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10331


Based on review of policies, records, and interviews, it was determined that the hospital did not consistently comply with requirements for the distribution of information to patients or their representatives about Patient's Rights, including the Bill of Rights and the Important Message for Medicare (IM's).

Findings include:

1. Concurrent medical records that were reviewed during the survey found lack of consistent documentation where applicable patients or their representatives were provided with the notice of the Important Message from Medicare (IM) within 48 hours of admission. There was no evidence that follow up notices were provided at least 48 hours prior to discharge where indicated. Records did not demonstrate consistent distribution of the patient information package which includes a compilation of required documents including the "Patient's Bill Of Rights".

2. Review of the policy titled "Important Message from Medicare" dated 6/2012, notes that the initial notice must be delivered to patients or their representatives within 48 hours of admission and that the second notice is delivered from 48 hours to 4 hours before discharge. The distribution of the initial notice is the responsibility of emergency department (ED) financial staff and if these staff are unavailable, admitting staff shall deliver the notice to the patient or their representative who must also sign and date the notice. If admitting staff is unavailable the charge nurse and/or case managers act as the back up. The second notice is delivered to the patient or the representative by the nurse. The policy further notes if either the patient or representative is unable to sign, this must be recorded on the notice.


This policy is incomplete as it does not specify how follow up is conducted with the patient in instances when the patient's condition renders the patient unable to sign. The policy notes all efforts to deliver the notice must be documented in the electronic record. The policy does not specify that staff shall make future attempts to distribute notification during instances when patients' condition improves to a degree that enables comprehension of information (i.e., patients who regain awareness following temporary incapacitation). Furthermore, the policy does not include a mechanism to ensure distribution of the required notices to patient representatives who cannot present in person to the hospital. The policy does not explain how patient representatives who are not present in the hospital (next of kin, proxy, or guardian) shall be notified by phone, mail, or telegram, especially during instances where patient incapacity is deemed to be ongoing.

Review of the nursing policy titled "Admission of Patient to Hospital" on 1/14/13 determined the patient's bill of rights is reviewed on admission. No further information is described.

3. Staff interviewed on 1/11/13 did not provide consistent responses to surveyors' questions regarding staff who are responsible for distribution of the IM notifications. During the tour of unit 3N on 1/11/13 at approximately 3 PM, it was stated by the head nurse that it is the responsibility of the patient case manager to distribute the initial IM notices to patients. However at follow up interview with the case manager shortly after, it was stated that the admissions staff provide the first notice and the second IM notice is delivered by unit-based nursing staff.
4. Three of five concurrent records reviewed during a tour conducted of unit 3N on 1/14/13 found that the hospital failed to consistently document distribution of the notice for the Important Message from Medicare (IM) or the Patients' Rights Package as required by hospital procedures.
During the tour of 3 North on 1/11/13 at 3 PM it was noted that 3/5 records reviewed lacked evidence of the provision of the IM within required time frames or documentation of provision/ explanation of patient's rights.
MR # 1: This 87 year old patient was admitted on 12/27/12 for left hip fracture. The concurrent electronic medical record was reviewed on 1/11/13, which found no scanned documentation to verify that the Important Message from Medicare (IM) was provided within 48 hours of admission.

MR # 2 : This 73 year old patient was admitted on 1/4/13 for ventral hernia. The electronic nursing admission assessment noted "no data filed" in the section that denotes delivery of patients' rights information. The electronic medical record (EMR) lacked evidence that the IM was delivered within 48 hours of admission and no evidence that this document was scanned.

MR # 3: This 82 year old male was admitted on 12/11/12 for rhabdomyolisis. There was no evidence that the Patient's Bill of rights nor the IM notice were provided. The nursing admission section noted " no data filed" in the section for the patient's rights information.

5. Similar findings were noted in MR#4, MR# 5, MR# 6 and MR# 7 where there was a failure to provide the IM within 48 hours of admission or patients' rights information

MR# 8: Review of a closed medical record on 1/15/13 for this 88 year old patient who was admitted on 11/4/12 and discharged from the hospital on 11/12/12 found no evidence that the Important Message from Medicare (IM) was given within 48 hour of admission and that a follow up notice was given 48 hours prior to discharge.

MR # 9: During surveyors' tour of unit 6S on 1/15/13, an attempted interview found that this 82 year old male was confused. Review of the record determined he had fallen prior to hospital arrival on 1/10/13. The nursing admission assessment in the electronic record noted that Patients' Rights information was given to the patient. It was unclear how the patient would comprehend this information given his altered mental status.

MR # 10: This 95 year old patient was admitted on 1/4/13 for dehydration, failure to thrive and advanced dementia. On 1/14/13 during the tour of the unit at approximately 1 PM surveyors were advised that the patient was ready for discharge to a nursing home. Social work documented on 1/14/13 at 1220 PM that the patient's nephew was reached and agreed with placement. The pick-up was arranged for 4:30 PM on 1/14/13. As of approximately 1:45 PM on 1/14/13, the medical record lacked documentation that discharge notice was provided to the nephew.




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Based on review of grievance procedures, grievance records, and staff interviews it was determined that the facility did not conform to its grievance process and did not establish an effective structure and process for grievance investigations.

Findings include:

On 1/15/13, during review of the hospital's grievance procedures titled "Grievance Process/Compliment Management" the following deficiencies were noted:

The policy did not require verbal complaints that are solved to be forwarded for quality assurance/tracking and trending analysis. It noted that unsolved verbal complaints are to be documented and actions taken are forwarded to Administration.

The policy notes all investigation and responses shall be completed within 1 week of receipt. However it also notes that a complete copy of the patient complaint form and written responses shall be completed by the department head and returned to the President's Office and Performance Improvement (PI) within 10 days. If no departmental response is received, a reminder is sent to the department head requesting follow up within an additional 5 more working days. If unresolved a grievance committee is enacted on ad hoc basis. The PI department maintains the case file.

This process does not ensure tabulation and analysis of solved verbal complaints that do not escalate into written grievances. Furthermore, the policy stated all grievances and complaints are logged tracked and reviewed for trends to be reported to PI Committee, but did not specify a plan to include tabulation and analysis of verbal complaints.

Review of the facility's grievance logs and interviews with Performance Improvement (PI) and nursing staff on 1/14/13 finds that the facility has not fully followed this grievance process.

1. Nursing maintains a separate complaint log where it was determined that not all cases were referred back to Performance Improvement as required to ensure completeness of investigation and centralized tracking.

2. Review of attachments to Performance Improvement meetings for the first quarter of 2012 and third quarter of 2012 (referenced in 10/4/12 Performance Improvement Council meeting minutes) found that nursing complaints and complaints handled by Performance Improvement were separately analyzed and were not fully merged and aggregated for trend analysis. While Performance Improvement (PI) minutes for 1/5/2012 noted that PI is the centralized area for documenting complaints from all sources, this process had not been implemented.

3. Review of the 2012 Performance Improvement Grievance tracking log and Nursing Complaint logs on 1/14/13 found that there was lack of consistent documentation in logs and associated grievance files selected for review. The date of intake, source of complaint, method of complaint (verbal,phone,mail, e-mail), date of incident, date of departmental review, departmental response, results of staff interviews and medical record reviews, analysis of findings, and conclusions were not always documented in each case.


4. Despite the policy's mandate for ad hoc Grievance Committee meetings, there was no evidence that this process was implemented. There was no evidence of any meeting of the Grievance Committee.

Responses to patients did not fulfill the requirement to advise patients of the findings resulting from the hospital' s investigation. (See findings written under tag #A123).
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16140


Based on record review and interview, it was determined that the facility failed to formulate and implement a policy and procedure to process complaints made to the facility regarding allegations of misconduct of persons who are not employees.

