussed it with the unit clerk.
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Based on record and document review and staff interviews, it was determined the facility failed to ensure that medical records were (1) promptly completed in 2 of 3 medical records reviewed (Patient #s 16 and #20), and (2) ensure that records are properly authenticated in 6 of 8 medical records reviewed (Patient #s 16, 17, 18, 19, 20, 21).


This finding includes:

1) a. Review of medical record for patient #16 on 11/20/13 revealed there was no dictated operative report for this patient who had surgery on 8/30/13.

Review of the hospital policy titled Incomplete and/or Delinquent Medical records noted that all medical records of discharged patients must be completed within 30 days from the date of discharge. A review of the policy titled Un-dictated operative Reports noted that operative reports must be dictated or written immediately following surgery.

An interview was conducted with Staff member #15 on 11/18/13 at 11:30 AM. Information about incomplete medical record was discussed. The staff stated that the chairperson of each department received a daily e-mail notification of all incomplete records for each physician in their respective departments.

A review of the delinquent records list created on 11/15/13 noted that there were one hundred and forty five (145) un-dictated operative reports.

b. Review of the medical record for patient #20 on 11/20/13 noted that notes written by a Physician Assistant (PA) on 8/13/13 were not countersigned by a physician as required.


2) a. Review of medical record for patient #16 on 11/20/13 noted that proper authentication by authors were not included at the conclusion of entries such as history and physical, progress notes and consult for surgery. Authentication was done by electronic signature which only showed names of the authors but did not include the professional titles or initials indicating professional credentials.

Review of patient # 19's medical record on 11/20/13 noted that history and physical entry was electronically signed and cosigned by two practitioners. The electronic signature showed the name of the authors but did not include the professional titles or initials indicating professional credentials.

Findings were confirmed with staff member #9.
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Based on observation, interview and record review during the Federal Recertification Survey, it was determined that the facility did not ensure medications were secured from unauthorized individuals.

Findings:

Observations on 11/18/13 in the Ambulatory Surgery unit revealed that eye medications were left unsecured and unsupervised by the nursing staff at the patients' chair sides.

1) In the Pre Admit Room on 11/18/13 at 11:33 am Patient #10, Patient #10's aide, Patient #8, and one visitor were observed sitting in a semicircle with four bottles of eye drops (Vigamox, Mydriacyl, Mydfrim and Cyclogyl) on the over the bed table. The over the bed table was within reach of each individual.

At 11:36 am Staff Member #1 was observed entering the room. She took the four bottles of eye drops from the over the bed table and administered the eye drops to Patient #8's left eye. She returned the bottles of eye drops to the over the bed table and exited the room.

At 11:49 am Staff Member #1 returned to room and repeated the same process of administering the eye drops to the same patient then left the room with the medications.

2) At 12:15 PM during another observation Staff Member #2 was observed administering eye drops to Patient #1. Staff Member #2 left the 4 bottles of eye drops (Vigamox, Mydriacyl, Mydfrim and Cyclogyl) on the patient's bed side table and exited the room. Sitting next to Patient #2 was another patient who was within reach of the medications. This patient had a visitor who was observed walking in and out of the room pushing the table with the medications each time.

At 12:26 PM Staff Member #2 returned to the room and repeated the same process of administering the eye drops to Patient #2. She returned the bottles of eye drops to the bed side table and exited the room.

On 11/19/13 in the morning Staff Member #9 was notified of the these findings.

Review of the policy entitled "Patient Care Area Inspections" dated 06/15/10, revealed the pharmacy inspection of the patient care areas includes ensuring patient assigned medications are stored in a secured area.

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Based on observation, record review and interview during the Federal Recertification Survey, it was determined that the facility did not ensure that expired medications were not available for patient use.

Findings:

1) An inspection of the Ambulatory Surgery unit on 11/18/13 at 2:30 PM revealed a 250 cc bag of D5W expired 02/2012.

2) An inspection of the PACU on 11/18/13 at 3:00 PM revealed a 500 cc bag of 0.9% N.S. expired 11/01/2013.

Staff Member #6 acknowledged this finding and removed the bags.

3) An inspection of the O.R. Medication Room on 11/19/13 at 11:35 AM revealed a 500 cc bag of 20% Mannitol expired 08/2013.

Staff Member #14 acknowledged this finding and removed the bag.

Review of the policy entitled "Patient Care Area Inspections" dated 06/15/10, revealed during the monthly pharmacy inspections of the patient care areas expired medications will be removed.

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Based on observation, staff interview and review of documents, it was determined that the Director of Food and Nutrition failed to monitor all areas of the kitchen including sanitation, safety practices for food handling and food preparation.

Finding includes:
A tour of the kitchen was conducted on 11/18/13 at approximately 10:15 AM. Present at the tour was the Assistant Director of the Food Service Department. The following was observed and confirmed by the Assistant Director (Staff #30).
A. Sanitation and Food Safety
1-Three refrigerators were out of compliance in regards to temperature. Refrigerator standard is 40 degree and below. These refrigerators contained food. Perishable foods items were discarded and non-perishables food items were transfer to other refrigerators.
a) Nourishment refrigerator was 51 degrees (standard is 40 degrees)
b) Air Curtain Refrigerator #1 was 52 degrees
c) Air Curtain Refrigerator #2 was observed to be 58 degrees

2- Refrigerator #4 contained open bags of parsley with no labels

3- A half tub of Yogurt was open and had no labels

4- The cold prep area had uniform and sweater beneath the counter.

5- The Dairy Kosher Refrigerator had water at the base of the refrigerator and a foul odor.

6- The eye washing sink had no guideline posted on how to use the sink.

