HospitalInspections.org

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Based on record review and staff interview during the Federal Recertification Survey, it was determined that the facility did not comply with the Condition of Participation for Patient Rights. This was evidenced by the scope of the facility's non-compliance with the standards to protect the patients' rights.

Findings:

The facility failed to ensure that all Medicare beneficiary patients / patients' representatives were provided with the standardized notice "An Important Message From Medicare About Your Rights" (IM) within two (2) days of admission as an inpatient, and that the facility presented a copy of the signed (IM) in advance of the patients' discharge to the patients / patients' representatives, but no more than two (2) calendar days before the patients' discharge.
(See Tag A 117)

The facility failed to develop and implement Care Plans for patients placed in Four (4) Point Restraints (Level II Restraints).
(See Tag A 166)

The facility failed to follow their Policies on Physician notification when patients' restraints or seclusion (Level II Restraints) were discontinued.
(See Tag A 174)

The facility failed to ensure that the face-to-face evaluation for patients placed in Level II Restraints was comprehensive and contained all of the required elements.
(See Tag A 179)

The facility failed to ensure that staff had the required training in the use of First Aid techniques and certification in the use of Cardiopulmonary Resuscitation (CPR).
(See Tag A 206)

The facility failed to ensure that staff training is provided by a person with demonstrated qualifications including education, training and experience.
(See Tag A 207)

The facility failed to document in the Personnel Files of the Code Gray staff training and competency in a "Code Gray Response".
(See Tag A 208)
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Based on record review and staff interview during the Federal Recertification Survey, the facility failed to ensure that all Medicare beneficiary patients / patients' representatives were provided with the standardized notice "An Important Message From Medicare About Your Rights" (IM) within two (2) days of admission as an inpatient, and that the facility presented a copy of the signed (IM) in advance of the patients' discharge to the patients / patients' representatives, but no more than two (2) calendar days before the patients' discharge. This was evident in three (3) out of six (6) records reviewed for patients who were Medicare beneficiaries (Patients #27, #46 and #18).

Findings:

Patient #18 was admitted to the facility on 04/17/14 and discharged on 05/06/14. Record review lacked documented evidence that the patient / patient's representative was provided with the standardized notice "An Important Message From Medicare About Your Rights" (IM) prior to discharge.

On 06/11/14 at 12:05PM Staff #4 confirmed this finding.

Patient #27 was admitted to the facility on 03/11/14. Record review lacked documented evidence that the patient / patient's representative was provided with the standardized notice "An Important Message From Medicare About Your Rights" (IM) on admission.

This finding was confirmed with Staff #186 in the afternoon of 06/13/14.

Review of the facility Policy titled "Important Message from Medicare for the Inpatient Medicare Population on Admission" dated 01/2013, documents that all inpatient hospitalized Medicare beneficiaries must be provided with a copy of the Important Message from Medicare on admission.

Patient #46 was admitted to the facility on 05/28/14. Record review lacked documented evidence that the patient / patient's representative was provided with the standardized notice "An Important Message From Medicare About Your Rights" (IM) prior to discharge on 06/03/14.

This finding was confirmed with Staff #186 in the afternoon of 06/13/14.

Review of the facility Policy titled "Important Message from Medicare for the Inpatient Medicare Population on Discharge" dated 01/2013, documents that all inpatient hospitalized Medicare beneficiaries must be provided with a copy of the Important Message from Medicare prior to discharge.
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Based on record review and staff interview during the Federal Recertification Survey, the facility failed to develop and implement Care Plans for patients in Level II Restraints (Violent/Self Destructive Level) for one (1) out of seven (7) Medical Records reviewed (Patient #45).

Findings:

Review of the Electronic Medical Record (EMR) on 06/13/14 at 12:17PM revealed that Patient #45 was admitted to the Emergency Department (ED) on 06/07/14 at 11:45PM and placed in Four (4) Point Restraints due to violent behavior. On 06/08/14 at 1:15AM the restraints were removed.

On 06/13/14 at 12:17PM Staff #6 was asked to display in the Electronic Medical Record (EMR), the Restraint Care Plan for Patient #45. Staff #6 was unable to present the Restraint Care Plan to the Surveyor stating "It is empty".

Review of the facility's ED (Emergency Department) "Plan of Care for Restraint Prevention" revealed it was not updated to reflect the patient's condition, it was blank.

This finding was confirmed with Staff Members #4 and #185 at the time of the EMR review.
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Based on document review and interview during the Federal Recertification Survey, the facility failed to ensure Physician notification as per the facility's Policy when patients' restraints / seclusion were discontinued for one (1) out of one (1) Medical Record reviewed (Patient #27).