Findings include:

Review of the policy and procedure "Code G - titled Grievance Process/ Compliment Mgt." determined that there is no reference to the steps to be taken when a patient alleges abuse and it is found that thai abuse involves non hospital staff who have access to the hospital.

Specific reference is made to the person identified as the mother of the patient noted in MR # 11, who was a minor child. Review of the complaint on 1/12/13 found that on 11/25/12 the mother of a minor child alleged that there was sexual abuse by a male EMT in the presence of that child on an ambulance en route to the hospital. This allegation was reported to employees in the ED. Review of the complaint form found that the allegations were of improper sexual contact during the course of an informal physical examination made by an EMT in the ambulance when the complainant stated that she had chest pain.

It was found that the ambulance was not one operated by the hospital but was operated by FDNY. At interview with the facility pre-hospital care co-coordinators on 1/15/13, it was stated that once it was found that the ambulance involved was operated by the NYC Fire Department, it was decided to terminate the matter and provide the patient with the phone number of EMS.

There was no evidence of any direct call was made to FDNY in order to ensure that the alleged perpetrator was identified and an investigation commenced.

The ED staff failed to take the complaint, failed to offer a physical examination of the patient, failed to call the Police to report an allegation of sexual abuse, and failed to ensure that the incident was immediately reported to the Fire Department EMS Division Boro Commander.

Based on review of grievance logs from nursing, Performance Improvement departments and grievance records, it was determined that the hospital did not fully investigate or respond to complainants in writing regarding the notification results of the hospital's grievance investigations.

Findings include:

The facility did not conform to its policy which requires that if the complainant is dissatisfied with the hospital response, they will be directed to contact the New York State Department of Health Complaint Hotline or the Joint Commission Office of Quality Monitoring.
The following grievances did not include documentation of complete investigations or provision of appropriate written responses that detailed the findings of hospital investigations.

Deficient findings were noted in 6/6 complaints sampled from 2012 nursing patient complaint logs:

MR # 12: A written complaint dated 4/19/12 was received from the family of this patient who was allegedly restrained forcibly by security against his will. The patient was elderly and asked to be discharged. The allegation was of physical abuse by security staff where they assaulted and restrained the patient with no justification. Review of the security report found that the patient was restrained by staff. However, the response letter denied that the patient was restrained.

MR # 13: The family complained that the patient was in restraints on 4/22/12. The written response dated 6/22/12 was not provided within 21 days in accordance with grievance policy. The letter explained the sequence of events including that the patient became agitated, received ativan, and was stumbling. A Posey restraint was applied to prevent the patient from falling. The physician evaluated the patient and recommended that he be watched instead and the restraints were removed. However, the letter acknowledged that " physician notified posey restraint was placed due to patient manifestation", but this statement was not explained further. No option to contact regulatory authorities was included in the grievance notification letter. In addition, this complaint was not included in Performance Improvement grievance/complaint logs.

MR #14: There was a written complaint from the daughter of this patient that noted a decubitus ulcer that was never reported to the family, and failure of the nursing staff to provide adequate hygiene care. The complaint was reviewed in the nursing log but not documented in the Performance Improvement grievance log. The notes indicated that the staff addressed the issue with nursing staff and with the family. No written response was provided to the complainant nor was any summary of the hospital's investigation attached.

MR# 15: A review of the nursing complaint log noted that a complaint was received 8/16/12. The patient complained in writing that he was discharged in pain and that the physician behaved inappropriately and made alleged insensitive remarks. The nurse apologized to the patient and spoke with staff. No written response was provided to the patient nor there was no evidence of a written investigation other than a note written on the patient's statement (no date recorded). This complaint was not recorded in the hospital's main Performance improvement grievance log.

MR #16: This patient complained on 12/10/12 of inadequate nursing care, including failure to respond to call bells, delay in bedpan assistance and receiving medications during an October 2012 hospitalization. The nursing complaint log recorded that the manager met with staff to investigate and "addressed all issues". The patient was called and an apology expressed. It was noted that the patient was satisfied with corrective action taken. A follow up noted that the patient called on 12/12/12 and was satisfied with the response. No written letter of response was issued nor there was no evidence in the grievance file of investigative details and written conclusions to resolve these complaints other than an e-mail dated 12/11/12.

MR# 17: This patient complained in writing to nursing that on 11/7/12 she was insulted, verbally abused, and "stabbed " twice with a needle by the nurse. Attached to this grievance was a written note from a nursing employee who explained the patient's behavior and allegation. No written summary was included nor there was no evidence of an investigation. Review of the nursing grievance log noted that "nursing supervisor investigated complaint and addressed issue with patient and staff ". No written response was provided to the complainant . In addition, the main performance improvement log did not include written documentation of this grievance.

Six of eighteen cases sampled from the 2012 Performance Improvement grievance logs revealed the following deficiencies:

A series of e-mails submitted by a physician to Performance Improvement and administrative staff detailed multiple complaint issues between the date range of 1/26/12 and 7/2/12.

Patient complaints issue included:

Failure to respond to call bells (MR#s 18, 23).

Lack of nursing assistance with hygiene care (MR#s 18,19).

Lack of timely pain medication for patients, including diagnosed sickle cell patients (MR#s 20, 23).

Surgery delays (MR#21).

Lack of timely ordering and correct processing of laboratory work during night shift (MR# 22).

These complaints were followed up through department feedback, however the facility failed to advised the patients in writing regarding the findings of these complaints.

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Based on review of procedures, records, observations, and staff interviews it was determined that the facility did not implement effective and safe patient restraint practices.
Findings include:
1. The facility's restraint procedures that were reviewed on 1/15/13 did not correspond to actual practices being implemented at the hospital, specifically related to documentation of restraint orders in the electronic record.
Review of the restraint procedure, titled "Use of Restraints for Non-Behavioral Health" on 1/15/13 found a paper attachment referenced as a template for restraint orders and monitoring flow sheets. This form requires documentation of previous but unsuccessful interventions attempted prior to restraint application. However, this combined paper order and monitoring form was no longer used. Restraint orders and monitoring records are documented on an electronic form that is entered into the EPIC computer system for medical record recording. The electronic restraint order form does not record alternatives attempted prior to restraint initiation.

2. The restraint policy titled "Restraints for Violent Behavior" reviewed on 1/15/13 indicated that chemical restraints are not used. However, during an interview on 1/14/13 with nursing staff on unit 6 South, it was reported that chemical restraints may be used on occasion. The electronic restraint monitoring form does not document medications used concurrently with physical restraints nor document the patient's physiological response when both medication with physical restraints are used conjointly.

3. The facility did not ensure documentation of adequate orders or monitoring of patients who require restraint application.
Seven of seven applicable inpatient concurrent records reviewed on 1/14/13 during a tour of Medical/Surgical unit 6 South found no documentation of alternatives attempted prior to issuance of restraint orders. Electronic Nursing monitoring forms in records reviewed listed "face to face" documentation and "less restrictive alternative" in checklist format but this checklist lacked details. Charts reviewed contained no documentation of any reassessment of restraints usage by a physician.
Two patients with active restraint orders were observed not to be in active restraints. The Staff that were interviewed stated these devices were temporarily released but documentation in the corresponding records lacked reasons and criteria for discontinuation. (MR #9, #25)

MR #24: This 76 year old patient admitted for asthma exacerbation was observed during a tour of unit 6S on 1/14/13 at approximately 1 PM. This patient was observed to be restrained in bilateral wrist restraints on 1/14/12 at approximately 1PM. A subsequent review of the record found restraints were ordered on 1/14/13 at 1:37 AM for "secured mitt: both". Orders for bilateral mittens were not implemented. Staff interviewed reported that the restraint was to prevent the pulling out of the patient's NG tubes. The reason given for the restraint order was interference in medical treatment. However, there was no documented evidence as required by policy that an alternative treatment was atempted prior to restraint initiation.

