HospitalInspections.org

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Based on record review and staff interview, the facility failed to ensure compliance with all applicable state regulations and guidelines for facilities.
Findings:

As per review of New York State Department of Health Records while preparing for this survey on the morning of 05/03/15, the facility was issued a site-specific Operating Certificate (i.e., License) a licensed outpatient extension clinic (the Family Counseling Services Clinic) located at 385 Oak Street, Garden City, NY. It was also noted that the facility had submitted a Certificate of Need (CON) application (CON Project #151115) for the relocation of the above mentioned extension clinic to 506 Stewart Avenue, Garden City, NY but that this project had not been issued approval nor had the facility been granted approval to close the clinic located at 385 Oak Street, Garden City, NY.

Interview with Staff H on 05/11/16 at approximately 2:45PM revealed that the facility had closed the clinic at 385 Oak Street, Garden City, NY and moved to this new location on 06/15/15
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Based on record review and interview, in three (3) of six (6) medical records, the facility did not ensure that an "Important Message" (IM) Form CMS-R-193, was provided to the patient in the required timeframe.

By not providing the Important Message form in a timely manner, the patient will not have sufficient time to appeal a discharge.

Findings:

Review of Patient #11's medical record identified no evidence of an Important Message to Medicare on admission. This patient is a 91 year old who was admitted on 05/01/16 and was still in house as of 05/18/16.

Review of Patient #67's medical record identified no evidence of an Important Message to Medicare on admission and follow up notice, as required, prior to discharge. This patient is a 65 year old who was admitted on 03/24/16 and was discharged on 05/10/16.

Review of Patient #68's medical record identified no evidence of an Important Message to Medicare follow up notice, as required, prior to discharge. This patient is a 71 year old who was admitted on 05/04/16 and discharged on 05/08/16 at 3:30PM.

The facility policy and procedure titled "Discharge Notices (Important Message from Medicare and 24 Hour Discharge Notice)," last revised 12/2015, states that "All Medicare in-patients will receive the Important Message from Medicare (IM) at admission and at discharge as required by the Center for Medicare and Medicaid Services (CMS) regulations. The IM notifies the patient of their hospital discharge appeal rights".

This policy also stated that it is the Admitting Department registrar will obtain the signature of all admitted Medicare beneficiaries on the IM at the time of admission or within two days of the patient's admission. Upon discharge the second IM must be delivered as early as possible, but no earlier than two (2) calendar days before the planned discharge date. If the patient cannot sign, the representative will be contacted by the case worker or the social worker and may sign the form after speaking to the representative.

Per interview of staff J, Admitting Clerk, on 05/10/16 at 10:30AM, the Admitting Patient Representative stated that she is the one who initially gives the patient their Patient Rights packet and has them sign the IM letter.

During interview of Staff K, a Nurse Case Manager, on 05/10/16 at 1:30PM, stated that it is the Case Managers who ensure that the IM's are signed.

During interview of staff C, Nurse Manager, on 05/11/16 at 11:30AM, the Nurse Manager, also stated that it is the Case Manager that is responsible for getting the Important Message signed when it is not completed by the time the record reaches the unit.
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Based on record review and interview, in two (2) of six (6) medical records, the facility did not ensure that informed consent or consent forms for specific procedures were signed before treatment was rendered.

This failure denies patients the right to make decisions about their care.

Findings:

Review of Patient #11's medical record identified no evidence of a signed General Consent form for treatment. This is a 91 year old patient admitted on 05/01/16 with a diagnoses of sepsis and a urinary tract infection. The patient has dementia and aphasia and was incapable of signing any forms herself.

Review of Patient # 67's medical record identified no evidence of a signed General Consent form for treatment. This is a 65 year old male admitted on 03/24/16 with a diagnosis of anemia. There is no evidence of a signed General Consent for Hospital Services / Treatment or consent for examination and Emergency Treatment both dated 03/24/16. Each of these forms had a label affixed by the facility to the signature area stating "Conditions of Admission Not signed. Please have signed by patient or next of kin." The patient was discharged on 05/10/16.