Findings:

Review of the Medical Record for Patient #27 on 06/13/14 revealed the patient was placed in seclusion on 03/15/14 from 2:00PM until 4:15PM, when he was released.

There is no documented evidence that notification was made to the Physician when the patient was released from seclusion.

This finding was confirmed by Staff #186 on 06/13/14 in the afternoon.

Review of the facility Policy titled "Restraints: Physical Restraints and Seclusion" revealed in Section A #9: "Early Release / Discontinuation: Restraints" that the Physician is notified when the restraint is ended before the Order expires.
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Based on record review and staff interview during the Federal Recertification Survey, the facility failed to ensure that staff monitored a patient who was in Four (4) Point Restraints as per facility Policy for one (l) out of seven (7) Medical Records reviewed with Level II (Violent) Restraints (Patient #7).

Findings:

Review of the Behavioral Health Restraint Log revealed on 12/19/13 at 6:30PM, Patient #7 diagnosed with Psychosis, was placed in Four (4) Point Restraints.

Review of the Violent / Self Destructive Restraint or Seclusion Monitoring Form dated 12/19/13 at 6:30PM documented that Patient #7, without provocation, punched another male patient in the face several times. Patient #7 was placed in Four (4) Point Restraints and at 6:45PM medicated with Haldol, Benadryl and Ativan intramuscularly.

At 8:00PM when the patient was no longer a threat to himself or others, the restraints were discontinued. The "patient was taken to his room and on constant observation".

A review of the Physician's Orders dated 12/19/13 at 8:37PM documented an Order for constant observation.

However, while Patient #7 was restrained, there was no documented evidence he was on constant observation as per facility Policy.

Review of the Policy titled "Restraints: Physical Restraints and Seclusion" dated 05/2014 documented a patient placed in violent restraints will have "monitoring accomplished by continuous in person observation".

An interview with Staff #2 on 06/10/14 at 10:40AM revealed it is protocol to immediately place a Four (4) Point Restrained patient on constant observation. Staff #2 also agreed there is no documented evidence that the patient was on constant observation while he was restrained.
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Based on record review and interview during the Federal Recertification Survey, the facility failed to ensure that the face-to-face evaluation for patients placed in restraints contained an assessment of the patient's medical and behavioral condition for six (6) out of seven (7) Medical Records reviewed (Patients #7, #8, #26, #27, #45 and #46).

Findings:

During a review of the Medical Record for Patient #27 on 06/13/14, the Medical Record lacked documentation of a complete review of the patient's systems and an assessment of the patient's history noted in the face to face evaluation during seclusion on 03/15/14 from 2:00PM until 4:15PM.

During a review of the Medical Record for Patient #45 on 06/13/14, the Medical Record lacked documentation of a complete review of the patient's systems and an assessment of the patient's history noted in the face to face evaluation during restraints on 05/07/14 from 11:45PM until 1:15AM on 05/08/14.

During a review of the Medical Record for Patient #46 on 06/13/14, the Medical Record lacked documentation of a complete review of the patient's systems or an assessment of the patient's history noted in the face to face evaluation during restraints on 05/27/14 from 6:30PM until 8:15PM.

Review of the facility's policy and procedure, "Procedure for Care of the Patient Requiring Non-Violent Non-Destructive Secured Restraints and Violent/Self Destructive Restraints" dated 05/14 includes that the Assessment of the patient in Violent /Self Destructive restraints must include "complete review of systems assessment, behavioral assessment, as well as review and assessment of the patient's history...."

These findings were confirmed by Staff #186 on 06/13/14 in the afternoon.

Similar findings were noted in the Medical Records for Patients #7, #8 and #26.
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Based on interview and review of the Personnel Files during the Federal Recertification Survey, the facility failed to ensure that: a) the Behavioral Health Psychiatric Assistants had certification in the use of Cardiopulmonary Resuscitation (CPR) for forty-four (44) out of forty-four (44) Personnel Records reviewed (Staff Members #21 through #64), b) the Code Gray Team had certification in the use of CPR and education in First Aid techniques for eighty-eight (88) out of eighty-eight (88) Personnel Records reviewed (Staff Members #65 through #181), c) the Emergency Department Patient Care Assistants had certification in the use of Cardiopulmonary Resuscitation (CPR) for two (2) out of three (3) Personnel Records reviewed (Staff Members #19 and #200), and d) that the Restraints: Physical Restraints and Seclusion Policy was consistent with the Federal Regulation.

