HospitalInspections.org

Based on observation, interviews, and review of procedures, records, and documents, it was determined that the governing body failed to ensure appropriate oversight of departments and staff to ensure adequate monitoring of complex hospital operations and adherence to safe standards of patient care in accordance with regulatory requirements.

Findings include:

Due to the prevalence and severity of deficient findings that adversely impact on the delivery of safe patient care, the Condition of Participation of Governing Body is not met as follows:

1. The facility did not meet the following requirements for:
§482.13 Condition of Participation: Patient's Rights
§482.52 Condition of Participation: Anesthesia Services
§482.55 Condition of Participation: Emergency Services

2. The governing body did not ensure effective monitoring to uphold patients' rights, including, but not limited to, lack of complete investigation or follow up of patient grievances, inadequate management of patients receiving chemical and physical restraints, and lack of adherence to distribution of required information for patients' rights. See findings noted under tag # A115.

3. The facility failed to protect and promote a safe and secure environment for an inpatient who walked off a patient care unit in the middle of the night and who was later found dead on the facility's premises. See findings noted under tag # A115.

4. The hospital did not ensure that anesthesia services were delivered in a safe and appropriate manner. Two serious incidents were identified that compromised patient safety as follows:

A patient was administered an anesthetic gas by an unknown person in the OR and this error resulted in dangerous hypotension which persisted throughout the surgery jeapordizing both the patient and the unborn infant. The clinical quality review of the event failed to address key points for safe delivery of anesthesia during operations.

A patient received an overdose of heparin intra-operatively in error.
The above findings represent a recurrence of problems in the Department of Anesthesiology that were previously cited during the survey of 6/11/12 in the failure to fully correct systemic problems in the monitoring of anesthesia services provided to patients. There was no evidence of the proper supervision of staff who delivered anesthesia intra-operatively.

See findings noted under tag A1000.

5. The hospital did not formulate and implement a triage policy and procedure that ensures the safe and timely medical screening process of patients who present for treatment in the emergency department. See findings noted under tag A1100.

Based on review of documents, observations, and interviews, it was determined the hospital did not fully comply with the Condition of Participation for Patient's Rights
in the failure to formulate and implement procedures to ensure the safety and welfare of patients. Specifically, deficient findings were observed in 40/104 records reviewed.


Findings include:

The facility failed to meet the Condition of Participation for Patient Rights due to the non-compliance with the requirements as follows:

1a. The facility failed to protect and promote a safe and secure environment for an inpatient who walked off a patient care unit in the middle of the night and who was later found dead on the facility's premises.

1b. There is no evidence that the facility had policies and procedures to ensure the safe monitoring or inter-departmental actions to be taken to search for patients who elope, walk out of the facility, and who are missing for protracted periods.

1c. Review of MR#1 on 10/15 /12 found that the patient was found dead on a roof of the facility by hospital staff who were not part of any search and who noted the body from a window of the Children's Hospital. The patient had been a patient on the adult unit of the adjacent building and had been noted as missing for 3 hours.

(Cross refer to specific findings noted under tag # A142);

2. The facility failed to implement procedures to ensure proper distribution of patients' rights notices, including the Important Message from Medicare (IM's). (See findings at A117);

3. The facility did not develop and implement sufficient procedures for the complete investigation and resolution of patient complaints and grievances. The grievance mechanism policy did not contain a clear description of the process to integrate the results of departmental investigations with customer service activities in order to document complete resolution of complaints. (See findings at A121);

4. Complaint files found investigations were incomplete due to lack of inclusion of departmental investigations or did not address all of the complaint issues raised. The hospital did not consistently provide patients/patients' representatives with adequate written notification of all findings or instructions for filing a complaint with regulatory authorities for independent review in the event the complainant disagrees or is dissatisfied with the hospital's response.
(See findings at A123);

5. The facility did not ensure the provision of patients' personal privacy during medical examinations. (See findings at A143);

6. The facility did not develop policies and procedures specifically identifying and addressing medications used as restraints. (See findings at A160);

7. The restraint procedures do not define instances when chemical restraints, or medications used to manage behavior, are used concurrently with physical restraints. (See findings at A167)

8. The facility did not meet requirements for implementation of safe restraint practices, including the management and supervision of patients receiving both physical and chemical restraints. (See findings at A167);

9. Review of the facility daily restraint logs on 10/15 and 10/16/12 identified that chemical restraints are used. However, the facility's procedures do not identify the use of chemical restraints and defines only that chemical restraints do not include medications used for therapeutic goals. (See findings at A167);

10. The facility did not ensure accurate documentation for ordering or monitoring of restraints.There is lack of a mechanism for restraint flow sheets to monitor chemical or medication restraints (See findings at A167);

11. The facility used PRN medication orders in prohibition of psychiatric restraint policy.
(See findings at A167).





























16140

10331



Based on review of records, policy and procedures, and staff interviews, the hospital did not comply with requirements for the timely distribution of the Important Message for Medicare notices (IM's) to applicable patients or their representatives upon admission or prior to discharge. This finding is noted on 11 out of 13 applicable medical records reviewed.

Findings Include:

The facility did not implement or monitor compliance with its procedures that requires the eligible patient or his/her representative to be provided with the standardized notification of the Important Message from Medicare (IM), within 2 days of admission or within two days before patient's discharge.

The procedure titled, "Discharge from the Acute Care Setting" documents that the admission associate provides the initial IM at the point of admission. Within two days of the proposed discharge, the staff nurse shall re-issue the IM to the patient, or legal representative or next of kin if the patient lacks capacity.

The following records at the Moses site were missing IM's or did not demonstrate timely provision or follow up with patients or their representatives as directed in policy:

1. MR #4
Concurrent review of the patient's record on 10/15/12 found no evidence of the provision of the required IM notice. Patient was alert, but confused and in restraints at interview.

Follow up on 10/16/12 found an IM notice in the record with notation the patient was unable to sign. No effort of contact was evident with the patient's representative to explain these rights as required by procedures.

2. MR #5
The patient admitted on 8/20/12 and discharged on 9/12/12.

Review of record on 10/17/12 found an IM notice dated 8/20/12 with notification that patient unable to sign.

There was no evidence that patient's representative was contacted to explain these rights as required.

3. MR #6
The patient was admitted on 10/9/12 for treatment of exacerbation of COPD.

The patient was in the process of being discharged 10/15/12 at approximately 11:30 AM. The patient was interviewed and stated she was still waiting for papers.

Review of the medical record revealed no evidence the patient received admission or discharge follow up IM notices.

4. MR #7
The patient was waiting for placement at a hospice on 10/15/12. Review of the record found no evidence of IM distribution. The patient was unresponsive during attempted interview.

5. MR #8
During an interview with the patient at 10/15/12 at approximately 11AM. He was asked if he received notices for IM and Patient's Rights. The patient stated he was unsure, but thinks his wife took paperwork.

Review of the patient's chart on 10/16/12, found that the patient was scheduled for discharge on 10/16/12 and had signed the IM on 10/16/12, despite having been admitted on 10/12/12.

Similar findings were noted in:
MR #s 9, 10, 11, 12, 13, and 14 at the Moses Division.
In addition, similar findings related to non-compliance with issuance of required IM notices were also identified at the Wakefield Campus.

During an interview with the Care Management Administrative staff (Associate Vice President of Network Care Management, Director of Utilization Management, and Director of Social Work Network) on 10/18/12, it was reported that the process for distribution of the Important Message from Medicare (IM's) had not been monitored since 10/14/11.













18224

Based on review of grievance procedures, grievance files, and staff interview, it was determined the hospital's procedure for patient grievances did not clearly describe all steps necessary to resolve patient grievances and complaints.

Findings include:

Review of the hospital's complaint and grievance procedure titled, "Patient Grievance Mechanism" on 10/22/12 found that it was incomplete for the following reasons:

1. The process lacked a clear description of the steps to be taken to ensure feedback with results of investigations is communicated to customer service staff in a timely manner, (before 7 days deadline) and the method of documentation used.

2. Review of the written process for complaints was inaccurate because it does not ensure that complaints that are not immediately resolved are correctly classified as grievances. The procedure requires "feedback" from "complaint responders" as expected within seven days. Regulations require that complaints that are not resolved immediately must be treated as grievances.

3. The policy lacks a mechanism to require that written grievance responses provided to the complainant contain instructions for filing a complaint with regulatory authorities for independent review in the event the complainant disagrees or is dissatisfied with the hospital's response.

4. The grievance procedure included a flow chart of the actions to be taken in investigation but lacked description in the process to account for submission of departmental reviews and corrective actions as necessary.

5. The grievance mechanism policy did not contain a clear process to integrate results of departmental investigations with customer service activities in order to document complete resolution of complaints. The procedure did not clearly describe how results of departmental investigations are obtained and incorporated into the Customer Service department grievance records.

6. Review of Customer Service department grievance and complaint files at the Moses site on 10/19 and 10/22/12, found these files did not consistently incorporate receipt of written follow-up departmental investigations or conclusions, including specific corrective actions taken, where needed to address each complaint issue raised. The hospital utilizes an electronic system for complaint management, where inter-departmental communication is comprised mainly of e-mails summarizing contacts and was lacking in investigative details.

Refer to 19/23 examples cited under tag #A123.

7. At interview with the Director of Customer Services on 10/23/12 at approximately 1 PM, it was stated that the grievance procedure did not include a process to require written results of departmental investigations are received by Guest Relations staff nor specify a time frame required for response from departments prior to seven days.

It was further stated during this interview with the Director of Customer Services that department investigations are never submitted but that the guest relations representative would have discussion or e-mail with departments regarding the results of the complaint review. A written grievance response is then prepared by the customer service staff. However, actions taken by departments may not be shared with the Customer Service department to communicate to the complainant where confidentiality is of concern. It was acknowledged that complaint files would therefore contain mostly general results and would not include records of departmental investigations nor document all corrective actions taken.

Based on review of patient grievance records, procedures, and staff interviews, it was determined that grievance investigations were incomplete and that written responses were either not provided or did not document resolution for all complaint issues. These findings were identified for 19/23 grievance and complaint files reviewed. Findings include:

1. Complaint files reviewed on 10/19/12 found investigations were incomplete or did not address all of the complaint issues raised.
Refer to MR #s 15, 16, 17, 18, 19, 22, 23, 25, 26, 27, 31.2. The facility's grievance process did not incorporate a clearly defined process for the integration of departmental investigations and corrective actions into grievance files.
Grievance files were missing critical elements of the investigative process, including complete results of interviews with all staff, complete medical record reviews, audits of personnel files, and observations. Additionally, documentation of corrective actions was also missing from grievance files.Refer to MR #s 15, 16, 17,18, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30
3. Review of grievance records on 10/19/12 found that written grievance files did not consistently contain evidence that final letters of response outcomes were provided to complainants, or, if issued, were not provided within time frames as prescribed in the facility's policy.

The facility did not consistently adhere to its procedures titled, "Patient Grievance Mechanism", Policy JC13.1, reviewed/revised 11/10, which documents a turnaround time for required responses to complaints and grievances with results within 7 days or 30 days.
Refer to MR #s 15, 18, 20, 21, 23, 28, 31, 32.
4. Grievance response letters issued to complainants did not provide answers or resolutions for all issues raised. In addition, for those files where written grievance responses were issued, letters did not include instructions about how to contact the State Agency if the complainant disagrees or is dissatisfied with the investigation.
MR #16, 17, 19, 22, 24, 25, 27, 29, 30, 61.

Examples identified at the Moses Division :1. MR #15
Patient filed a verbal complaint by telephone to Customer Services on 1/26/12 that he was grabbed and physically thrown out of the emergency room by security staff after presenting with a physician note requesting medical assessment and admission. A letter was sent to the patient from Customer Services dated 2/7/12, in which it was stated the issue was referred to the manager and requested the patient to call the Customer Service representative.

The electronic grievance file contained an e-mail response from staff dated 2/7/12, which indicated Security staff had spoken with medical staff who reported they would not be able to see the patient without registering. The patient allegedly became physically aggressive, resulting in the officers escorting the patient out of the ED.

The facility grievance file contained a note dated 2/6/12, reporting a verbal response was provided to the complainant during which he refuted the finding and asked staff to further examine video tape records. The grievance file lacked inclusion of a departmental investigation.

A security report was subsequently provided to the surveyor, dated 1/26/12, in which it was noted the patient was irate upon being told of need to register. He tried to strike the officer and then was escorted out of the emergency room.

The grievance file lacked follow up investigation evident to include videotape review. The grievance file did not include follow up letter provided to the complainant to explain the investigation outcome.

2. MR #16
On 7/3/12 a patient filed a verbal complaint with Customer Services that alleged a physician placed her hand on his genital area and rocked back and forth. The Customer Service file failed to include a record of interview with the patient to ascertain the alleged date the event occurred. A physical description was provided of the employee. The patient was alleged to have delirium per psychiatry and intermittent confusion reported by the family.

On 7/10/12 an e-mail response was sent to the Customer Service staff from the Physician investigator indicating that one staff member met the physical description of the alleged physician. This person was interviewed and stated he was was not alone with the patient. In this e-mail response also noted that this patient was alleged to have delirium per psychiatry, and intermittent confusion was reported by the patient's family. The physician reviewer did not believe any further investigation was warranted. The patient was subsequently called by Guest Relations staff on 7/10/12 but did not comprehend what the staff was talking about.

A letter dated 7/18/12 was sent to the patient which noted the findings that an individual matching the description said he was not alone with her. The letter also noted the staff could not investigate the allegation about sexual misconduct. The letter did not include an option to contact regulatory agencies if dissatisfied. There was no evidence of record review or written reports of interviews with relevant staff. The investigation was incomplete and the response did not contain sufficient explanation of the steps taken to conduct an investigation as specified in this regulations.

3. MR #17
Telephone complaint received on 9/14/12 from a patient who complained that the phlebotomist placed his hand on her groin. The complainant reported the employee had apologized when she advised him she was married. A preliminary letter was sent on 9/24/12 requesting need for more time to complete the investigation and that a response would be provided in 30 days.

An e-mail was sent to the Customer Service representative from the Manager on 10/1/12, which indicated that an apology was provided. This e-mail reported that interview of the employee stated he accidentally rested his hand for positioning for the phlebotomy and he thought he was leaning on the bed and covers. He apologized to the patient and was unaware he was leaning on the patient.

A response letter was provided to the complainant on 10/10/12 indicating the employee was counseled. The investigation was incomplete because the employee's statement was missing from the grievance file and there was no follow up of the reasons for counseling. No departmental review was documented. The response letter was incomplete in that it was missing the steps taken to resolve the grievance. There was no option included to contact regulatory agency for review in the event the complainant disagreed with the findings. During an interview with the Director of Customer Services on 10/23/12 it was reported the departmental review and actions taken with employees would not be sent to Customer Services due to confidentiality.