The facility's Policy and Procedure titled "Consolidated Statement of Policy and Procedures for Informed Consents, revised June 2015, states that "Documented evidence of such informed consent shall be included in the patient's medical record." If the patient is determined to lack capacity to consent, then consent may be obtained from one of the following representatives, which is inclusive of the spouse.

The findings were confirmed with Staff K, Nursing Care Manager, and Staff L, Quality Assurance Nurse, on 05/11/16 at 11:30AM.
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Based on record reviews and staff interviews, in two (2) of four (4) records reviewed for patients placed in four point violent restraints, the one hour face to face evaluation did not document a complete comprehensive review of the patient ' s medical condition as required by the facility's policy.

This failure has the potential for resulting in patients being inappropriately placed in restraints.

Findings:

The facility policy and procedure titled "Restraints and Seclusion (Violence)" dated November 2015 stated the following: "the implementation of restraint shall be pursuant a physician's order based on the results of a personal examination of the patient by the physician." "the mental status assessment shall include the patient's behavior, thought content, and level of consciousness", "the physical assessment shall include the patient general condition, and vital signs," "the physician shall review the patient existing medication orders and shall assess the need for modifying such orders" and "the results of the examination shall be documented in the medical record."

Review of Patient 45's medical record identified the following information: this year 60 old was admitted to the emergency room for complaints of insomnia and mental confusion on 05/03/16 at 12:26 PM. The patient was documented to have a long history of chronic psychiatric illness with multiple past psychiatric admissions. The nurse's note documented that "the patient became verbally and physically abusive", "agitated without provocation" was "threatening other patients" and needed to be placed in four point restraints. The physician orders revealed that the ED Nurse Practitioner ordered four point "Restraints violent or self-destructive" at 1:59AM. The ordered set includes the statement "I have performed a face to face evaluation. Alternatives are not appropriate at this time" but there is no corresponding documentation of a patient examination as required.

Review of Patient 44's medical record identified the following information: this 51 year old was admitted to the emergency room for a psychiatric evaluation at 7:39PM on 04/22/16. The triage nurse documented that the patient had been discharged from another facility and the patient stated she was hearing voices that were telling her to kill herself. The patient verbalized a plan and was immediately placed on one to one constant observations. The patient remained housed in the emergency room awaiting admission with documented periods of agitation controlled with medication until 1:00PM on 04/24/16 at which time the nurse documented that "the patient became violent, severely agitated and physically aggressive with staff". The physician documented at 1:00 PM "patient being evaluated by psychiatrist" and "became severely agitated". "Placed in restraints with frequent checks" but there is no documented physical examination.

This lack of documentation was confirmed during the onsite record reviews with Staff X (Psychiatric Nurse Educator) and Staff Y (Director of Psychiatry) on 05/12/16.
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Based on medical record (MR) review, document review, and interview, in three (3) of three (3) MRs, the nursing staff did not perform timely pressure ulcer re-assessments as per facility policy.

The failure to perform timely re-assessments may result in delayed wound healing.

Findings include:

The facility policy and procedure (P&P) titled "Pressure Ulcer Prevention, Assessment, Management and Documentation" last revised 10/22/15, stated the following: "Skin assessment is to be completed on admission ...every Tuesday and Friday (twice a week), upon transfer to another unit and at discharge. "

Review of Patient #12's MR identified the initial skin assessment on Wednesday 05/04/16 noted the patient had a 1cm x 1cm Stage I sacral pressure ulcer on admission. Skin Assessment Flow Sheets lacked indication the patient's skin was assessed on Friday 05/06/15. Patient #12 was transferred from the Intensive Care Unit (ICU) to Telemetry on 05/08/16, and the Skin Assessment Flow Sheet lacked indication the patient's skin was assessed upon transfer.

Review of Patient #32's initial skin assessment identified a 4cm x 3cm Right Buttock Stage II pressure ulcer, an 8cm x 4cm Left Ischium Stage II pressure ulcer and an 8cm x 5cm Left Sacral Stage II pressure ulcer present on admission on Monday 4/25/16. Skin Assessment Flow Sheets lacked indication the patient's skin assessments due Friday 04/29/16, Tuesday 05/03/16 and Friday 05/06/16 were performed.

The same lack of documentation was found in the MR for Patient #33 for review period 03/24/16 to 04/18/16.

