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Based on review of documents and staff interviews, it was determined that the facility failed to conform with requirements for the reporting of accurate numbers of patients receiving treatment in psychiatric units exempt from Federal inpatient prospective payment system requirements under §412.25 and §412.27.
Findings include:
Review of documentation submitted by the hospital on March 29, 2012 stated that attested compliance with requirements for the Prospective Payment System (PPS) exempted inpatient psychiatric units found that the facility failed to report accurate numbers for units meeting PPS exempt requirements (Fiscal year 7/1/12- 6/30/12). The facility reported a total of 327 psychiatric beds in 14 units exempted from the inpatient prospective payment system for acute psychiatric services. This count included a total of 64 psychiatric beds located on two inpatient forensic psychiatric units within the hospital operated by New York City Corrections Department. These units,19 West and 19 North, represent inpatient services provided in two forensic psychiatric units licensed by the New York State's Office of Mental Health.
These forensic units are not PPS exempt based on discussion with facility staff, since the care of these patients is not paid for by Medicaid or Medicare.
It was determined, based on interview of the facility's CEO and Chief Financial Officer on 8/30/12, that the prisoners receiving acute psychiatric care in these two units are under the direct jurisdiction of the New York City Department of Corrections, an alternative agency responsible for the care of patients receiving forensic psychiatric services. It was stated that the hospital only provides staffing and clinical services on this unit which is entirely managed by Corrections. It was further stated that no billing or payment is received from either Medicare or Medicaid to reimburse the cost of caring for these inmates.
It was stated that the bills are paid by New York City through a special tax levy that covers the cost of caring for inmates' health needs. For prisoners the practice is to pay the Medicaid rate as a proxy for those payments. For forensic psychiatric patients, the proxy payment is based on the Medicaid per diem rate, whereas for forensic medicine patients the proxy is paid on Medicaid DRG payments.
Review of three billing records on 8/30/12 for forensic psychiatric inpatients found that bills were submitted under a special care prisoner payment code.
As such, the facility reported the forensic psychiatry beds in the PPS psychiatric unit bed attestation to New York State and CMS in error. The facility failed to accurately report the number of patients receiving acute psychiatric care in PPS exempted psychiatric units, since the psychiatric forensic units are by definition not exempted from PPS requirements.
In addition, the facility's PPS attestation included report of emergency psychiatric beds in CPEP EOU (#6) and Children's EOU (#6) which is reported in error since these are not inpatient psychiatric beds.

Based on review of documents and interviews it was determined that the chief executive officer does not provide management for the physical environment of the forensic units.

Findings incude:

During an interview with the Chief Operations Officer (COO) on 8/30/12, he was informed by the sanitarian of the presence of looping hazards in the Psychiatric Forensic unit, and the lack of an adequate number of handwashing sinks in the Medical Forensic unit. He stated that no improvements, modifications or correction of any such deficiencies can be done without the authorization of the Department of Correction and only at the Commissioners' level. This was reiterated by the CEO (Chief Executive Officer) on 8/31/12.

Review of the document titled "Memorandum of Understanding between the Department of Correction (DOC) of the City of New York and the Health and Hospitals Corporation of the City of New York in relation to the Operation of the Forensic Psychiatric Service of Bellevue Hospital Center" (MOU) dated 10/90 on 8/31/12 found no reference to the Department of Correction as having sole permission to remove hazards and make any changes in the physical plant.

Specific reference is made to Section D-part 1, of the document titled " DOC Staff Authority Responsibilities" in which it is stated that "DOC shall have the responsibility to maintain the physical integrity of the Forensic Ward, so as to prevent escapes and the introduction of contraband."

Based on observation, staff interview and review of medical record and hospital policy, it was determined that the facility did not consistently ensure a safe environment for all patients.
Finding incurring:
During the tour of the unit 16N on 8/28/12, at approximately 12:00 PM, the four patients housed in Room 16N52 were observed. It was observed that a staff member was sitting in the center of the back of the room with a monitoring sheet. The staff was interviewed and reported that she was monitoring for fall precaution.
Review of MR #10, the patient in room 16N52 bed D, noted that the physician ordered 1:1 observation for this patient.
The hospital's 1:1 policy indicated that "the staff member is assigned to care exclusively for one patient and must always be within arms length." The patients in this room were on 4:1 monitoring, even though each patient was to have 1:1. (One patient being directly observed by one person.)
It was observed that one of these patients (MR #10) walked out of the room and he was walking on the unit. It was observed that this staff member left the room with this patient, leaving the other 3 patients unattended, therefore creating a potential for an unsafe environment.