4. MR #18
A child's mother complained on 9/10/12 about being reported to the Agency for Children's Services (ACS) by a Social Worker and alleged the worker's intent to punish her.

The file did not contain a departmental review. E-mails summarized that a nurse reported on 9/10/12 that the mother told the worker she could not care for the child and that ACS was called. Verbal contact was made with the parent who was told to speak with the nurse manager.

A second complaint was received on 10/3/12 from the parent complaining that another ACS report was made. Telephone contact with the Social Worker on 10/3/12 reported the child was left by the mother in the ER and was unreachable. It was also reported a court case was initiated by ACS. The mother was verbally informed by Customer Services of the response on 10/3/12 and the parent hung up. The file noted on 10/3 the parent was dissatisfied. However on 9/11/12 , it was noted "complainant was satisfied at that time." The investigation was incomplete in that it did not contain an independent review of the record by the department and a written response was not issued with sufficient explanation of the steps taken to conduct an investigation as specified in the regulations.


5. MR #19
Patient submitted written complaint dated 8/6/12 containing several complaints including: alleged 7 hour delay in medical evaluation in the ER, multiple failed attempts to draw blood before successful drawing, placement in a hallway for several hours, and lack of discharge instructions.

The hospital's complaint file included referrals to three staff for investigation and contained several e-mails upon receipt of the complaint on 8/13/12.

The review from the ED Director indicated by e-mail, she was seen little more than two hours after presentation and that she refused a head CT, due to a study conducted the day prior. She was seen by a neurologist who concluded a migraine and assistance was provided with connecting to the outpatient provider.

A response letter was provided to the complainant dated 8/29/12, which reported she was seen by a physician slightly more than two hours following presentation, and noted she refused the head CT. The patient was seen by the neurologist.

The response letter did not detail an investigation of the remaining allegations about multiple unsuccessful blood drawing attempts, being left in the hallway for hours, and lack of discharge instructions. Additionally, the Customer Service files did not contain detailed reports of follow up departmental investigations. The letter did not advise the complainant about the alternative of contacting the regulatory agencies if dissatisfied with the response.

6. MR #20
A parent of child filed a telephone complaint on 6/18/12, for several issues related to lack of proper discharge planning, provision of incorrect face mask for bipap machine, and lack of arrangements for needed oxygen. The mother asked for home care services during the week.

A written e-mail response was received from the Social Work manager on 6/19/12, which documented a response including that the permanent mask was on back order and the family was instructed to use the hospital mask during the interim. In addition, it was reported the mother declined additional oxygen, as she had some in the home.

A follow up response received from the hospital's Home Care Agency on 6/21 and 6/22/12, in which the mother requested weekend service only and service arrangements were noted . The mother was noted to have agreed with this plan.

The written response provided from Customer Services dated 7/17/12, found that referrals were made to Social Work and Home Care for their investigation and that the Customer Service representative attempted to call the complainant without success.

The file lacked evidence of provision of a written response issued to the complainant that detailed investigative findings. The hospital did not adhere to its process for provision of a response within required timeframe of 7 days or extension to 30 days if the grievance investigation requires additional time.

7. MR #21
A patient s father complained by telephone on 9/27/12 that his 16 year old daughter was transferred to another hospital following an overdose without parental consent. On the same date, the customer services staff explained to the parent how physician judgement determines decisions around treatment.

Customer Services phone follow up with the physician on 9/28/12, noted that transfer had been discussed with both parents who reported they would do anything advised by the physician. Telephone follow up with the complainant on 9/28/12, conveyed the physician discussion of need for inpatient treatment. The father said the statement was, "lies." However, the file inaccurately noted the complainant was "satisfied" on 9/28/12.

No written letter of response was provided to the complainant. The file did not incorporate a departmental investigation with summary of chart review findings.

8. MR #22
Verbal and written complaint dated 8/13/12 was initiated by the family about alleged rough handling of a patient by nursing staff, along with additional complaint of an interaction between family and nursing staff resulting in Security involvement on 8/10/12.

A series of e-mails were received from department supervisors where it was concluded the standard of nursing care was met. There was no evidence of departmental review of written staff interview to ascertain how this determination was concluded. The file noted there was miscommunication and an apology was made to the family.

The facility response letter provided to the complainant dated 8/17/12 requested 30 days to investigate. The final response letter dated 9/12/12 noted nursing staff was spoken to about care and that counseling was provided. However the response did not answer the allegation about alleged rough handling .

9. MR #23
Complaint received on 8/6/12 about receipt of the wrong prescription under another patient's name. Grievance file contained only e-mails from staff summarizing that an apology was made regarding the prescription error and a prospective plan to QI the matter and that the error was due to "time factors."

No written response was provided to the complainant nor a detailed departmental investigation to specify the findings or corrective actions taken for the error.

10. MR #24
E-mail complaint received 8/28/12 (dated 8/23/12) from the stepdaughter and proxy of a patient who passed away. Complaints included failure to communicate about treatment decisions that delayed palliative care referral and lack of proper pain management during end of life care.

The grievance file did not contain evidence of detailed departmental investigations and was comprised of e-mails that summarized plans to obtain bioethics discussion and the inability to contact the physician. A nursing review referenced was not included for review. The file also lacked detailed departmental review.

A file copy of the response letter to the complainant, dated 10/9/12 acknowledged record did not address concern about pain and comfort measures. The response exceeded the time frame for response as mandated by facility procedures and lacked departmental investigation of corrective actions taken for problems noted.

11. MR #25
Daughter of a patient complained via e-mail on 8/9/12 about discharge planning and return to the emergency room eight hours later due to pneumonia. She requested a review of the medical care in that she alleged the patient was not examined prior to discharge. The complainant also indicated Social Worker would not speak with her.

The grievance file did not contain a complete departmental investigation.

The electronic grievance file was limited to e-mail that the medical review suggested standard of care was met yet suggested further review by the department of surgery in order for consensus of findings. There is no evidence this further review was conducted. The file also lacked results of any departmental review from Social Services.

The response letter dated 8/30/12 noted the first Physician's finding the care met standard and that the supervisor "addressed" the Social Worker. The letter apologized for the experience. The response also failed to include contact information for external regulatory agency in the event the complaint disagreed with the findings.

12. MR #26
In-person complaint received on 10/2/12 from the parent of a patient who alleged nursing staff failed to respond to calls bells for suctioning and the patient was choking. A request for departmental review was made on 10/3/12.

An e-mail response from the Nursing Manager was received 10/5/12 who reported a response was provided to the patient and mother with reassurance for increased attendance at night. The nurse in question had not been back to work and follow up was planned.

A telephone follow up was recorded for the mother on 10/17/12 in which she declined a letter stating things had improved. There was no documented departmental investigation of actual findings or determination if follow up corrective action was needed with the involved staff.

13. MR #27
Patient complained on 7/10/12 that on 7/9/12 while he came to the ER for treatment of chest pain, he was accosted by a head nurse who he claims accused him of taking pictures in the ER and demanded to see his phone. He claimed during this interaction, he was physically assaulted and pounded on the chest by a security officer and then he and his wife were thrown out of the ER.

Series of e-mails summarized the hospital ' s review of the complaints and noted that it was the wife who took pictures and the event was witnessed by multiple staff in the ER. Another account indicated the patient was abusive to staff. Attached Security statements found that the female companion was asked to delete the pictures off the phone. The investigation never addressed the patient ' s contention he was physically struck by a security officer.

The written response letter provided to the patient was dated 9/13/12 (more than 30 days as required by procedure) noted the hospital ' s procedure regarding prohibition of picture taking and that the patient will be requested to leave the premises if refusing to comply.

14. MR #28
Telephone complaint received on 7/3/12 from the parent of a patient who claimed delay in triage and treatment while the patient had a high fever. The complainant alleged a negative interaction with the triage nurse. The case was referred for investigation and it was requested the staff call the complainant.

The Customer Service staff requested a follow up of the response to the complaint from the department. It was noted in an e-mail on 7/23/12 there were gaps of time in between care, the nurse was spoken to about the interaction, and the nurse resigned. It was also noted the mother was satisfied. However, the items noted were not explained and no corrective actions were noted. No departmental review was included. The complaint was closed on 7/24/12. No letter of response to the complainant was evident in the file.

Review of the medical record by the surveyor on 10/19/12 found that the patient was pre-triaged at 4:46 AM, vitals were taken at 4:56 AM, which revealed a temperature of 103. Triage was not recorded until 5:52 AM. No corrective action was taken for this finding suggesting a delay.

15. MR #29
A written grievance was received on 10/1/12 from a patient who complained about a security officer ' s verbal and physically threatening behavior towards her when she was called into the emergency room fast track for treatment. She alleged the officer refused to listen to her name just prior to the incident when she attempted to communicate her need to step out briefly from the ED.

An e-mail response dated 10/2/12 indicated the patient had problematic confrontational behavior in past with Security officers; the Police Officer stated she began to yell at him when he explained he does not listen for names.

The officer was reminded about " customer care procedures " and noted the officer was not "hung over" as alleged.. The specific issues identified were not recorded nor evidence of a detailed departmental investigation.

The grievance file did not include review of the complaint about the officer ' s alleged behavior. The response letter dated 10/16/12 indicated a conclusion was reached but did not explain findings other than the officer was counseled on proper customer procedures.

The response letter failed to include contact information for external regulatory agency in the event the complaint disagreed with the response.

16. MR #30
Patient complained by telephone on 9/27/12 that she waited over 1 hour for assistance in the ER and when she alerted the nurse she received a rude response that she was not yet registered. The patient admits that, due to lack of assistance, she shoved equipment because she was in pain, which accidentally hit another patient. The nurse asked her to leave and she was escorted out by security with no treatment.

The electronic grievance folder noted an e-mail from staff that reported she was waiting only 1 hour and 12 minutes and the nurse stated pain medication could be ordered as soon as the MD saw her. The patient went into a " tirade " and threw the vital sign machine on a floor which struck another patient.

The nursing e-mail response dated 10/2/12 determined the pain could not be addressed more expeditiously due to excessive volume. Triage level assigned allowed two hours to be seen; the reviewer noted patient ' s behavior was not acceptable and in future she would be assigned to security watch because there had been prior incident with this patient.

The response letter dated 10/15/12 was sent to the patient and consisted of an apology, acknowledged a delay, and concluded the treatment met the standard of care.

The letter offered no option to contact regulatory authorities if the patient disagreed with the complaint findings. The grievance file did not reflect the medical record review nor involve an interview with Security Staff. Corrective actions were not evident for the acknowledged delay due to high volume.

17. MR #31
A review of the grievance log revealed that a complaint was lodged by the patient ' s family on 9/7/12. According to the file, the patient had Alzheimer ' s disease. The following issues were lodged in this grievance:

1. The patient did not receive his methadone maintenance during this stay.
2. The patient was discharged home without family notification or discharge instructions.
3. The physician was advised by the family he needed escort and assistance at discharge and that the MD refused to provide a Social Work referral.
4. The patient was missing after discharge because the patient was sent home without home care services or ambulette transportation.

A review of the electronic grievance file evidence multiple e-mails and report of staff meetings. A review of the file indicated that the patient reportedly went home by subway and filled his own prescriptions. The facility ' s file showed that during an interview with the nurse it was reported that the patient was alert and oriented times three and was able to participate in discharge planning.

There was no evidence of any corrective action taken. The facilities ' investigation did not address alleged lack of appropriate discharge planning, the concerns raised by the complainant, particularly for lack of Social Services referral, and lack of communication with the family.




16401


During review of 4 Emergency Department complaints at the Weiler Division, it was determined that the patient/patient's representative did not receive a timely written response in 2/4 grievance files reviewed. Examples include:
18. MR#32
A review of the greivance on 10/16/12 revealed that the facility failed to provide a timely written response to the patient/patient's representative. This complaint was initially filed on 4/19/12, there was no evidence by 10/16/12 of any written response issued to the patient/patient' s representative. The facility did not provide a written response regarding the steps taken to investigate the complaint, the date of completion, or the outcome of the investigation.
19. MR #61
This patient was seen in the ED on 6/11/12. The facility failed to advise this patient/patient's representative that if he/she was not satisfied with the outcome of the investigation, options could include follow up contact with regulatory agencies to review the matter.

Based on record review, interview and observation it was determined that the facility failed to formulate and implement a policy and procedure to ensure the safety and welfare of patients who elope from units. Specifically, a missing inpatient was found dead on the 4th floor roof of the Foreman Pavilion at the Moses site.

There was no facility wide plan that calls for the ongoing assessment of all areas that are unauthorized for patient access to determine the level of surveillance required.

The facility had no policy and procedure to ensure that patients who leave the unit but not the hospital are supervised so that they cannot tresspass to other patient care areas.


Findings include:

The facility medical, nursing and security staff failed to formulate and implement a policy and procedure to ensure that patients who leave the units at night are assessed for their ability to return safely and that they are not in other unauthorized areas.

Review of MR# 1 and security reports on 10/15 /12 found that the patient who had a hip replacement was found dead on the 4th floor roof of the Foreman Pavilion by hospital staff who were not part of any search team and who noted the body from a window of the Children's Hospital.

The body was found to be one of a person who was a patient on the 7th floor ( room 749A)adult unit of the adjacent building and who had been reported as missing for 2 1/2 hours during the night. There was a large hole in the window found when facility staff stated that they inspected the floor from where they presumed the patient had "jumped." A fire extinguisher was found next to the patient.

Review of the Security Incident Report dated 6/23/12 referred to a statement that the hospital had been thoroughly searched on the night of the incident. The search did not include the roofs of the hospital in that the patient was found dead on the 4th floor roof 3 floors down from the patient's room and 5 floors down from the elevator control room which is not a patient authorized area and is not staffed at night.

Review of the policy # JD 15.1 titled "Elopement of Patients" on 10/15 /12 found that there is no reference defining what constitutes a " thorough search. "by security staff. Interviews with engineering and administrative staff on 10/15/12 verified this finding.

Review of MR#1 found that the patient had left the unit AMA on 6/20/12 after hip replacement surgery. He then was re-admitted from the ED with complaint of dizziness ( patient had an hematocrit of 12. ) On the night of the event the patient left the unit and advised the staff at 2:30 am, returned at 3:30am and once again at 4:45 am hours left the unit without notifying any staff in advance.

