HospitalInspections.org

Based on findings from document reviews and interview, the hospital did not provide education to clinical staff regarding policies and procedures related to HIV confidentiality requirements, as required by New York State Department of Health (NYSDOH) regulations.

Findings include:

--In 14 of 14 clinical staffs' personnel files/training records reviewed, each lacked documentation that education regarding HIV confidentiality was provided at the time of initial employment.

--NYSDOH regulation 63.9(a) in Title 10 of the New York Codes, Rules and Regulations requires that health facilities provide initial employee inservice education regarding "the legal prohibition against unauthorized disclosure (of HIV confidential information) in Public Health Law Article 27-F and provisions of Article 21, Title III," and provide updates to all employees when there are changes to relevant laws and regulations.

--During interview on 04/23/13 at 10:45 am, the Director of Clinical Education stated that information regarding infection control and confidentiality is provided to staff during orientation but acknowledged that information specifically regarding HIV confidentiality is not provided.

Based on findings from document reviews and interviews, 2 of 5 patients' medical records (MRs) reviewed in outpatient services did not contain consistent and accurate information related to advance directives.

Findings include:

-- Per review of 1 of 2 MRs in the outpatient Observation Unit on 04/22/13 at 9:00 am, Patient A's Face Sheet indicated he/she did not have a Health Care Proxy (HCP). However, Patient A's MR included a signed HCP form.

During interview on 04/22/13 at 9:00 am, this finding was confirmed by Nurse Manager #1.

-- Per review of 1 of 3 MRs for the Emergency Department (ED) on 04/18/13 at 10:00 am, Patient B's Face Sheet indicated he/she had a HCP. However, a nursing note by RN #1 indicated the patient did not have a HCP or an advance directive.

During interview on 04/18/13 at 10:15 am, RN #1 acknowledged that the HCP information he/she documented in Patient B's MR was incorrect.

Based on findings from document reviews and interview, in 3 of 4 episodes of restraint application reviewed (in 2 MRs) the physician orders did not specify the exact type of restraint to be used. In 1 of the 4 episodes of restraint applications reviewed, the physician order for restraints was not dated and timed and did not provide the duration of restraint use.

Findings include:

-- Per review of the MR for Patient C, he/she was brought to the Emergency Department (ED) after a suicide attempt and admitted to the Mental Health Unit (MHU) for further treatment. In the ED an order for "Restraints" was written that is not dated or timed and does not specify the type of restraint or its duration of use.

-- Per review of the MR of Patient D, he/she was evaluated and treated in the ED and then admitted to the MHU with the diagnosis of bipolar disorder. Two Restraint Order forms, one in the ED and one on the MHU 3 days later, each contain non-specific physician orders for use of "4/5 point restraint."

--- During interview on 4/22/13 at 11:15 am the Psychiatric Nurse Educator acknowledged the findings above.

Based on findings from document reviews and interview, the hospital policy and procedures (P & P) addressing adult restraints for behavioral management and the corresponding "Restraint Orders" medical record form did not provide staff guidance for using the least restrictive restraint intervention.

Findings include:

-- The hospital P & P titled "Adult Restraint Policy/Procedure," last revised 02/20/12, defines and addresses the following types of restraints: 4 points, defined as all four limbs restrained; and 5 points, defined as all four limbs restrained, with additional use of an abdominal restraint. The P & P indicates the physician must assess which category (level) of restraint applies.

-- The hospital's pre-printed "Restraint Orders" medical record form contains a single checkbox to order "4/5 point restraint."

-- The P & P lacks guidance regarding when the lesser restrictive 4 points restraint should be used versus the more restrictive 5 points restraint. The order form combines the use of either 4 or 5 points restraint in one order and leaves it to nursing staff to determine which level of restraint to apply.

- See Tag A 164 for related medical record review findings.

-- During interview on 04/19/13 at 3:40 pm, the Psychiatric Nurse Manager acknowledged that the order form allows nursing staff to choose either 4 or 5 point restraints for patient and/or staff safety when "4/5 point restraint" is ordered.

Based on findings from document reviews and interview, the hospital policy and procedures (P & P) addressing adult restraints for behavioral management did not incorporate New York State Education Department (SED) scope of practice information in its assessment requirements, and did not provide staff consistent and accurate guidance for monitoring patients in restraints. Also, in 2 of 2 MRs reviewed, nursing documentation regarding use of restraints was not in accordance with the hospital P & P.