During interview of Staff C (Nurse Manager) on 05/09/16 at 2:00PM, she stated "The skin reassessment for Patient #12 was not done ...it should have been done on 05/06/16 and when the patient was transferred from ICU." This was confirmed with Staff D (Director of Nursing).

The same lack of documentation regarding the twice a week skin assessments was found during interview of Staff E (Nurse Manager) on 05/10/16 at 10:20AM, when she stated that the skin reassessments for Patient #32 and Patient #33 had not been performed. This was confirmed with Staff D (Director of Nursing).
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Based on medical record (MR) review, document review and interview, the staff: (1) did not provide a complete wound treatment order, and (2) administered wound treatment without a practitioner's order.

These failures place patients at increased risk for worsening pressure ulcer development.

Findings pertinent to (1) above include:

Patient #32's MR review identified inconsistent administration of the wound treatment intervention, Triad Hydrophilic Wound Paste. Practitioner order for Triad was entered on 05/02/16 at 10:03AM by Staff F (Nurse Practitioner). Frequency of Triad administration was ordered as "Until Discontinued".

During interview of Staff F (Nurse Practitioner) on 05/10/16 at 11:40AM, she acknowledged the frequency of the Triad was not specified. This was confirmed with Staff E (Nurse Manager) and Staff D (Director of Nursing).

As per interview of Staff A (Director of Nursing Education) on 05/12/16 at 9:15AM, practitioners, "should order [Triad] with a frequency of application".

Findings pertinent to (2) above include:

Review of Patient #33's MR identified no evidence of a practitioner's order for Triad Hydrophilic Wound Paste from 03/24/16 to 04/04/16. The record documented that Triad was initiated on 03/24/16 and administered from 03/25/16 to 04/04/16.

Interview with Staff E (Nurse Manager) and Staff D (Director of Nursing) on 05/10/16 at 11:15AM confirmed no order was placed for the Triad during this time period and that an order is required for the administration of Triad.

Interview with Staff F (Nurse Practitioner) on 05/10/16 at 11:40AM also confirmed a practitioner order is needed for the Triad.
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Based on medical record (MR) review, document review and interview, in 1 of 3 MRs, the staff did not document wound treatment.

This failure places patients at increased risk for worsening pressure ulcer development.

Findings include:

The facility policy and procedure (P&P) titled, " Pressure Ulcer Prevention, Assessment, Management and Documentation, " last revised 10/22/15, stated the following: " All prevention, assessment and management strategies are to be documented in the patient ' s electronic medical record (Doc Flowsheet - Wound LDA section) ... "

Review of Patient #12 ' s MR identified an order for Triad Hydrophilic Wound Paste was entered on 5/3/16 for application every shift [Day shift and Night shift]. Wound flowsheets revealed Triad was administered 5/4/16 at 8:00pm (night shift), but not administered 5/5/16 during the day shift. The next administration on the 5/5/16 night shift was twenty-four (24) hours after the previous administration.

On 5/6/16 at 8:00am (day shift), Triad was administered. Wound flowsheets lacked indication Triad was administered on the 5/6/16 night shift or either the day or night shifts on 5/7/16. The next administration was documented on 5/8/16 day shift, forty-eight (48) hours after the previous administration.

During interview, Staff C (Nurse Manager) on 5/9/16 at 2:30pm, stated, " It [documentation of Triad administration] isn ' t here. " When asked if the documentation can be found anywhere else in the MR, Staff C pointed to the Wound Section of the Flowsheet and stated, " This is where they are supposed to enter that information. " This was confirmed with Staff D (Director of Nursing).
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Based on observations and staff interview, the facility failed to ensure 1) that all food preparation and storage areas were maintained in good repair and in a clean condition and 2) that facility food temperature logs and food equipment sanitizing logs were completed in accordance with facility policies and procedures.

The findings pertinent to (1) above include:

On the morning of 05/09/2016, a slight to moderate build-up of dust was observed on blower unit fan guards and ceiling surfaces in the Lower level Kitchen Vegetable and Meat Walk-in Coolers.

On 05/09/2016 at 10:50 AM, a hole that was approximately 1-inch in diameter was noted in a wall (near the floor/wall juncture) in the rear food preparation area of the 1st floor Patio Grill Coffee Shop.