A tour of the the floor by the nursing surveyor and the sanitarian with the Engineering Director on 10/15/12 where the patient was alleged to have "jumped" found that the door was locked. There was an invoice that reflected that the lock was replaced after the incident. This was reported to have been a new lock. Review of the incident report found that when facility management staff attempted to access the 9th floor on the date of the incident, it appeared locked. When they attempted to gain access, they reported that upon turning the lock, they were able to gain access without force. The window pane had a " large hole. "There was a fire extinguisher on the 4th floor roof, not in the wall area. .
Review of the incident report dated 6/23/12 determined that this was the 9th floor and it was referred to as the "engineering floor" which houses elevator machinery. The room was found to have dangerous machinery.

The facility investigative report dated 7/6/12 documented that the patient was found on the 4th floor of the Foreman Pavilion. The statements identified that there were no routine inspections of the locks on the door of the Foreman Pavilion. Further reference was made to the finding that the door that was used to gain entrance to the 9th floor was found to be "locked" after the incident.

There was a statement in the facility incident summary written by investigators contracted by the hospital that wrote a statement attribututed to the Security Director on 7/6/12 that stated "security goes around the hospital and "checks the locked doors every night." Furthermore, the statement continued that there is no record of any such scheduled " rounds ". The Engineering Director reported that there are no routine inspections of the locks on the doors of the Foreman Pavilion.

There was no reference that the nursing staff assessed the patient's behavior which included pulling out the foley catheter, unsafe ambulation and leaving the unit at night. The patient had a low hematocrit (14 ( normal 40) but had refused any transfusions for religious reasons. .

Nursing progress notes dated 6/23/12 at 0755 hrs. found an entry that the patient was " relocated for better visibility, rounding for every hour or more frequest toileting. The patient had been off the unit and in fact was dead on the roof at that time.

Review of interview statements made to the facility by staff found that there was evidence that the patient demonstrated potientially violent behavior on 6/20/12 when he was attempting to leave the facility. Specifically, it was stated at interview that the Unit Secretary observed that the patient attempted to push the PA and resident when confronted by them and security had to be called. The patient was allowed to sign AMA.

Review of interview summaries by the Director of Security on 10/15/12 found that security aborted any search for the patient in that they confused the missing patient that was eventually found dead with another patient from the same unit who was also missing from the unit but had returned. He attributed this to nursing staff on that unit not being specific as to the identity for each patient involved.

The security report dated 6/23/12 stated that " after a thorough search of the hospital the body was found" This contradicts the event as reported. It was not the " search " that resulted in finding the patient. It was uninvolved nursing staff from another pavilion. (CHAM) . ( Childrens Hospital at Montefiore ) .

A physician's ( attending ) note written 6/23/12 at 9:00 AM after the death of the patient stated that he ordered a 1 to 1 observation " through the house staff " after the second elopement once the patient " returns " but there is no evidence that this was communicated.or implemented in that the patient never returned to the unit but was in fact missing.

Where a patient is missing and the physician determines that the patient requires a 1 to 1 observation when he returns, a search for the patient should be escalated and that the security office be advised that this patient's location is vital.








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Montefiore Extension Clinic at 1621 Eastchester Road

Based on observation at the extension clinic, it was noted that the facility staff did not ensure the patient's personal privacy while being examined by a physician.

Findings include:


On 10/22/12 at 3:05PM, during observation of the examination rooms, witnessed by Staff #6, the facility Administrator, a patient was observed in examination room #19 with 2 other persons in the room.


The patient's shirt was off and the upper torso was fully exposed. It was noted that the door to the examination room was open and the privacy curtain was not drawn to shield the patient from public view.

During the observation of this patient Staff #6 was made aware of this issue.

Wakefield Division

Based on medical records reviews, facility document review and staff interviews, it was determined that the facility did not develop policies and procedures specifically identifying and addressing medications, used as restraints. This is evident in 2 of 58 medical records reviewed at this division. MR #s 33 and 34.

Finding
The facility policy and procedure titled, "Restraints or Seclusion, Care of the Adult Patient Requiring," issued 5/97 and revised 7/12, documents in policy #9, " ....does not use chemical restraints."

The policy failed to identify when psychotropic drug use fit the description of chemical restrains and failed to guide staff in the management and monitoring of patients who are restrained with higher doses of psychotropic medications and who require vital signs observations to ensure their safety.

1. MR#33
The patient is a 46 year old male patient admitted on 10/14/12 with a 30 year history of alcohol dependence, now on admission for detox.
It was observed on10/17/12 at 12:10PM on the Detox Unit at Wakefield Division that the patient was given a stat dose of Ativan - a benzodiazepine- 2mgs (milligrams) orally at 11:56AM on 10/17/12, for agitation. The medical record documented that the patient's routine prescribed dose of "PRN", Ativan 0.5mgs orally, was not given when due Q6H at 12:00PM because of the higher stat dose had been given.

The nurse's note written on 10/17/12 at 11:30AM, documented that the patient also received Haldol 5mgs orally and Benadryl 50mgs on 10/17/12 at 11:30AM.

Further review of the medical record revealed that the staff did not document the alternative interventions provided to the patient, such as redirection, the vital signs prior to and after the administration of the medication.

There was no documentation by the physician of a face to face evaluation before the stat dose of Ativan 2mg was given.

During interview with the charge nurse for the unit, Staff #2, RN Manager Wakefield Division , it was stated that a stat dose of 2 mg Ativan, was not considered a chemical restraint, as the facility does not use chemical restraints on patients. He further stated that routine vital signs were done on the patients 3 times a day and it is not a policy of the facility to perform additional vital signs on the patients when psychotropic drugs are used in larger than usual doses to control the patients' agitated behaviors. Hence the response of the patient to the larger dose was not monitored or documented.

During an interview at 2:05 PM on 10/17/12, Staff #1, Director of Nursing Wakefield Division, stated that she does not belief that the facility has a policy on medications used as a restraint.

2. MR#34
On 10/17/12 at 2:30PM the medical record of a patient, MR#34, who was secluded the previous day (10/16/12) was reviewed. It was noted by the physician that prior to seclusion the night before; the patient was given IM Haldol 5mg, Ativan 2mg and Benadryl 50mg at an unspecified time before the seclution with undocumented effect. On 10/16/12 at 10:10AM, the patient was given IM Haldol 5mg, Ativan 2mg and Benadryl 50mg and was secluded again for "appearing acutely paranoid and violent."

The nurse documented in the progress note on 10/16/12 that at11:06AM, that the patient was calmly sitting on the floor in the seclusion room (there was no bed in the seclusion room). The patient was released from seclusion 2 hours later.

During interview with Staff #4, the physician director of the unit, on 10/17/12 at 3:00PM, he stated, "we don't give chemical restraints. Medications are given to manage patients' behaviors and are not considered as chemical restraints."

Based on observation, review of records, procedures, and staff interviews, it was determined the facility did not administer safe and appropriate restraints as follows: Specifically,
-records lacked accurate documentation for ordering or monitoring of restraints;
-records did not adequately reflect sufficient monitoring of concurrent physical restraints and medications used as restraints;

-flow sheets lacked a mechanism to monitor chemical or medication restraint used simultaneously;

-instances of use of PRN medication orders were noted in prohibition of psychiatric restraint policy.

-orders written for restraints on Moses division cardiac intensive care unit ICU were not implemented.

These findings were noted in 7/12 applicable records reviewed at the Moses Division.


Findings include:


A. The facility did not implement safe practices for ordering and monitoring of patients receiving physical and chemical restraints.

B. The facility has three restraint procedures which do not integrate practices for administration of restraints. These include:

Procedure S03-08-02 titled " Seclusion and Restraint/psychiatric Settings;
Procedure R-2, " Restraint or Seclusion, Care of the Pediatric patient requiring " ;
Procedure R-1, " Restraint or Seclusion, Care of the Adult patient requiring " .

The procedures documented that chemical restraints are not used in Children's Hospital at Montefiore (CHAM). The procedures do provide a regulatory definition of chemical restraints as a "psychoactive medication that is not a usual or customary part of a diagnostic or treatment, procedure, or dosage for the patient's condition, and is used to restrict a patient's freedom of movement." However, no specific mention is made regarding the facility's position on chemical restraint use on the adult, psychiatric, or detoxification services.

These procedures also define conditions that are not considered chemical restraints. The procedure indicates that chemical restraints do not include medications used for "therapeutic goals, such as, but not limited to: sleep promotion, treatment of agitation /aggression secondary to psychiatric condition, sedation for procedures/life support equipment, or withdrawal from substance abuse /medications." There is no statement for facility-specific policies with respect to use of chemical restraints in the adult, detoxification, or psychiatric service. However, restraint order logs for 10/15 and 10/16/12 includes behavioral chemical restraints.

Psychiatric restraint procedures, Procedure S03-08-02 titled " Seclusion and Restraint/psychiatric Settings" note, reviewed identify that seclusion PRN (as necessary) and PRN medication orders are prohibited.

The policy does not define instance when chemical restraints, or medications used to manage behavior, are used concurrently with physical restraints.

Review of the facility daily restraint order logs dated 10/15 and 10/16/12, note that behavioral chemical restraints are used. The specific medications being used as restraints are not recorded in this log.

The restraint monitoring flowsheets for non-violent and violent restraints do not have a form and structure to describe when medications used to address behavior are used at the same time as physical restraints or seclusion, in order to monitor concurrent effects of the medication.

The violent restraints flow sheet note alternatives attempted include: " medication changes after PRN medications " but do not specify the monitoring methods to be implemented for concurrent use of medications used as restraints and physical restraints.

The Psychiatric restraint procedures note monitoring includes administration of medications as ordered, yet the restraint monitoring form for self destructive/violent behaviors describes alternatives may include medication change as an alternative to offer PRN medications. However, the Psychiatric restraint policy notes the use of PRN medications is prohibited as noted above.

During an interview with two psychiatrists on 10/15 and 10/16/12, inconsistent reports were given regarding the use of chemical restraints in the hospital or PRN medications used for management of behavior.

During an interview on 10/15/12 at approximately 12;15 PM, it was stated by a consultation-liaison covering psychiatrist, that there are instances when chemical restraints are used for agitated or violent behaviors.

During an interview of a unit chief psychiatrist on 10/16/12 at approximately 11AM, during tour of inpatient Psychiatry at the at Moses Division, it was stated that chemical restraints are never used and PRN orders for medications to decrease agitation are permitted, as prescribed to manage symptoms of the underlying Psychiatric etiology.

The following deficiencies were observed at the Moses Division:

1. MR #4
During tour of the inpatient Moses NW8 medical unit on 10/15/12 at approximately 11:40 AM, this 77 year old patient was observed in bed with bilateral wrist restraints tied to the bed and mittens present on both hands. The patient was receiving 1:1 supervision. A mattress was placed near the bed on the floor. The head nurse reported this was placed to prevent falls. The patient was alert, but incoherent.

Review of the medical record on 10/15/12 in the afternoon found the patient was admitted on 10/1/12, from a nursing home with severe agitation and aggressive behavior. History was significant for Alzheimer' s dementia, paranoid schizophrenia, coronary artery disease (CAD), and DM.

According to Psychiatry notes dated 10/9, 10/10, 10/11, 10/12, 10/13, 10/14/12, and 10/15/12, the patient was being followed for management of dementia and behavioral disturbance.

On 10/14/12 Psychiatry noted the patient had hypotension following Haldol decanoate injections. The patient received 1 mg Ativan and 3 mg Haldol at approximately 11 am on 10/14/12. The 10/14 Psychiatry note mentioned to continue Haldol and Ativan together as a PRN for that date while checking frequent blood pressure.

Chemical restraints used PRN were not included in restraint monitoring flow sheet records in addition to inconsistent recording of restraints as identified during a restraint episode on 10/14/12. The flow sheet record for restraints for the restraint episode occurred from 7 pm to 7 am on 10/14 to 10/15/12. Review of nursing progress note dated 10/14/12 at 7:10 PM found the patient was confused, with 1:1 constant observation and wrist mitten restraints in place. At 12 AM the nurse recorded Ativan IM given with little effect. The violent/non self destructive restraint flow sheet for that time period did not record the type of restraint being used.

During an interview with the Head Nurse of unit Moses NW8 on 10/15/12 at approximately 12:30PM, it was stated the patient was combative and had to be immediately restrained while awaiting pending orders at 11AM.

The record also noted written physical restraint orders on 10/15/12 which were not accurately recorded. Two orders for " tied mittens both " were noted on 10/15/12 at 11:34 AM (discontinued 1208) and at 1208. These orders did not specify wrist restraints used in addition to tied mittens as ordered nor reference the active use of existing PRN medications ordered for agitation that were in effect (Haldol and Lorazepam IM 1mg Q6H6 were ordered PRN on 10/14/12 for agitation. The indication written on the restraint orders was "interference with treatment."

Nursing record review found that on 10/15 at 11:00 AM the patient was combative, kicking, restless, cursing, and hitting staff. The nursing notes noted bilateral wrist applied to both upper arms but never referenced simultaneous mitten usage as observed during the tour by the surveyor.

The restraint monitoring record form dated 10/14 and 10/15/12 found the type of restraint used was not completed (blank). Staff utilized the same flow sheet record for restraints that were in effect from a previous restraint episode (which occurred from 7 pm to 7 am on 10/14 to 10/15/12). This same flow sheet was used for the emergency administration of restraints pending physician order at 11 AM on 10/15/12. This flow sheet form did not specify the type of restraint used nor reference the use of chemical PRN medication, used as restraints that was administered simultaneously with the physical restraint.

At interview with the Psychiatrist at 12:30 PM on 10/15/12 it was stated the patient was receiving PRN medications for chemical restraint management.

2. MR #36
An eight month old child was admitted for asthma exacerbation on 10/14/12. Bilateral Wrist restraints were ordered 1224 pm 10/15/12, for interference with treatment.

Observation of child on 10/16/12 at approximately 1:10 PM, revealed NG tube in place with elbow restraints. The restraint order dated 10/15/12 at 1224 PM noted both wrists due to interference with treatment. The order expired on 10/16/12 at 0600 hours.

Interview of the Director of Nursing of CHAM on 10/16/12 at approximately 1 PM, identified that "No No" restraints are used for elbows only, but orders and violent/non destructive restraint flow sheets noted bilateral wrist restraints and did not reflect the use of pediatric elbow restraints.

3. MR #37
This patient with vascular dementia and schizoaffective disorder was ordered to have 25 mg diphenhyrdramine Hcl PRN Q4H (as needed every 4 hours)on 9/11/12 and received this dose at 13:03 on 9/11/12. This was in contrast to facility ' s written PRN medication policy that prohibits PRN orders.

At interview with the unit chief psychiatrist on 10/16/12 at approximately 11 AM, during tour of inpatient psychiatric unit, it was stated that chemical restraints are not used and that PRN orders for medications to decrease agitation, may be prescribed for the underlying psychiatric etiology.