Based on observation, staff and patient interviews, the review of medical records and review of hospital policy, it was determined that the facility did not consistently ensure that the staff responsible for the supervision and evaluation of nursing care, provide each patient with a complete admission assessment, and that each patient was properly monitored. This deficiency was noted in three of seven applicable medical records reviewed (MR #s 10, 11 & 12).
Findings include:
On 8/28/12 at 11:00 AM, MR #11 was reviewed. It was noted that this was a 73 year old patient who has a history of esophageal cancer. Review of the Admission Assessment Record (Medical/Surgical), nursing initial assessment dated 7/1/12 at 1624 noted that this patient was not referred to Social Work Department for an assessment as the nurse documented "SW referral not indicated."
Based on Social Work Referral and Assessment policy, the patient met moderate risk therefore required a social work referral.
Similar finding noted in MR #11, SW referral was not indicated.
It was also noted that the patient (in MR #12) was identified as low nutritional risk. This patient was admitted with diagnosis of failure to thrive and should have been identified as high nutritional risk.
During the tour of the unit (16N) on 8/28/12, at approximately 12:00 PM, it was observed that the patient MR #10 was walking and talking very loud on the unit. It was observed that a staff leaded him back to his room, RM #16N52
On entering room #16N52, it was observed that this room housed four patients and there were four patients currently in the room. It was observed that the patient's (in MR #10) bed was closest to the door on the right. The patient was sitting on his bed. The patient was talking very loud disrupting the other patients. The patient informed this surveyor that he was "held against his will and they were watching him".
It was observed that a staff member was in the center of the back of the room sitting down. This staff was interviewed. She stated that she was monitoring the patients in the room to prevent falls. It was observed that the staff had a Surveillance Rounds Monitoring Tool form listing the names of the patients in the room including patient MR #10. It was observed that this staff was not within arms length of the patient MR #10.
While still on the unit, approximately 15 minutes later, it was observed that the patient (MR #10) was now on the unit walking. It was observed that the staff doing the 4:1 monitoring was walking behind the patient. It was observed that other patients in room #16N52 were left unattended.
The charge nurse was interviewed and reported that the staff member was assigned to the patient in MR #10 for 1:1 monitoring.
Review of MR # 10 noted that this 60 year old patient with history of poorly controlled Diabetes Mellitus, CAD, HTN and CVA (resulting in residual R sided weakness and dysarthria). The physician's orders noted that on 8/24/12, the patient was placed on 1:1 observation for elopement.

Based on review of medical records and staff interviews, it was determined that the facility did not ensure an accurate electronic system for the recording of pediatric inpatient psychiatric health and physical assessments.

Findings include:

Review of six of nine concurrent inpatient pediatric psychiatric records on 8/28/12 and 8/29/12 found that the facility staff utilized an incorrect adult template for recording of the history and physical assessments (H&P's) for pediatric psychiatry inpatients.
This adult template was missing information regarding immunizations and developmental history assessments specific to the evaluation of children. For example, the adult H/P template used for children included a section to elicit assessment of "Stroke/VTE Diagnosis". A comparison with a pediatric Health and physical template used for a patient hospitalized on medical pediatrics ( MR #1), sections were evident in the pediatric H/P template for birth, immunization, and developmental histories. (MR#1)

Refer to MR #s 2,3,4,5,6,7.

Examples:

MR #2: Record reviewed on 8/28/12 for 8 year old male admitted for treatment of increased aggression in setting of past history of ODD, expressive language disorder, sleep terror disorder, and mood disorder NOS. The electronic record template dated 8/14/12 noted: "unscheduled History and Physical (Adult)" and did not include immunizations and developmental history sections.

MR#3: Record reviewed on 8/31/12 for 10 year old child admitted for increased aggressive and acting out behaviors in setting of history of ODD and ADHD. The child became combative in day treatment program when it was stated his aunt refused to take him home. Review of electronic record template dated 8/20/12 noted: "unscheduled History and Physical (Adult)" which did not include immunizations and developmental history sections. In addition, under section titled "stroke/VTE diagnosis" it was noted "oppositional defiant disorder".

MR #5: Record for 11 year old female reviewed for admission of aggressive behavior in setting of history of ADHD, ODD, mood disorder, and head trauma. The electronic health and physical assessment dated 8/18/12 lacked sections for immunizations and developmental history . A section in this adult H/P template was titled "stroke/VTE diagnosis", which noted "intrinsic asthma, unspecified."

Similar findings were evident in MR#s 4,6, and 7.

This adult template was missing information regarding immunizations and developmental history assessments specific to the evaluation of children. For example, the adult H/P template used for children included a section to elicit assessment of "Stroke/VTE Diagnosis". At comparison with a Pediatric Health and Physical template used for a patient hospitalized on medical pediatrics ( MR #1), sections were evident in this pediatric H/P template for birth, immunization, and developmental histories. (MR#1)


At interview with Administrative Risk Management staff on 8/30/12 it was stated the adult history and physical assessment electronic medical record template was an inaccurate format due to limitations of the electronic medical record system, in the way it was set up. It was also stated by the Administrative and medical leadership staff, that the facility is planning to replace the electronic medical record system within an approximate time frame of two years.