On 05/09/2016 at 10:54 AM, painted surfaces on a wall in 1st floor Patio Grill Coffee Shop in the vicinity of the slicing machine in the rear food preparation area were noted to be in disrepair (e.g., marred and chipped).

As per concurrent interviews with the facility staff member G (Director of Engineering) and I (Director of Dietary Services), they acknowledged the above mentioned deficiencies and said that they would inform hospital administration of them.


The findings pertinent to (2) above include:

On 05/09/2016 at 9:55 AM, the daily temperature monitoring log for the " Prep Salad " Refrigerator in the Lower Level Kitchen was not completed on 05/08/2016.

As per concurrent interview with facility staff member I, she acknowledged the above mentioned deficiency and said that the temperature of this refrigerator is supposed to be checked twice a day, once in the morning and once in the afternoon, and the temperature recorded in the log book.

On 05/09/2016 at 10:42 AM, the daily Pot Washing Sink Sanitizer Strength monitoring log for the Ware washing Area in the Lower Level Kitchen was not completed between 05/03/2016 and 05/08/2016.

As per concurrent interview with facility staff member I, she acknowledged the above mentioned deficiency and said that the sanitizer strength in this sink is supposed to be checked five times a day, and the results recorded in the log book.

On 05/09/2016 at 10:54 AM, the daily temperature monitoring log for the " Milk/Breakfast " Refrigerator in the 1st Floor Patio Grill Coffee Shop was not completed in the afternoons of 05/06/2016 and 05/07/2016.

As per concurrent interview with facility staff member I, she acknowledged the above mentioned deficiency and said that the temperature of this refrigerator is supposed to be checked twice a day, once in the morning and once in the afternoon, and the temperature recorded in the log book.
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Based on observations and staff interview, the facility failed to ensure that all ceiling, door, cabinetry, and wall finishes in the hospital building were maintained in good repair.

The findings were:

On 05/09/2016 at 2:10 PM, some of the painted surfaces on a wall in Clean Utility Room 2046 were noted to be in disrepair (e.g., marred and chipped).

On 05/10/2016 at 2:36PM, some of the painted surfaces on a wall by the unused space where the facility intends to convert to Hospice Unit by exit stair 1 were noted to be in disrepair (e.g. marred and chipped)

On 05/11/2016 at 9:30 AM and 9:32 AM, some portion of the cove base by Patient cubicle 5 and 3 at ICU on the fourth floor were noted to be in state of disrepair (the cove base is peeling off)

On 05/11/2016 at 10:02 AM, some of the painted surfaces on a wall in a 4th floor corridor (vicinity of the Critical Care Office and the Electrophysiology Lab) were noted to be in disrepair (e.g., marred and chipped).

On 05/11/2016 at 10:23 AM, surfaces of cabinetry near the ice making machine in Room 3143 Rehab Unit Dining Room were noted to be in disrepair due to delamination.

On 05/11/2016 at 10:56 AM, an approximately 4 by 8 inch ceiling tile in clean supply room of the respiratory unit was noted to be stained from water leak.
On 05/11/2016 at 1:37 PM, surfaces on a pair of cross-corridor doors in the Lower Level (vicinity of Electrical Closet G41) were noted to be in disrepair due to delamination.

As per concurrent interviews with the facility staff member G (Director of Engineering) and H (Assistant Director of Engineering),they acknowledged the above mention deficiencies and said that he would inform hospital administration of them.
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Based on observations and intervews, the hospital did not ensure that the life safety from fire requirements are met.

Findings:

See Life Safety Code survey, K20, K29, K56, K62, K69, K130, and K147.
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Based on observations and staff interview, the facility failed to ensure that accessible facilities were designed and maintained in accordance with Federal, State and local laws, regulations and guidelines. Specific reference is made to compliance with requirements of both New York State and federal accessibility guidelines (e.g., the American's with Disabilities Act).

This failure places patients at risk for physical harm.

The finding was:

On 05/11/2016 at 1:04 PM, in the parking lot in the rear of the Main Building one designated accessible parking space was noted to lack the required access aisle and the asphalt walking surfaces of an access aisle that served another designated accessible parking space was noted to be in disrepair (e.g., surfaces pitted and uneven) and have the potential to be a tripping hazard for anyone using this access aisle.

