HospitalInspections.org

Based on document review, observation and interview, the facility is not in compliance with applicable federal laws. Specifically, for 23 of 23 medical records reviewed the "Patients' Bill of Rights" provided to patients and the "Patients' Bill of Rights" posted in the Emergency Department (ED) were not the current version.

Findings include:

Observation on 02/04/25 at 11:00 AM in the Emergency Department revealed the posted "Patients' Bill of Rights" for individuals receiving care was dated February 2016. This was not the current version of February 2019.

Review on 02/04/25 of the policy titled "Patient's Rights", dated March 2024, revealed the facility's commitment to protecting and promoting each patient/resident rights. This will be done in all its levels of care (inpatient, emergency services, and outpatient settings). These rights are outlined in both 405.7 NYS [New York State] Minimum Standards and 482.13 HCFA [Health Care Financing Administration] Condition of Participation. A copy of the 405.7 NYS Patient Rights will be provided to all patients/residents and will be posted throughout the system. A copy of the Patient's Bill of Rights will be given to the patient or representative on admission by the patient registration staff. This is in the Patient Information Booklet. The signature acknowledging the receipt of this document will be obtained by the patient registration and placed on the medical record. Copies of the Patient's Bill of Rights (Attachment A) will be provided to each Emergency Department patient, or person coming for outpatient services. Review of Attachment (A): "Patients' Bill of Rights in a Hospital" is dated February 2019.

Review on 02/05/25 of the facility document titled "Your Rights as a Hospital Patient In New York State [NYS]", last revised December 2016, included the February 2016 "Patients' Bill of Rights", from Public Health Law (PHL) Section 2803(1)(g) Patient Rights, 10NYCRR. 405.7 (a)(1), 405.7 (c). This document is presented to patients receiving care.

Review on 02/05/25 of 23 out of 23 medical records revealed the "Patients' Bill of Rights" provided to patients in the admissions packet were dated February 2016. This was not the current version of February 2019.

Interview on 02/04/25 at 04:25 PM with Staff (A), Risk revealed verified the findings.

Based on policy review, document review, and interview, the hospital failed to follow manufacturer's instructions for use for patient care supplies. Specifically, a single use disposable piece of equipment was sterilized and reused and a detergent used for the decontamination process of soiled surgical instruments was not measured to ensure the proper amount of detergent was adequate for amount of water used.

Findings include:

Findings #1:

Review on 02/06/25 of the "Sterilization Policy for Sterile Processing Department," last reviewed November 2024, revealed for cleaning and decontamination; all instruments must be manually or mechanically cleaned with approved detergents and by use of enzymatic cleaners (detergents to break down proteins) to remove organic debris.

Review on 02/06/25 of the "EmPower Technical Bulletin" (enzymatic detergent instructions for use) revealed the recommended application for instrument reprocessing, presoak, manual cleaning, ultrasonic cleaner, dental evacuation system cleaner and automatic washers is one ounce of detergent per one gallon of water.

Observation and interview on 02/05/25 at 01:00 PM Staff (KK), Sterile Processing Technician poured an unmeasured amount of EmPower enzymatic detergent into an unmarked sink basin located next to a sink basin with a labeled fill-line, with an unmeasured amount of water for the decontamination process of soiled surgical instruments. Staff (KK) stated they were unaware of the detergent to water ratio necessary for the decontamination process of soiled instruments.

Finding #2:

Review on 02/06/25 of the "Welch Allyn Kleenspec" disposable otoscope speculum covers, product #52134, instructions for use indicated the product is to be used once and discarded.

Observation and interview on 02/05/25 at 04:15 PM revealed three Welch Allyn Kleenspec disposable otoscope speculum covers floating in a prepared basin of EmPower enzymatic detergent solution located in a procedure room where ear, nose and throat procedures were performed. There were several reprocessed and packaged specula covers located in the office with Staff (JJ), Nurse Practitioner's name written on the product packages. Staff (JJ) stated the covers are sent to the sterile processing area for reprocessing and was unaware the item was a single use product that should be discarded after use.

Interview on 02/06/25 at 09:30 AM with Staff (C), Chief Nursing Officer, verified these findings.

Based on policy review, medical record review, and interview, the hospital failed to ensure in one of four records reviewed that nursing staff documented the monitoring of restraints.

Findings include:

Review on 02/06/25 of policy "Patient Restraints," dated 04/01/19, revealed safety checks and circulation will be monitored and documented at minimum every 15 minutes. Vital Signs will be monitored and documented at minimum every 30 minutes.

Review on 02/05/25 of the Emergency Department medical record for Patient #15, dated 08/16/24, revealed at 08:47 PM, Staff (OO), Physician Assistant ordered the application of four-point behavioral restraints. At 08:50 PM, Staff (NN), Registered Nurse, documented police with Patient #15 during triage process. Patient #15 was attempting to get out of bed and fight staff. Patient #15 placed in four-point restraints. At 09:07 PM, Staff (OO) documented Patient #15 was unconsolable, agitated violent behavior requiring restraints for their own safety as well as staff. Medications were administered to attempt to treat Patient #15. At 09:37 PM, Staff (NN), documented restraints removed from Patient #15.

There was no documented evidence by nursing staff of safety checks/circulation checks on 8/16/24 at 09:05 PM and 09:20 PM. There was no documented evidence by nursing staff that vital signs were obtained at 09:29 PM.

Interview on 02/05/25 at 02:10 PM with Staff (X), Corporate Educator, revealed the "Behavioral Restraint Flow and Monitoring Sheet" every 15-minute nursing documentation was not in the record of Patient #15.