16790


Based on review of medical record and the greivance file it was determined that the facility did not ensure that patients' medical records were accurate and complete.
Review of Grievance File on 8/31/12 noted that the patient's son in MR #14 filed a grievance with the facility, that the patient fell on 7/11/12 and he was not informed.
Review of the MR noted that the nurse documented on 7/11/12 at 2012, that the patient was found on the floor on at 3:55 PM. It was noted that the nursing staff documented the event over four hours after the patient fell. The MR indicated that the event time was dated 7/11/12 at 1958. It was noted that the internal reporting indentified that the patient fell at 3:55 (1555) not 1958 (7:58).
It was noted that the physician who examined the patient after the patient fell, failed to document the physical examination in the medical record.

26259


Based on a tour of several inpatient units and interviews, the facility failed to implement a system for effective removal of unused and expired medications and biologicals from patient care areas.

Findings include:

1. On 8/28/12, at 12:00PM, 3 blue Vacutainers with the expiration date of 04/2012 were found in the Emergency Box in the Critical Care Unit (CCU).

2. At 1:15PM, 6 bottles of 0.9% normal saline for injection were noted in the procedure cart located in the medical ICU. Four (4) of the bottles had expired since 5/1/12. One (1)expired on 7/1/12 and the last bottle expired on 8/1/12.

3. On 8/27/12, the inspection of the floor stock on 16 North found four (4) vials of Digoxin 500mcg/ml that expired in June 2012.

4. The medication refrigerator on 16 North contained an intravenous bag of Sodium phosphate 3mmol with expiration date of 8/23/12.

5. Also in the refrigerator were 18 bags of Vancomycin of various strengths labeled with the patient's name. Based on the review of medication administration records of these patients, it was noted that 10 of the 18 bags of Vancomycin have either been discontinued or the patients have been discharged.
The IV vancomycin for MR #150718 was discontinued on 8/10/12.
The patients in MR # 3488055 and MR# 1473720 had their IV vancomycin discontinued on 8/24/12 and MR #3336945 was discontinued on 8/25/12.
One of the IV vancomycin belonged to a patient that had been discharged.

At interview with the unit nurse on 8/27/12 at 3:45PM, she stated it was the Pharmacy Department's responsibility to remove all unused medications including those stored in the medication refrigerator. A follow up interview with a registered pharmacist on 8/31/12 revealed that the collection of unused medication is done daily and there is a designated blue bin on each unit for the storage of unused medications.


Based on observation, the facility failed to ensure medications are appropriately labeled and dated to assure patient safety.

Findings include:

1. A bottle of opened and undated 1000cc sterile water for irrigation was noted in Room 10N18 at 12:20PM. The bottle was ½ full.

2. An IV bag of potassium chloride 10meq and a bag of Magnesium Sulfate 1gm were unlabeled. At interview with the staff nurse, she stated that the medications were for pick up and were delivered to the unit labeled with patient's name.

Based on observation and staff interview, the facility failed to ensure that the hospital is constructed, arranged, and maintained to ensure the safety of the patient as evidenced by the overall and cumulative findings of A-701 and A-749 that included but were not limited to:

1. The structures in the psychiatric areas present suicidal looping hazards.
2. The lack of cleanliness and sanitation of the different patient care areas of the hospital.
3. The facility's failure to perform and read the test results of the Biological Indicator and to adhere to the recommendation of CDC and AAMI standards.
4. The improper storage of sterile instrument trays and medication cart in the scrubbing areas of the Operative Suite (OR) with the potential risk of contaminating these items.
5. The presence of gaps between the ceilings tiles of the ORs that accumulate dirt and are potential risk of infection.
6. The lack of illuminated exit signs in many locations of the hospital as required.
7. The lack of nursing call bells of many patient bathrooms.

Cross Refer to A701 and A749

Based on observations and staff interview, the facility failed to maintain the physical plant in a manner to provide a safe and sanitary environment for the treatment of patients.

Findings include:

During the tour of the emergency department on 08/27/12 at approximately 11:00AM, it was noted that the facility did not maintain a clean environment in the emergency department.
The perimeter of the floor in the Urgent care and Emergent care areas was heavily soiled and grimy.

The drawers of the exam tables in the exam room #s 7, 8 and 9 of the Urgent Care area were black in color and dirty. The matting on the foot rest of these tables were observed to be peeling off. The upholstery of the exam table in exam room #8 was observed to be torn and was held together with pieces of tape rendering the table uncleanable. It was also observed that the peices of tape had collected dirt and appeared black in color.