Findings include:

-- The hospital P & P titled "Adult Restraint Policy/Procedure," last revised 02/20/12, specifies that a patient's circulation, mobility, sensation, tactile sensation and skin integrity will be assessed at least every 15 minutes but notes that this can be done by a "Care attendant or Psychiatric Assistant, who has received education" under the supervision of a registered nurse (RN). Per SED, assessment activities fall within the scope of practice for an RN and therefore cannot be performed by the unlicensed care attendants or psychiatric assistants allowed by this P & P.

One section of the P & P (page 13 of 17) specifies that for violent behavioral management restraints, an RN will assess and address the patient's level of distress and agitation, mental status, cognitive functioning and other care needs at least every 1 hour during restraint use. Another section (page 14) indicates the RN will evaluate the patient for appropriateness of restraint removal at least every 15 minutes. Evaluation of the patient for appropriateness of restraint removal every 15 minutes entails assessment of the patient's level of distress and agitation, and mental status, which, in contrast, the P & P requires to be checked every 1 hour.

-- Per review of the MR for Patient C, he was brought to the Emergency Department (ED) after a suicide attempt. The Restraint Flowsheet in the ED for Patient C indicates use of 5 point restraints was initiated at 6:20 pm and discontinued at 8:00 pm. An RN did not begin to document his/her assessments of the patient (every 15 minutes) until 7:47 pm, i.e., 1 hour 27 minutes later. The hospital "Adult Restraint Policy/Procedure" referenced above requires RN observation and documentation at least every 1 hour.

One day following admission to the MH unit, at 8:40 am Patient C was again restrained and the type of restraint listed on the Restraint Orders form is right and left arms and right and left legs. The first 15 minute patient assessment at 8:55 am was not documented on the Restraint Flowsheet until 10:47 am, i.e., 1 hour 52 minutes later. Also, a 35 minute interval occurred between the last assessment of the patient's condition (at 9:15 am) and when the patient was released from restraint at 9:50 am. This time interval exceeding 15 minutes was not compliant with the hospital P & P, failing to ensure timely assessment for conditions which could lead to injury or death under this high level of restraint, and timely identification of the earliest possible time the restraint could be discontinued.

-- Per review of the MR for Patient D, he/she was seen in the ED and then admitted to the MH Unit with the diagnosis of bipolar disorder. The Restraint Orders form in the ED MR indicates the patient was placed in 4/5 point restraint at 2:20 pm and released at 3:30 pm, but nursing did not document the initiation of the restraint and the subsequent 15 minute assessments until 4:12 pm, i.e., 1 hour and 52 minutes later.

--- During interview on 4/22/13 at 11:15 am the Psychiatric Nurse Educator reviewed the MR restraint flowsheets for Patients C and D and acknowledged that the nursing documentation regarding use of restraints for these patients was not timely.

Based on findings from document reviews and interview, in 1 of 2 practitioner credential files reviewed regarding the process of granting additional privileges, the medical staff appraisal procedures did not include evaluation of the practitioner's qualifications for the additionally requested privilege.

Findings include:

-- Review of the credential file for Radiologist #1 revealed a request for an additional privilege for cryoablation (a process that uses extreme cold to destroy or damage tissue) on 04/09/12. The credential file did not contain any information to support current competency with this privilege, such as special training, professional education, documented experience, etc. There is documentation that Radiologist #1's additional privilege of cryoablation was approved by the Department Chairman (04/10/12), the Credentials Committee (04/10/13), the Medical Executive Committee/MEC (04/23/12) and the Board of Directors (04/26/12).

-- The Credentials Committee meeting minutes of 04/10/12 indicate that Radiologist #1's request for an additional privilege of cryoablation was "Recommended for approval" and the committee's action was "Refer to MEC".

-- During interview on 04/23/13 at 10:30 am, the Medical Staff Services Administrator confirmed his/her attendance at the Credential Committee meeting on 04/10/12 and verified that Radiologist #1's credential file did not contain supporting documentation for the additional cryoablation privilege when the committee met or when reviewed with surveyor on 04/23/13.

Based on findings from document review and interviews, nursing staff did not document all information required on the hospital's medication reconciliation form, i.e., the date and time patients last took a medication(s) prior to admission.

Findings include:

--Per review of the "Medication Reconciliation List" forms present in the MRs of Patients E through I , the column indicating the date and time of the last dose for each medication listed is blank.

--During interview on 04/23/13 at 2:00 pm, Director of Nursing #1 acknowledged that nursing staff should document the last date and time that a medication has been taken prior to admission.