MR # 9: This 82 year old male was admitted 1/10/13 following a fall. The patient was observed during a tour of unit 6S on 1/14/13 at approximately noon. Staff reported that this patient had been placed in bilateral wrist restraints for agitation. The restraints had been temporarily released. The patient was confused and said he was in the "latest place". Review of the record found that right and left wrist restraints were ordered on 1/13/13 at 1 :14 PM for interference with medical treatment. No alternative treatment attempts were noted prior to restraint initiation per policy.

MR# 25: During tour of inpatient unit 6S on 1/14/13 at approximately 12:30 PM, surveyors were advised that this patient was in restraints. Staff had reported that the restraints were temporarily removed because he was eating. On interview the patient was found alert and verbal but displayed periodic confusion where he did not know the current year.

Review of the record found that this patient was brought to the hospital following a suicide attempt where he attempted to jump out of the window in his house. He was evaluated by psychiatry in the ER on 1/7/13 and was determined to have suicidal ideation and depression. He was placed on 1:1 observation. The patient was subsequently admitted to MICU and then to a Medicine unit following development of delirium tremens. The patient was given ativan IV on 1/9/13. Orders for bilateral wrist restraints were noted on 1/14/13 at 3:04 AM for 24 hour duration due to interference with medical treatment. No alternative treatment was attempted and noted on these orders prior to restraint initiation. A review of restraint flow sheets found restraints were continued through 7:02 AM on 1/14/13. Restraint checklist flow sheets contained blank spaces after 7:02 AM dated 1/14/13. No reason for this discontinuation was noted.

Psychiatric follow up on 1/14/13 at 10:50 AM noted that the patient was receiving 1:1 observation but does not require 1:1 as he is not an acute risk.

A new restraint order was written by a different MD for bilateral wrist restraints at 10:20 AM for 24 hour duration due to "interference with medical treatment." A review of restraint flow sheets showed documentation that bilateral restraints had been continued on 1/15/13 at midnight. There was no documentation of less restrictive alternatives attempted, including reinstatement of 1:1 or an explanation why this option was not considered.

Similar findings regarding the incomplete restraint orders which did not include alternative treatment attempts prior to initiation of restraints were also noted in MR #10, # 26, # 27 and # 28.
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1. Based on review of quality assurance reports and staff interviews, it was determined that the facility did not implement data analysis of patient care indicators relevant to outpatient program or specialty clinics.

Findings include:

Review of Ambulatory Care QAPI meeting minutes on 10/23/12 and staff interview on 1/15/13 found that there was no specific implementation of data collection or measurement of indicators as planned to assess quality of care provided in the pediatric high risk or other ambulatory care specialty clinics. This finding does not apply to the pediatric Infectious Disease clinic, which was voluntarily suspended by the facility on 12/19/12, and was not in operation at the time of this survey.

Review of Performance Improvement Committee meeting minutes dated 10/23/12 on 1/15/13 found there were no clinical patient care indicators to measure patient care for each operating specialty clinic. It was noted that there were plans to have a performance improvement project implemented at every specialty clinic. This was in response to findings of lack of testing and follow up of laboratory work identified during a previous Allegation survey conducted by the New York State Department of Health on 9/20/12.

Review of the report on 1/15/13 from the Ambulatory Care Network for the period 12/12 stated that the facility needed to revise the Quality Assurance plan to address the deficiencies cited, during the prior survey, for the death of an infant with prenatal HIV exposure. This document noted that subspecialty clinics were incorporated into the Ambulatory Care QAPI Plan. This document also specified the expectations for clinical indicators in clinic areas covering pediatrics, adolescent, adult preventative care, prenatal care, and PI clinics in specialty clinics "to include identification of high volume, high risk and problem prone clinical opportunities for improvement."

A third document was provided on 1/15/13 which listed Ambulatory care Subspecialty Clinic Performance improvement Indicators for 2013. This data collection tool listed indicators for each of 30 specialty clinics. Review of these proposed performance improvement (PI) indicators for 2013 found specific indicators were developed and data collection is prospectively planned for each specialty clinic. However, no data was collected or analyzed at the time of review of this tool on 1/15/13.

At interview with Administrative staff on 1/15/13, it was reported that the facility did not yet implement data collection for analysis of planned clinical patient care indicators for specialty care clinics as noted in the plan of correction dated 12/12. The plan of correction noted that the indicators would be developed by 12/17/12 and maintaining would begin in January 2013. This implementation of data collection had not yet begun at the time of follow -up interview with Performance Improvement staff on 1/25/13.

Of note, it was stated at interview with Administration on 1/10/13 at 10AM that the services of the pediatric high risk clinic was suspended voluntarily by the hospital during a conference call with representatives of New York State Department of Health on 12/19/12. Review of documents furnished by the facility found an e-mail transcription dated 12/28/12 from the Assistant Director of the Bureau of Ambulatory Care Services of the AIDS Institute addressed to the Administrators of the Hospital. This document summarized the voluntary clinic suspension of the pediatric HIV clinic at the hospital, which was underway as of 12/21/12 and which noted that children were in the process of being transferred to other programs.

This is a repeat deficiency for the failure to implement data collection and analysis of QAPI indicators for the remaining clinics in operation by January 2013.

Cross-refer to findings noted also under tag A273 for Event ID # ELLQ12.

2. Based on review of QAPI documents and staff interviews it was determined that data collected for discharge planning and social work indicators were not fully analyzed. Identified problems were not followed up with Hospital wide Performance Improvement Council.

Findings include:

a. Review of Social Work and Discharge planning Quality assurance tracking reports on 1/15/13 found that 19 indicators for medical-surgical discharge planning were documented. However, there were only written results analyzed for only one indicator (#18: appropriateness of discharge plans). Interview with two Social work managers on 1/15/13 found the results of all 19 indicators and data is reviewed concurrently for open records. The results are discussed in person via supervision with staff for corrective actions to be immediately taken. There was no separate analysis in the report for the percent compliance for each measured indicator.
These reports were not documented for analysis in order to identify and review trends.

b. It was determined that the Case Management/Social work departments did not report quarterly to the hospital wide committees for quality assurance meetings. The last report of managed care denials was submitted to the hospital-wide Performance Improvement Council on 2/2/12. No reports were evident subsequent to that time. In addition, Department of Case Management and Social Work Performance Improvement project for 2012 identified low compliance with issuance of the Important Message for Medicare upon admission and prior to discharge. Follow up was noted in March 2012, June, and September 2012, which revealed low compliance rates. Recommendations were added in January 2013 for a '"hard stop" in the EPIC medical record system.

This information was not reflected in hospital wide Performance Improvement Council (QAPI) meetings.

Based on record review the staff failed to provide care for pressure ulcers as per facility policy on 3 of 7 medical records reviewed.
Findings include:
Review of MR #3 on 1/14/13 noted that this patient was admitted on 12/11/12 with skin intact. On 12/13/12 nursing documentation noted bruising to the left arm and right ankle, bilateral extremities abrasions. A stage III pressure ulcer to the right leg was noted on 12/14/12. On 12/17/12 multiple pressure ulcers noted: stage II to the right elbow, right foot, right hip and anterior right thigh, right buttock-3cm. Nursing documentation failed to indicate that pressure ulcers were being measured weekly as per facility's policy.

Review of MR #29 on 1/11/13, noted that this patient was admitted on 12/20/12 with intact skin. On 1/4/13, a 0.5 X 0.5 abrasion is noted to the sacrum. On 1/8/14 a stage II pressure ulcer to the sacrum measuring 2 X 3cm was being treated with wound gel. There was evidence of a physician's order for pressure ulcer care.