Findings:

a) Review of the forty-four (44) Personnel Education and Training Records for the Behavioral Health Psychiatric Assistants who participate in Code Gray (physical holds, take downs and application of restraints), lacked evidence of CPR education (Staff Members #21- #64).

b) Review of the eighty-eight (88) Personnel Education and Training Records for the Code Gray Team (ancillary staff) who participate in Code Gray lacked evidence of education in First Aid techniques and CPR (Staff Members #65 - #181).

c) Review of the two (2) Personnel Education and Training Records for the Emergency Department Patient Care Assistants who participate in Code Gray lacked evidence of CPR education (Staff Members #19 and #200).

d) Review of the Policy titled "Restraints: Physical Restraints and Seclusion" dated 05/2014, incorrectly documented "training requirements for staff who are under the direct supervision of the Registered Nurse may apply restraints without certification in the use of CPR and education in First Aid techniques".

An interview with Staff Members #2 and #4 on 06/10/14 at 10:30 AM revealed Behavioral Health Psychiatric Assistants apply Four (4) Point Restraints to patients and they don't receive CPR training.

An interview with Staff #108 on 06/12/14 at 11:10AM revealed the Code Gray Team staff, who participate in physical holds, take downs and application of restraints, are not required to have education in First Aid techniques or CPR as per facility Policy.
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Based on interview and record review during the Federal Recertification Survey, the facility failed to ensure that staff training is provided by a person with demonstrated qualifications including education, training and experience. This was evident in one (1) out of three (3) staff identified as the facility Trainers (Staff #130).

Findings:

Review of Staff #130's Personnel Education and Training Records revealed a form titled Code Gray Response Training Quiz dated 04/30/14 and a form titled Leather Restraints Competency Based Performance Checklist dated 04/30/14. However, there was no documented evidence that the staff member received the "Code Gray Training 2014" or demonstrated qualifications to ensure that this staff member was able to provide staff training.

Interview with Staff #108 on 06/12/14 at 11:10AM revealed there are three (3) Instructors that teach the Code Gray Team, Staff Members #108, #117 and #130. Staff Members #108 and #117 took the CPI (Crisis Prevention Intervention) Training. Sometime in May 2014, the date is not known, Staff Members #108 and #117 trained Staff #130. The power point, module and the restraint were reviewed with Staff #130 verbally. There is no documented evidence when the training took place. Staff #130 works nights and trained the overnight crew.

A review of the Code Gray Training 2014 dated "Overnight" documented ten (10) signatures for Staff Members #68, #78, #92, #105, #109, #118, #120, #133, #137 and #182. At that time the interview was continued with Staff Member #108. He stated Staff #130 wrote "Overnight" instead of the date he instructed the staff. Staff #108 stated he believes the training took place on 05/21/14. Staff #108 agreed there was no documented evidence that Staff #130 was qualified to train staff.
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Based on interview and review of the Personnel Files during the Federal Recertification Survey, the facility failed to ensure: a) that there was documentation in the Personnel Files of the "Code Gray Team" of the required "Code Gray Response Training" for fifty-one (51) out of eighty-eight (88) Personnel Records reviewed (Staff Members #65, #67, #68, #72, #74, #76, #78, #79, #80, #82, #84, #85, #88, #91, #96, #98, #100, #104, #105, #107, #109, #110, #112, #113, #114, #116, #117, #118, #119, #120, #125, #126, #127, #130, #131, #133, #134, #135, #137, #139, #162, #164, #165, #167, #169, #173, #175, #176, #178, #178 and #180), b) documentation of competency in restraint application ("Leather Restraint Competency Based Performance Checklist") for twenty-seven (27) out of eighty-eight (88) Personnel Records reviewed (Staff Members #65, #67, #68, #72, #74, #76, #79, #80, #82, #84, #85, #88, #92, #93, #96, #98, #100, #104, #114, #119, #131, #139, #162, #167, #173, #176 and #180), and c) that Emergency Department (ED) Nursing Staff had training in the use of physical holds and restraints. This was evident for two (2) out of six (6) Nursing Staff Personal Records reviewed (Staff Members #189 and #200).

Findings:

a) Review of the fifty-one (51) (Staff Members #65, #67, #68, #72, #74, #76, #78, #79, #80, #82, #84, #85, #88, #91, #96, #98, #100, #104, #105, #107, #109, #110, #112, #113, #114, #116, #117, #118, #119, #120, #125, #126, #127, #130, #131, #133, #134, #135, #137, #139, #162, #164, #165, #167, #169, #173, #175, #176, #178, #178 and #180) Personnel Education and Training Records for the "Code Gray Team" who participate in physical holds, take downs and application of restraints, lacked evidence of "Code Gray Response Training".

b) Review of the twenty-seven (27) (Staff Members #65, #67, #68, #72, #74, #76, #79, #80, #82, #84, #85, #88, #92, #93, #96, #98, #100, #104, #114, #119, #131, #139, #162, #167, #173, #176 and #180) Personnel Education and Training Records for the "Code Gray Team" who participate in physical holds, take downs and application of restraints, lacked evidence of competency in restraint application ("Leather Restraint Competency Based Performance Checklist").