7- Refrigerator labeled " Pharmacy " was observed to have a box of Coffee Rich Creamers, containers of applesauce and containers of half and half milk.

8- Meat slicer was not in use and was not covered.

9- A can of oven cleaner that stated " Flammable " was inside of the Vulcan oven.

10- Brown titles beneath the deep fat fryer cracked and 4 tiles were missing.

11- A dirty, sticky binder containing Production Sheets was found in a drawer.

12- Two drawers located beneath the cook table were dirty and grime

13- The pot washing area was extremely dirty. A large black fan on the window had excessive accumulation of dirt and grime. The dust was hanging from the fan.
Gray wall tiles were cracked or missing. Wall tiles had accumulated layers of dried yellow and black food stuck on them. Clean pots and pans were stored in an open rack across the pot washing sink which contained dirty pots and pans.
Floor in the pot washing room was dirty.
Approximately 80 clean dripping wet sheet pans were stored one on top of the other.
A rack of pots and pans was observed in the kitchen. The bottom rack closest to the floor had miscellaneous pots and pans exposed to the floor.

14- Menus were not posted in the kitchen.

B. Emergency Supplies
A review of the Food Service Department Emergency Preparedness Manual was done on 11/18/13.
The food supply is not centralized and there was no diagram in the manual to locate and retrieve the food items listed on the menu. The menu was not modified to meet all diets. The menu also listed foods that required cooking. Food portion was not listed on the menu. The menu listed powdered milk to be prepared. The manual did not have a recipe to reconstitute this powder milk. Water and miscellaneous items such as paper supplies, aprons, and can openers were not listed. The total amount of foods required for this menu was not listed hence the emergency food supply required to meet this menu is uncertain. There was no mention of enteral feedings nor was the location of these feedings in the manual. There no data pertaining to the feeding of staff during an emergency. A copy of the manual was not readily available in the diet office. The Emergency Preparedness Manual was inadequate.

C. QAPI program
The Food Service division of the Food and Nutrition Department had no quality assurance program. There was no food service indicator that was being measured for performance improvement.
The Food Service Director confirmed that only the Clinical Nutrition Division had a quality assurance program. There was no quality assurance program for food service.
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Based on menu review and staff interview, it was determined that the Food and Nutrition Department did not ensure that diets prescribed by physicians met the therapeutic needs of the patient.

Findings include:
A review of Regular and Therapeutic Menus were reviewed. There was no age specific Pediatric menu at the hospital. There was no nutrient analysis performed by the clinical nutrition division of the department. Regular, Therapeutic or Pediatric Menus had not been analyzed to assess compliance to the National Standard titled "Recommended Daily Intakes". Nutrition adequacy and adherence to dietary restrictions on menus are unknown since there is no nutrient analysis of menus. Due to the lack of a nutrient analysis of menus, it is unknown if the food receive by the patient meets the physician prescribed diet.

At interview with Staff #30, she stated the facility does not have nutrient analysis for menues currently used in the facility.

21204

Based on observation, staff interview and document review, the hospital failed to maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured.

Findings include:

Emergency Department (ED):

During a tour of the Emergency Department, Intensive Care Unit and Coronary Care Unit and Endoscopy Suite on 11/18/2013 from 11:00 am to 4:00 PM, the following findings were identified in the presence of the Director of Engineering who accompanied the state surveyor during the survey.


1- The ceiling tiles of the airborne isolation room # 2 were from the regular type, not the washable ceiling tiles that are required for this type of room.


2- The floor of the emergency department was observed to be dirty especially at the perimeters of the rooms and hallways, and many areas/ rooms were observed to have papers, tissues and syringes' caps.


3- The hand washing sink of the asthma room was observed to be dirty and had dirty tissues and towels that blocked the sink.


4- The exit door next to the ambulance entrance was not working properly and did not have a positive latch.


5- The handicapped patient bathroom #1-048 of the Emergency Department did not have a working nursing call bell. Also, draining pipes underneath the hand wash sink was not insulated or otherwise configured to prevent abrasions or burns of the patients using wheelchairs. Furthermore, this room did not have a mirror.

6- The soiled utility room of the ED was found to have positive airflow instead of the negative airflow required for this type of room.


7- The nursing call bell of the patient bathroom in front of room #4 was not working.
The cover of the thermostat on the corridor of the ED was observed to be broken and taped to the wall with an adhesive tape to keep it from falling.


8- There was a clean linen cart placed in front of room #1-031 and it was covered by an old, dirty and torn cover and it had a sign saying soiled linen on it. However, during an interview with the nurse manager, she stated that the sign was not correct and that the cart had only clean linen.

9- The nursing call bell of the shower room #1-047 A was not working.

10- The floor of the Fast Track Area and its waiting area were found to be very dirty and the privacy divider in this area was found to have many adhesive tapes on its surface; which make it difficult to clean or disinfect it.

11- There was no nursing call bell in the patient bathroom of the fast track area.

12- There was an opening that was about 4"x 4" in size in the ceiling tiles next to the men's bathroom in the waiting area.

13- The clean utility room of the pediatric ED did not have a positive airflow as required for this type of room.

14- The patient bathrooms of the pediatric ED did not have a nursing call bell.

15- Exit signs in the Emergency Department areas were not lit. Examples included but were not limited to the Exit sign outside the trauma room and outside the ambulance entrance door.

Coronary Care Unit (CCU) & Intensive Care Unit (ICU):
16- The Coronary Care Unit (CCU) which has 8 beds and the Intensive Care Unit which has 8 beds did not have an airborne isolation room. At least one airborne infection isolation room shall be provided at each unit as per AIA 7.3.A14

17-The ceiling tiles of the CCU and ICU was from the regular ceiling tiles not the washable ceiling tiles that can easily be cleaned or disinfected when needed.