Review of MR #30 on 1/10/13, noted that this patient was admitted on 12/12/12. A stage II pressure ulcer to the left inner buttock was identified on 12/28/12 measuring 2.5 X 2.5cms. There was evidence of a physician's order for pressure ulcer care.

Based on observation, record review, and staff interview, it was determined that the facility did not ensure medical records were complete and that vital clinical information was readily retrievable from electronic medical records (EMR's) by clinical staff in a timely manner.

Findings include:

1. The hospital did not ensure that staff had sufficient knowledge and proficiency in the operation of its electronic medical record system to ensure competency in immediate access to portions of medical records. Specific reference is made to the widespread pattern of lack of staff knowledge and ability to retrieve complete and relevant patient data.
Medical records were incomplete and portions were not readily retrievable in a timely manner.

2. It was stated at interview with the administrative staff on 1/14/13 that the facility launched its electronic medical records system on August 1, 2011. Interview of nursing staff on 1/14/13 found that staff underwent a 5 day training course and have had only sporadic follow-up.

The facility did not ensure adequate monitoring of ongoing staff training needs to ensure competency in the ability to immediately access and retrieve vital data from patient medical records. It was observed during tours of patient care units on 1/11/13 that staff was unable to access portions or selected documents from patient records in a timely manner.

It was stated by nursing and administrative staff on 1/11, 1/14/13, and following the survey on 1/17/13, that the electronic medical record system, EPIC, was implemented simultaneously on 8/1/11. According to interview of nursing staff development on 1/17/12, there was no gradual transition from paper records to electronic system. The system went " live " over the course of the same day for all areas, with the exception of ambulatory care, which went live in June 2011.
Training provided to medical residents was limited to a two day training program followed by proficiency testing after teaching of modules and successful completion of testing using case scenario examples.
3. Specific instances were observed by surveyors during tours of inpatient units on 1/10/13 and 1/11/13 where it was observed staff was unable to locate or obtain relevant patient data from electronic medical records.
On 1/10/13 during tour of the neonatal ICU, staff was unable to readily locate data from MR #31 . Medical and nursing staff were observed signing on and off the system for this medical record in order to access and retrieve different patient data, including the psychosocial assessment.

3. Specific instances were observed by surveyors during tours of inpatient units on 1/10/13 and 1/11/13 where it was observed staff was unable to locate or obtain relevant patient data from electronic medical records.
3a. On 1/10/13 during tour of the neonatal ICU at approximately 1 PM the staff was unable to provide evidence of the collection of the newborn HIV screening specimen. The staff was unable to locate this newborn screening HIV testing documentation in MR #31.
It was stated at interview with a physician and a nurse on 1/10/13 that this HIV screening specimen is not collected until within 48 hours following birth and is sent to the lab within 72 hours of birth. It was stated that the sample will be sent out the same date and that it would be completed. This infant was delivered on 1/7/13 and the specimen collection should have been completed by 1/9/13.

Review of the revised draft policies on 1/15/13 for "Maternal-Pediatric HIV prevention and Care program policy and procedure (revised 12/12)" and Department of Pathology "NYSDOH HIV testing of high risk infants" finds different requirements for the timeline of collection of specimens and documentation. The pathology policy requires the whole blood specimen to be collected less than 48 hours after birth which should be received at Wadsworth lab within 72 hours of collection, whereas the Maternal Pediatric HIV prevention policy requires the nurse to complete documentation and to send the newborn screening blood collection to Wadsworth Lab within 24 hours.

3b. On 1/11/13 during tour of the emergency labor and delivery suite at 11 AM, patient MR #32 was reviewed. The patient returned to the hospital around 6:01 AM on 1/11/13 for seizures and elevated blood pressure after having signed out against medical advice on 1/10/13 at approximately 2:15 PM. The patient had been hospitalized on 1/6/13 for post-partum preeclampsia and labile blood pressure where the patient was observed for hypertension.
The resident's note indicated that the patient has a newborn at home who is being cared for by her mother and that the mother could not stay long term. The record lacked evidence of the final blood pressure taken prior to the patient's departure against medical advice . The record showed blood pressure of 136/90 at 10:25 AM on 1/10/13. There was no blood pressure recorded at 2:45 PM on 1/10/13 despite the presence of other vital signs taken. Staff could not locate the vital signs. It was stated that this information streams into the electronic record from armband monitoring equipment. Approximately 20 minutes later, the nursing staff was able to provide vital signs for the missing time period. The prior BP was 136/97 on 1/10 at 1448. No explanation could be provided for this missing information and subsequent discovery of this data.
3c. On 1/11/13 during tour of unit 3 North at approximately 3 PM, staff was unable to locate information for missing patients' rights data.

Based on observation and staff interview, it was determined that the director of food service failed to take responsibility for the daily management of dietary services to ensure proper food safety.

Findings include:

During a tour of the kitchen on 1/10/13 food items were observed not labeled with the day or date the food was prepared, or the date or day the food should be discarded. There were no labels observed on fruit cups, cottage cheese, diet pudding, macaroni salad, potato salad, cole slaw, tuna sandwiches, egg salad sandwiches and turkey sandwiches.

The absence of dated labels on food was prevalent in the kitchen.

Based on observation staff interview and document review, the hospital environment was not maintained in such a manner that the safety and well-being of patients are assured.

Findings include:
During tours of different units of the hospital in the period from 1/10- 1/14/2013, the following findings were identified in the presence of the Director of Engineering, Director of Fire Safety and Director of facilities who accompanied the surveyors throughout the survey.
Operating Rooms (OR):
On the morning of 1/10/2013, during a tour of the Operating Rooms, the followings were identified and brought to the attention of the hospital staff who acknowledged them:
1. There was an orthopedic fracture table stored in the scrubbing area between OR2 and OR3 and was obstructing the door of the sub sterile room.
2. Also, all the scrubbing areas were noted to house medical equipment and the sub sterile room being obstructed which imposed a potential infection of the medical equipment.
3. There was a broken adrenaline ampule and a Cefazoline 1gm ampule on the floor of the clean supply room next to the Omni cell machine (medication dispensing machine). Also, there was a biopsy torcher needle on the floor that was used for taking a biopsy. During the observation staff took the torcher from the floor and put it back on the shelf with the other sterile torchers which are a potential of infection.
4. The laparoscopes sterilization was performed in the soiled utility room which presents a potential of infection.
5. Oxygen cylinders, clean towels and other clean supplies were stored in the soiled utility room of the OR suite.
6. There were four (4) soiled linen bags and plastic container full of soiled linen being stored on the corridor near room 6 and next to those soiled items there was a clean supply cart that housed 0.35 Balloon Expandable Stent.
7. The hospital stored items very close to the ceiling in the sprinkled room and not leaving a space of > 18 inches in the general storage room next to room 7.
8. The soiled utility room of the OR suite (sprinkled room) was noted to have items stored very close to the ceiling tiles. This room did not have an exhaust and the corner beam of the room was broken. Also, the room did not have a sign to identify it.
The Ambulatory Surgery Suite:
1. The surface of bed #2 was found to be torn and had adhesive tapes to cover the torn areas.
2. The floor of the nutritional area next to the file cabinet was very dirty and dusty.
3. There were 10 turkey sandwiches kept in a refrigerator that was not working and did not have a thermometer. Therefore, the refrigerator and the turkey sandwiches most likely were at room temperature.
Emergency Department - (Ground Floor):
During a tour of the ED on 1/10/2013 at approximately 3:00pm the following findings were identified in the presence of the hospital staff who acknowledged the deficiencies.

The Soiled Utility Room in the ED had no room signage, and there were small holes in one of the walls.