4. MR #38
44 year old female was hospitalized on Moses surgical intensive care unit (SICU) for upper alveolar, neck, and sinus cancer. The patient was intubated and observed in bilateral wrist restraints on 10/17/12 at approximately 11 AM. The restraint order dated 10/17/12 at 0805 noted both limb wrist restraints.

review of the restraint flow sheets did not match orders for type of restraint used. The patient was placed in right wrist restraint at 7 AM on 10/17/12, yet orders noted bilateral wrist restraints dated 10/16 and 10/17/12.

Review of restraint order logs for 10/15 /12 determined two patients had orders for multiple types of restraints, including but not limited to, wrist restraints and chemical restraints.
Review of 2/2 applicable concurrent Moses site cardiac ICU records from this list on 10/15/12 found these patients had orders written for restraints that were not implemented.

During at interview with the Head Nurse on 10/15/12 during the afternoon tour of the cardiac ICU, it was stated that the orders were never implemented. No explanation was given for these orders. Examples includes:

5. MR #39: the patient was hospitalized on 10/12/12 for cardiac arrest and in septic shock on ECMO. Bilateral wrist restraints were ordered due to "potential for self harm" on 10/15 at 7 AM but had not been implemented.

6. MR # 41 the patient was admitted on 9/27/12 for cardiac arrest, the patient was ordered to have bilateral wrist restraints on 10/14/12 at 0722 AM, but the patient was not restrained. A previous restraint ordered bilateral wrist restraints on 9/27/12 ,but the corresponding restraint flow sheet for that date found the type of restraint being monitored was not documented.

7. MR #40
73 year old admitted on 10/12/12 for GI bleed found concurrent use of PRN orders for agitation and physical restraints.

The patient was ordered to have bilateral wrist restraints for reason noted as potential for self harm on 10/15, 10/16 , and 10/17/12. Midazolam Q4H PRN was ordered from 10/15 to 10/22/12 for agitation and administered 10/15 and 10/17/12 at 0105.

a review of the restraint flow sheets do not include a section for monitoring of PRN medications used as a restraint.

7. MR #14
This 67 year old female with multiple medical problems including HTN, DM, and CVA, polysubstance abuse was admitted for chest pain. The patient underwent CABG on 9/17/12.

A restraint was ordered at 1359 or 2 pm on 9/18/12 for bilateral wrist restraints due to interference with treatment. The order was active for 24 hours. Review of restraint flow sheet records found that the patient was restrained from 9/18/12 at 12:30 pm through 9/19/12 at 8pm. There was no renewal order documented for restraint or reassessment after 2 PM on 9/19/12. Additionally, the restraint flow sheet for 9/19/12 did not document or check the type of restraint being monitored.

Based on observation, staff interview and review of hospital policy, it was determined that the facility fail to ensure that patients receive an appropriate nutritional screen upon admission. This finding was found in two of ten medical records. (MR #43 and MR# 44).

Findings include:

1. Review of MR #43 at the Moses Division noted a patient was admitted from a nursing home on 5/30/12 with a diagnosis of Sepsis. The patient was on a vent, was fed through a PEG tube and had multiple pressure ulcers. Three of these pressure ulcers were stage IV and one was stage III. These conditions are high risk nutritional triggers however the patient was nutritionally screened by nursing as "No triggers identified".
2. Review of MR #44 at Moses Devision noted a patient was admitted on 10/9/12 with a diagnosis of Hyperglycemia and seizures. The patient was admitted with two pressure ulcers- stage IV (heel) and II (sacrum). The nurse did not fill out a nutrition screen which resulted in the Dietitian not performing an initial nutrition assessment on the patient until 10/15/12 (six days after the patient was admitted).

Based on interview and the review of medical record, it was determined that admitted patients with extended stay in the Emergency Department (ED), did not have a nursing care plan established to meet their care needs. This finding was noted in 6 of 6 medical records reviewed. (MR #45, #46, #47, #48, #49, #50, #51, and # 52).


Findings include:


1. MR #45
The patient is a 99 year-old female with past medical history significant for dementia and multiple myeloma. The patient was triaged in the ED on 10/13/12 at 2:47 PM with complaint of shortness of breath and was admitted with diagnoses of new onset atrial fibrillation and rule out pneumonia.

The ED record showed that a nursing care plan was not developed to address the needs of the patient during the two days in the ED. The Nursing ED Assessment form completed on 10/13/12 at 3:38 PM, did not identify the patient care needs.

There was no documentation of a comprehensive nursing assessment of the patient for each nursing shift after the initial nursing assessment and how needs such as nutrition, activities of daily living, and pressure ulcer prevention were being met.

The nursing progress note indicated the patient was in a stretcher for almost two days until she was put on a hospital bed in the ED on 10/15/12 at 3:46 PM.

The initial nursing assessment of the patient upon arrival to the inpatient unit on 10/15/12 at 9:59 PM, revealed she was at high risk for the development of a pressure sore and had developed a stage II sacral pressure sore, 2cm x 1cm, which was acquired in the ED.

During an interview with the ED Director on 10/18/12 at 2:15 PM, he stated that admitted patients are not separated from other ED patients and there is no exclusive staffing for their care.

Similar findings regarding the lack of a nursing care plan and adequate documentation of care provided to patients were noted in MR #s 46, 47, 48, 49, and 50.

These were patients who have been admitted but remained in the Emergency Department for 24-72 hours awaiting inpatient bed.



16401

Based on review of medical records, review of hospital policy and interview, it was determined that the hospital failed to ensure that each patient's care plan was kept current in regards to pressure ulcers management. This was evident in MR #51 and MR #52.

Findings include:
1. Review of MR #51 on 10/17/12 noted this76 year old patient was admitted on 9/22/12 with sepsis, respiratory failure, A-fib and Pneumonia. A stage II pressure ulcer measuring 6 x 6 cm was noted on admission. Collagenase ointment was ordered on 10/10/12 to be applied to the affected area daily. On 10/17/12, nursing documentation indicated the ulcer measured 7x7.5x0.5cm and was unstageable.
During an interview with the patient's primary nurse on 10/17/12 at about 11:45am, the nurse stated that the pressure sore was being treated with Allevyn. The prescribed treatment by the physician for the management of the pressure ulcer was not being implemented. The patient received Allevyn which was not ordered by the physician.
2. Review of MR #52 on 10/17/12 noted this 101 year old patient was admitted on 9/17/12 for altered mental status and UTI, the patient was noted with stage IV pressure ulcer to the sacrum.
Nursing documentation on 10/10/12 identified that the patient developed ulcers to the right and left heels, measuring 8x6 cm and 4x2 cm respectively. The bilateral heel ulcers were not timely recognized and treated at the time of identification, both heels were observed to have eschar.
There was no evidence of communication between the nurses and the physician regarding the management of the bilateral heel ulcers until 10/16/12 when a physician order was written for the management of the pressure ulcers.

Based on a observations of several inpatient and outpatient units and interviews, the facility failed to implement a system for effective removal of unused and expired medications and biologicals from patient care areas.

Findings include:

1. Wakefield Emergency Room - witnessed by Staff #1, Director of Nursing Wakefield Division

a) On 10/15/12 at 10:25AM, 3 Pediatric electrodes with expiration dates of 2012/07/09, 2012/03/26 and 2011/12/04 were observed in the emergency box.

b) On 10/17/12 at 11:25AM, expired IV fluids were observed in the Endoscopy Unit. 6 bottles of 500cc D5W with the expiration dates of 1/9/12. Another bottle of 500cc of D5W with the expiration date of 1/8/12 and 4 bottles of D5W 1000cc with expiration date of 1/10/12.

c) On 10/17/12 at 2:50PM, 16 extra protective cream with expiration dates of 08/2012 were observed on 7 South.


2. Medical Unit of the extension clinic at 1621 Eastchester road-witnessed by Staff #6, the Administrator.

a) On 10/22/12 at 1:30PM, 2 vials of 1% Lidocaine with the expiration dates of 7/10/12 were observed in the storage.

b) On 10/22/12 at 1:40PM, 100 BD Eclipse injectable needles with the expiration dates of 10/9/12 were observed in the storage room.

c) An opened bottle of 0.9 normal saline 250mls was observed stored in a cabinet in the examination room. The bottle was not labeled with the date and time of opening.

Based on observation, staff interview and other documents, it was determined that the Director of Food Services failed to take responsibility for the daily management of dietary services to ensure proper sanitation and food safety .

Findings include:

A. During observation of the Wakefield campus kitchen, document review and staff interview on 10/18/12 between 12:00 PM to 1: 15 PM, following issues regarding the environment were noted:

1. During the tour of the refrigerator and store room it was noted that there were various food items present that were either not dated when it was open or did not have expiration date on them. Additionally, some items had dates that they have either expired or need to be thrown out. Items noted were:
(i). A large bowl/pan of broth was noted with a hand written date of preparation as 11/12. It is to be noted that this date was incorrect because November 2012 is a future date.
During an interview with the Director of Nutrition (DON), it was stated that this broth was prepared recently. However, there was no documented evidence of the exact date of preparation.
(ii). A cart of about 10-12 trays of frozen food items (such as burgers, patties, chicken nuggets, and other convenience items) was noted stored in the walk-in refrigerator for the purpose of thawing.
During an interview 10/18/12 between 12:00 PM to 1:15 PM, the DON stated that the items on the cart are being thawed for the next day preparation.
The cart had a plastic cover with the date of 10/14. since the observation was made on 10/18 and the date on cart was 10/14, it could not be determined if the items on the cart were thawed for 4 days.
(iii). A portion of yellow cheese approx. 1/2 lbs, 1 gallon of red hot sauce, a bottle of Marsala wine, Red vinegar, a bottle of cinnamon powder, frozen cake and some waffles were found open and stored in the refigerator on racks. These items were not dated for the date of opening.
During an interview at that time, the DON was asked how long a food item was good once it was opened. The DON could not provide an answer.
A policy titled 'Labeling and Dating of Food products' with revised date of 10/12, was provided to the surveyor the next day on 10/19/12. The policy was requested on 10/18. The policy did not identify how long an item was good for after it is opened.
2. During the tour of the Wakefield Kitchen, 5 refrigerators located in the kitchen were noted having broken/dirty gaskets.
3. The two cold cut slicers were noted having residue of food and black specs in the cervices.

4. The temperature at the dishwashing machine at 12:45 PM was noted to be 140*F at the wash. As per the log for dishwashing the temperature at the wash should be between 150*F-165*F for complete and proper sanitation. It was noted that for the month of October 2012, the wash temperature has been consistently between 120*F-147*F with temperatures reaching above 150*F to max of 155*F only few times.

During an interview on 10/18/12 at 12:00 PM, the DON stated that the machine is out of order and that is why he has ordered the staff to use the sink for wash. The sink for wash was noted empty with no soap/sanitizer and it was noted at the time of observation that the staff were loading trays in the machine to be washed.

All the findings were verified with DON and DOE at the time of observation.


B- 1-During the tour of the kitchen at Moses Devision on 10/16/12 at approximately 11AM with the Director of the Food and Nutrition Department, it was observed that a rack containing pre portion soup had a cluster of black dust on top of a covered soup. The floor was dirty in the freezer and all food pans on racks in the freezer were dated, but not labeled as to the food content in the pan. Some pans were not completely covered by the plastic wrap.
2-The temperature of the trayline freezers was maintained by ice cubes thrown in the freezer. The freezers did not have an internal or external termometer. The temperature of the freezers were logged by using a manual termometer on only one food item. There was no evidence that temperature of food items located in the center or at the bottom of the freezers were being checked.
3- The employee's water dispenser in the kitchen was empty and contains no paper cups for drinking. It was observed that approximately six open and closed water bottles were found throughout the trayline, walk-in refrigerators and preparation area of the kitchen. These water bottles were not labeled for patient use. In addition, it was observed that on the walls in the kitchen and food preparation area had many bug catching devices stuck on the walls.
4- There was an abundance of "Roach Motels" (device for controlling insects) observed stuck on walls and behind the trayline refrigerators and prep area of the kitchen. These findings were shared with the Director of Food Service.
5- The temperature in the Kosher refrigerator in the kitchen were not recorded daily as per department policy. Temperature was recorded 4 out of 16 days (10/6, 10/11, 10/12 and 10/16).








27378

Based on staff interviews and review of medical and pertinent records, it was determined that the facility failed to provide initial nutritional assessments and reassessments to ensure that patient's nutritional needs are met. This finding was noted in 10 of 14 applicable records reviewed. (MR # 60, #62, #63, #64, #65, #66, #67,# 68, #69 and #70).

Findings include:
(a) Patients with no nutritional Assessment

1. Review of medical record on 10/17/12 noted that this 17 year old patient, MR #62 with past medical history of diabetes, hospitalization for Diabetic Keto Acidosis ( DKA) and non compliant with medication presented to the hospital on 9/14/12 with headache, vomiting and hyperglycemia.

The patient was admitted with diagnosis of DKA. Medical Surgical and Critical Care Admission Data Base and Flow Sheet done on 9/14/12 showed no nutritional triggers identified and no nutrition referral made. The patient was discharge home on a regular diet on 9/15/12.

2. MR #63 is an 89 year-old patient with past medical history of Hypertension, Dementia and Diabetes was admitted to the hospital on 9/10/12 with right foot gangrene.

The patient was not identified to be at nutritional risk and her nutritional status was not assessed by the dietitian. Consistent carbohydrate soft diet was ordered by the physician on 9/11/12. The patient was discharged home on 9/14/12.

3. Review of MR #64 on 10/17/12 noted that this 85 year old male patient with past medical history of Diabetes, Hypertension, COPD, GERD was found leaning to the left in wheelchair, drooling from the left side of his mouth and with slurred speech was brought into the hospital by Emergency Medical Services from nursing home on 9/8/12.

The patient was seen by speech/swallow pathology for dysphagia evaluation; the impression was mild oropharyngeal dysphagia and recommendation was made for a soft consistency diet by mouth as tolerated and no restriction on liquids.

The patient was not identified to be at nutritional risk by nursing. The patient was not seen by the dietitian and his nutritional status was never assessed. The patient was discharged on 9/13/12.


(b) Late nutritional assessment.

1. Review of MR #65 noted that this 22 year old patient with past medical history of Hypertension, Diabetes, Anemia, End Stage Renal Disease ESRD on dialysis was admitted to the hospital on 8/25/12, with a diagnosis of Diabetic ketoacidosis (DKA).

The patient was not identified at nutritional risk and his nutritional status was assessed 17 days after admission on 9/11/12.