Review of the Policy titled "Security & Response Team (Code Gray) Protocol dated 05/2014 documented the Code Gray was "initiated to ensure the effective management of disruptive, agitated and combative individuals by utilizing a select group of hospital employees who have been trained to respond to persons exhibiting aggressive behavior. The Code Gray Team includes Security, Administration and trained staff designated from the following Departments: Transportation, Environmental Services, Engineering and Patient Care Services. The Code Gray Team will assist staff with use of restraints, assistance with medicating a patient and show of force. All members of the Response Team will receive annual training including but not limited to how to apply physical restraints. Following the training of the members of the Code Gray Team, their competency will be assessed and documented by the Director of Safety & Security."

Review of the Policy titled "Restraints: Physical Restraints and Seclusion" dated 05/2014 documented the facility trains staff on the use of restraints and seclusion and assesses their competency during orientation, before participating in the use of restraints and seclusion and periodically thereafter. Staff who are under the direct supervision of the Registered Nurse may apply restraints, receive the training and demonstrate competence in the safe use of restraints.

Interview with Staff #108 on 06/12/14 at 11:10AM revealed the "Code Gray Team" holds the patient while the Nurse gives the medication. The Team is trained to apply restraints. The Security Guard Supervisors received the "Code Gray Training" one (1) at a time when they came in. It was done one (1) on one (1). It took about one-half (1/2) an hour to forty-five (45) minutes to review the information with them. It was done verbally. The Supervisor did not have to sign in for the class. Staff #108 could not explain why the "Code Gray Team" were missing "Code Gray Response Training" and competency in restraint application ("Leather Restraint Competency Based Performance Checklist").

On 06/12/14 and 06/13/14 Staff #11 reviewed the Personnel Education and Training Records for the "Code Gray Team" with the Surveyor and confirmed the above findings.



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c) Review of the Personnel Record for Staff #189, a Per-Diem Registered Nurse (RN) assigned to the Emergency Department, revealed the RN had not received training and education on safe use of restraints, physical holds and/or seclusion.

Review of the Personnel Record for Staff #200, a Patient Care Assistant (PCT) assigned to the Emergency Department, revealed the PCT had not received training and education on safe use of restraints, physical holds and/or seclusion.

This finding was confirmed by Staff #11 on 06/13/14 at 1:50PM.
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Based on record review and staff interview during the Federal Recertification Survey, the facility failed to implement their Policy for data collation and tracking and trending of the "Code Gray Response Team Data" forms to ensure issues identified during debriefings were addressed to improve performance improvement. This was evident during review of the Security Department's "Code Gray Response Team Data" forms dated 01/2014 - 06/2014.

Findings:

A review of the Security Incident Reports between 01/2014 - 06/2014 revealed the Security Officers responded to approximately two hundred twenty-five (225) calls for assistance with agitated / combative patients of which eighty-six (86) sheets documented the patient was restrained.

The forms were not being completed as per facility Policy in two hundred twenty-four (224) of two hundred twenty-five (225) events that occurred from 01/2014 to 06/2014. The forms were left blank and specifically lacked debriefing assessments and/or consistently documented inclusion of Nursing Staff participation / collaboration during these events / incidents.

Review of the Policy titled "Security and Response Team (Code Gray) Protocol" dated 04/2013 documented that after a Code Gray incident the Security Supervisor will conduct a debriefing assessment in collaboration with the Nurse Administrator immediately following each event. The Security Supervisor will document the Response Team interventions on a Security Incident Report called a "Code Gray Response Team Data" form in the section titled "Issues identified and any other necessary follow up action that needs to be addressed to improve performance improvement during future calls" and complete the appropriate form to collate data. The Director of Safety and Security will review every Code Gray Response Team Data form, identify any performance improvement issues and take immediate action to correct issues that are identified.

During an interview with Staff #108 on 06/12/14 at 11:30AM, the staff member stated that "I look at the forms every day but I only document on the forms if something needs to be said".

During an interview with Staff #6 on 06/12/14 at 11:40AM, Staff #6 agreed as per Policy the form should be filled out after each Code Gray and stated "we could improve on this".
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Based on record review and staff interviews during the Federal Recertification Survey, the facility failed to ensure that all Orders for drugs and biologicals were obtained from a practitioner responsible for the care of the patient prior to administration in two (2) out of four (4) Infant Records reviewed (Patients #9 and #10).