18- The linen of the bed in room # 6 of the CCU unit was found to be torn and had three (3) holes on it.
19- Room # 7 of the CCU unit was found to be dirty and dust laden where a previous closet was located and was recently removed from this room; however, the area was not cleaned before it was made available for patient use.
20- Rooms # 8 and #5 of the CCU unit did not have a nursing call system for the patients when they need assistance.
21- There were two beds blocking the corridor and the exit way of the CCU unit next to the two smoke doors of the unit.

22- The floor of the ICU unit was observed to be very dirty.

Endoscopy Suite:
23- The corridor and the exit way of the endoscopy suite was observed to be blocked by two (2) supply carts , a garbage container, a bed side unit and a bronchoscopy cart.

24- The floor of the Endoscopy Suite was observed to be very dirty and the unit was very cluttered with many carts and equipment on the corridors of the unit.

25- The Endoscopy Suite has three (3) procedure rooms and the ceiling tiles of these rooms were the regular type, not the washable type that is required for this type of rooms.

26- Procedure room #3 had IV pole that was very rusty and dirty especially its base.

27- The recovery area of the Endoscopy Suite was cluttered and its floor was very dirty with a mud like- material was seeping through the seams of the tiles. Also there were many broken tiles on the floor which makes the floor uneven and a potential tripping hazard.

28- The cover of the nursing call bell in the patient bathroom of the endoscopy suit was broken and falling apart.

29- No hand-wash sink was provided at the scope processing room and the staff wash their hands in the same sink where the scopes are being cleaned which is a potential for cross contamination and spread of infections.

30- The water pressure pump next to the ultrasonic machine and its pipes and wires were observed to be dust laden and very dirty. Also, the paint of the wall next to the ultrasonic machine was chipped.
Review of the documentation of the Emergency Generator monthly testing on 11/19/2013 revealed that the hospital failed to record the time of the transfer switch as required per NFPA 99.
During a tour of the hospital on 11/19/2013 at approximately 11:00 AM, the corridor of the outpatient clinics especially outside the surgical clinic was partly obstructed by at least 12 chairs and that the corridor (Exit passageway) was used as a waiting room.

Labor and Delivery (L&D):
31- During a tour of the Labor and Delivery unit on the 12th floor on 11/19/2013 at 2:00 PM, the nursing call system of room 12-005 was not working.

32- The clean utility room #12-026 had negative air pressure instead, of the required positive air pressure for this type of room.

33- The clean utility room # 12-011 had negative air pressure instead, of the required positive air pressure that is required for this type of room.

34- No airborne isolation room was provided for this unit.

35- During a tour of the Maternity Suite on the 11th floor " Maternity South": on the afternoon of 11/19/2013, revealed that no airborne isolation room was provided for this unit.
During review of the records of sprinkler system tests on 11/21/2013, revealed that the the tests of the main drain were not done during the years of 2012 and 2013.
During a tour of the Radiology Department on the 1st floor, it was noted that the hospital did not provide a soiled utility room for this department as per AIA guidelines.

Surgical Suite- 4th Floor :
During the tour of the Surgical Suite on 11/18/13 between 11:30 AM to 02:45 PM, following issues were observed.

36. In the waiting room of the pre-op area , the fire extinguisher is installed in such a manner that a chair is situated in front of it. If a visitor/patient in the waiting room sits on this chair, the fire extinguisher will be blocked and not available for in case of emergency access.

37. The pre-op and post-op beds/bays were intermingled in their use and the bays were not labeled for identification.

38. The pre-op/post-op bays were noted having only one oxygen outlet for 3 bays. As per AIA 1996-97 Table 2 , there should be one oxygen outlet and one vacuum outlet accessible to each bed.

39. The refrigerator in the pantry of the pre-op/post op area had a suspicious black growth in the gaskets and the refrigerator was noted dirty.

40. The housekeeping supplies were noted stored in the soiled utility room. This arrangement may lead to cross contamination as housekeeping supplies and items are dirtier than the items and work done in a soiled utility room. Furthermore, the soiled utility room was noted very dirty in its perimeters and walls.

41. The exit corridor by sterile room near the ORs was observed to be obstructed/impeding in the means of egress by equipment and carts.

42. The sterile storage room did not have any means to ensure the humidity level in within the AIA 1996-97 Table 2 requirements.

43. The housekeeping closet near the sterile storage room was noted storing clean supplies such as toilet tissue rolls and hand towels that is for patient /staff use. This arrangement may lead to cross contamination from dirty area to clean items.

44. The timers to shut off the water on the scrub sinks were noted to be not consistent. Some scrubs have timer set for water to run 5 minutes before it shuts off, some had 10 minutes before shut off, and some were blinking without any specific time and water was shutting within 1 minute. Director of Engineering was asked for the Policy and Procedure regarding the standard setting that should be followed for the timer. He acknowledged not having any policy or preventive maintenance on these timers.
45. The sub-sterile space between OR # C & B , was noted dirty and dusty in its perimeter and about three ceiling tiles were noted stained. The sub-sterile space/room by OR #G was also dirty behind the sterilizer and the mechanical vents were dirty.

46. The floor outside OR # B was noted to be stained/dirty.

47. The water faucet of the scrub sinks between OR #E & D were noted having dirty heads.

48. Fire extinguishers in various area of the surgical suite/floor were noted not installed in a manner that it's top most part is 60 inches above the finished floor. Most of the extinguishers were installed very high. An example includes but not limited to is the fire extinguisher in OR #E.

49. The ceiling tiles in OR #E were noted having red/brown stains. Furthermore, the perimeters of the ' Boom ' were noted dusty and dirty.