2. Review of MR #66 noted that this 72 year old patient with past medical history of Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), respiratory failure, vent dependent and on Percutaneous Endoscopic Gastrostomy (PEG) tube feeding was admitted to the hospital on 10/8/12 with diagnosis of pneumonia.

The patient nutritional status was assessed 8 days after admission.

Similar findings of delayed nutritional assessment was noted in MR #s 67, 68, 69 and 70.

(c) Untimely Nutrition Reassessments:

Review of MR #60 at Moses Devision noted the patient was admitted on 5/30/12 with multiple pressure ulcers which included stage III and stage IV. Patient was initially nutritionally assessed on 5/31/12. There were twenty six nutrition reassessments done for this patient. Seventeen out of twenty six reassessments were untimely. These seventeen reassessments were done from 5 to 10 day interval.
The facility's policy titled " Nutrition Risk Identification, Prioritization of Services- Adult Acute Care Patients " for reassessment of high risk patients indicates within 7 day intervals for reassessments. The review of several medical records revealed reassessments were done at 5 days or more intervals.
During a discussion with the VP of Clinical Services on 10/17/12 at approximately 2PM it was stated that the average length of stay is approximately 5 days. Due to the short length of stay, high risk patients do not have the benefit of a nutrition reassessment before discharge to assure that the nutritional needs are being met.



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Based on observation, staff interview and review of other documents it was determined that the physicians diet orders were not documented as prescribed on the patient ' s menu. Ten out of ten menus did not have the physician's prescribed diet transcribed to the patient's tray menu.
Findings include:
1. Review of 20 patient menus at Moses Division on 10/19/12, noted that physician prescribed diets are recorded in an abbreviated mode that is not consistent with the physician prescribed diet.
Physician prescribed diets such as 2 gm potassium is recorded on the patient menu as K2gm, 2 gm sodium, low fat, low cholesterol is recorded as Na2gm LF/LC.

2. A new diabetic diet titled, " Consistent Carbohydrate " which utilizes grams of carbohydrate, instead of calories was approved by the hospital.
During an observation of the diet on the hospital computer, it was found that this diet was not assigned any specific grams of carbohydrate or levels for the physician to choose. The diet is incomplete without the grams of carbohydrate.

Based on medical record review, staff interview and review of other documents, it was determined that the facility failed to ensure that patients with different stages of pressure ulcer meet nutritional criteria's set forth for the different stages of pressure ulcer.
Findings include:
During tour of medical units on 10/17/12 at approximately 1PM, two staff dietitians on different medical units was interview concerning the nutrition department's protocol on pressure ulcers. These Dietitians stated that the department does not have a protocol for staff to follow when assessing patients with pressure ulcers.
The Director of Clinical Nutrition Services was asked on 10/17/12 for a copy of the policy or protocol for Dietitians to follow when assessing patients with pressure ulcer. The surveyor was provided a policy titled, "Clinical Nutrition Standards of Care- Adult " that had a 15 page article attached to the policy on the role of nutrition in pressure ulcer.
The hospital policy dated 4/12 on Clinical Nutrition Standards documented the different calculations Dietitian would utilize for a standard nutritional assessment. This policy did not address specifically a guideline for the assessment of patients with different stages of pressure ulcer, nor did it address if oral supplement and amount of ascorbic acid or zinc had been approved by the nutrition committee in the treatment of pressure ulcers.
There is no nutrition policy or guidelines that address the nutritional care of patients with varied stages of pressure ulcers.

A. Based on observation, staff interview and record review, the hospital failed to ensure that the condition of the physical plant and the overall hospital environment is developed and maintained in such a manner that the safety and well-being of patients are assured. Specifically the looping hazards on the psychiatric unit, the lack of exit signs in different areas of the hospital, the malfunctioning of nursing call bells in different patient bathrooms, the obstruction of some of the means of egress.
Findings included:
Moses Division - Operative Suite:
A tour of the Operative Suite was made on the morning of 10/15/2012, and the following findings were noted and verified with the VP of facilities during the tour:
1. The air pressure of the hood of the pathology room next to OR 4 as well as the air pressure of the room was found to be positive air pressure instead of the negative air pressure required.
2. An empty bag of saline was found on the scrubbing sink next to OR 5.
3. Two clean linen plastic carts (8 ft. x3 ft. x6 ft. ) were observed being stored on the corridor of the OR next to the exit door and blocking the exit passageway.
4. About 50 boxes of supplies were found to be stored on the corridor of the surgical suite by the exit door. This is a potential for fire hazard and would impede the timely evacuation in the event of fires.
5. During a tour of the Same Day Surgery it was noted that the hospital has stored three patient chairs in one cubicle and one of the patient chairs was torn at the hand part of it which makes it difficult to be cleaned.
6. An empty saline bag was observed at the hand washing sink of the same day surgery.

Moses Division - Psychiatric Unit:
During a tour of the psychiatric unit on the morning of 10/16/2012, the following issues were identified and brought to the attention of the Head Nurse of the unit.
1. The fire alarm's manual pull station next to the exit doors of the unit were square shaped and have edges which make them to be a potential looping hazard.
2. In the patient rooms there are two sockets at the two ends of the closets used to support the clothes hanging rod and these present a looping hazard.
3. The overhead speaker in the unit was mounted on the wall next to room 227 leaving a gap of about 4-6 inches between the speaker and the wall that presents a looping hazard.
4. The data wiring of the electric IT access point was exposed and presents a looping hazard.
5. The door handle of the linen chute next to room 226 has a potential risk for looping.
6. The exterior locks of the two seclusion rooms which are a 'L' shaped metal sliding rod with a protruding metal part at the end of the locking rod present a safety hazard for the psychiatric patients.
7. The screens of the windows of the seclusion rooms were dust laden and the walls of the rooms had stains.
8. The door handles of the bathroom and other rooms next to the seclusion rooms were 'L' shaped regular type, and not the safety type required for psychiatric units. These handles presented a looping hazard.
9. The surface of the ice machine in the dining room was dirty.
10. The light switch of the shower room was a 'L' shape metal lever which presents looping hazard.
11. The exit signs of the psychiatric unit were mounted to the ceiling leaving a gap between them and the ceiling which can be used for looping.
12. The door of the laundry room was observed to have sticky dirty stains in the area below the door handle.

Moses Division - Pediatric Psych ED:
1. During a tour of the pediatric psych ED on the morning of 10/17/2012, it was observed that the pediatric patients of this unit were sleeping on the floor and some of them were sleeping on uncomfortable chairs.
There were no beds available for those children to sleep in that unit.
Interview with the ED supervisor on 10/17/2012 at approximately 11:30 am, revealed that the Psych ED has 5 beds and that the children on this unit stay about 24 hours, but sometimes they stay longer waiting for a locatation of a pediatric psych unit that will accept and admit them.
2. The wiring of the TV and computer on the children psychiatric area was exposed and presented a looping hazard.

Moses Division - Kitchen and Food Service Area:
During a tour of the kitchen and the food service area on the morning of 10/17/2012, the following were identified and brought to the attention of the Hospital's VP of facilities, the Director of Food services & nutrition and the Director of Engineering.
1. No illuminated exit sign at the hot production area of the kitchen.
2. There was a pool of water accumulated under the steamer.
3. The sink where the green salad is washed was not clean and there were small flies observed around the green salad's washing area.
4. No exit sign was provided in the dry storage area of the kitchen.
5. The floor of the dish washing area was observed to be uneven and had accumulation of water in multiple areas of that floor.
Moses Division - The Emergency Department (ED):
During a tour of the Emergency Department on 11:30 am on 10/17/2012, the following were identified:
1. The nursing call bell of the patient bathroom in the fast track area was not working.
2. The nursing call bell of the patient bathroom of the adult ED next to stair B was not working.
3. The nursing call bell of the patient bathroom next to room 112 and the lab was not working.
4. The nursing call bell of the bathroom of the pediatric ED did not have audio annunciation.
5. Some ceiling tiles were missing from the isolation room of the pediatric ED, and other tiles were found to have stains and signs of leaking on them.
Moses Division - MICU
1. The ceiling tiles of the airborne isolation room of the medical ICU were from the regular type, not the washable type.
2. There was no toilet provided for the airborne isolation room of the medical ICU as required.
Moses Division - Klau Building:
On the morning of 10/19/2012, during a tour of the medical and surgical units on the 4th , 5th and 6th floors, the following issues were identified in the presence of the director of engineering who acknowledged the findings:
1. None of the patient rooms had private bathrooms. Instead, each two patient rooms shared one bathroom. (Example included but was not limited to: Room K 427 with 4 beds and room K 426 that had one bed shared one bathroom).
2. None of the patient bathrooms had hand-washing sinks.
3. The nurse call bell in all the bathrooms did not have audible annunciations at the room door or at the nurse station.
4. The staff locker room was also used as a lounge room, and this presented a concern regarding infection control.
5. A soiled hamper was stored in the shower room of Clau 4th floor.
6. The hospital stored clean linen in the service elevator bank K which presents a fire hazard.
7. The clean utility room of Klau 4 was found to have negative air pressure instead of the required positive air pressure that is required to this type of room.
8. The mirror of the patient handicapped bathroom of Klau 4 was mounted at a level higher than 40 " from the floor. As per ADA, the mirror of the handicapped bathroom need to mounted at a level of 40 " from the floor.
Also, the drain pipes of the handicapped bathroom were not insulated or otherwise configured to prevent burns or abrasions as per ADA requirement.
Endoscopy Suite- Moses Division:
1. During a tour of the endoscopy suite in Rosenthal Building at 11:25 on 10/19/2012, the scope processing room was found not to have a hand-washing sink for the staff to wash their hands.
2. The floor of procedure room 5 was found to have cracks and broken parts which make it difficult for cleaning and disinfection and present potential for infection control issues.
3. Procedure room 5 had regular ceiling tiles instead of the washable ceiling tiles that is required for this type of room.
Radiology Department- Moses Division:
During a tour of the radiology department on 10/19/2012 at 3:00 pm, the following were identified in the presence of the Hospital's VP of Facilities:
1. All of the dressing rooms next to all the radiology rooms, including the CT, Mammography rooms, and sonogram rooms did not have nursing call bells. Examples included but were not limited to dressing rooms 2, 3, 4.
2. Soiled hampers were stored in all of the dressing rooms.
3. Three clean supply carts on shelves (each one was 8 ft. x 3 ft. in diameter) were stored on the corridor next to X-ray room E and X-ray room F.
4. No illuminated exit sign was provided in the corridor of silver zone of the radiology department that was also referred to as the staff corridor.
MRI- Moses Division:
During a tour of the MRI suite on10/19/2012, at approximately 4:00 pm the housekeeping kit used for cleaning the MRI room was found to have ferrous material.

Cham Hospital-Moses Division:
During a tour of the Cham hospital on the morning of 10/22/1012, the following were identified in the presence of the Director of Engineering:
1. The nursing call bell of the patient bathroom 1025 was tested and no staff responded to the call for more than 5 minutes. The nurse call bell did not produce an audible alarm outside the patient room or at the nursing station.
2. The wall of the smoke barrier on the 10th floor of the Cham building at the wall of room 1009 did not extend to the deck above and had a gap of approximately 6 inches of penetration between the wall and the deck above.
3. The fire rated wall at the elevator service bank had a penetration that was not sealed with the correct fire stops. The penetrations were sealed with a white colored material. When asked, the staff could not produce documented evidence to prove that the material has the correct fire rating and was a UL listed fire stop.
4. The GFI electric outlet under the hand-washing sink of the patient bathroom (room C910) was broken and presented hazards for fire and electric shock.
5. The clean holding room on the 9th floor of Cham building did not have positive air pressure as required for this type of room.
6. The corridor of the 7th floor of the Cham building was blocked by three (3) stretchers.
7. There was a space heater that was in use in the pharmacy satellite on the 7th floor of the Cham building. The presence of space heater in the pharmacy presents a fire hazard.
8. The paint cage room which is part of the paint shop did not have a sprinkler head as required for the hazardous area of the hospital.
9. The carpenter shop did not have an exit sign to direct the staff to the exit in the event of fire or smoke.
Weiler Division:
During a tour of the Operative Suite on the morning of 10/23/2012, the following were identified in the presence of the Nurse Manager of the Preoperative Services and the Director of Facilities who acknowledged the findings:
1. The soiled utility room did not have a hand-washing sink for the staff to wash their hands as per the AIA guidelines.
2. Two clean linen plastic containers (each one of them was 3 ft. x 5ft x 6ft in diameter) were stored on the corridor and blocking it in front of the PACU.
3. The nursing call bells of the two bathrooms of the post-operative suite at the ambulatory surgical suite did not have audible annunciation.
4. The central corridor of the Operative Suite next to OR 15 was partially blocked by three (3) supplies carts, three (3) C- arm machines, and robot surgery equipment.
5. There was no hot water at the scrub sinks of the Operative suite. This was due to the timed sensor on each faucet of the scrub sinks.
6. The nursing call bell for the dressing rooms next to the CT- Scan and X-Ray rooms on the 3rd floor did not have audible annunciation.
7. The clean utility room of the CISU unit had a negative air pressure instead of the positive air pressure required for this type of room.
8. The medication room of the ICU on the 4th floor (room #N-434) was found to have negative air pressure instead of the positive air pressure required to this type of room.
9. During a tour of the ICU unit on the 4th floor of the hospital at 12:45 pm, the air borne isolation room 2044411 was found to have a patient who had been admitted to rule out TB. The room did not have a negative air pressure at the time of testing it as per the CDC and AIA guidelines.
During interview with the head nurse at approximately 12:30 pm on 10/23/2012, it was revealed that the patient was admitted to this room on the morning of that day.
The nurses stated that they did not call engineering to turn the room to negative pressure because the light indicator was green indicating that the room was already having a negative air pressure.
During an interview with the Engineering staff at approximately 1:00 pm on 10/23/2012, they stated that the nurses should have called the engineering department to turn the room to a negative room upon arrival of the patient.


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B. During the tour of the Wakefield Campus (WC) and Moses Medical Art Pavillion (MAP) Building from 10/15/12 to 10/23/12 between 10:30 AM to 4:30 PM, the following issues were noted which were verified with the staff accompanying the surveyor.

Findings include:

PHYSICAL/OCCUPATIONAL THERAPY UNIT-WC

1. During the tour of the Physical Therapy Department on 10/15/12 at 10:30 AM, it was noted that there were numerous clean items stored in the ADL (Activities of Daily Living) bathroom of the unit. This includes furniture such as cabinets with files and other clean supplies and items.

2. An artificial tree was present in the corridor whose flame spread rating could not be determined or verified.

3. There was a duct access shaft by the whirlpool that was found not to be secured.

4. The telephone closet/box in the corridor was found to be very dusty and there was also dust and dirt on the corridor floor.