Based on findings from document review and interview, in 2 of 2 medical records of ambulatory surgery patients reviewed, verbal orders were not complete and lacked indication they were read back as required by hospital policy.

Findings include:

-- The MR of Patient J contains a verbal order not dated or timed that indicates the name of the anesthesiologist who provided the verbal order, but not the name of the individual who actually wrote the verbal order. The order also lacks indication that it was read back to the prescriber to verify accuracy.

During interview on 4/18/13 at 5:15 pm, the OR Manager acknowledged these findings.

-- The MR of Patient K contains a verbal order written on 04/18/13 but not timed. This verbal order does not indicate who wrote the verbal order or that it was read back to verify accuracy.

These findings were acknowledged on 04/23/13 at 4:15 pm by the Assistant Vice President of Quality & Outcome Management

-- The hospital policy and procedure (P & P) titled "Medication Management Policy," dated 05/15/12, indicates that a medication order will include the date and time of the order and the prescriber's signature. Additionally, it requires verbal orders to be read back and confirmed.

-- The hospital's Medical Staff Policies (Rules and Regulations), last revised August 2010, indicate that after confirming the identity of the caller, the order will be transcribed and signed by the licensed professional to whom it was dictated or sent and that all verbal orders received by telephone must be read back to the practitioner by the person authorized to receive them in order to verify their accuracy.

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Based on findings from observations and interviews, the hospital did not provide pharmaceutical services in accordance with current standards of professional practice. Specifically, 1) expired medications were available for patient use, and 2) pharmaceuticals and injectable medications were not stored in secure areas.

Findings pertaining to (1) above include:

-- During tour of the hospital's Physical Medical Rehabilitation (PMR) Unit conducted on 04/18/13 at 10:15 am, the following expired medications and pharmaceuticals were observed:

* Humulin R insulin, injectable, 10 ml vial - dated 03/12/13;

* Vancomycin 125 mg/2.5 ml, oral solution, expired 04/17/13;

* Ertapenem Sodium Chloride 0.9% ,50 ml injectable, expired 04/17/13;

* Cefazolin Sodium 20 mg/ml with Sodium Chloride 0.9%, injectable, expired 04/17/13; and

* Glycerin (used for oral cleansing) ,4 fluid ounces, lacked an expiration date.

The above findings were acknowledged by the PMR Nurse Educator during the tour.

Findings pertaining to (2) above include:

-- During tours of the hospital units noted below, the following were observed:

* PMR Unit on 04/18/13 at 10:15 am - four (4) enemas (Fleet type) were stored in the unsecured Clean Utility room on the PMR Unit. This finding was acknowledged by the PMR Nurse Educator during the tour.

* Outpatient Observation Unit on 04/22/13 at 09:00 am - a 50 cc bottle of hydrogen peroxide, 23 bottles of 10 cc injectable 0.9% Sodium Chloride, and 20 bottles of 10 cc injectable Sterile Water were observed in an unsecured cabinet. This finding was acknowledged by the Director of Nursing #1 during the tour.

Based on findings from observations and interview, the condition of the physical plant and the overall environment of the St. Luke's Hospital and the Urgent Care Center on the Faxton campus were not maintained in a manner that would assure the safety and well-being of patients.

Findings include:

--Per observations at 11:45 am and 3:49 pm on 04/18/13; 12:23 pm on 04/19/13; and 12:42 pm. on 04/22/13, there were no ground fault circuit interrupters (GFCIs) in the following patient care areas as required by the NFPA 70 (National Electrical Code), section 210.8: exam room B of the medical office building outpatient OB suite; the physical therapy suite adjacent to the central hand washing sink in OT/PT (first floor) of Allan Calder (AC) west; the emergency room dental clinic; and adjacent to the eye wash station in the morgue, respectively. (OB = obstetrical; OT/PT = occupational therapy / physical therapy)

--Per observations at 2:15 pm and 3:31 pm on 04/18/13; 8:30 am and 9:20 am on 04/19/13; and 10:40 am on 04/22/13, soiled rooms containing regulated medical waste in the following areas were not secure as required by Title 10 of the New York Code of Rules and Regulations, Part 70: second floor AC2 east; medical surgical in AC1; labor and delivery suite; radiology area; and the cardiac care unit. Part 70 states that prominent signage shall be displayed indicating the space is used to store regulated medical waste and that the storage area shall be designed or equipped to prevent unauthorized access.

