HospitalInspections.org

Based on document review, interview and in one (1) of 24 medical records reviewed, it was determined that the hospital did not ensure that a properly executed consent for an incapacitated- mentally delayed patient was performed.

Findings include:

Review of the medical record for Patient #3 revealed: On 4/9/20 a 36-year-old female arrived at the Emergency Department with the chief complaint of fever. She is incapacitated and is mentally delayed; lives at a group home and was accompanied by an attendant. History of a hospitalization two days prior where she had been tested for Covid -19 and the result was positive. Patient was admitted to the facility on 4/10/20. During hospital stay, patient became unresponsive and her prognosis was poor. It was determined by the Nurse Practitioner that the cardiac Full Code needed to be revised.
On 4/15/20 Nurse Practitioner progress note noted "Code Status: MOLST updated-see form." Review of the medical record showed there was no evidence of an updated MOLST (Medical Order for Life-Sustaining Treatment) Checklist and Form in the medical record.

During interview on 10/16/20 at approximately 1:00 PM, Staff A, Attending Physician and Staff B, Attending Physician confirmed the findings.

The hospital has no policy or documented training for the clinical staff concerning the use of the MOLST for patient mentally delayed or with developmental disabilities.

Based on document review and interview, the facility failed to ensure that data collected on advance directives for Do Not Resuscitate (DNR) and Do Not Intubate (DNI) were analyzed, corrected action implemented and monitored for effectiveness.

Findings include:

Review of the facility's Risk Management documents identified emails to facility staff, dated 4/28/2020 at 3:28 PM and at 4:12 PM, documented the Risk Management received inquiry from Mental Health Legal Services (MHLS) regarding "Administrative DNR/DNI" for 2 patients, and reportedly with improperly executed directives. The emails further documented, "Next steps: Update MOLST form, update policies and protocols reflecting the new form, and in-service to providers ..."

The facility's policies and procedures on advance directives were reviewed and there was no documented evidence the protocols were updated as planned, to reflect the use of the New York State Medical Orders for Life-Sustaining Measures (MOLST) form.

There was no documented evidence that next steps/action plan were implemented to correct the identified problems.


During interview with Staff C, Director of Risk Management on 10/16/2020 at approximately 2:30 PM and on 10/20/2020 at 10:34 AM, staff stated they did not have any QA meeting for a while since the pandemic, approximately since March 2020. Staff C was unable to provide documented evidence that action plan for the identified problems were implemented.

Based on document review and interview, it was determined that the facility failed to ensure that the hospital-wide Quality Assessment and Performance Improvement (QAPI) plan is fully implemented and all departments report to the hospital-wide Performance Improvement Committee as documented in the plan.

Findings:

Review of the facility's "Quality Assurance/ Performance Improvement and Patient Safety Plan (2020)" revealed Departmental Performance Improvement Committees reports to the Hospital-wide Performance Improvement Committee. Departments specified for reporting includes Group B. Group B consists of 12 Departments.

Review of the facility's Departmental Minutes 9/2019-9/2020 revealed all departments for Group B did not regularly report to the hospital-wide Performance Improvement Committee (HWPI) from 9/2019-12/2019. Specifically, Central Sterile, Environment of Services/Housekeeping, Food and Nutrition, Guest Relations/Language Assistance Services, Hospital Police, Utilization Management. As a result, there was no documented evidence that data was being analyzed, tracked, and trended for these departments.

Review of the Hospital-wide Performance Improvement Committee Reporting Calendar 2019 identified Group B department's reporting schedule which states:
-Central Sterile-September 2019
-Environment of Services/Housekeeping-December 2019
-Food and Nutrition-November 2019
-Guest Relations/Language Assistance Services-October 2019
-Hospital Police-November 2019
-Utilization Management-November 2019.

The 2020 QAPI plan revised their departmental reporting schedule during the COVID-19 pandemic. It was noted
-Central Sterile-No revised schedule identified.
-Environment of Services/Housekeeping- no revised reporting schedule identified.
- Food and Nutrition - revised to report in August 2020.
- Guest Relations/Language Assistance Services- revised to report in July and October2020.
-Hospital Police- revised to report December 2020.
-Utilization Management-to report in November 2020.

These findings were discussed with the Staff Aa Chief Medical Officer/ Chair of Quality on 10/20/20 at 1:10 PM. He
stated: Category A is scripted and mandated to report to the hospital-wide. Category B is not mandated to report. They are special areas that report if or when projects are being done. We focus on the high volume, high risk, problem prone or new areas.

During interview with Staff Bb Chief Executive Officer, on 10/20/20 at 2:57 PM, she acknowledged that the facility has not had a Quality Officer since May 2020 and Staff Aa is wearing two hats. When asked about the process of Group B's reporting ad hoc system, she stated: "The facility did not have a criterion for Group B reporting into the hospital-wide Quality. Group B appears in the meeting agenda, but not reported. The report is ad hoc. The department leader has a dashboard. Trend analysis not there. Reports do not go through a review process. There is no document/policy to address Group B's ad hoc system of reporting to the hospital- wide quality."

Based on observation, document review, and interview, the facility failed to ensure that all staff and visitors are consistently screened for signs and symptoms of COVID-19, in accordance with the nationally recognized infection prevention and control guidelines issued by the Center for Disease Control (CDC) and Centers for Medicare & Medicaid (CMS).

Findings:

Observation in the facility's three (3) main lobby entrances identified the following:

On 10/15/2020 at approximately 9:30 AM, four (4) surveyors entered the hospital main lobby and no screening questions were asked. Two (2) other persons entered behind the surveyors and no screening questions were asked. While waiting for hospital personnel, the surveyors observed two (2) other visitors entered the lobby and no screening questions were asked. Three (3) uniformed personnel also entered the lobby and were not asked the screening questions.

On 10/16/2020 at approximately 11:40 AM, during observation at the FAST TRACT emergency entrance, three (3) patients entered and were greeted by the receptionist who asked them about the purpose for their visit and other pertinent information, and were asked to sit in the waiting room. No screening questions for sign and symptoms for COVID-19 were asked.

On 10/16/2020 at approximately 11:55 AM, during observation at the Mural Pavilion Building entrance, there was a kiosk on the left side of the entrance with two (2) hospital staff working at the location. Approximately five (5) people walked to the kiosk but they were not asked the screening questions by the staff.

During an interview conducted on 10/16/2020 at approximately 3:15 PM, this finding was confirmed by Staff Bb, Chief Executive Officer (CEO), who stated, "staff who are stationed at the hospital lobby are performing screening for COVID-19 infection. The staff use an App questionnaire on the phone daily and the screening staff must check the app for date and expiration time."

The facility's policy, "Point Of Entry Screening For COVID-19," effective 9/15/20, states: "All persons entering the building must complete exposure screening ...."