Findings:

Review of the Medical Record for Patient #9 on 06/09/14 revealed the infant was born on 06/07/14. The Electronic Medical Record (EMR) documents the Nurse administrated Erythromycin 0.5% ophthalmic ointment once to each eye (eye prophylaxis) and Phytonadione 1mg injection once at 12:50PM on 06/07/14, however, the Physician did not sign the Order until 1:12PM after the medications were given.

Review of the Medical Record for Patient #10 on 06/09/14 revealed the infant was born on 06/08/14 at 4:05AM. The Electronic Medical Record (EMR) for the infant's mother documents that the Nurse administrated eye prophylaxis to each eye and a Vitamin K injection in the Delivery Room. However, the Physician did not sign the Orders in the infant's Medical Record until 6:31AM on 06/08/14 after the medications were given.

Review of the Policy titled "Eye Prophylaxis (Erythromycin)" dated 2013 states "All newborns will have Erythromycin Ophthalmic ointment placed in each eye within one (1) hour of birth" and to "obtain MD Order for Erythromycin ophthalmic ointment" then "document on Delivery Room Record administration of Eye Prophylaxis".

Review of the Policy titled "Vitamin K Administration" dated 2014 states a single dose of Vitamin K is given to all infants within six (6) hours of birth and that "the Delivery Room RN, Intensive Care Nurse and Well Newborn RN may administer the Vitamin K" but does not include obtaining a Physician's Order prior to administration.

Interviews on 06/09/14 during the afternoon with Staff Members #1 and #7 confirmed that the Nursing Staff implemented the Electronic Orders prior to the Physician placing the Orders.
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Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that all ceiling, door, and wall finishes in the hospital building were maintained in good repair.

Findings:

a) On 06/09/14 at 1:31PM a stained ceiling tile was found in a corridor (vicinity of Exam Room 1 in the Radiation Oncology Unit).

b) On 06/09/14 at 2:05PM a stained ceiling tile was found in a Ground Floor Storage Closet (vicinity of Electrical Panel HGLCL1 in the Radiology Office Suite Area).

c) On 06/10/14 at 8:30AM the protective plate (which appeared to be of a vinyl or similar plastic material) on a door from the OR Unit to a 1st Floor corridor (vicinity of the entrance to the PACU) was noted to be in disrepair (peeling off of the door) at the time of the inspection.

d) On 06/10/14 at 8:35AM three (3) stained ceiling tiles were found in a 1st Floor corridor (vicinity of the entrances to the OR unit Male Staff Locker Room and the OR Unit Electrical Service Room).

e) On 06/10/14 at 8:52AM a stained ceiling tile was found in a corridor (vicinity of 3rd Floor Storage Room E3746).

f) On 06/10/14 at 9:35AM a stained ceiling tile was found in a corridor (vicinity of the entrance to the 1st Floor ASU Post-Op Area).

g) On 06/10/14 at 10:42AM a stained ceiling tile was found in a Ground Floor Dietary Services Department Storage Room (the one located near the Loading Dock).

h) On 06/10/14 at 12:50PM a stained ceiling tile was in 3rd Floor Room 3565 OB/GYN On-Call Room.

i) On 06/11/14 at 8:15AM the cove base and surfaces of cabinetry in the 2nd Floor Cardiac Rehab Treatment Area in the Multi-Specialty Care Center Outpatient Building located at 440 Merrick Road, Oceanside, New York were noted to be in disrepair (delaminating).

As per concurrent interviews with the facility's Director of Facilities Management, he will notify facility Administration concerning the above-mentioned conditions.

42 CFR 482.41(a)
10NYCRR, 405.24 (a) (1)
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Based on observations and staff interview during the Federal Rectification Survey, the facility failed to ensure that: 1) accessible facilities were designed and maintained in accordance with Federal, State and Local Laws, Regulations and Guidelines, and 2) hand wash sinks were installed in compliance with all requirements.

Findings:

1a) On 06/09/14 at 1:28PM the drain pipe and control valves underneath a hand wash sink in a designated accessible staff toilet room (vicinity of the Gamma Knife Planning Room) lacked required insulation to prevent against contact with sharp/abrasive and/or hot surfaces. As per concurrent interview with the facility's Director of Facilities Management, he will have required insulation installed as soon as possible.

b) On 06/10/14 at 11:20AM two (2) dry-well covers that had three-inch by two-inch wide cells (openings) in them were found in accessible walking surfaces (e.g., designated accessible parking space access aisles) in a hospital parking lot (near the Ambulance Entrance to the Emergency Department and resident housing structures). Openings that are no more than ½-inch wide are permitted in dry-well or similar manhole covers that are in an accessible walking surface.