In the Clean Utility Room there was one sharp container, and two biohazard containers being stored on the counter top next to the ice machine.

In the Clean Utility Room the surface of the ice machine was dirty and the ice machine was placed on a counter top that was damaged (i.e. stained, broken, dirty, etc.).

The Clean Utility Room in the ED had negative pressure.

Women's GYN:
In Exam Room #1, the examination table was damaged/torn, which make it difficult to be cleaned or disinfected.

The sharp container in that room was being held together with adhesive tape, and there were two small holes found in one of the walls near the alcohol wipe dispenser.

Various debris including cups were found on the floor of the Electrical Closet of the Emergency Department.

The Janitor's Closet, located in the vicinity of the Sonogram Room had no exhaust vent installed and was found to have a positive air pressure instead of the negative air pressure that is required for this room. Also, some boxes were stored less than 18" from the sprinkler heads.

Pediatric Emergency Department:
The caulking around the base of the sink in the vicinity of the Resuscitation Bay was damaged and dirty. Tape layers were also found on the wall panel that was located over this sink.

In the Storage Room, two wall based hazardous waste containers were located directly over/touching various Christmas supplies and a stroller.

Clean and soiled items were stored in the soiled utility room of the pediatric ED.

The clean utility room of the pediatric ED was found to have a negative air pressure instead of the required positive air pressure for this type of room.

The printer located in the Pediatric Emergency Room registration area was very dirty /dusty.

Adult Emergency Department:
In the Adult Emergency Department waiting room the following was found - the lower wall cove base by one of the entrance columns was missing, the corner bead was also exposed in this same column; the garbage can was covered in multiple layers of adhesive tape. It was also very dusty/dirty behind the radiator in this room.


Kitchen:
During a tour of the Kitchen on 1/11/2013 at approximately 10:30am, the following findings were identified in the presence of the hospital staff who acknowledged the deficiencies.


The exit door near to kitchen was observed to be blocked by an empty box and a safety cone which impedes the closure of the door.

No illuminated exit signs were found in the preparation and assembly area of the kitchen.

Sprinkler head escutcheons in the corridor outside the dish washing area, and other areas of the kitchen were partly broken and not flush with the ceiling tiles.

There was a container of egg salad kept in one of the refrigerators and had no label to indicate the time and date of its preparation. When asked, the Director of Dietary said that the container was prepared on that day of the inspection. The temperature of the chicken salad was 56 F, and the refrigerator temperature was 50 F.

The three Silverstar convection ovens were dirty /visibly stained and had black crusts of dried food next to their doors.

The area behind the Soup Vat and Pasta Vat was extremely dirty. Specifically, the metal beam and the gas pipes had accumulations of dirt

The floor along the edges of the various large kitchen equipment (the vats, the ovens, etc.) was very dirty and dust laden.

The gas pipes and the metal supporting beam behind the soup and the pasta preparation vats were extremely dirty and dust laden. Loose dust covering the area which is very near to the open vats.

A cockroach was seen at this time crawling on the metal piping behind these vats.

The floor underneath the soup and pasta preparation area was broken and very dirty and there was an accumulation of water.

The hand-washing sink located near the Janitor's Closet was damaged and the soap dispenser installed above it was held together with duct tape.

Central Sterile Room:
No illuminated exit signs were found in the clean preparation area.

The ceiling tiles of the Central Sterile area were of the regular type and not of the washable ceiling tiles that is required.

Three damaged sprinkler head escutcheons were found in this area.

This room did not have a hand washing sink.

Multiple stained ceiling tiles were found and paint was peeling from one of the walls.

Decontamination Room:
The kick-plate on the entrance door was damaged, and the door handle plate was missing a screw.

There were various damaged/cracked floor tiles found in this room.

In the vicinity of the Steris Washer/Disinfector there were dirty/rusty pipes and dirty floors.

An electrical plug for a transformer was wire-tied to the wall to keep it plugged in.

Dialysis:

The cove base was missing behind Station #2.


An electrical outlet cover-plate in the vicinity of Station #1 was loose in the wall, and this outlet does not cover the wall cutout.

A soiled linen cart and a biohazard infectious waste container was touching a privacy curtain and a spare wheelchair.

The Water Treatment Room had no signage.

MICU/CCU:

The Isolation room of the MICU was found to have regular ceiling tiles instead of the washable ceiling tiles that are required for this type of room.

The soiled utility room of the MICU was found to have a positive air pressure, instead of the required negative air pressure for this type of room.

A cutout in the wall for an electrical outlet cover plate was too large in MICU-Bed 2. It was not covered by the cover plate.

One damaged ceiling tile, and one stained ceiling tile was found in MICU-Bed 1.

A module housing unit was held together with a piece of wood and medical tape in MICU-Bed 6.

Adult Psychiatric ED:

During a tour of the Adult Psychiatric ED on the afternoon of 1/11/2013, the following findings were identified in the presence of the hospital staff that acknowledged the deficiencies.

1. The unit had only one bathroom area for both males and females at the end of the unit (toward the section that houses the male beds). During the site visit one patient complained and expressed concern about this issue.

2. All the patient stretchers and or beds had features that presented a looping hazard.

Psychiatric Unit- 2nd floor of C Building:
During a tour of the Psychiatric unit on the second floor of the C building on the morning of 1/14/2013, the following findings were identified in the presence of the hospital staff who acknowledged the findings. The hospital staff stated that the hospital is planning to renovate the two psychiatric units and will correct all the deficiencies.
All patient rooms, bathrooms, and the handrail of the corridor had looping hazards and presented a potential risk for the psychiatric patients who might have suicidal tendencies as follows:
a. The faucets of the hand washing sinks of all the bathrooms of the patient rooms were of the regular type of hardware that present a looping hazard.

b. The showers heads of all the bathrooms of the patient rooms were of the regular type of hardware that present a looping hazard.

c. Shower water controls of all the bathrooms in the patient rooms were of the regular type of hardware that present a looping hazard.

d. All the patient beds had several metal restraining hooks in each bed, that present a looping hazard.

e. Many patient rooms had broken night stands with missing drawers, that present a looping hazard.

f. Room #250 had a regular medical bed with many parts that present a looping hazard.

g. The floor and the wallpaper outside room 250 were observed to be broken in many areas.

h. The call system in the hallway outside the patient rooms had openings and/or projections that present a looping hazard and/or safety risk.

i. The seclusion room had a metal projection of the lock in the interior surface of the door that presents a safety risk for the patients.

j. The seclusion room was not padded and presents a safety risk for the patients.

k. The faucet and the hand-washing sink in the bathroom of the seclusion room is square in shape and presents a looping hazard.

l. The pipes underneath the hand-washing sink were exposed and presents a looping hazard.

m. The doors handles of the seclusion room are L shape and present a looping hazard.

n. The cove base of room 259 was noted to be broken and in disrepair.

o. Room 262 had a smell of urine in the room. The room had a medical bed that presents a looping hazard.

p. The TV box by the north lounge was mounted at >4 feet from the floor and was found to have 36 openings on the four sides of the box that presents a looping hazard.

q. All of the hardware in the patient bathroom by the north lounge (sink, faucet, flushing system and exposed pipes ...etc.,) were of the regular type, not of the safety type that are required for the psychiatric units as they present a looping hazard.

r. Some flies were observed around the soiled utility room of the psychiatric unit.

s. The water faucet of the fountain was of the regular type and presents a looping hazard.

t. The handrails of the corridor outside the patient bedrooms had a gap of two (2) inches between the rails and the wall that presents a looping hazard.

u. The cord of the cassette and electric sharpener of the activity room presents a looping hazard.

v. The doors of the storage closets in the activity room had multiple features that present a looping hazard. Examples include, but were not limited to, the locking pad, the gaps between the closet and the upper frame of the door.

w. The patient bathroom next to the activity room and the patient bathroom in front of the laundry room had multiple features that present looping hazards that included but were not limited to: gap between the sink and the wall, regular faucet, regular door handle, exposed pipes and the toilet flushing system.