--Per observations at 12:05 pm on 04/19/13, the following ligature hazards were identified in the emergency department bathroom adjacent to the psychiatric observation rooms: the toilet paper holder and the soap dispenser. Additional ligature hazards were observed at 11:45 am on 04/22/13 in rooms 024 and 027 of the Mental Health Unit - the toilet paper holders, sink faucets, paper towel dispensers, soap dispensers, and door latch covers. In each of these instances, the type of fixtures present were not safe due to their weight bearing capacity and design.

--The Director of Facilities Management who was present at the times the above observations were made confirmed each of these findings.

Based on findings from observation and interview, the bathroom doors located in the patient rooms on the sixth floor of the hospital required more than one releasing motion to operate.

Findings include:

--Per observations at 1:27 pm on 04/17/13, two motions were required to open the patient bathroom doors on the sixth floor of the hospital (oncology unit) when the bolt was engaged by the patient using the bathroom: the first motion was to turn the bathroom door handle and the second motion to unlock the bolt. NFPA 101 (2000), Chapter 7.2.1.5.4, states that doors shall be operable with not more than one releasing operation.

--The Director of Facilities Management who was present at the times the above observations were made confirmed each of these findings.

Based on findings from observations, document reviews and interviews, lapses in generally accepted infection control practices were identified relative to the cleaning of glucometers between patients (in 2 of 2 observations, and 1 of 4 separate interviews), storage of red bag waste, air quality control, cleanliness of a hospital extension clinic, and the availability of personal protective equipment (PPE). Also, a policy & procedure (P&P) for blood glucose monitoring that was not approved for use in the hospital was available to staff in one of the hospital's extension clinics.

Findings include:

-- Per interviews on 04/18/13 of RN #2 on the Oncology unit at 9:40 am, RN #3 on the Physical Medicine and Rehabilitation unit at 10:55 am, and the the Operating Room Manager at 11:50 am, glucometers (used for point of care glucose testing) are cleaned between patient uses.

Per observation on 04/18/13 at 12:00 pm in the Post Anesthesia Care Unit (PACU), RN #4 performed a blood glucose test and then returned the glucometer to the case without cleaning it. This was observed and acknowledged by the Operating Room Manager. NOTE: In this process, the fingerstick was done using a single-use lancet device. RN #4 then used a pipette to collect the patient's blood sample and transfer the blood to the glucometer test strip. Patient contact with the glucometer itself did not occur.

During a tour of the hospital's Faxton Urgent Care Center (a hospital extension clinic) on 04/19/13, in response to questions during interview at 08:20 am, RN #5 indicated the glucometer was not cleaned between patients. He/she described the glucose testing procedure as follows: A single-use lancet device is used to prick the patient's finger. The nurse touches the glucose test strip to the blood droplet, and then places the test strip on the glucometer to obtain the result. When asked for a copy of the glucometer P&P, RN #5 gave the surveyor a P&P from the hospital's contracted laboratory service. This P&P titled "Abbott Precision PXP Glucose, MS-POC-002," did not address cleaning the glucometer between patient uses.

On 04/22/13 at 3:00 pm in the Endoscopy Unit, RN #6 was observed finishing use of a glucometer at a patient's bedside - he/she then returned the glucometer to the case without cleaning it. When questioned, RN #6 indicated he/she was not aware the glucometer should be cleaned between patient uses.

The hospital P&P titled "Blood Glucose Monitoring and Finger Stick Sampling," dated 01/10/13, indicated the glucometer should be cleaned before and after each patient use. The P & P described the blood glucose testing procedure as follows: "The certified operator will wash his/her hands prior to donning gloves and follow standard precautions when performing blood glucose monitoring . Lancets are single-use only. The selected patient site is cleansed with alcohol prep and allowed to air dry. A single-use lancet is used to puncture the skin and obtain the blood sample. Blood is collected directly onto the test strip in the machine and the test result obtained."

In February 2009 and again in 2011, the New York State Department of Health (NYSDOH) issued a health advisory to healthcare facilities and providers indicating that blood glucose monitors should not be shared between patients, but when they are, they should be cleaned and disinfected after every use.


-- Per observations on 04/22/13 at 10:14 am, the room adjacent to stairwell K and next to the pediatric waiting area was being used as an environmental services room and to store waste (regulated medical and unregulated waste). Use of this room to include both housekeeping and waste storage is not consistent with accepted infection control practices.