c) On 06/11/14 at 8:21AM the accessible room identification signage for an accessible men's toilet room on the 2nd Floor of the Multi-Specialty Care Center Outpatient Building located at 440 Merrick Road, Oceanside, New York was mounted on the wall adjacent to the hinge side of the door to this room. Accessible room identification signage is required to be installed on the wall adjacent to the latch side of the door.

d) On 06/11/14 at 8:33AM the coat closet by the Waiting Room on the 1st Floor of the Multi-Specialty Care Center Outpatient Building located at 440 Merrick Road, Oceanside, New York was found to lack an accessible coat hook. Accessible coat hooks are required to be installed at a height no higher than 48-inches.

As per concurrent interviews with the facility's Director of Facilities Management, he will notify facility Administration concerning the above-mentioned conditions.

42 CFR 482.41(c)

10NYCRR, 711.2 (c), Design standards for the disabled. The Americans with Disabilities Act of 1990 (ADA) extends comprehensive civil rights protection to persons with disabilities. Health care facilities must comply with the ADA and the regulations which implement it. Title 28 of the Code of Federal Regulations, Public Health Parts 35, Non-Discrimination on the Basis of Disability in State and Local Government Services, and Part 36, Non-Discrimination on the Basis of Disability by Public Accommodations and in Commercial Facilities, including Appendix A, "Standard for Accessible Design", 2004 Edition. 28 CFR Part 36 ADA Standards for Accessible Design: 4.24.6

2a) On 06/11/14 at 9:50AM a hand wash sink in the D-Wing Ground Floor Lecture / Conference Center Pantry was noted to lack wrist blades (the sink was provided with conventional twist-type knobs). Hand wash sinks are required to be trimmed with valves that could be operated without hands.

b) On 06/11/14 at 10:21AM a hand wash sink in the D-Wing Ground Floor Lecture / Conference Center Pantry was noted to lack wrist blades (the sink was provided with conventional twist-type knobs). Hand wash sinks are required to be trimmed with valves that could be operated without hands.

As per concurrent interviews with the facility's Director of Facilities Management, he will notify facility Administration concerning the above-mentioned conditions.

42 CFR 482.41(c)

10NYCRR, 711.2 (b) (6) Guidelines for Design and Construction of Health Care Facilities, 1996-1997: 7.31.E1 (c)
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Based on documentation, interviews and observations during a Federal Recertification Survey, the facility failed to follow Infection Control Practices and did not ensure that: a) staff maintained standard infection control practices during medication administration in two (2) of four (4) observations (patients #3 & #14) b) staff maintained standard infection control practices while obtaining a patient's blood sugar levels in five (5) out of eight (8) observations (Patients #3, #14, #26, #53.....) and c) staff followed the facility policy and procedure for glucose monitoring, in five (5) out of eight (8) observations (Patients #3, #14, #26, #52.....)
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Findings:

The facility failed to ensure that staff demonstrated proficiency with a glucometer while obtaining a patient blood sugar level in one (1) out of six (6) observations.

The facility failed to ensure that a Vendor followed facility Policies to maintain sanitary conditions with orthopedic prosthetics in the Perioperative Surgical Areas.

The facility failed to ensure staff who reprocess medical equipment had current training.
(See Tag A 749)
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Based on record review, interviews and observations during the Federal Recertification Survey, the facility failed to follow Infection Control Practices and did not ensure that: a) staff demonstrated proficiency with a glucometer while obtaining a patient's blood sugar level in one (1) out of six (6) observations (Patient #15), b) Vendors followed facility Policy to maintain sanitary conditions with orthopedic prosthetics in the Perioperative Surgical Areas (one {1} of one {1} Vendor), and (c) that staff who reprocess medical equipment had current training (one {1} of one {1} staff member).

Findings:

a) Observations on 06/09/14 at 11:45AM in the Behavioral Health Unit revealed Staff #5 performing a glucometer test on Patient #15.

During the procedure, Staff #5 was observed resting Patient #15's finger on top of the glucometer device and then proceeding to puncture the patient's finger with a lancet. The patient's blood was placed on the testing strip which was attached to the glucometer device, however, an error occurred with the device requiring the test to be repeated.

Staff #5 then repeated the test on the same patient a second time causing the staff member's gloves to become visibly soiled. The staff member was then observed re-entering the glucometer strip container with the soiled gloves to remove a new test strip. The staff member then proceeded to obtain more blood from Patient #15's finger.

A second error occurred with the device and another observation was made of Staff #5 re-entering the glucometer strip container with the same gloves that were visibly soiled with blood to obtain a new strip and repeating the test obtaining additional blood from the patient's finger.