As per concurrent interviews with the facility staff member G, he acknowledged the above mentioned deficiencies and said that he would inform hospital administration of them.
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Based on observations and staff interview, the facility failed to ensure that the condition of the physical plant and overall hospital environment is developed and maintained in a manner that provides an acceptable level of safety and well-being of patients, staff, and visitors.

The finding was:

On 05/11/2016 at 10:16 AM, the pull chain of a nurse calling station in the toilet room in patient room 3104 was noted to be in disrepair (e.g., most of the cord had broken off, leaving only about a two-inch long section). Due to the shortened length of the cord, a patient who fell on the floor of this room might have difficulty reaching it.

As per concurrent interviews with the facility staff member G, he acknowledged the above mentioned deficiency and said that he would inform hospital administration of it.
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Based on observations, interviews, and policy reviews, the facility failed to ensure that the facility implemented an infection control program, including environmental services, to protect patients from exposure to infections and communicable diseases.

These failures place patients at risk for harm.

Findings:

See Tag A 749
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Based on observation and interview, the facility failed to ensure staff maintained proper infection control practices 1) during cleaning of the Operating Room (OR), 2) in semi-restricted and restricted areas, 3) after transportation of patients, and 4) in the designated airborne infection isolation room.

These failures place all patients at risk for infection.

Findings pertinent to (1) above include:

(1) During observation of the cleaning of operating room #3 on 5/9/16 between 1:15 - 2:00PM, Staff O, OR Housekeeper, stated " I have three pairs of gloves on, so if they get bloody I can just take them off and I have clean ones underneath. "

When asked if facility policy instructs housekeeping staff to wear 3 pairs of gloves Staff P, Housekeeping Supervisor, replied " No. "

The facility policy and procedure titled " Surgical Areas Cleaning " , last revised April 2016, lacks instructions on handwashing or changing of gloves when contaminated or visibly soiled.

During observation of the cleaning of operating room #3 on 5/9/16 at 1:35pm, Staff O was observed entering a sterile supply cabinet wearing gloves, that he wore to take the garbage out, and taking bottles of solidifier powder from a bucket on the bottom shelf.

This was observed in the presence of Staff P, Housekeeping Supervisor, who confirmed he should not be entering a sterile supply cabinet with soiled gloves.

The facility policy and procedure titled " Surgical Areas Cleaning " , last revised April 2016, lacks instructions for cleaning in areas where sterile supplies are stored.

During observation of the cleaning of operating room #3 on 5/9/16 between 1:15 - 2:00PM, Staff O, OR Housekeeper, was observed mopping the OR floor.

During the mopping of the floor, he was observed cleaning the perimeter of the OR room, then dragging the mop through the blood under the OR table and then back over the just cleaned perimeter of the OR room with the same dirty mop.

This was observed in the presence of Staff P, Housekeeping Supervisor.

During observation of the cleaning of operating room #9 on 5/10/16 between 9:30 - 10:00AM, Staff O, OR Housekeeper, was observed mopping the OR floor.

During the mopping of the floor, he was observed cleaning the perimeter of the OR room, then dragging the mop through the dirty area under the OR table and then went back over the just cleaned perimeter of the OR room with the same dirty mop.

This was observed in the presence of Staff P, Housekeeping Supervisor, and Staff Q, Director of OR services.

The facility policy and procedure titled " Surgical Areas Cleaning " , last revised April 2016, lacks instructions on mopping floors from the cleanest areas first to the dirtiest areas last.

Review of Staff O personnel record revealed Staff O has been employed at the facility for 49 years, since 4/2/1967.

Per interview with Staff R, Director of Environmental Services, he has been a housekeeper in the OR for 30 years.

During interview of Staff R, on 5/11/16 at 12:55pm, when asked if Housekeeping staff receive unit specific training, he replied " No."

During observation of the cleaning of operating room #3 on 5/9/16 between 1:15-2:00PM, Staff M, Anesthesia Tech, was observed cleaning anesthesia equipment without a gown or apron on.