-- Per observations, on 04/19/13 at 10:31 am, required positive / negative air pressure relationships were not maintained between the soiled and clean areas of the central sterile department due to the presence of three openings: a pass though between the two areas that was continuously opened at the time of the survey; an opening used to pass trays from the clean area to the soiled area next to the washer; and an opening in the wall immediately adjacent to the washer.

Section 711.2 in Title 10 New York Codes Rules and Regulations requires compliance with both the 1996 and 2010 editions of the Guidelines for Design and Construction of Health Care Facilities, which require air movement in a hospital to be from clean to less clean areas. -- Per observations on 04/19/13 at 8:30 am, and on 04/22/13 at 9:30 am, 10:20 am, 10:38 am, and 10:41 am, required positive / negative air pressure relationships were not maintained in the following areas due to the lack of either supply or exhaust air: the room in the labor and delivery services area containing anesthesia and other clean supplies; the clean supply room across from the radiology medical imaging suite; the clean supply room in the ambulatory surgery suite; the bathroom in the cardiac testing area used by patients; and, the IV clean room in the cardiac care unit, respectively. With the exception of central sterile, the Director of Facilities Management who was present at the time these observations were made confirmed the findings. The Central Sterile Manager who was present during the observations made in the central sterile soiled and clean areas confirmed those findings. -- Per observations on 04/19/13 at 08:30 am, 11:00 am and 11:45 am during tours of service areas in the hospital's Faxton Division outpatient facility located at 1676 Sunset Avenue, Utica, NY, the required negative air pressure relationship was not maintained in the following areas due to the lack of either supply or exhaust air: the patient bathroom in the Urgent Care Center, the patient bathroom located next to the ultrasound room #9, and the bathroom in radiology room #3, respectively. These findings were acknowledged by the Director of Nursing #1 who was present at the time these observations were made.

-- Tours of 27 hospital acute care and outpatient departments /units during the 4 day survey resulted in a finding of unclean and non-sanitary conditions at one of the outpatient departments. Per observations between 8:20 and 9:20 am on 04/19/13 during a tour of the hospital's Urgent Care Center located at 1676 Sunset Avenue, Utica, NY, the following areas/items were not clean and sanitary, i.e., they were covered with dust and/or contained residues from dried spills or splashes of fluids that were never cleaned:

* the medication room sink area and floor;

* the outer rooms of exam rooms 7 and 8 (sink, the area under the sink, the exam table, the treatment cart including the top and drawers);

* exam room 2 (treatment cart, sink area, drawers beneath the sink, and exam table);

* the pediatric and adult crash carts including the equipment attached to the outside of the carts (such as the pediatric ambu bag and adult ambu bag);

* exam rooms 3, 4, and 5 (floors, sink area, drawers, and exam table); and

* exam room 6 (the laceration closet, ophthalmic closet housing a suitcase and supplies, the exam room floors, and the supplies in the closet).

These findings were acknowledged by the Director of Nursing #1 who was present at the time these observations were made.

-- Per observations on Unit AC 3 on 04/19/13 at 9:00 am, signs were posted outside room numbers 360, 382 and 367 indicating that the patients who occupied the rooms were on contact precautions. It was observed that PPE was not stocked immediately outside rooms - staff used isolation closets for PPE storage which were 9 to 15 feet away from patient rooms.

Per review of the hospital P & P titled "Standard and Transmission Precautions," last revised 03/2013, it indicated that for patients on contact precautions, an "over the door" PPE holder should be placed over the door of patient rooms and kept stocked with appropriate PPE by floor staff.

During interview on 04/19/13 at 10:00 am with the Nurse Manager of AC 3, he/she acknowledged that supplies should be immediately available for use, i.e., stored right outside patient rooms.

Based on findings from document reviews and interview, 4 out of 10 medical records reviewed in the Critical Care Unit (CCU) lacked documentation by the discharge planner.

Findings include:

-- Per MR review, each of the following patient's MRs lacked a discharge planning assessment despite the patient being hospitalized for the number of days noted:

* 9 days - Patient L;

* 5 days - Patient M; and

* 4 days - Patients N and O.


-- During interview on 04/19/13 at 10:15 am with the Director of Case Management / Social Work / Utilization Review, in connection with discharge planning he/she indicated that an admission review done on inpatients within 1 working day following the day of admission includes an evaluation of discharge planning needs and need for social work referrals. He/she also indicated that this evaluation is documented.

-- During interview Case Manager #1 on 04/23/13 at 01:00 pm acknowledged that discharge planning should begin on day 1 of a patient's hospitalization and noted he/she had not been able to get to all assigned patients in a timely manner.