Upon completion of the glucose monitoring, Staff #5 changed gloves after performing hand hygiene and was observed cleaning the glucometer which was visibly soiled with blood, then wiped down the bedside table, placed the machine on the clean table and disposed of the Sani Wipe.

Staff #5 did not clean the blood off the tip of the machine by the glucose strip insertion site before placing it on the clean table.

After Staff #5 placed the glucometer on the bedside table, Staff #2 then told Staff #5 "don't forget to clean the tip".

Review of Nursing Inservice Training for Accu-Chek glucometers revealed that Staff #5 received glucometer training on 04/07/14.

Review of the Policy titled "Glucometer Device Blood Glucose Testing System" dated 04/14, documents in Section VII: Procedure: #6 "After the blood test is complete, dispose of the used lancet in a biohazard sharps disposal container", #7 "Remove gloves and perform hand hygiene" and #10 "Don gloves before cleaning the glucometer device with an alcohol swab or Sani Cloth in between patient use and allow to air dry".

b) Observations on 06/10/14 at 10:50AM revealed a Vendor working in the Perioperative Holding Area had placed a plastic container on the floor. The Vendor proceeded to empty out the container filled with boxes onto the floor, inside the boxes were "Revision Joint Implants" intended for orthopedic surgery.

During an interview conducted on 06/10/14 in the morning, Staff #20 stated "that this was a breach of Infection Control and that the Vendor should have removed the boxes stored in the plastic bin and placed them on a metal cart to be transported to the Intraoperative Area".

On 06/11/14 Staff #15 stated "that the Holding Area is not always monitored, but that the person would not be able to pass the desk by the Operating Room (OR) Suites or past the Circulating Nurse in the OR".

Review on 06/11/14 of the Vendor's Personnel File Training and Certificates revealed Infection Control Training which was inclusive of "Aseptic Techniques and OR Protocol Training". The Vendor's certificate for AORN (Association of PeriOperative Registered Nurses), "Operating Room Protocols: Operating Room Infection Prevention and Aseptic Technique Principles" dated 09/03/09.

Review of the email from the Vendor's company, dated 06/11/14 and timed 1:44PM, to the Vendor documented "that any of the training certificates that are older than three (3) years I would insist you take again".

The facility's Policy titled "Vendor Access and Solicitation Policy" dated 03/2013 states that the intention of this Policy is to ensure that "all entities are in strict compliance with all legal and system Policies".

c) An onsite visit was conducted at the Multi-Specialty Care Center (South Nassau Hospital Extension Clinic) on 06/12/14 at 11:30AM. An interview on 06/12/14 at 11:30AM revealed that Staff #12's job responsibilities include the sterilization and re-processing of instruments in the steam autoclave. When asked what the proper temperature range and pressure (PSI) (Pounds per Square Inch) was for sterilizing instruments in the autoclave, Staff #12 did not know the answer and stated "the PSI is twenty-six (26) or something like that. The machine would alarm if a code comes up and there is a problem." Staff #12 stated on 06/12/14 at 12:00PM that she has been performing this duty for fifteen (15) years and added "I should know".

The "Position Description" of Staff #12 documented that this employee position is "responsible for the sterilization of instruments as per the Manufacturer's Guidelines for the department and ensures that the Log Book is accurately maintained". Review of the Personnel File revealed that Staff #12 had received initial training from the Manufacturer's Representative but has not received retraining since hire.

Staff #12's last competency was completed in July of 2013 for use of the autoclave but was not inclusive of the machine's temperature or PSI range required for proper sterilization. A review of the Manufacturer's Guidelines for the M11 Autoclave revealed that the standard cycle parameters for permitted temperature range for proper sterilization is 250 degrees to 275 degrees F and the pressure should be 27.1 PSI when the chamber pressure is 270 degrees F.
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33919

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Based on record review and staff interviews during the Federal Recertification Survey, the facility failed to assure continued care of a patient in need of post emergency treatment but not in need of inpatient hospital care. Specifically, the ED Staff failed to document appropriate referrals for a patient who presented to the Emergency Room (ER) ten (10) times in a thirteen (13) week period (03/20/14, 04/10/14, 04/15/14, 04/24/14, 05/09/14, 05/12/14, 05/17/14, 05/21/14, 05/24/14 and 06/10/14) in one (1) out of four (4) Emergency Room Medical Records reviewed (Patient #23).

