HospitalInspections.org

Based on policy and procedure review, medical record review and interview, the facility does not ensure adherence to policy and procedure related to appraisal of emergencies, initial treatment and referral when appropriate, as evidenced for 2 of 2 transferred patients (Patients #3 and 4).

Findings include:

Review of policy "Emergency Transfer Form-NSG.116" (last reviewed 5/2014) revealed that "the inter-institutional transfer form is completed and sent with the patient to the facility he/she is transferred to. A copy of the form remains at Brylin."

Medical record review on 5/28/15 revealed the following:
- Patient #3 was transferred to an area emergency room on 1/16/15. There was no evidence of an inter-institutional transfer form in the medical record.
- Patient #4 was transferred to an area emergency department on 4/20/15. There was no evidence of an inter-institutional transfer form in the medical record.

This finding was confirmed with VP (Vice President) Patient Care Services RN (Registered Nurse) Staff #1 on 5/28/15 at 3:00PM.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 8/11/11.

Based on policy and procedure review, medical record review, and interview, the facility does not ensure nursing staff develop and keep current the plan of care for all patients for 1 of 19 patients (Patient #19).

Findings include:

Review on 5/28/15 of policy "Multidisciplinary Treatment Plan" (last reviewed 6/2014) revealed a comprehensive individualized treatment plan is developed for each patient by the multidisciplinary treatment team within 48 hours of admission. The treatment plan takes into account cultural, spiritual, and social factors as well as the particular characteristics, conditions, and circumstances of the patient.

Medical record review on 5/28/15 for Patient #19 revealed on the Admission Psychiatric Assessment, Obesity-directly impacts on the patient's mood under Axis III. The multidisciplinary treatment plan for medical issues and the problem statement had no entries for medical issues. There was no evidence of a plan of care to address the medical condition of obesity.

This finding was verified with VP Patient Care Services RN Staff #1 and Director of Quality RN Staff #3 on 5/29/15 at 11:30AM.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 8/11/11.

Based on interview, the facility failed to implement a medical record system allowing medical records staff to retrieve a medical record by diagnosis and procedure.

Findings include:

Interview on 5/26/15 at 2:50PM and on 5/29/15 at 8:50AM with Medical Records Staff #5, 6 and 30 revealed that in order to access a patient medical file, a patient name and date of service is required. Medical Records Staff #5, #6 and #30 revealed they are unable to access a patient file by diagnosis and procedure.

This finding was verified with VP Patient Care Services RN Staff #1 and Director of Quality RN Staff #3 on 5/29/15 at 11:30AM.

Based on policy and procedure review, medical record review, and interview, the facility does not ensure that hospital reports are properly dated, timed and authenticated according to policy and procedure for 1 of 19 patients (Patient #20).

Findings include:

Review on 6/4/15 of facility policy (emailed to NYSDOH on 6/3/15) "Record Authentication" (reviewed 7/14) revealed "Authentication serves to identify the author of an entry and also indicates that the author has reviewed the entry or report for accuracy and attests to it. . . Proper authentication shall be added at the conclusion of each entry and shall consist of the professional title or initials indicating the professionals credentials."

Review on 6/4/15 of facility policy (emailed to NYSDOH on 6/3/15) "Record Documentation" (last reviewed 7/14) revealed "entries in the medical record will be made to reflect each patient event of care". According to the policy, the time of events are to be documented as close to the time of the event as feasible and all entries will be timed and dated.

Review on 5/28/15 of lab results for Patient #20 revealed lab results reported on 2/26/14 at 12:55PM, 2/27/14 at 8:03AM, 3/4/14 at 6:28AM, and 3/5/14 at 7:40AM were missing the date, time and professional title or initials indicating the professional credentials.

These findings were verified with VP Patient Care Services RN Staff #1 and Director of Quality RN Staff #3 on 5/29/15 at 11:30AM.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 8/11/11.

Based on policy and procedure review, medical record review, and interview, the facility does not ensure all telephone orders are dated and timed for 3 of 19 patients (Patients #20, 21 and 24).

Findings include:

Review on 5/28/15 of policy "Physician Orders/Telephone Orders" (last reviewed 5/2014) revealed the RN writes each order with the following information: the date and time the order was received. All telephone orders are cosigned by the physician within 24 hours of the given order.