5. The door handle/lock of the ADA toilet in the unit did not comply with the requirement of ADA 4.13.9 that requires handles/lock to be operable without tight grasping, pinching or twisting of the wrist to operate.


SURGICAL UNIT/ORs

1. During the tour of the Surgical Unit on 10/15/12 at 01:30 PM it was noted that the scrub sink #1 did not have hot water and had a very weak water flow as compared to the three sinks adjacent/near to it.

2. The hot water temperature of the scrub sinks was 121*F which is more than the required maximum temperature of 110*F.

3. The janitorial closet had an abundant amount of clean items and supplies such as suction cups stored in this room. Such arrangement of storing clean and dirty items together may contribute to cross contamination.

4. The mechanical vents by the wall in 0R#2 were noted to be dusty and dirty.

5. The electrical isolation panel opposite OR #7 and OR #6 was noted blocked by a stretcher and other mobile equipments.

6. The Soiled Utility room (SUR) was noted to have janitorial items stored in the same room. It is to be noted that janitorial items are considered dirtier than items that are brought into the SUR and therefore these janitorial items should not be intermingled in the Soiled Utility room.

7. The gasket of the tissue specimen refrigerator was noted to be dirty with a black colored growth in the cervices.

8. The chairs in the Ambulatory Unit were noted to be dirty and dusty underneath the seat, in the corners and inside the cervices.

9. The electrical closet was noted to be dusty and dirty.


EMERGENCY DEPARTMENT-WC

1. During the tour of the Emergency Department on 10/15/12 at 2:30 PM, it was noted that the entrance to the department from the Ambulance side/bay was dirty around the perimeters of the entrance alcove and in the corners.

2. An infant warmer was noted stored in a patient shower room.

3. A portable oxygen tank in room # A6 was noted not secured. Furthermore, the oxygen tanks were not conspicuously labeled regarding which ones were empty and which ones were full.

4. The Director of Engineering was interviewed at the time of observation to provide information regarding the maintenance of the Hazmat Showers. He stated that the preventive maintenance was done in the Spring and Fall, however there was no documention nor verification provided indicating that such preventive maintenance schedule existed in the facility.


LABORATORY-WC

1. During the tour of the Laboratory Department on 10/15/12 at 3:15 PM, it was noted that the room labeled as 'Hazardous Material' housed chemicals and other items, and had a very dirty and dusty floor. The room had a grill over the whole floor and in between the grill and the floor there was an abundant accumulation of garbage and dirt.

2. The hand washing sink by the accession area in the Lab did not have wrist blades. The faucet was fitted with valves that could not be operated without the use of hands.


CLEAN LINEN ROOM, & BIOHAZARD STORAGE AREA.-WC

1. During the tour of the ground floor and the Main Clean Linen room on 10/16/12 at 10:45 AM, it was noted that the room had thick layers of dust and dust accumulation on the exposed water / other utilities pipes that were right above the linen carts.
The perimeter of the entire room also had accumulations of thick dust and dirt.

A suspended ceiling is required where dust fallout may present a problem. The clean linens stored in the room are used by the patients and therefore storing the linens in a environment where so much dust and dirt is present may lead to cross-contamination.

Linen carts were seen covered with a thin plastic bag/cover but were not tightly covered and had exposed areas therefore dust and dirt had the potential to get inside those areas.

2. On 10/16/12 at 11:45 AM during the tour of the loading dock where the biohazard and sharp containers were stored to be picked up by the vendor, it was noted that the containers did not have any means to lock and secure them and the containers were noted having biohazard waste and used syringes.


5 NORTH (MED/SURGE & TELEMETRY), ICU & PSYCH-WC

1. During the tour of 5 North Floor on 10/16/12 at 2:00 PM, it was noted that the clean utility room was exhibiting neutral air pressure instead of positive air pressure.

2. An abundant amount of tissue and clean supplies were noted stored in the janitorial closet.

3. Many wooden doors of the patient rooms in the unit exhibited disrepair and posed the risk of splinters.

4. Some rooms such as #504 on the unit had dirty and dusty perimeters and accumulation of dust was found under the air conditioning/heating units.

5. During the tour of the ICU on 10/16/12 at 2:45 PM, it was noted that the clean utility room had negative air-pressure instead of positive air-pressure and the janitorial closet exhibited neutral air pressure.

6. The grill of the air conditioning/heating units by Stairwell F and the ICU waiting room exhibited thick accumulation of dust and dirt. Furthermore, in the ICU waiting there was an artificial plant/tree that did not have any tag or information regarding its flame resistance/rating.

7. The room in ICU #14 was noted dusty and dirty around the perimeters and around the electric receptacles.

8. the janitorial closet had storage of clean tissue rolls and other clean supplies. This situation of storing clean and dirty items together in the janitorial closet was noted in almost all janitorial closets that were surveyed.

9. During the tour of the Psych unit on 10/16/12 at 3:15 PM, it was noted that the seclusion room had a window that did not have any fire rating information written on it.

The DOE was asked to provide information regarding its rating. The DOE was not aware of the rating of this window and regarding the one hour fire rating of the padded wall. No information was provided to the surveyor to verify that the room and all openings are protected with one hour fire rating construction as required by AIA 7.6.D.

10. The bed sheet for the bed in room #704 was noted stained. As per staff this room/bed was cleaned and ready to be used by the next patient.

11. During the tour of the Medical Art Pavilion-(MAP) Moses campus the following issues were noted:

i. On the 8th floor Primary care Unit, the supplies closet had supplies stored up to the top of the ceiling thus blocking the sprinkler head.

ii. Room #N on the 8th floor had dirty corners, perimeters and a brown color stain was noted on the floor near the corner of the window.

iii. One of the corridor doors for the entrance to the medical records room on the 8th floor was noted not opened and unsecured.

iv. Exam romme # G had dirty and dusty corners and the area behind the examination table and the wall was noted to be dirty.

v. The asthma room on the 8th floor was noted to have oxygen tanks stored without being labeled conspicuously for empty and full. They were not stored separate from each other.

vi. In the laboratory department of the MAP building it was noted that the refrigerator for specimens had a broken gasket and was a black color inside the creases.

vii. The Same Day Surgery area had stretchers with ripped upholstery.
viii. The Mammography room #1 in the Radiology Department was noted dirty and dusty.

ix. The MRI control room ceiling tile was noted to be stained.

x. The examination table in the ultrasound room had ripped upholstery.

xi. A door stopper was found in the CT room that was used for propping the door open.

xii. The MAP building is a fully sprinkelred building however a closet opposite the supervisor's building in the Radiology department was noted to have no sprinkler head.

xiii. An artificial tree in the Ophthalmology waiting room was found not to have any information regarding its flame-spread rating.

A. Based on observations it was determined the facility failed to provide care in a setting that would minimize the spread of infections. Specifically, operating room supplies were stored near dirty items.
Findings include:
1. Clean supplies were stored near dirty objects and in dirty environments.
During a tour on October 15, 2012 at 1:25 PM, a garbage bin was observed to be touching an umbrella, which was hanging on a cart. The umbrella was also touching several clean surgical pants in the women's locker room at the Wakefield Campus. In addition, 7 lab coats were noted stored in the bathroom of the women's locker in the operating room suite along with 6 boxes containing several packages of clean towels.
This finding was witnessed by the Nurse Manager of the Operating Rooms at the time of the observation.

2. Correct hand hygiene was not followed in the operating suite in keeping with current standard of practice.
In OR #5, on October 1, 2012 at 1:37 PM, the circulating nurse was observed placing her hand in an empty garbage container then placing her hand in her pocket. She proceeded to touch clean gloves and conduct the instrument count without sanitizing her hands. These actions were inappropriate as hand hygiene was not followed after she changed her gloves to prevent the spread of infection.
At 1:50 PM that day in OR #5, another employee was observed collecting a specimen in OR #5 while using gloves. She then removed the gloves and without sanitizing her hands, proceeded to stock a shelf with sterile packages which included, but were not limited to sterile packages of sutures.
In OR #5, the circulating nurse Staff #13was also observed on October 15, 2012 at 1:52 PM, removing the wrapping from packages used during surgery with her gloved hands. She removed the gloves and without sanitizing her hand, touched the patient that was having surgery, adjusted the sheet that was covering the patient, removed those gloves and put on clean gloves and then documented in the patient's electronic record without sanitizing her hands.
On the same day in OR #5 at 1:55 PM the Certified Registered Nnurse Anesthesist was observed removing her gloves after removing the patient's endotracheal tube and attending to the patient's airway. Without sanitizing her hands she put on clean gloves.
3. Clean and sterile supplies were not stored in a clean environment.
In OR #2 on October 15, 2012 at 2:20 PM, forty-eight boxes of sutures were secured in place with tape on a suture stand and the stand was noted to be dirty.
The fetal monitor in the Labor & Delivery unit in OR #3 was observed to be dirty on October 18, 2012 at 11:47 AM.
The cup holder on a stroller in the pediatric unit was observed to be very dirty on October 18, 2012 at 12:32 PM.
Stored in the dirty/sterilization room in the ophthalmology clinic on October 19, 2012 at 11:20 AM, were 9 bottles of 500 ml bottles of sterile water.


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B. Based on observations throughout the organization, it was not evident that the infection control nurse ensured a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.

Findings include:

Moses Division witnessed by Staff #5.

1. On 10/16/12 at 10:30AM, a linen cart with linen on both shelves was observed stored in a tub room on 7 West Foreman unit.

2. On 10/16/12 at 2:15PM, a used uncovered oxygen face mask, was observed hanging on the O2 delivery pipe in Room #600.

3 On10/16/12 at 2:55PM, 6 oral airways were observed in the emergency cart on 6NW. The oral airways were noted uncovered and dusty.

4. On 10/16/12 at 2:20PM, 2 beds were observed in the patient's lounge on NW6 unit. One of the beds was occupied by a patient. It was noted that the room lacked a hand washing sink, toilet and privacy curtain.

Wakefield Division witnessed by Staff #1.

1. On 10/17/12 at 2:50PM, the seclusion room on 7 South was observed to be
without a mattress. The nurse documented a progress note in patient #34's
medical record that on 10/16/12 at11:06AM the patient was
"calmly sitting on the floor in the seclusion room".


Medical Unit of the extension clinic at 1621 Eastchester Road witnessed by Staff #6, the Administrator.

1. On 10/22/12 at 2:45PM gauze swabs used in IV access procedures were noted in large numbers uncovered and in a dusty cabinet.





26934


C. Based on observation and staff interview, it was determined that the facility did not ensure a safe environment consistent with recognized infection control practices and prevention of cross contamination in its Wakefield Campus.

Findings include:

1. (a) On 10/17/12 at 10:25 AM during survey of the Central Sterile Supply Room (CSSR)-WC, it was observed that the ceiling tiles in the room were porous/had holes that may retain dirt (they were not monolithic) and thus were not as per AIA 7.28.B8. Such porous ceiling tiles compromise thorough cleaning which is required to keep the environment of Central Sterile as clean/sterile as possible.

(b) The CSSR room exhibited neutral air-pressure.

(c) The vinyl coved by the sterilizer and around the perimeter of the room exhibited dirt and dust.

(d) Three ceiling tiles were noted stained in the CSSR.

(e) The humidity of the CSSR is not monitored to ensure it is at the maximum of 70*F.

(f) The sinks of the de-contamination room did not have wrist blade handles.

(g) A non-disposable lab coat used by a staff to wear over their attire while stepping out of the de-contamination room was observed stored in the room thus coming in direct contact with the environment of the de-contamination room.

2. During observation of the isolation room in the Emergency Department-WC on 10/15/12 at 12:00 PM, it was noted that the isolation room did not comply with the requirements of AIA Section 7.2.C4 for isolation rooms.
The requirement states that 'air borne infection isolation room shall have self-closing devices on all room exit doors'. The isolation room in the Emergency Department did not have self-closure or self-closure mechanism installed at the exit door. Also the ceiling tiles in the isolation room were porous/had holes that may retain dirt (they were not monolithic) and thus were not as per AIA 7.28.B8

3. During the survey of the Intensive Care Unit (ICU)-WC on 10/16/12 at 3:30 PM, the Nurse Manager stated in an interview that there is no negative air pressure room on the unit. If required the room can either get a HEPA filter or an airborne patient may be sent to the Emergency Department isolation room.

Review of the policy titled, 'Tuberculosis, Admissions and Suspected Cases of ' dated 08/12 under bullet # 5 states that 'portable HEPA units will not be used as an alternative to negative pressure rooms. The HEPA unit use will be limited only to those patients who cannot be transferred to a negative pressure room elsewhere in the hospital, due to inability of the hospital to provide highly skilled and specific medical treatment to the patients at the new location. As soon as the need for this care is no longer necessary, the patient is to be transferred as soon as possible to a negative pressure room'.

The Intensive Care Units did not have an negative pressure room (as required by AIA 7.3.A14) nor did it have any room constructed with non-porous ceiling tiles and self closure (in rare cases when HEPA filter is used) to ensure it is terminally and thoroughly cleaned to avoid cross-contamination.

4. During the survey of the newborn nursery and NICU-WC on 10/17/12 3:15 PM, it was noted that the facility does not have any isolation room provision in the facility (as per AIA 7.3.E9) nor was any policy provided regarding how the facility will handle a baby with an air-borne disease.

5. During the survey of the Endoscopy Suite-WC on 10/18/12 at 2;30 PM, it was observed that it did not have two utility sinks for cleaning (As per AIA 9.9.B2).

6. During the survey of the Medical Arts Pavilion -Moses building on 10/23/12 from 11:00 AM to 4:00 PM, it was observed that on various floors of the building the nurses station was also being used as a specimen holding station.
Urine samples were seen sitting next to medical items such as glucose meters and office supplies such as printers, computers and others equipment used at the nurses's station.

There was no clean workroom and soiled workroom found anywhere on any floors of the building.

The staff acknoweldged that there were no clean/soiled workrooms on any floors.

All above findings were verified with Director of Engineering at Wakefield Campus and Vice President of Facilities at Mosses.

7. Based on observation and staff interview, it was determined that the Director of Food Services failed to take responsibility for the daily management of dietary services to ensure proper sanitation and food safety. Thus, the issues identified in the kitchen posed an infection control risk issue. Refer to Tag 620.