50. The mechanical vents were noted dirty in the OR rooms specially including but not limited to OR #E.

51. In the PACU area , ambu bags were noted hanging on the oxygen flow meter.

52. Many Red/brown spots were noted on the floor in the PACU area. When an alcohol wipe was used on one or two spots, those spots came off.

53. The hand wash sink behind nurse's station in the PACU was noted having a green growth under the sink.

54. All smoke doors in the OR suite were observed not latching positively and thus leaving a linear gap. Some of the doors were also noted broken/lacking self-closure such as smoke door by OR #G.

55. The mechanical vent over clean linen cart near OR #G was noted dusty.

56. The isolation room ceiling tiles in PACU were not cleanable and non-porous kind as required by AIA 1996-97 section 7.28.B8.

57. No sprinkler head was noted in the telecommunication room of the pre-op/post-op area that is considered to be a fully sprinklered suite as per Director of Engineering.

CENTRAL STERILE- Basement:
During the tour of the Central Sterile processing area on 11/18/13 between 3:00 PM to 3:55 PM following issue were noted:

58. The fire extinguisher at the main entrance of the Central Sterile Clean workroom was observed not installed in a manner that it's top most part is 60 inches above the finished floor. The extinguisher was installed higher than the 60 inches.

59. The air pressure in the sterilizing equipment room (behind the sterilizer) was neutral instead of negative. ( AIA 1996-97 Table 2)

60. The Clean sterile Workroom was noted neutral to decontamination area and negative to corridor instead of being positive to both areas. (AIA 1996-97 Table 2).

61. The temperature and the humidity of the Clean Sterile Workroom room was noted to be 80*F and 17%. The Director of Engineering stated there was no monitoring of this area and there were no logs indicating how long the temperature and humidity was in the range that was noted at the time of observation. As per AIA 1996-97 Table 2 the humidity should be between 20-60% and temperature should be maximum of 75*F.

62. The Clean Sterile Work room did not have any alarm installed to notify loss of air-flow as required by AIA 1996-97 section 7.31.D19.

63. The storage closet in the Clean Sterile Workroom was noted not having any sprinkler head and the suite was observed to be fully sprinklered and verified by Director of Engineering.
The findings in the Surgical Suite were verified with Acting Director of Peri-operative services and all the findings were verified with Director or Engineering.

6th Floor South:
64. During the tour of 6 South on 11/21/13 at approximately 3: 15 PM, it was observed that the ceiling tile in 616 , above the window closed to bed B was loose. It was also noted that several other ceiling tiles had yellow discoloration.
The patient in room 616 - B commented that the ceiling was falling down.


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26934

Based on observations and interviews during the Federal Recertification Survey, it was determined that the facility failed to ensure that expired equipment was not available for patient use and supplies are stored and maintained in a manner that assures patient safety.

Findings:

1) An inspection of the Ambulatory Surgery pediatric code cart on 11/18/13 at 2:30 PM revealed a purple intubation module expired 10/2013.

Staff Member #7 confirmed this finding.

2) An inspection of the PACU adult code cart and pediatric code cart on 11/18/13 at 2:55 PM revealed a suction catheter tray that expired 07/2013 and a pediatric emergency intubation system expired 10/2013 and a pediatric aspiration needle expired 09/2013.

Staff Member #8 confirmed this finding.

3) An inspection of the PACU on 11/18/13 at 3:00 PM revealed the following expired equipment:

a) Two probe cover kits expired 12/2009 and 12/2011.

b) One bottle of Iodoform packing strip expired 02/2010.

c) Four central line dressing change kits expired 07/2011, 11/2011, 03/2012 and 12/2012.

d) One Shiley 10 DCT low pressure cuffed cannula expired 02/2012.

e) One CSF collection bag expired 10/2013.

Staff Member #6 confirmed this finding and removed the equipment.

4) An inspection of the O.R. Medication Room on 11/19/13 at 11:35 am revealed 81 red 10 ml vacutainers expired 12/2012.

Staff Member #14 confirmed this finding and removed the equipment.

5) During observation rounds on 11/18/13 at 12:15 PM in the inpatient unit -5 South, patients in beds 520A, 520B, 519B, 525 and 507 were observed with intravenous lines and Hep-locks that were not labeled and dated.

At interview with staff #19 on 11/18/13 at 12:20 PM, she stated the facility's protocol is to replace intravenous lines every 72 hours. She added that each intravenous line should be labeled with the date of initiation and expiration of the line when it is set up for use.

6) An inspection of patients' refrigerator located in the 5-North pantry on 11/18/13 at 11:30 AM noted 2 of the 3 brown bags containing patient's food items were not labeled. The two unlabeled bags contained strawberries, cantaloupe and grapes that were moldy and decaying. The labeled bag also contained moldy strawberries. In addition, there was a fruit cup that expired on 11/11/13.

At interview with staff #19 on 11/18/13 at 11:35 AM, she stated the refrigerator is used for patients only and food items should be labeled and dated by staff.

Upon further investigation it was noted that the patient whose name was on the labeled bag had been discharged on 11/15/13, three days prior to this observation.

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16399

Based on staff and patient's representative interviews and reviewed of medical records and hospital's policy, it was determined that the hospital failed to effectively implement its criteria for identifying those patients who require discharge planning. This deficiency was found in two of eight applicable medical records reviewed (MR # 30 & MR # 31).

Findings include:
Policy: Social Work High Risk Criteria - Code 7040 .1.18 effective 4/11/2013 was reviewed on 11/18/13. This policy included in its Criteria for Social Work Referrals for Discharge Planning that - "Nursing Assessment form (Discharge Planning Evaluation) Risk factor Index score of 10 or higher" was one of the criteria for social work discharge planning.