Findings:

Review of the Medical Record for Patient #23 revealed the patient had a past medical history of Inguinal Hernia, Prostatitis, Shoulder Surgery and Anxiety. The patient presented to the Emergency Room on 04/24/14 with complaints of pain in the right lower quadrant radiating to the right testicle. The Emergency Room Physician Assistant (PA) documented that "the patient states he has constant sharp right lower quadrant pain radiating to the right groin." The PA documents "spoke with Urologist, aware of case, states nothing Urology related for him to do". The ER PA then documented "spoke with Surgeon, reviewed history / physical and examination, aware patient, is a frequent flyer, does not think it is Appendicitis will have Surgical Resident come and evaluate patient". The PA documents the "patient was seen by Surgery and Urology then cleared for discharge". "Will prescribe small supply of Percocet." "Pt advised to follow up with Surgery for elective Hernia Repair and Urology for Prostatitis" but there is no documented evidence that the patient was referred to Social Services or for pain management.

The patient next presents to the Emergency Room on 05/17/14 and the Nurse documented the patient's chief complaint as "needs refill of Flomax and Percocet" and that the patient "was complaining of right lower abdomen pain seven (7) out of ten (10). The Emergency Room Physician documented "the patient presents to the ED from home for prescription refill of Percocet and Flomax, which he has been taking for several weeks". The Physician documents "patient states he is in severe pain and urinary retention is worse" since he ran out of medication. "Patient was seen here two (2) days ago." The Physician documented that he "spoke with the covering Urologist who offered to call in a prescription for Flomax but the patient insisted he needed Percocet so the patient was instructed to come to the ED if he was in that much pain". The patient was then discharged to follow up with the Urologist with no documented evidence the patient was referred to Social Services or for pain management.

The patient then presented to the Emergency Room (ER) on 05/21/14 with complaints of abdominal pain into the right groin ten (10) out of ten (10). The Emergency Room Physician documented "male patient presented to the ER with complaint of right groin pain, has known Inguinal Hernia on this side". "Evaluated in the past by General Surgeon but told he could electively have it fixed at that time." "Radiology results discussed with patient. Patient counseled regarding persistent visits to the ER and risk of repeated radiation exposure. Patient states he does not have money to have the Hernia repaired on the outside. Made recommendation to register with County hospital for indigent medical care. Explained to patient that he has a chronic condition and it would not be corrected on emergency basis" but there was no documented evidence the patient was referred to Social Services, pain management or received information on Charity Care.

The patient again presented to the Emergency Department (ED) on 05/24/14 with complaints of pelvic and right groin pain ten (10) out of ten (10). The Emergency Room Physician documented the patient complained of pain "which has been present for many months". The patient "states that he ran out of Percocet and is here for refills" and "states he has an appointment with the Surgeon this week". The Physician documented the treatment plan as "pain from Hernia" "question drug dependence", "had follow up with Surgeon this week", "no acute process discharge to follow up". The ED Nurse documented "patient has had multiple revisits to the ED for same problem and was told to follow up as an outpatient for small Hernia". "ED Physician called the Surgeon for plan." The Surgeon "has seen patient during every ED visit, reports Hernia very small and does not require emergency surgery". "ED Physician discussed with patient and discharged ordered." The patient was then discharged with prescriptions for Zofran and Percocet but there is no documented evidence the patient was referred to Social Services or pain management.

This same patient presented to the Emergency Room on 06/10/14 with complaints of right arm pain seven (7) out of ten (10) after a fight. The patient was documented to be taking Zofran, Percocet, Tylenol, Klonopin, Flomax, Toradol and Flexeril at home. The Physician Assistant documented "reviewed I-STOP" and "the patient had ten (10) previous prescriptions from 04/10/14 to 05/24/14 for Oxycodone". "Will not give narcotics due to drug seeking behavior." The patient was diagnosed with a hand contusion, placed in a splint then discharged with instructions to follow up with an Orthopedist, but there is no documented evidence the patient was referred to Social Services.

Interviews during the afternoon of 06/11/14, with Staff Members #187 and #188 revealed that the ED Physician or Nursing Staff can make a referral to Social Services if a discharge is felt to be unsafe. They also see patients who are identified as needing assistance for placement or who might require home care. The staff members stated that they review the patients' Triage information and if the complaint is felt to be a valid medical issue, then the patients would not have been seen unless requested by the Medical Team.

A concurrent interview with Staff #184 revealed that anyone without insurance is provided with a referral for Charity Care and that during the day a Representative will met with them, but there is no current documentation placed this Electronic Medical Record.

On 06/13/14 during an interview in the morning, Staff #6 stated there is no requirement for Discharge Planning for outpatients in the Emergency Room. However, this facility has staff available to assist patients identified or referred to Social Services as needing assistance. The staff member stated that the ED has an "Emergency Department Resource Directory" that includes information the ED Staff can provide to the patients.