Rehabilitation Unit - 5th floor of AB building:
During a tour of rehabilitation unit at 3:15 of 1/14/2013 the following findings were identified in the presence of the facility's staff who acknowledged the findings.
1. There was a hose coming from above the ceiling tiles that extended to drain into the hand washing sink of the gyn area. The staff said that the hose is draining a leak from the floor above. That presents a potential of infection for the staff and patients.
2. The patient bathrooms in many patient rooms (examples included but were not limited to: Room TCU521 and TCU 520) had garbage containers and soiled hampers in the shower areas of the bathrooms.
3. The airborne isolation room #519 of the Rehabilitation unit had regular ceiling tiles instead of the required washable ceiling tiles that are required for this type of room.
4. The formica of the dining table in the dining room at the occupational therapy area was in disrepair that presents an infection control concern.
The Medical Surgical Unit:
1. The nursing call bell of room 542 did not have a light annunciation and it was not identified correctly at the nursing station. When the nurse call bell was activated in that room the staff could not locate the room correctly although they heard the sound of the bell.
Endoscopy Suite:
During a tour of the Endoscopy suite on the morning of 1/15/2013, the following findings were identified in the presence of the hospital staff who acknowledged the findings.
1. The procedure rooms are very tight and small in size (about 120 square feet) and the hand washing sink was not accessible because it was obstructed by the medical equipment.
2. The surfaces of the metal cabinets in the procedure rooms were rusted and dirty.
3. The surfaces of the supply cart and the paper towel holder in the procedure room were rusty.
4. The nurse call bell in the patient bathroom in the endoscopy suite was not working.
5. The hallway of the endoscopy suite was partially blocked by two supply carts and two supply cabinets. Only three feet of the exit way was available for stretchers and suite evacuation in the event of emergency or fire.
The Radiology Suite:
During a tour of the Radiology Suite at 10:45 am of 1/15/2013 the following findings were identified in the presence of the facility's staff who acknowledged the findings.
1. The nurse call bell of the patient bathroom in the waiting area did not annunciate at the nursing station. When it was activated, no nurse or staff member responded to the nursing call bell of that bathroom.

2. Six big boxes full of supplies were stored in one of the dressing rooms.

3. The chair inside a dressing room was found to be dirty, torn and had adhesive tape.

4. The hospital used one dressing room as a janitorial closet.

5. Six dressing rooms did not have nursing call bells, chairs or hangers for patients to hang their clothes.

6. Ultrasound room #2 did not have a hand washing sink.

7. Ultrasound room #3 is used for thyroid biopsy and Hystro sonography. This room was found to have a microwave, cups, food foil trays and a refrigerator used for storing food for the staff. This presents an infection control concern.

8. The floor of the CT scan room was noted to be dusty, dirty and stained.

9. Medical supplies were found being stored in a room with 6 cabinets used as lockers for staff. There are dirty shoes on the floor. The room was found to have a negative air flow.

10. The Mechanical area on the 6th floor did not have readily accessible illuminated exit signs to direct staff to the exit door in the event of smoke or fire.

Based on observation and staff interview, the facility did not maintain a sanitary hospital environment and did not maintain safe air handling systems in areas of special ventilation, such as soiled utility rooms, intensive care units, and airborne infection isolation rooms.
Findings include:
During tours of different units of the hospital in the period from 1/10 - 1/14/2013, the following findings were identified in the presence of the Director of Engineering, Director of Fire Safety and Director of the facility who accompanied the surveyors throughout the survey.
Operating Rooms (OR):
On the morning of 1/10/2013, during a tour of the Operating Rooms, the following were identified and brought to the attention of the hospital staff who acknowledged them.
1. There was an orthopedic fracture table stored in the scrubbing area between OR2 and OR3 and was obstructing the door of the sub sterile room.
2. Also, all the scrubbing areas were noted to house medical equipment and the sub sterile room being obstructed which imposed a potential infection of the medical equipment.
3. There was a broken adrenaline ampule and a Cefazoline 1gm ampule on the floor of the clean supply room next to the Omni cell machine (medication dispensing machine). Also, there was a biopsy torcher needle on the floor that is used for taking a biopsy. During the observation staff took the torcher from the floor and put it back on the shelf with the other sterile torchers which are a potential of infection.
4. The laparoscopes sterilization was performed in the soiled utility room which presents a potential of infection.
5. Oxygen cylinders, clean towels and other clean supplies were stored in the soiled utility room of the OR suite.
6. There were four (4) soiled linen bags and plastic container full of soiled linen being stored on the corridor near room 6 and next to those soiled items there was a clean supply cart that housed 0.35 Balloon Expandable Stent.
The Ambulatory Surgery Suite:
1. The surface of the bed #2 was found to be torn and had adhesive tapes to cover the torn areas.
2. The floor of the nutritional area next to the file cabinet was very dirty and dusty.
3. There were 10 turkey sandwiches kept in a refrigerator that was not working and did not have a thermometer. Therefore, the refrigerator and the turkey sandwiches most likely were at room temperature.
Emergency Department - (Ground Floor):
During a tour of the ED on 1/10/2013 at approximately 3:00pm the following findings were identified in the presence of the hospital staff who acknowledged the deficiencies.
- The Soiled Utility Room in the ED had no room signage, and there were small holes in one of the walls.
- In the Clean Utility Room there were one sharps container, and two biohazard containers being stored on the counter top next to the ice machine.
- In the Clean Utility Room the surface of the ice machine was dirty and the ice machine was placed on a counter top that was damaged (i.e. stained, broken, dirty, etc.).
- The Clean Utility Room in the ED had negative pressure.

Women's GYN:
- In Exam Room #1, the examination table was damaged /torn, which make it difficult to be cleaned or disinfected.
- The sharp container in that room was being held together with adhesive tape, and there were two small holes found in one of the walls near the alcohol wipe dispenser.
- Various debris including cups were found on the floor of the Electrical Closet of the Emergency Department.
- The Janitor's Closet, located in the vicinity of the Sonogram Room, had no exhaust vent installed, and was found to have positive air pressure instead of the negative air pressure that is required for this room.

Pediatric Emergency Department:
- The caulking around the base of the sink in the vicinity of the Resuscitation Bay was damaged and dirty. Tape layers were also found on the wall panel that was located over this sink.
- In the Storage Room, two wall based hazardous waste containers were located directly over/touching various Christmas supplies and a stroller.
- Clean and soiled items were stored in the soiled utility room of the pediatric ED.
- The clean utility room of the pediatric ED was found to have negative air pressure instead of the required positive air pressure for this type of room.
- The printer located in the Pediatric Emergency Room registration area was very dirty /dusty.

Adult Emergency Department:
- In the Adult Emergency Department waiting room the following was found - the lower wall cove base by one of the entrance columns was missing, the corner bead was also exposed in this same column; the garbage can was covered in multiple layers of adhesive tape. It was also very dusty/dirty behind the radiator in this room.


Kitchen:
During a tour of the Kitchen on 1/11/2013 at approximately 10:30am, the following findings were identified in the presence of the hospital staff who acknowledged the deficiencies.

The exit door near to kitchen was observed to be blocked by an empty box and a safety cone which impedes the closure of the door.

No illuminated exit signs were found in the preparation and assembly area of the kitchen.

Sprinkler head escutcheons in the corridor outside the dish washing area, and other areas of the kitchen were partly broken and not flush with the ceiling tiles.