The facility ' s Policy Administration Discharge Planning Code: 1.33 was reviewed on 11/18/13. This policy indicated that "Nurse: Assesses the patient's possible post-hospital care needs and indicates them on the Nursing Assessment form upon admission".

1 - During the tour of the unit (3 south) on 11/18/13 at approximately 11:45 AM, Patient # 30 was reviewed. It was noted that the patient, an 81 year old female with history of hypertension, breast cancer (2004), colon cancer (2013), dementia, was admitted to the facility on 11/8/2013 with diagnosis of colitis/ diarrhea and dehydration. The Nursing Admission Assessment was reviewed. The Self-Care Needs Assessment section of the assessment tool indicated that the patient required assistance in feeding. The Nursing Admission and Initial Learning Screen Part 2 - section on Discharge Planning dated 11/9/13 at 0104 (1:04 AM) was reviewed. This discharge planning evaluation section of the assessment instructed the user to "check the applicable category and total ". It was noted that the staff completing the assessment for this patient failed to check the category "dependent in eating/feeding" ; a score of dependent in eating/feeding is 1. The final score for this patient was 9. A "score of 10 or greater will automatically trigger a referral in the Social Service and Discharge Planning Department". A referral to Social Service Department was not triggered.

It was noted that, on 11/11/13 at 0747, the physician wrote a Social Service Consultation order. The Social Work Discharge planning assessment was dated 11/11/13 at 1352 (1:52 PM). It was noted that although the Social Work Assessment and Reassessment of Patient policy indicted that the social worker has forty eight hours to complete a bio-psychosocial history and patient's needs assessment. This assessment was not timely as on 11/12/13 physician wrote a discharge order for the patient. The patient could not be discharged because the patient's post-hospitalization service was not finalized.

2 - During the tour of the unit (6 South), on 11/21/13 at approximately 2:10 PM, the daughter for the patient in room 616-D was interviewed at bedside. The patient's daughter stated that she was called to pick up her mother because she was discharged. The patient's daughter stated that her mother lives alone and she is getting frail; she fell at home and she needs more assistance at home before she can be discharged.
Staff # 23 was interviewed. This staff stated that a discharge evaluation was not done for this patient as Social Service referral was not done. She stated that she knows about the patient through case finding today.

The record for Patient # 31 was reviewed on 11/21/13. It was noted that patient, an 85- year- old Spanish speaking with past medical history of hypertension, anemia, and adenocarcinoma of stomach, was admitted on 11/15/13 with complaints of vomiting and poor appetite. It was noted that there was a written discharge order for today, 11/21/13 and there was a discharge summary dated 11/21/13. The Nursing Admission and Initial Learning Screen - Discharge Planning Evaluation was reviewed. It was noted that the risk factor index total score for this patient was 12. According to this assessment tool, a "score of 10 or greater will automatically trigger a referral in the Social Service and Discharge Planning Departments". There was no evidence that social services department was notified as the date and time of the referral was not completed.

Staff #22 was interview on 11/22/13. It was noted that the Initial Nursing Admission Discharge Planning Evaluation, for patient in MR # 31, indicated that Discharge Planning was notified on 11/6/13. It was noted that this form did not indicate that Social Service was notified. The issue was discussed with staff #22. This staff stated that Social Work is responsible for completing the discharge planning evaluation and has to been notified by nursing or a physician.
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Based on staff and patient's interviews and review of medical records and hospital's policy, it was determined that the facility failed to ensure all patients identified as needing discharge planning received timely and complete discharge evaluations. This deficiency was noted in six of fourteen applicable medical records reviewed (MR# 32, MR # 33, MR # 34, MR # 35, MR # 36 & MR # 37)

Findings include:

1 - During the unit tour (3 south) on 11/18/13 at approximately 11:45 AM, the medical record for Patient #32 reviewed, the patient is a 56 year-old Spanish speaking female with past medical history of Diabetes Mellitus type 2, Hypertension, End Stage Renal Disease on Hemodialysis, Chronic left foot ulcer, was admitted to the facility on 11/11/13. The presenting problem was lower abdominal pain.

Social work Discharge Planning Assessment dated 11/13/13 9:12 AM was reviewed. The social worker (SW) noted that the patient received dialysis on Mondays, Wednesdays and Friday. The SW noted that the patient refused any other kind of home care services. It was noted that the assessment did not include where or who provided the patient's wound care.

The Physician ' s Discharge summary dated 11/15/13 at 1734 (5:34 PM) was reviewed. It was noted that the physician wrote "wound culture growth Pseudomonas and Acinetobacter, she was started on Fortaz and will send the patient to SNF (skilled nursing facility) for six weeks for IV (intravenous) antibiotics". It was noted that on 11/16/13 at 1238 (12:8 PM) the physician noted "the patient refused discharge to SNF at this time social work contacted will re-start antibiotics on the floor until placement sorted out". It was noted that this physician completed a discharge summary and discharge plan before having a discussion with the patient.


On 11/16/13 1126 (11:26 AM), SW noted "case was referred to SW by floor RN (registered nurse) for discharge. SW reviewed the discharge planning notes and the plan was home with reinstated (HD) Hemodialysis. SW noted referred the case to Americare CHHA (certified home health agency)". It was noted that it was documented on 11/13/13 that the patient refused home care services. There was no documentation that there was a discussion with the patient before the patient was referred to Americare home care agency. It was noted that the physician's notation regarding discharging the patient to SNF on 11/15/13 was not addressed in this assessment.