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D- 1-During the tour of the kitchen at Moses on 10/16/12 at approximately 11AM with the Director of the Food and Nutrition Department, it was observed that a rack containing pre portion soup had a cluster of black dust on top of a covered soup. The floor was dirty in the freezer and all food pans on racks in the freezer were dated, but not labeled as to the food content in the pan. Some pans were not completely covered by the plastic wrap.
2-The temperature of the trayline freezers was maintained by ice cubes thrown in the freezer. The freezers did not have an internal or external termometer. The temperature of the freezers were logged by using a manual termometer on only one food item. There was no evidence that temperature of food items located in the center or at the bottom of the freezers were being checked.
3- The employee's water dispenser in the kitchen was empty and contains no paper cups for drinking. It was observed that approximately six open and closed water bottles were found throughout the trayline, walk-in refrigerators and preparation area of the kitchen. These water bottles were not labeled for patient use. In addition, it was observed that on the walls in the kitchen and food preparation area had many bug catching devices stuck on the walls.
4- There was an abundance of "Roach Motels" (device for controlling insects) observed stuck on walls and behind the trayline refrigerators and prep area of the kitchen. These findings were shared with the Director of Food Service.
5- The temperature in the Kosher refrigerator in the kitchen were not recorded daily as per department policy. Temperature was recorded 4 out of 16 days (10/6, 10/11, 10/12 and 10/16).

Based on observation, review of procedures, records, and staff interviews it was determined that the system for initial screening of discharge planning needs did not ensure accurate identification or referrals of patients at high risk of adverse outcomes without proper discharge planning. This finding is noted in 6/ 12 applicable records reviewed. (MR #6, #14, # 73, #74, #75, and #77).

Findings include:

a. The nursing admission screening contained in the patients admission database and flow sheet form found that nursing staff did not accurately screen or refer patients meeting high risk criteria that would warrant referral for Social Services or Case Management.

The nursing admission database forms for patients at risk was checked for "no triggers identified" despite the presence of high risk social needs.

b. Review of the policy titled, "Documentation, all patient care units except obstetrics, NICU,..." found that the paper admission database forms must be completed by the nurse within 8 hours of admission. The database form contains multiple sections for screening of abuse, home care needs, psychosocial needs and requests a CIS (computer-based) referral must be made if the patient is identified with a need based on a list of high risk triggers.

This policy is not coordinated with procedures for " Discharge from the Acute care setting " and "Transitional Care Coordination of Inpatients" which describe that patients on certain transitional care units will be assigned to one of three possible levels which dictates the personnel responsible for discharge planning and the type of referral required as follows:

Level I is assigned for patients who return home with no services and for whom the unit based nurse performs the discharge planning.

Level II is assigned for patients who require return or reinstatement of services in place before admission and the Care Transitions Clinical Coordinators (CTCC) nurse is the responsible discharge planner.

Level III is assigned to anyone who requires new services or changes in service level or where a psychosocial assessment is required and the social worker is the responsible primary discharge planner.

The level system and the staff assigned do not correspond to the procedures in the paper admission database for discharge planning referrals. There is no section in the admission database that assigns this risk level nor any mechanism in discharge planning notes in patient records that refers to this system.

The referral criteria listed in the policy titled "Social Services Screening, Referral, and Assessment" do not fully correspond to criteria listed in the CIS (computer system) system menu that warrants a referral to Social Services, especially for high risk abuse cases that must be assessed within 24 hours of admission.
For example, the admission database paper form requires CIS referral for suspected abuse, yet the computer drop down menu in the CIS referral system does not contain these referral options.

Additionally, the CIS screen shots provided for Social Service referrals do not refer to the level system of assignment for discharge planning as specified in hospital discharge policies.

At interview with Care Management and administrative staff (Associate Vice President of Network Care Management, Director of Utilization Management, and Director of Social Work Network) on 10/18/12 at approximately 3 PM, it was reported that the department is transitioning to a new model for discharge planning.

c. The following six records lacked accurate screening for discharge needs on admission:

1. MR #6
The patient had been hospitalized from 10/9/12 for exacerbation of Chronic Obstructive Pulmonary Disease (COPD) and had pre-existing home care service.
The initial admission database recorded on 10/9/12 that CIS referral (computer referral) was made on 10/9/12 to Social Services. However a different section in this database form checked that no home care triggers were identified, despite an inconsistent note in the discharge plan section that recorded the patient receives home care services. The name of the home care agency had been left blank.

A discharge planning assessment note was recorded by the care manager nurse on 10/10/12 but was not completed as the patient was sleeping. A referral had was notinitiated for social work services until 10/15/12.

The patient was observed to be waiting for discharge on 10/15/12 at approximately noon but discharge planning evaluation and confirmation for the reinstatement of home care services was not evident.

2. MR #73

A 52 day old female infant was transferred from another hospital on 7/26/12 for seizure activity that occured during the treatment of a left parietal skull fracture and bilateral subdural hematomas. The patient had multiple injuries that were reflective of non-accidental trauma.

The pediatric patient admission database dated 7/26 at 1330 did not document or identify risks. There was no referral for social service/discharge planning needs in accordance with hospital procedures.
The first page noted "3 episodes of generalized shaking". Under the section for substance use/abuse the nurse documented "CIS". The psychosocial section documented "none noted" in the problem/need area. In the section for abuse assessment, the nurse checked "no" for suspected abuse/neglect/exploitation. Under the section social services triggers, the nurse checked "no new triggers identified". There was no check for the CIS referral to be made for Social Services to ensure an evaluation of possible abuse.
The patient was assessed by social work on 7/27/12. This case was reported to Agency for Chilren's Services for suspected abuse.

3. MR #74

A 13 year old male was admitted on 8/11/12 following violent physical altercation with his mother. It was reported that the mother allegedly struck the child with a stove burner on the head resulting in a forehead laceration.

The pediatric patient admission database that screens for suspected abuse or neglect was checked "no". However on the social service section of the form, domestic abuse was circled. The box representing referral to social services through CIS computer was not checked.

4. MR #75

During a tour of unit NW8 on 10/15/12, the surveyor was advised this patient was pending discharge to hospice.

During interview with the Social Worker on 10/15/12, it was reported that discharge is pending approval of placement at a hospice. The Social Worker was unsure if the patient and the family member agreed with palliative care plan. The patient was unresponsive during attempted interview.

Examination of the record on 10/15/12 found that the admission database dated 9/20/12 identified no triggers for social services, despite existing self care deficit and gastric cancer diagnosis. However, an initial social work assessment was provided on 9/21/12, which noted that the patient had metastatic gastric cancer and had capacity.

5. MR #14

A 67 year old patient was admitted from 9/15/12 to 9/24/12 for CABG on 9/17/12. The patient had HIV disease and last used crack/cocaine 3 months prior.

The admission database dated 9/15/12 noted no triggers were identified for social services or homecare, despite inconsistent documentation in another section that recorded the name of a home care agency and duration of service. The patient's needs were not accurately identified on initial screening.

6. MR #77

A 69 year old patient was hospitalized for COPD exacerbation from 9/5- 9/7/12. History was significant for chronic obstructive pulmonary disease (COPD), liver cirrhosis, hypertension (HTN), dementia, hepatitis C, kidney mets/liver cancer, hepatic encephalopathy, and substance abuse on methadone maintenance.

The patient's nursing admission database dated 9/6/12 documented past a history of Alzheimer's disease. The patient also noted to have history of depression and was alert and oriented in three spheres. It was noted that the patient resides with his wife and received 6X6 (six hours for six days weekly) of home care services. However, no social service or home care triggers were identified and no referral was made.

Based on review of records and staff interview, it was determined that discharge planning evaluations were incomplete. Specifically, discharge planning assessments did not reflect participation from the patient or representative nor confirm arrangements for services where necessary. This finding is noted in 8/12 applicable records reviewed for discharge planning.
(MR#6, #14, #37, #79, # 80, #81, #83, and #84).

Findings include:

Review of procedures for Transitional Care Coordination of Inpatients and Social Services Screening/Referral/Assessment on 10/18/12 finds that the hospital did not adhere to requirements for provisions of assessments and safe discharge.

Discharge planning evaluations were incomplete as follows for cases observed at the Moses Division:

1. MR #6

The patient had been hospitalized from 10/9/12 for chronic obstructive pulmonary disease (COPD) exacerbation and had pre-existing home care service.

The initial admission database recorded on 10/9/12 that CIS referral (computer referral) was made to Social Services on 10/9/12 but yet checked no home care triggers were identified, despite noting in another discharge plan section that the patient had help at home. The name of the home care agency had been left blank.

A discharge planning assessment note in the medical record was recorded by the Care manager nurse on 10/10/12. The note documented that the patient was sleeping and the boyfriend was interviewed. The patient lives alone. The plan noted to interview the patient when she wakes up to obtain information about home health aide. There was no documentation of a follow up interview with patient occurred.
The patient's record contained no discharge order.
The discharge planning assessment was incomplete, and there was no documentation that formal home care reinstatement arrangements had been made.
The patient was interviewed while waiting for discharge on unit NW8 on 10/15/12 at approximately 11:30 AM. She reported that she was waiting for her papers and had called her home attendant.
Staff interviewed on 10/15/12 confirmed she was awaiting discharge. Physical therapy and resident notations in the medical record documented need for podiatry follow up and custom orthotic, as well as outpatient sleep study follow up.
During an interview on 10/15/12 with staff it was stated that the CIS (computer) referral to social work was made on 10/15/12.

2. MR #79

Patient was admitted on 10/12/12 for severe COPD from a nursing home.
Social work notes in the medical record documented a discussion with the patient and wife, which identified a plan to return to the nursing home of origin.
There was no documented evidence of a psychosocial assessment at the time of the follow up unit tour on 10/16/12. The patient was in the process of being discharged on 10/16/12.

The social worker interviewed on the unit on 10/16/12 at approximately noon documented that computer systems for "All scripts" and "ECIN" is not linked to the Electronic medical record system known as CareCast. It was stated that the workers must manually print discharge notes for filing in the hard copy record.

There were two of two applicable pediatric psychiatry emergency room records reviewed during the ED tour on 10/18/12. It was determined that pediatric patients awaiting psychiatric disposition, and discharge arrangements did not have noted input from discharge planner/social work incorporated in the medical records. Examples:

3. MR #80

A seven year old patient was hospitalized in the ER from 10/16/12 for suicidal ideation.
The patient was assessed by psychiatry on 10/16/12. This assessment noted the Agency for Children's Services (ACS) was contacted due to concerns of abuse by parents, for hitting patient and medical neglect.

The patient was medically cleared for psychiatric admission on 10/17/12 at 1 PM.
On 10/18/12 during tour at 1 PM, the patient remained in the ED pending transfer to another hospital for inpatient acute psychiatric care.
The patient had been assessed by social work, but notes were not documented in the record.
During an interview on 10/18/12 at approximately 1PM with a physician, it was reported there was no access to social work notes in the computer.

Follow up social work assessment notes dated 10/18 at 12:15 PM were submitted to the surveyor at 2 PM explaining that the patient was still in process for authorization to be admitted to a psychiatric hospital. No mention of follow up with ACS was evident. One hour later at 3 PM, a revised social work note was submitted by the staff which recorded that follow up contact was made with ACS staff. This document contained an amendment to the same note previously submitted at 2 PM, but was recorded at 12:16 PM.

4. MR #81

A16 year old was assessed in pediatric emergency room (ER) on 10/17/12 for suicidal ideation. Patient was assessed medically and psychiatrically and found to require inpatient psychiatric admission during tour of the ED on 10/18/12 at approximately 1PM.
There was no documented social work discharge plan in the record. At 2 PM, the social work discharge plan was provided to the surveyor that was previously missing from the medical record.


5. MR #14

A 67 year old patient was admitted from 9/15/12 to 9/24/12 for coronary artery bypass graft CABG on 9/17/12. The patient last used crack/cocaine 3 months prior.

The admission database dated 9/15/12 noted no triggers were identified for social services or homecare, despite inconsistent documentation in another section that recorded the name of a home care agency and duration of service.

A social work assessment on 9/18/12, documented that it was unclear if the patient would return home with home care service or if she would require short term rehabilitation.

A follow up social work note on 9/24/12, indicated the patient was ready for discharge and a referral was made to VNS. It was noted that the patient agreed with plans that she would be going home with her son. The record lacked documentation and verification of the amount and type of home care to be provided along with the start date. The patient's capacity for self care was not reassessed despite discharge instructions that limited physical activity.

6. MR #37

A patient was hospitalized from 8/31/12 for treatment of schizophrenia.
This patient was noted to have a Protective Services Agency (PSA) referral prior to admission secondary to a prior allegation of elder abuse by a substance-abusing son living in the home. Review of medical record inpatient psychiatric progress notes indicated that the patient was oriented x 3 yet repeatedly noted throughout hospitalization to have poor insight and moderately impaired judgment.

The medical record noted that the patient refused all alternatives presented, including placement and discharge to relative's home. Despite inability to obtain 24 hour home care, patient refused all alternatives presented, including placement and discharge to relative's home. The facility planned to discharge this patient to home with pre-existing level of home care services (10 hours x 7days). There was an incomplete assessment of patient capacity and the availability of services to meet the patient's safety needs. The granddaughter agreed to be the designated contact person for the home care agency.

The patient claimed she would not allow her son in the home. The PSA case was reportedly closed because the patient remained in the hospital. As of 10/16/12, safety plans were not clearly addressed nor a clear statement noted about the patient' s decisional capacity. The limitations and feasibility of reliance on a granddaughter in another state to oversee the patient's care in the community was not addressed. Coordination and follow up with PSA was not documented.

7. MR #83

During tour of unit NW8 on 10/15/12, the surveyor was advised that this patient was pending discharge to hospice.
During an interview with the social worker on 10/15/12 at, it was stated that approval was pending for placement at a hospice, but it was uncertain if the patient and the family member agreed with palliative care plan. The patient was unresponsive during attempted interview.

Initial social work assessment dated 9/21/12 had noted that the patient had metastatic gastric Cancer and had capacity.
Social work follow up on 10/12/12 noted that the plan awaited authorization from the insurance company and likely hospice acceptance. The patient's sister and proxy was advised of need to determine patient wishes for DNI/DNR. A psychiatric referral was made on 10/12/12 to assess capacity, but as of 10/15/12 at noon, there was no evidence that this assessment was completed. There was no explanation why the hospice plan was pursued in advance of provision of psychiatric assessment of capacity and patient /family agreement with palliative care plan focus.

8. MR #84

This record determined that an unsafe discharge had occurred for a 69 year old patient who was hospitalized for COPD exacerbation from 9/5- 9/7/12. History was significant for COPD, liver cirrhosis, hypertension, dementia, hepatitis C, kidney mets/liver cancer, hepatic encephalopathy, and substance abuse on methadone maintenance.
The patient had history of Alzheimer's Disease and confusion. He was discharged to home alone on 9/7/12 at 1:30 PM without evidence that the plan to return home was safe. Review of the medical record demonstrated an incomplete discharge planning assessment nor evidence of discharge arrangements for evident needs.