There was a container of egg salad kept in one of the refrigerators and had no label to indicate the time and date of its preparation. When asked, the Director of Dietary said that the container was prepared on that day of the inspection. The temperature of the chicken salad was 56 F, and the refrigerator temperature was 50 F.

The three Silverstar convection ovens were dirty /visibly stained and had black crusts of dried food next to their doors.

The area behind the Soup Vat and Pasta Vat was extremely dirty. Specifically, the metal beam and the gas pipes had accumulations of dirt

The floor along the edges of the various large kitchen equipment (the vats, the ovens, etc.) was very dirty and dust laden.

The gas pipes and the metal supporting beam behind the soup and the pasta preparation vats were extremely dirty and dust laden. Loose dust covering the area which is very near to the open vats.

A cockroach was seen at this time crawling on the metal piping behind these vats.

The floor underneath the soup and pasta preparation area was broken and very dirty and there was an accumulation of water.

The hand-washing sink located near the Janitor's Closet was damaged and the soap dispenser installed above it was held together with duct tape.

Central Sterile Room:
- The ceiling tiles of the Central Sterile area were of the regular type and not of the washable ceiling tiles that is required to this type of room/area.
- Three damaged sprinkler head escutcheons were found in this area.
- This room did not have a hand washing sink.
- Multiple stained ceiling tiles were found and paint was peeling off one of the walls.

Decontamination Room:
- The kick-plate on the entrance door was damaged, and the door handle plate was missing a screw.
- There were various damaged/cracked floor tiles found in this room.
- In the vicinity of the Steris Washer/Disinfector there were dirty/rusty pipes and dirty floors.

Dialysis:

- The cove base was missing behind Station #2.
- A soiled linen cart and a biohazard infectious waste container were touching a privacy curtain and a spare wheelchair.
- The Water Treatment Room had no signage.

MICU/CCU:

The Isolation room of the MICU was found to have regular ceiling tiles instead of the washable ceiling tiles that are required for this type of room.

The soiled utility room of the MICU was found to have a positive air pressure, instead of the required negative air pressure for this type of room.

A cutout in the wall for an electrical outlet cover plate was too large in MICU-Bed 2. It was not covered by the cover plate.

One damaged ceiling tile, and one stained ceiling tile was found in MICU-Bed 1.

A module housing unit was held together with a piece of wood and medical tape in MICU-Bed 6.

Rehabilitation Unit- 5th floor of AB building:
During a tour of rehabilitation unit at 3:15 of 1/14/2013 the following findings were identified in the presence of the facility's staff who acknowledged the findings.
1. There was a hose coming from above the ceiling tiles that extended to drain into the hand washing sink of the gyn area. The staff said that the hose is draining a leak from the floor above. That presents a potential of infection for the staff and patients.
2. The patient bathrooms in many patient rooms (examples included but were not limited to: Room TCU521 and TCU 520) had garbage containers and soiled hampers in the shower areas of the bathrooms.
3. The airborne isolation room #519 of the Rehabilitation unit had regular ceiling tiles instead of the required washable ceiling tiles that are required for this type of room.
4. The formica of the dining table in the dining room at the occupational therapy area was in disrepair that presents an infection control concern.
Endoscopy Suite:
During a tour of the Endoscopy suite on the morning of 1/15/2013, the following findings were identified in the presence of the hospital staff who acknowledged the findings.
1- The procedure rooms are very tight and small in size (about 120 square feet) and the hand washing sink was not accessible because it was obstructed by medical equipment.
2- The surfaces of the metal cabinets of the procedure rooms were rusted and dirty.
3- The surfaces of the supply cart and the paper towel holder in the procedure room were rusty.
The Radiology Suite:
During a tour of the Radiology Suite at 10:45 am of 1/15/2013 the following findings were identified in the presence of the facility's staff who acknowledged the findings.
1. Six big boxes full of supplies were stored in one of the dressing rooms.
2. The chair inside a dressing room was found to be dirty, torn and had adhesive tape.
3. The hospital used one dressing room as a janitorial closet.
4. Ultrasound room #2 did not have a hand washing sink.
5. Ultrasound room #3 is used for thyroid biopsies and Hystro sonography. This room was found to have a microwave, cups, food foil trays and a refrigerator used for storing food for the staff. This room presents an infection control concern.
6. The floor of the CT scan room was noted to be dusty, dirty and had stained.
7. Ultrasound room #3 is used for thyroid biopsy and Hystro sonography. This room was found to have a microwave, cups, food foil trays and a refrigerator used for storing food for the staff. This presents an infection control concern.

Based on review of records it was determined that discharge planning evaluations were incomplete or did not result in plans that fully addressed identified needs.

Findings include:

1. 3/3 records reviewed for both postpartum and newborns on 1/15/13 determined that discharge planning social work/assessments contained incomplete assessments and demonstrated lack of implementation of discharge plans.

A. MR#33 Patient delivered newborn on 12/13/12. Mother had diagnosed HIV and had reported domestic violence during pregnancy. Social work evaluation dated 12/14/12 indicated FOB occasionally stays with her and her 11 year old son. Mother reported FOB is verbally abusive but not physically abusive, however the assessment noted she had to call Police and did not press charges. Mother denied safety issues, denied child ' s exposure to violence, and denied Child Protective agency involvement. No independent check with Agency for Children's Services (ACS) was considered by the worker nor documentation to explain why this was not considered.

A list of domestic violence resources was provided to the patient but no specific agency was noted or arrangements made for follow up. The assessment did not consider checking with Visiting Nurse for pre- discharge home evaluation or reason why this referral was not needed.

Clinic follow up with the infant ,MR#34, on 12/27/12 and 1/8/13 found no social service follow up during pediatric ambulatory care appointments.

B. MR #35: Mother with positive HIV status delivered newborn infant via normal vaginal delivery NSVD on 12/13/12. Social work assessment dated 12/12/12 confirmed patient resides with brother and had recent history of being punched by father of baby (FOB ) on 7/4/12. There was no reported Police involvement. Domestic violence resources were provided but no specific agency name was indicated nor was any arrangement made for follow up. It was noted patient feels safe to return to brother ' s home.

Patient had not informed FOB of her status and the assessment noted mother requested to speak with HIV counselor.

On 12/19/12 the social worker noted in the infant ' s record (MR #36) that no home care referral was required for infant but did not explain the rationale for this decision. The assessment did not consider checking with Visiting Nurse for pre- discharge home evaluation or reason why this referral was not needed.

The child returned to clinic on 1/8/13 but no social work follow up was evident.

C. MR # 37 and infant MR # 31:
During tour of NICU on 1/10/13, medical record was reviewed for this infant boy with RDS and rule out sepsis. Records for both infant and mother determined incomplete discharge and social work assessment.

The family was referred as required to the Agency for Children's Services (ACS) for maternal positive urine toxicology for cannabis (infant was negative). The mother had no prenatal care and denied marijuana use during pregnancy but admitted to past use. The mother claimed she lived with her daughter and her friend in a housing development where marijuana is smoked in the building. No history including maternal mental health history (other than for postpartum depression history) was elicited.

2. The following inpatient records reviewed determined incomplete discharge planning evaluations and lack of implementation of timely discharge plans. This was evident in 2/3 applicable records reviewed for patients with pending imminent discharge:

MR # 9:
During tour of unit 6S on 1/14/13 at approximately 1 PM, review of the record found that this 82 year old male was admitted on 1/10/13 after a fall. The patient had been restrained but was observed to have been released from bilateral wrist restraints during the tour. During attempted interview of patient by surveyors, the patient was confused but verbal; he did not recall the date and was unaware of hospitalization (patient stated he was "in the latest place" ).