On 11/16/13 1800 (6:00 PM), SW noted case discussed with MD and MD stated that patient needs IV therapy with HD and wound care. The SW noted case discussed with Americare and the RN stated they need to get insurance authorization prior to provide service.


On 11/17/13 0224 (2:24 AM), the physician noted discharge today. On 11/16/13 at 1129 (11:29 AM), the SW noted "patient was discharged with RDC HD and Americare CHHA referral". It was noted that this patient was still on the unit on 11/18/13.


Staff # 24 was interviewed on 11/18/13. This staff stated that the patient was still in the hospital because they were waiting for insurance authorization for the home care. This staff also stated that the discharge plan was never SNF placement. This patient remained in the hospital although she was medically cleared due to inadequate discharge planning,


2 - The medical record for Patient # 33 was reviewed on 11/20/13. It was noted that this patient, 83- year- old patient with medical history included COPD (chronic obstructive pulmonary disease) and lung cancer was admitted on 8/4/13 for sudden episode of respiratory distress.


The Social Services Notes Entered 8/14/2013: "patient is for discharge today". The social worker (SW) noted that the patient's daughter stated that patient has Bipap (bi-level positive air pressure) machine and oxygen at home via Medstart. The SW noted that the patient's daughter stated that the patient needed additional oxygen tank; " she will pay $300.00 for oxygen tank which was pending". There was no psychosocial assessment for this patient. The discharge planning evaluation was incomplete as all of the patient's post- hospitalization needs were not included in the discharge assessment. In addition, the assessment did not include how often the patient required oxygen tanks and if there were any financial barriers in obtaining this medical equipment as the daughter had to purchase oxygen tanks for the patient.


The SW noted that Americare Home Care Service was notified and that the patient will receive VN (visiting nurse) on 8/15/13. The nursing admission indicated that the patient would require "new home care services". It was noted that the discharge planning assessment did not include the reasons for visiting nursing services or if the patient required any other home care service. The physician's discharge summary was dated 8/9/13. The SW discharge notes indicated that the patient was discharged on 8/14/13. The reason for the delay in discharge was not discussed in the final discharge notes.

Based on interview with patient and patients' representative and medical record, it was determined that the facility failed to ensure that discharge planning evaluation documented in the medical record was accurate and complete. This deficiency was noted in two of eight applicable medical records reviewed (Patient #s 30 and # 38)


Findings include:
1 - The review of medical record for Patient # 30 on 11/18/13 noted that this 81 year old patient with history of hypertension, breast cancer (2004) and colon cancer (2013) was admitted on 11/08/13 with diagnosis of colitis and diarrhea. The Social Work discharge planning assessment dated 11/11/13 1352 (1:52 PM) noted the SW met with patient's daughter at beside who stated that the patient lived alone and had no home care services prior to admission.


The physician ' s order 1/13/13 2213 (10:13 PM) category social services: reason for consultation existing home services was reviewed. This physician's order reason for consultation was "existing home services and patient family requesting more hours instead of the patient being placed in nursing home". It was noted that there was no evidence that home care services instead of nursing home was discussed with the patient/ patient ' s representative. It was noted that this discharge plan is contradictory with the social work discharge planning. The social work discharge planning indicated that the discharge plan was placement in a skilled nursing facility.


2 - During the unit tour 8S- Pediatric on 11/21/13, the patient in room 814A and patient's mother were interviewed on 11/21/13 at 4:00 PM at bedside. The mother was Spanish speaking and the interview was conducted with a resident in the unit as an interpreter. The patient and mother stated that the patient was not scheduled for discharge. The mother stated that the surgeon inform them that the patient will be discharged in three days. They admitted that the SW informed them that the nurse would visit the home after discharge. However, the date and time of the nurse visit was not stated. The SW assigned to the patient could not be reached. The surgeon was paged to see the patient.


Review of medical record for Patient # 38 on 11/21/13 noted the patient, a 13- year old male with no significant past medical/surgical history. The patient presented to the facility ' s Emergency Department with chief complaint of abdominal pain. He was admitted on 11/15/13. The patient was admitted with diagnosis of ruptured appendix; the patient underwent appendectomy. It was noted that the discharge summary dated 11/20/13 was signed on 11/21/13.
The Discharge planning documentation was reviewed. The social work notes dated 11/20/2013 1249 (12:49 PM) indicated a call was received from surgery resident regarding the need for homecare for daily midline abdominal packing. On 11/20/13 1448 (2:48 PM), SW noted she met with patient and mother and discussed the need for home care services and that a nursing staff will perform clinical treatment and train an identified person to perform the duties as the homecare agency is allowed a certain number of visits.

Although it was documented in the record that the parent and child were aware of the discharge plan and services, it was noted that there was lack of communication between patient and parent and hospital staff in regard to the patent's discharge date.

The staff assisting with reviewing the electronic medical record was unable to locate a complete psychosocial assessment for this patient. The patient's level of functioning and level in school was not in the record. Therefore, the level of comprehension could not be determined. It was also noted that the discharge assessment was incomplete as it was unclear who the family has appointed to be trained to perform wound care. The expected numbers of home visit by the visiting nurse was not indicated in the record.

Based on interviews with patient and patients ' representative and review of medical record, it was determined that:
1. The facility failed to effectively communicate with all patients/patients representatives ' information regarding the requirement for skilled nursing facility (SNF) placements.

2. The facility failed to consistently provided patients/patient's representative a list and choice in SNFs / HHAs (health care agencies. This deficiency was noted in two of eleven
Applicable medical records reviewed (Patient #s 30, and # 38)

Findings include:

During the tour of the unit (3S med/surg) on 11/18/13, the patient's family (son) requested to speak to the surveyor. The patient's son and daughter were interviewed at patient's bedside in room RM 302-B. The patient's representatives stated that early in the patient's admission they requested that their mother be placed in a skilled nursing facility (SNF). The patient's daughter stated that she requested "Vida" and she was under the impression that once she selected this nursing home that her mother would be placed there. However, her mother is still in the hospital without a placement as the facility rejected her mother. She also stated that they were now trying to place her mother in another facility that did not meet their criteria.