Medical record review on 5/28/15 revealed the physician did not date and time two telephone orders for Patient #20, two telephone orders for Patient #21, and one telephone order for Patient #24 when cosigning a telephone order.

This finding was verified with VP Patient Care Services RN Staff #1 and Director of Quality RN Staff #3 on 5/29/15 at 11:30AM.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 8/11/11.

Based on document, personnel file review, and interview, the facility failed to ensure that the Life Safety Code for Fire Requirements was met. Specifically, that facility did not ensure facility staff had annual fire safety training for 10 of 18 staff. (Staff #1, 8, 10, 12, 16, 18-20, 22 and 23)

Findings include:

Review on 5/28/15 of "Corporate Compliance Plan for 2015" revealed for Article VI. Education and Training: the mandatory annual education program is required for all employees. Participation and attendance at compliance training is mandatory and a condition of continued employment.

Review of 18 personnel files on 5/27/15 revealed that the files for Staff #1, 8, 10, 12, 16, 18-20, 22 and 23 showed no evidence of a report for annual mandatory compliance training.

Interview on 5/28/15 at 11:00AM with RN Staff Educator Staff #33 revealed that these staff (Staff #1, 8, 10, 12, 16, 18-20, 22 and 23) had not completed current annual mandated training, which includes fire safety.

Based on observation, interview and document review, the facility does not provide electrical safety to patients and staff related to the maintenance of the ECT (Electroconvulsive Therapy) Thymatron System IV unit.

Findings include:

Observation during tour on 5/26/15 at 1:05PM revealed the Thymatron System IV unit did not have a current biomedical inspection tag on the device. Review on 5/27/15 at 10:30AM of the Martin Medical Equipment Service Log revealed the device was not listed on the inventory.

Interview with Director of Plant Operations Staff #2 on 5/27/15 at 2:00PM revealed the Thymatron device was formerly inspected by the previous biomedical contractor and the new contractor, Martin Medical, does not have the capabilities of reviewing this unit.

These findings were verified with Staff #2 on 5/27/15.

Based on policy and procedure review, personnel file review, interview and observation, the facility does not ensure that the infection control officer has a system for identifying, reporting, investigating and controlling infections and communicable diseases; specifically:
1) The health of personnel is not assessed with action taken as needed, as evidenced for 7 of 18 clinical staff (Staff #8, 11, 16, 17, 19, 20 and 23).
2) The facility failed to ensure point of care devices (glucometers) are used according to hospital policies and procedures to maximize the prevention of infection and communicable disease acquisition, as evidenced for Patients #11 and 13.

Findings include:

Finding #1:
Review on 5/27/15 of policy " Employee Health Maintenance - #13.06.01/31.3331" (last reviewed 12/2013) revealed "All employees are required to have a completed health and physical examination which includes rubella immunity. The health status of all employees is reassessed annually. Tuberculosis skin testing is performed annually."

Personnel file review on 5/27/15 revealed:
- The files for Staff #8, 11, 16 and 17 did not contain evidence of a current health assessment and annual tuberculosis screen.
- The files for Staff #19, 20 and 23 did not contain evidence of immunization against rubella.

Interview on 5/28/15 at 1:00 PM with Infection Control Nurse Staff #25 revealed all staff are required to have annual health assessment and TB screen.

Interview on 5/29/15 at 9:00A with Staff #25 revealed that Staff #8, 11, 16 and 17 do not have a current health assessment and/or TB test. Staff #25 stated he reached out to Staff
#19, #20 and #23 for documentation for proof of rubella immunity, which is not currently in their personnel files.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 8/11/11.

Finding #2:
Review on 5/27/15 of policy "ACCU-CHEK Inform Glucose Monitoring" (last reviewed 5/2014) revealed that the cleaning instructions state that the meter must be cleaned after each patient use.

Observation on 5/27/15 at 10:45AM of Licensed Practical Nurse Staff #26 revealed that while using the glucometer, Staff #26 failed to clean the glucometer between patient use for Patient #13 and Patient #11.

This finding was verified with VP Patient Care Services RN Staff #1 and Director of Quality RN Staff #3 on 5/29/15 at 11:30AM.