Review of the medical record found the physician documented on 1/14/13 the patient was clinically stable for discharge home or home health aide or SNF on current medications. Social work documentation did not address the degree to which the patient ' s condition could impede the ability to return to the same level of care (home) as was in place prior to admission. The social worker documented on 1/11/13 indicated the patient ' s daughter was contacted for choices to sub acute facilities and a message was left. Listings of home care and facilities were also left bedside for daughter. No follow up was evident as of 1/14/13 at approximately 1 PM to include need for family interview.

Physical therapy (PT) was ordered on 1/11/13 at 0850 for evaluation and gait training but was not yet provided as of 1/14/13. No discharge orders were evident at that time.

Follow up as of 1/15/13 at 9:52 AM determined that the recommendation was made for sub acute rehabilitation but this plan was not yet discussed with family. Staff still awaited physical therapy evaluation for recommended subacute rehabilitation placement and Social work still had not validated an interview with the daughter, given the patient's confused mental status.

MR # 10: 95 year old patient was admitted on 1/4/13 for dehydration, failure to thrive and advanced dementia. On 1/14/13 during tour of the unit at approximately 1 PM and review of the medical record, surveyors were advised patient was ready for discharge to nursing home. Nursing admission assessment indicated the patient ' s right was " with parent /guardian " . The involvement of a guardian was noted but no paper work was presented or copied in the electronic record and confirmed at interview with the head nurse at that time.

Social work assessment dated 1/8/13 and follow up on 1/14/13 was incomplete. It noted patient lives with others and then followed up with the patient lives with his nephew. No information was obtained via validated interview of the nephew regarding the patient ' s baseline functioning at home before admission. Social work documented on 1/14/13 at 12:20 PM that the patient ' s nephew was reached and agreed with placement. The pick-up was arranged for 4:30 PM on 1/14/13. As of approximately 1:45 PM on 1/14/13, the record lacked documentation that discharge notice was provided to nephew.

There was no evidence of completion of a required discharge order, discharge summary, or documentation that discharge instructions were yet complete.

3. Based on review of procedure and record review, it was noted the facility did not include a method for incorporating unmet urgent discharge needs with patients who request to leave against medical advice. This finding was evident in 1/1 applicable records:

Findings include:

Review of MR # 32 during tour of inpatient emergency labor/delivery unit on 1/11/13 at approximately 11AM determined this patient had been readmitted on 1/11/13 at approximately 6 AM for seizures and highly elevated blood pressure. The patient signed out against medical advice the previous day (1/10/13). The patient had delivered a newborn on 1/1/13 at another hospital.

Medical resident ' s note at 2:15 PM on 1/10/13 indicated patient ' s desire to leave against medical advice because she has a recent newborn at home care for her mother and that the " mother cannot stay there forever " . The MD came to speak with the patient to advise of the risks of leaving and advised the patient to keep a blood pressure diary every 4 hours and discharge her on labetolol 500 mg PO BID and a blood pressure monitor.

The patient signed the AMA form consent as required by policy. The record lacked any consideration of referral to address unmet infant care needs and to examine if this would impact on a decision to remain in the hospital for medically necessary care.

The policy for AMA was reviewed on 1/14/13. This policy specifies that the need for discussion of risks by the MD and that the Administrator or Administrator on Duty shall be called when the patient is a minor, when there is a question of limited capacity and impaired understanding of risks, and for instances when the physician is concerned about the ability of family members to care for the patient safely. However there was no provision in the policy to address unmet discharge needs, in this instance related to imminent child care matters. Interview of staff on 1/11/13 found no consideration for referral for discharge planning or explanation why this possibility was not considered for the patient referenced above.

This finding was confirmed during interview with staff at the time of the unit tour on Labor and Delivery on 1/11/13.

Based on review of documents, procedures, and staff interviews, it was determined the facility did not meet requirements for the Condition of Participation for Outpatient Services. The facility did not fully implement changes in procedures for the comprehensive testing and follow up of infants at risk for HIV.

Findings include:

The Condition of Participation for Outpatient Services shall remain out of compliance as verified during the 1/14/13 re-visit survey for the following reasons:

1. The facility did not implement all activities, including correct policy revision and revised referral procedures, to reflect the changes made after the closure and voluntary suspension by the hospital of the pediatric HIV-ID clinic on 12/19/12.

At interview with Administration on 1/10/13 at 10AM, it was stated that the services of the pediatric high risk clinic was suspended voluntarily by the hospital after a conference call with representatives of New York State Department of Health on 12/19/12. Review of documents furnished by the facility found an e-mail transcription dated 12/28/12 from the Assistant Director of the Bureau of Ambulatory Care Services of the AIDS Institute addressed to the Administrators of the Hospital. This document summarized the voluntary clinic suspension of the pediatric HIV clinic at the hospital, which was underway as of 12/21/12 and which noted that children were in the process of being transferred to other programs.

2. The facility has not submitted a revised plan of correction to the NYSDOH for ambulatory care to reflect revised protocols and practices in the outpatient area, including revision of procedures, staff training, and QAPI activities to ensure safe patient care.

3. The facility has not implemented the plan of correction to analyze quality assurance data from specialty clinics. While indicators were developed specific to specialty clinics, no data collection or analysis has yet been performed during the site visit conducted between the dates of 1/10 and 1/15/13. The plan of correction from the Allegation Survey of 9/20/12 found that the plan to develop clinical indicators for subspecialty clinics on 12/17/12 and "review and maintaining" would begin in January 2013.
(Cross refer to citations written under tag A273.)
( This matter is also cited under the QAPI regulations for the Re-Visit Survey visit of 1/14/13 (Event ID ELLQ12))

4. The facility has not fully revised and accepted the HIV maternal-child testing procedures. Both revisions of procedures for Maternal Pediatric HIV prevention and care program, and Pathology Department procedures for NYSDOH HIV testing of high Risk Infants were in draft format and were not fully approved at the time of the survey.

5. Procedures document contradictory time frames for required collection of newborn HIV screening and testing specimens.
Review of the revised draft policies on 1/15/13 for "Maternal-Pediatric HIV prevention and Care program policy and procedure (revised 12/12)" and Department of Pathology "NYSDOH HIV testing of high risk infants" finds different requirements noted for the required timeline of collection of specimens and documentation. The pathology policy requires the whole blood specimen to be collected less than 48 hours after birth which should be received at Wadsworth lab within 72 hours of collection. However, the Maternal Pediatric HIV prevention policy requires the nurse to complete documentation and to send the newborn screening blood collection to Wadsworth Lab within 24 hours.


6. Follow up phone discussion with hospital administrative staff in the department of performance improvement on 1/25/13 found that the facility has not developed facility specific procedures for the mandatory Newborn Screening Program for all conditions, including HIV (heelstick), and defers to New York State Wadsworth Guidelines for this requirement. This requirement for mandatory newborn HIV screening of all newborns differs from the procedures to test infants who are HIV exposed. While the Maternal Pediatric HIV prevention policy refers to the screening requirement and need for screening blood specimen collection to be sent to Wadsworth within 24 hours, it refers to New York State Guidelines and does not adapt it specifically to facility needs.

7. Follow-up interview with Performance Improvement staff on 1/25/13 confirmed that on 1/23/13, contact with NYSDOH AIDS Institute staff recommended revision of the policy titled, "Maternal-Pediatric HIV prevention and Care program policy and procedure (revised 12/12)" to include changes since the temporary clinic suspension on 12/19/12. The policy was to be amended to include that follow up is to be conducted at Infectious Disease clinic for adults and at pediatric high risk clinic for the baby.
However, this policy does not incorporate specific procedures to be followed, including specialized referrals to other facilities to be accomplished upon confirmed positive HIV DNA PCR or RNA testing of the infants in the outpatient clinic.

Cross refer also to Tag A1076 for re-visit survey, Event ID # ELLQ12.