Review of medical record for Patient # 30 on 11/18/13 noted that this 81- year- old patient with history of hypertension, breast cancer (2004) and colon cancer (2013) was admitted on 11/08/13 with diagnosis of colitis and diarrhea. The discharge planning was reviewed. It was noted that on 11/11/13 1352 (1:52 PM) the SW noted "received referral today. Met with patient's daughter at beside who requested for SNF (skilled nursing facility) placement ". On 11/11/13 1358 (1:59), the SW noted met with patient's daughter who sated that her first choice was "Buenavida NH". It was noted that the process for nursing home placement, issues with bed available, insurance issues and how they may affect the nursing placement were not fully explained to this family member. The patient's daughter was not advice on selecting at least three choices of skilled nursing facilities and the family was not given a list of home care choice on the day the SNF placement was requested.


Review of medical record for Patient # 38 on 11/18/13 noted a 76- year- old Hispanic male with history of congestive heart failure, hypertension, diverticulosis and gout. The patient was admitted on 11/15/2013 with diagnosis of hyperglycemia and newly diagnosed Diabetes Mellitus type 2.
The discharge summary dated 11/18/13 at 8:42 AM was located in the record. The summary indicated that the patient's condition was hemodynamically stable. The patient was instructed to follow-up with the Endo clinic within one week. The Social Services notes entered on 11/18/2013 at 1300 (1:00 PM) indicted that the assessment was completed and the discharge plan was home with VN (visiting nurse) via "American CSS". The discharge assessment did not include if the patient was given a choice of home care agency.

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Based on observation and interview during the Federal Recertification Survey, it was determined that the facility did not ensure the staff could identify, locate, and set up equipment in the pediatric code cart.

Findings:

On 11/18/13 at 2:30 PM during the inspection of the Ambulatory Surgery Unit pediatric code cart with Staff Member #7 she could not locate the pediatric intubation equipment i.e. blades and endotracheal tubes. The surveyor located the equipment for the nurse.

On 11/18/13 at 2:45 PM during the inspection of the PACU pediatric code cart the surveyor asked Staff Member #8 to identify the pediatric defibrillator paddles. While holding the adult/pediatric defibrillator paddles in her hands she stated "we don't have pediatric paddles." The surveyor identified the pediatric paddles for the nurse.

On 11/19/13 at 9:35 AM while inspecting the ASU pediatric code cart Staff Member #2 could not locate the pediatric defibrillator paddles. She stated they do not use paddles, they use the Zoll machine. The surveyor asked Staff Member #2 to set up the Zoll machine. The nurse could not attach the Zoll cable to the machine. She asked Staff Member #11 to assist her who was also unsuccessful in attaching the cable to the machine.

Review of Staff Member #2's and Staff Member #7's 2013 Skills Competency List revealed competency in "Application of the Transcutaneous Pacemaker monitor (Zoll), Transvenous Pacemaker Monitoring and Therapeutic Intervention" and ACLS and BSL certification, and Staff Member #8's 2013 Skills Competency List revealed competency in "safely uses external pacing devices," and PALS, NALS, ACLS and BCLS certification.

On 11/21/13 at 2:00 PM during an interview with Staff Member #15 she stated the emergency education is lumped together. They need to make separate competencies with step by step return demonstrations.

Although the staff had documented competency in emergency equipment and certification in ACLS, BCLS, PALS and NALS they could not locate the pediatric intubation equipment i.e. blades and endotracheal tubes, the pediatric defibrillator paddles and attach the Zoll cable to the machine.
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Based on interview and record review during the Federal Recertification Survey, it was determined that the facility did not ensure the Operating Room (O.R.) register included all of the required information.

Findings:

Review of the 11/18/13 O.R. Register with Staff Member #12 on 11/19/13 at 3:45 PM revealed it did not include the name of the nursing personnel(scrub and circulating staff), the pre-operative and post-operative diagnosis and the age of the patient. She confirmed this finding.
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Based on interview and record review during the Federal Recertification Survey, it was determined that the facility did not ensure the operative reports included all of the required information for 4 of 6 medical records reviewed. (Patient #8, Patient #9, Patient #10, and Patient #11)

Findings:

Review of Patient #8's medical record revealed on 11/18/13 the patient was admitted to same day surgery for a left eye cataract extraction with lens implantation under monitored anesthesia care (MAC). A review of the operative report revealed the report did not include the type of anesthesia that was administered during the surgical procedure.

Review of Patient #9's medical record revealed on 11/18/13 the patient was admitted to same day surgery for a right eye cataract extraction with lens implantation under MAC. A review of the operative report revealed the report did not include the type of anesthesia that was administered during the surgical procedure.

Review of Patient #10's medical record revealed on 11/18/13 the patient was admitted to same day surgery for a left eye cataract extraction with lens implantation under MAC. A review of the operative report revealed the report did not include the type of anesthesia that was administered during the surgical procedure

Review of Patient #11's medical record revealed on 11/18/13 the patient was admitted to same day surgery for a right eye cataract extraction with lens implantation under MAC. A review of the operative report revealed the report did not include the type of anesthesia that was administered during the surgical procedure.

Review of the Surgical Services Bylaws revealed all operations performed would be fully described in the medical record by the operating surgeon.