Patient nursing admission database dated 9/6/12 at 4AM documented a history of depression and alert and oriented in three spheres. It was noted that the patient resides with his wife and received six hours for six days per week (6X6) of home care services. However, no social service or home care triggers were identified.

On 9/6/12 at 10PM , it was noted that the patient wanted to return home and was given Aricept for sleep.

On 9/7/12 at noon, nursing noted patient for discharge home per MD. Discharge papers and prescriptions were given and the patient left the unit ambulatory, without complaints at 1:30 PM. Instructions noted home with self-care. Physician note on 9/7/12 at 1:11pm noted urology and liver clinic follow up.

On 9/7/12 at 5:45 PM a social work follow up note was added after the patient's departure. This note indicated that the patient had been discharged alone and the patient subsequently went missing. The family arrived at the hospital (no time noted) pending police involvement. The social worker met with the patient's son, who reported the patient had times of appropriate conversation, but at other times there were other periods of confusion. At the time the family met with the social worker, they received a notification the patient was found at the pharmacy in another section of the Bronx. A referral was made to weekend staff for home care reinstatement. There was no documented evidence home care arrangements were completed.

Based on record review and interview it was evident that the facility failed to provide anesthesia services in a consistently safe manner. Specifically, the patient was administered an anesthetic gas by an unknown person in the OR and this error resulted in dangerous hypotension which persisted throughout the surgery jeopardizing both the patient and the infant.


Findings include:


1. Review of MR #2 on 10/15/12 identified that a patient who was undergoing a C-section for failure to progress on 6/10/12 under epidural anesthesia in the OR ( delivery room ) was noted by the surgeon to have sevoflurane gas being instilled to the patient via face mask. There was no reference in any part of the record as to the concentration and duration of the gas administered and who administered it.

Reference to this incident was found in the surgeon's notes only. The surgeons' notes dated 6/10/12 but dictated 6/11/12 at 10:56 PM stated " The patient remained hypotensive and subsequently it was noted that the patient was inhaling gas through the mask which was found to be sevoflurane. Once that was stopped at which point the patient was already receiving 2 units of blood . The patient's blood pressure slowly returned to normal. "

The Anesthesia record of 6/10/12 found no reference to the administration of the sevoflurane.

The Anesthesia notes signed by the CRNA on 6/10/12 at an unknown time stated "patient was given 100% oxygen for pre-oxygenation per the anesthesia attending' Patient to be intubated for low blood pressure. " The CRNA note continued " 1500 ( 3pm ) : Blood pressure low throughout case. Given 2 units PRC's (packed red cells).

The cesarean delivery note dated 6/10/12 referred to complications described as hypotensive likely secondary to medication. The patient progress record dated 6/11/12 found an entry that refers to " hypotensive episode secondary to anesthetic. " An undated entry in the patient progress notes that " hypotensive episode secondary to sevoflorane . " The discharge summary dated 6/13/12 found under hospital course that patient had a C-section complicated by hypotensive episode likely secondary to sevoflurane.

The QA summary for this event dated 6/10 /12, failed to determine who applied the face mask to the patient, how long the patient was receiving the gas, and whether the delivery system in place protects this type of error. It was noted that after a face mask was applied with oxygen the patient became hypotensive and unresponsive. It also failed to note that sevoflurane is not indicated for pregnant patients. There was no discussion as to nursing's role in the assessment of activities in the OR such as the use of inhalation gases in error. There was no reference to whether the infant's clinical status could be affected by the use of such an agent. There was no record of assessment of the patient who had received this gas in error.

Review of the medical record on 10/15/12 found that the patient's blood pressure dropped to 83/22 at approximately 3:30 hrs during this event. Review of notes entered by the CRNA stated " low blood pressure throughout the case. Given 2 units of packed red cells. " Reference is made to the time the blood pressure reading were noted. The nursing notes written 6/10/12 at 5:43 hrs. stated that the first unit of blood started at 3:35 pm with the blood pressure at 81/20. Another transfusion slip notes another unit of red blood cells (RBC's) started at 3:30 pm found that the pre-transfusion blood pressure was 83/22.2 There was no evidence that a complete assessment of all the possible causes of intra-operative hypotension was made. The surgeon and anesthesia staff assumed it was secondary to blood loss. There was no review by medical or nursing staff of all the treatments in process which would have included what type of respiratory support or treatments were in progress.

During an interview with the Director of Anesthesiology on 10/15 /12 at 1 PM, it was reported that a patient must be intubated prior to the induction of this gas and that it was not possible to find how this error could have occurred when all staff deny involvement.

2. Based on record review it was determined that the patient in MR#3, who was undergoing a left upper extremity brachiobasilic fistula, was ordered by the surgeon to receive 3000 units of IV Heparin. The patient received 20,000 units of IV Heparin instead. At interview with the Director of Anesthesia on 10/17/12 it was stated that the anesthesia resident who administered the heparin assumed that the Heparin vial contained a single dose concentration. Two doses of protamine totaling 50 mg of protamine were administered intra-operatively. The patient returned to the ED and then the OR within 24 hours to evacuate a large hematoma at the left upper extremity at the site of the newly created brachiobasilic fistula.

Based on review of policies and procedures and patient records and interview , it was evident that the facility failed to formulate and implement a triage policy that ensures the scheduled re-assessment of emergency patients.

Findings include:

Review of the policy titled " Emergency Department Traige " Manual Code: T-07 on 6/15/12 it was found that it does not provide for the scheduled re-assessment of patients who are classified in triage category ESI-3, 4, or 5. This deficiency finalizes the triage category and does not provide for upgrading based on clinical assessment.

At interview with ED nursing management staff on 10/15/12, it was stated that patients are not re-assessed at any intervals after the intitial triage determination. .


Based on review of emergency policies and interviews, it was evident that the hospital did not formulate a policy that defines the roles of the PCT ( Patient Care Technician ) in the mini-registrion process. Review of the PCT job description found no reference to the role of the PCT in the triage process.

At interview with Administration and Emergency Nursing management on 10/15/12 found that there are no additional triage policies other than those provided to the surveyor. It was stated that the PCT takes the patient's vital signs concurrent with the " greeter " in the mini-registration process. This is not considered triage. Triage nurses use the vital signs taken by the PCT in their triage decisions. They do not repeat the vital signs even if there is a protracted period of time between the mini-registration and the actual triage by the registered nurse. (RN) .

Review of medical records #53 found that the 2 month old infant arrived at 4:06 pm , had vital signs at 4:15PM and triaged at 6:32 PM. MR#54 found that the 52 yr old female registered at 11:58AM, had vital signs at 12:20pm and triaged at 2:12 PM. The vital signs were not repeated by the triage nurse.


Based on record review it was determined that the ED did not provide emergency rescescuative services in a safe manner.

Findings include:

Review of MR #88 on 10/15/12 found that a pediatric patient who required emergent intubation for an arrest had multiple failed attempts at endotracheal intubation. This included failed tracheostomy that occurred over a 1 hour period from 10:20 AM to 11:20 AM.

Review of the CPR flow sheet found that the paient had been administered Rocuronium IV prior to the attempts at intubation. This presented an unsafe situation for this patient.

The anesthesia attending that was called to the ED and succeeded in providing endotracheal intubation ETT #5 at 11:20 AM. There was clinical evidence that this child had a short neck, and that this would make intubation difficult.

A CT scan demonstrated findings consistent with hypoxemia.

Montefiore Medical Center - Weiler Division

1. Based on tour of the Emergency Department, interviews with staff, review of medical records and other documents, it was determined that the facility failed to conduct a timely triage upon arrival of patients to the Emergency Department. This finding was noted in 9 of 25 applicable records. (MR #s 89, 90, 91, 92, 93, 94, 95, 96 and 97.)

Findings Include:

At interview with the ED Director, on 10/15/12 at 11:00 AM regarding the facility's triage process, he stated that patients upon arrival in the ED are directed to the registration window where a mini-registration is done. The registration clerk obtains the patient's name and other pertinent information that allows a record to be generated for the ED encounter. The patients then wait to be called in turns for triage. During the wait period, the patient's vital signs are documented on a piece of paper by the Patient Care Technician (PCT).

Interview with the PCT on 10/15/12 at 11:45 AM revealed that only abnormal vital signs are reported to the triage nurse. In addition, patients with a complaint of chest pain, shortness of breath and extreme pain are directed to the nurse for immediate triage.


MR #89

During a tour of the ED waiting area on 9/15/12 at 11:15 AM it was observed that signs were posted directing patients to report chest pain for immediately triage assessment. However, this 52-year old female with a chief complaint of chest pain was not timely triaged. The patient's past medical history included diabetes, asthma, and hepatitis C. She was registered upon arrival to the ED on 8/6/12 at 11:58 AM; vital signs were obtained by a Patient Care Technician (PCT) at 2:20 PM. The triage assessment of the patient was conducted at 14:12 PM; this was over two hours after the mini registration.

The assessment notes a 52-year-old female with chief complaint of right sided chest pain that originates from the shoulder and radiates to the back; the pain was noted to have started three days ago. The patient was classified ESI 3 with a pain score of 7/10.

The physician impression was Atypical Chest pain based on an assessment of the patient at 4:19 PM. Electrocardiogram at 14:26 PM showed a normal sinus rhythm.

MR #90

This 40-year-old female was registered in the Emergency Department (ED) on 8/13/12 at 11:52 AM; vital signs were documented at 12:09 PM as follows: Temperature 98.7F, Blood pressure 94/62, Respirations 20, pulse 104, Spo2 97%.

The patient was triaged 77 minutes later at 1:09 PM with a chief complaint of shortness of breath.

MR #91

This is a 78 year-old male with past medical history of multiple myeloma. The patient was triaged in the ED on 9/16/12 at 5:36 PM with complaints of pain to the chest, shoulders and upper back. The patient's daughter reported changes in mental status, nausea and vomiting. The patient was noted to be alert, oriented and ambulatory; pain was rated 7/10; ESI - 3 assigned.

The triage was conducted about 90 minutes after arrival of the patient. The patient was registered at 4:07 PM and vital signs recorded at 4:20 PM. The patient was examined by the physician at 8:50PM and admitted for further treatment.

MR #92

The patient is a 29 year-old who was triaged on 8/16/12 at 12:40 PM with a chief complaint that she passed out at home; she reported nasal congestion and cough for the past four weeks. The patient is noted to be alert and oriented; she denies dizziness, chest pain and injuries.

It was noted the patient arrived at 12:00 PM and the triage assessment did not take place until 40 minutes later. Vital signs by the PCT at 12:05 PM were noted to be stable.

MR #93

The triage assessment of this patient on 9/15/12 at14:21 PM revealed a 65 year-old female with complaints of left facial droop, tongue numbness and right ear pain that extends to the right head. The patient was alert and oriented with positive facial asymmetry, biting of tongue and positive drooling but no slurring of speech. The mini registration record revealed the patient arrived at 1:33 PM and did not receive a triage assessment until 48 minutes later at 14:21 PM.

MR #94 was registered on 10/15/12 at 3:45 PM and triaged approximately four hours later at 7:47 PM.

MR #95 was registered on 8/21/12 at 4:51 PM and triaged 90 minutes later at 6:21 PM.

MR #96 was triaged on 6/11/12 at 11:50 AM, after 60 minutes of arrival in the ED.

MR #97 is a 33-year-old who was assessed at triage with a complaint of epigastric pain radiating to the left quadrant. The severity of the pain at triage was rated 10/10 by the patient.
It was noted that the patient arrived at 1:44 PM and had waited 90 minutes for the triage assessment.


2. The Emergency Department did not administer its quality assurance program to assure the identification of actual problems concerning patient care and the development and implementation of actions to correct identified problems.

Findings include:

The review of the Emergency Department Log revealed multiple patients who were noted to have eloped from the ED or did not answer when they were called to triage. Upon request of a sample of six records; MR #s 98, 99, 100, 101, 102, and 103, the Assistant Director of Regulatory Affairs stated that records were not generated because the patients left before triage. The ED Log did not capture the patients' chief complaint.

The review of several medical records revealed patients waited over thirty minutes and in one instance 120 minutes before triage. Due to the lack of records for patients who left before triage, there was no information on how long they waited before their departure from the ED. There was no indication that these patients had the opportunity to present the reason for their visit to a clinical staff during the ED visit.

The review of the Departmental Quality indicators for January - September 2012, noted the tracking of elopements for each month; there was no documented analysis of wait times and there was no plan in place to address the timely triage of patients.


3. Based on the review of medical records it was determined that patients were not appropriately reassessed prior to discharge from the Emergency Department. This finding was noted in 2 of 25 applicable records. (MR #s 104 and 105.)

Findings include:

MR#104 was not reassessed prior to discharge from the ED on 8/4/12 and 8/6/12. The medical record did not describe whether the patient was in pain or if the patient was experiencing contractions prior to discharge.

The patient is a twenty five year old patient who presented to the Labor and Delivery (L& D) unit on 8/4/12 at 7:36 p.m., with a complaint of irregular contractions since the previous night. The patient's gestational age was 38 weeks, with an expected date of delivery (EDD) of 8/17/12. The patient's pain assessment was 9/10. The patient's previous medical history included: myotonic dystrophy, recurrent UTI with multiple drug resistant Klebsiella pneumonia, monilia vaginitis at 36+ weeks, vulvae varicosities and asthma.

As per the medical record, the patient never took the prescribed medications for the urinary tract infection (UTI). Additional risk factors included, but not limited to "no show for prenatal visit, tobacco use, partner substance abuse and stressful activities". The patient was discharged home at 10:51 p.m.

There was no documentation or reassessment of this patient's pain score throughout the visit on 8/4/12. Also, there was no evidence that this patient's recurrent UTI was addressed,

According to the record, the patient returned to the L & D unit on 8/6/12 at 5:52 p.m. with complaints of contractions every 10 minutes with a loss of fluid. Vital signs taken 3 minutes later showed that the patient's vital signs were normal, but the pain score was 7/10. Physicians' notes revealed that the patient had occasional contractions and leakage of white fluid.The patient was discharged at 9:25 p.m. without any documentation of a reassessment of the patient's pain score.

MR #105 is an eighty four year old patient who was seen in the Emergency Department (ED) on 8/9/12, after the patient sustained a fall from bed in the nursing home that night. The patient's past medical history included dementia.

Upon the patient's presentation to the Emergency Department on 8/9/12 at 9:46 p.m., the patient was assessed. A pulse rate of 104 was also documented on arrival.

There was no evidence that this patient's physical, mental, neurological status, including a pain score and vital signs, were reassessed prior to the patient's discharge to the Nursing Home on 8/10/12 at 4:00 a.m.