This was observed in the presence of Staff S, OR Nurse Manager.

The facility policy and procedure titled "Surgical Areas Cleaning" , last revised April 2016, instructs "When cleaning OR room a disposable blue iso gown must be worn and changed after cleaning each room."

During observation of the cleaning of operating room #3 on 5/9/16 between 1:15 - 2:00PM, Staff N, OR Housekeeper, was observed wiping down the OR table and then using the same wipe to clean the Cautery machine.

This was observed in the presence of Staff P, Housekeeping Supervisor.

The facility policy and procedure titled "Surgical Areas Cleaning" , last revised April 2016, lacks instructions to use a new clean wipe for each piece of equipment.


Findings pertinent to (2) above include:

(2) During a tour of the operating room on 5/9/16 at 10:20AM, Staff M, Anesthesia Tech, was observed in the semi-restricted Anesthesia office without his facial hair covered.

This was observed in the presence of Staff S, OR Nurse Manager, who confirmed that he should have his facial hair covered.

During a tour of the operating room on 5/9/16 between 10:00 - 11:00AM, Staff T, Surgeon, was observed entering a restricted area OR #9, where a patient was prepped and ready for surgery, without a facemask on. He then stepped out of the room to ask staff in the semi-restricted hallway a question, then re-entered the OR with his face mask in his hand.

This was observed in the presence of Staff S, OR Nurse Manager, who confirmed the OR was a " Restricted area " and " the surgeon should have had a mask on before entering the room " .

During observation of the operating room semi-restricted are on 5/9/16 at 1:50PM, Staff U, Anesthesiologist, was observed in the semi-restricted hallway without his facial hair covered.

This was observed in the presence of Staff S, OR Nurse Manager, who confirmed that he should have his facial hair covered.

Facility policy and procedure titled " Surgical Attire " , last revised March 2016, instructs " All personnel and visitors in the semi-restricted area must wear surgical attire and surgical hood/bouffant covering all head and facial hair. "

Findings pertinent to (3) above include:

(3) During observation of the facility on 5/11/16 at 9:15am. Staff V, Volunteer, was observed on the elevator wearing gloves.

Per interview of Staff V on 5/1//16 at 9:15am she stated, " I just transported someone. I should have taken my gloves off. "

This was observed in the presence of Staff W, Director of Nursing for Critical Care, who confirmed the volunteer should have removed her gloves after transporting the patient.

The facility's policy and procedure titled " Infection Control and Hand Antisepsis " , last revised January 2009, instructs all healthcare workers to remove gloves after caring for a patient and perform hand hygiene.

Findings pertinent to (4) above include:

(4) On 05/09/2016 at 1:40PM, an unsealed cable penetration was noted in one of the walls that enclose airborne infection isolation room 4019.

As per concurrent interviews with the facility staff member G, he acknowledged the above mentioned deficiency and said that he would inform hospital administration of it.
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Based on interview and document review, the Medical Staff did not established criteria delineating the qualifications a Medical Staff Member must possess to supervise the provision of Emergency Care Services.

This failure may lead to a non-qualified Medical Staff Member supervising Emergency Care Services.

Findings:

The facility ' s policy and procedure titled " Chief ED (emergency department) Physician on Duty " , last revised March 2016, stated the following: " the emergency physician assigned to the 7:00 AM and 7:00 PM shifts will be automatically assigned the role of the Chief Emergency Physician " , but the policy lacks any criteria or qualifications for this designation.

The facility's Medical Staff Bylaws, dated November 2011, did not contain established criteria including the necessary education, experience or specialized training, delineating the qualifications a Medical Staff Member must possess in order to provide supervision of Emergency Care Services.

The facility ' s current contract with the " Long Island Emergency Medical Care P.C. (Professional Service Corporation) " dated August 8, 2012, does not contain the qualification needed for a P.C. physician to be assigned the role of the " Chief Emergency Physician " .

During an interview on 5/9/16 at 2:30 PM, Staff Z, (Director of Emergency Medicine) stated when asked if there were specific criteria delineating the qualifications a P.C. physician must possess in order to supervise Emergency Care Services, he responded " we do not have specific qualification criteria for assigning the role of the Chief Emergency Physician " .