During an interview with Staff Member #12 on 11/21/13 at 10:30 am he stated MAC is administered during cataract surgery. Also, he confirmed the operative reports did not include the type of anesthesia administered during the surgery.
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Based on interview and record review during the Federal Recertification Survey, it was determined that the facility did not ensure the post anesthesia evaluation included all of the required information for 4 of 6 medical records reviewed. (Patient #8, Patient #9, Patient #10, and Patient #11)

Findings:

Review of Patient #8's medical record revealed on 11/18/13 the patient was admitted to same day surgery for a left eye cataract extraction with lens implantation under monitored anesthesia care (MAC). A review of the post anesthesia evaluation revealed the evaluation did not include an assessment of the patient's mental status, pain and nausea and vomiting.

Review of Patient #9's medical record revealed on 11/18/13 the patient was admitted cataract extraction with lens implantation under MAC. The post anesthesia evaluation did not include an assessment of the patient's mental status, pain and nausea and vomiting.

Review of Patient #10's medical record revealed on 11/18/13 the patient was admitted for cataract extraction with lens implantation under MAC. The post anesthesia evaluation did not include an assessment of the patient's mental status, pain and nausea and vomiting.

Similar findings were identified in Patient #11's medical record.

Review of the Surgical Services Bylaws revealed the anesthesiologist is responsible to maintain a complete anesthesia record which includes a post anesthetic follow of the patient's condition.

During an interview with Staff Member #12 on 11/21/13 at 10:30 am he stated for patients who have cataract surgery the anesthesiologist does not document the post anesthesia evaluation on the Anesthesia Attending Recovery Room Note. The post anesthesia evaluation is documented on the Anesthesia Record under post anesthesia vital signs, general condition and fluid balance. He confirmed the post anesthesia evaluation did not include the assessment of the patient's mental status, pain and nausea and vomiting.
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Based on observation, interviews and reviews of medical record and other documents, it was determined the facility failed to ensure that each patient presenting to the emergency Department are timely evaluated and assigned a priority order to assure timely medical screening evaluation in accordance with its policy. This finding was noted in 5 of 20 Emergency Department records reviewed (Patient #s 25, 26, 27, 28 and 29).

Findings include:

During observation rounds in the Emergency Department on 11/18/13, a female was interviewed in the pediatric waiting area at 2:48 PM, she stated she arrived at 1:40 PM and had waited over one hour for triage. She stated she brought her 18 months-old son for evaluation of persistent cough, vomiting and sour throat. The patient was called in for triage at 2:49 PM.

The review of medical record for patient # 25 on 11/19/13 noted the patient arrived in the Emergency Department on 11/18/13 at 1:41 PM and triaged at 2:48 PM with complaints of cold symptoms for one week and recent worsening of symptoms including coughs that resembles "barking" sounds. The patient was noted to be stable at triage and assigned an Emergency Severity Level (ESI) - 4.

At interview with Staff #20 on 11/18/13 at 2:50 PM she stated a patient first contact upon arrival in the Emergency Department is a Registrar who obtains the patient's name, Date of Birth and the reason for the visit. This information is immediately available to the triage nurse who then evaluates each patient according to the severity of their complaint.

The Registrar, Staff #21 at interview on 11/18/13 at 2:53, stated patients with specific complaints such as chest pain, heart palpitation, stroke and seizures are referred immediately to the triage nurse for evaluation.

The facility's triage process did not ensure a face to face assessment of patients by a clinical staff upon their arrival to the Emergency Department. As a result patients are waiting for extended period of time before an assessment and the determination of their priority level. This practice is contrary to the facility's triage policy titled "Triage Assessment and Classification" (Reference #: PC-1.0) reviewed on 11/19/13. The policy notes the purpose of triage is to " ensure that every patient who presents for emergency treatment is assessed as quickly as possible upon arrival to the ED and care initiated according to priority level based on scientific data and pre-determined guidelines" .

The review of the triage policy notes the facility's current triage process is not written and the role of the registrar, a non clinical staff was not indicated in the policy.

The review on 11/20/13 at 2:00 PM of the Quality Management and Patient Safety Committee for the first and second quarter of 2013 and the Medical Board Report of the third quarter of 2013, reveals the average wait time from door to triage was extensive; 28 minutes for the first quarter, 25.7 minutes for the second quarter and 25.38 minutes for the third quarter.

Similar findings regarding the facility failure to conduct a timely assessment of each patient, determine the urgency of the patient's condition and assign a treatment priority were noted in the following records:

Patient #26 is a 19-months-old male who was brought to the facility for wheezing, coughing, fever and ear infection. The patient arrived on 11/18/13 at 12:01 PM and was triaged 67 minutes later at 13:08. The patient's past medical history was significant for asthma and febrile seizures. The physician assessment dictated at 2:40 PM notes wheezing bilaterally with decrease air entry to the left and right lungs, presence of rhonchi breath sounds, tachypnea and the use of accessory muscles. Physician orders were noted for stat Prednisolone and nebulizer treatments. Chest x-ray was negative. The patient was discharged home at 5:03 PM and noted to be in stable condition. The physician primary impression was Asthma attack.

Patient #27, a 3-year-old patient presented to the ED on 11/18/13 at 1:03 PM for complaint of nose bleed for two days. The patient's triage assessment was conducted at 2:22 PM, a period of one hour and nineteen minutes after the patient's arrival in the ED.

Patient #28, a 5-year-old female was triaged on 11/18/13 at 4:10 PM with complaints of coughing associated with chest pains. The triage nurse noted the patient was stable and was classified ESI-4. However, the triage assessment/assignment of treatment priority was made after the patient had been in the ED for an hour and 40 minutes. The patient arrived in the ED at 2:30 PM.
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