An unused dusty mattress was observed to be stored on a metal rack (located at the end of the corridor, opposite to exam room #8 of Urgent Care) containing plastic trays of clean supplies. These plastic trays containing packaged clean supplies were found to be dusty also.

The guard rails along the outer wall of exam room #7 of the urgent care area was covered with dust.

Blood drawing supplies were observed to be stored on a small table that was heavily soiled and a strand of human hair was noted on the table.

A white colored patient weighing scale (equipment Id #29425) stored in front of ED #5 of Urgent care was observed to be heavily soiled with embedded dirt and therefore appeared black in color.

Tour of the Clean Utility room revealed that the facility stored clean supplies on the floor. It was noted that a box of four (4) by four (4) guaze, a coffee pot in an open box, a overflowing box of neck braces, a plastic bag containing cereal, a box containing trash, a box of paper towels and a box of splash guards were stacked together on the floor beside an uncovered metal rack containing trays of clean supplies. An employee's street clothing was observed to be hanging on this metal rack containing trays of uncovered clean supplies.

The floor of this clean utility room was found to be dirty and strewn with debris.

The top of the medication refrigerator and the Pyxis machine was covered with dust.

Tour of the Dirty Utility room of the Urgent Care revealed that the facility stored HIV (rapid) testing supplies in a box in the Dirty Utility room. Additionally, a dirty cabinet full of clean supplies was noted to be stored in this room.


The tour of the Emergent Care Area revealed the following:

· The floor around the beds in the EKG bays was heavily soiled and grimy.

· The sonogram equipment stored outside room #98 ED was covered in dust. Packaged syringes and four (4) by four (4) were also observed to be stored on the base of the machine.

· The base of the ENT (Ear, Neck and Throat) treatment chair in room #88 ED was heavily soiled and grimy. The computer table in this room was also observed to be covered in dust.

· The Clean Utility room (#85 ED) was also found to be dusty and dirty. The sterile water bottles stored on a metal rack was observed to be covered with dust.

On 08/30/12, during tour of the 4 bedded Acute Dialysis unit on fifth floor, following observations were made:

· The floor of the Dialysis unit especially around the dialysis machines and the supply carts was heavily soiled and strewn with bandage wrapping, peices of tape, and plastic caps etc.

· An emergency cart and a metal shelf with stored clean supplies (uncovered) were observed to be stationed in very close proximity of a dialysis machine. The emergency cart was observed to be located at the far end corner of the room (right side) and would not be easily accessible in an emergency. This cart is being blocked by a dialysis machine, a clean supply metal shelf, nurses'desk and chair and 3 small oxygen cyclinders.

· An EKG machine and stand was observed to be covered in dust and 71 packaged syringes were noted be stored on the base of this cart.

Additionally, the facility failed to maintain a safe environment, free of physical hazards for the treatment of psychiatric patients in the Adult CPEP unit. The following observations were made in the unit:

· The doors of six (6) observation rooms had pivot hinges which are not continous and posed a looping hazard in the unit.

· The captain beds in all of the six (6) observation rooms had holes on the four corners of the mettalic baseboard and therefore these holes posed a looping hazard.

· An old unused call bell fixture installed on the ceilings of all the six (6) observation rooms were observed to be easily accessible to patients and removeable.

· All of the six (6) observation rooms were observed to have privacy curtains which were 100% polyester. These privacy curtains hung on the break away tracks and could be used by the patients for suffocation and asphixation.

· The surface mounted paper towel dispenser, bathroom tissue dispenser, and the hand soap dispenser in the patient bathroom (#195 ED) inside the adult CPEP unit had a flat top surface, and therefore was noted to be a looping hazard.

· The handwashing sink in the same bathroom was observed to be protuding out of the wall approximately 18 inches and therefore provided opportunities of looping.

· A glass mirror was observed in the bathroom that was not recessed into the wall. This mirror posed a risk of cutting and weaponization.

· A moveable shower chair was observed to be in this patient bathroom and this posed a risk of being used as a weapon to cause harm.

The tour of the Forensic Psychiatric unit on 19W revealed the following physical hazards on the unit:

· During the tour of the dining room, the surveyors observed a metal barricade (approximately 8'x8') across the window with square openings of 2"x2". This barricade can potentially be used to commit suicide by creating a ligature through the open slots. The door of this dining room also had pivot hinges that could be used to create ligature.

· During the tour of the shower room, the surveyors noted that there was a 2 and half feet deep shower tub in the room. This device can potentially become a drowning hazard in the room. The top of the shower head was observed to be flat and can potentially be used for looping. The faucet in the tub for the hot and cold water control valves (spigot type) were of the type that could potentially be used to create a a ligature.

· During the tour of the Day room (19W80), the surveyors noted a metal gate (between 19W and 19N) with open slots measuring approximately 3"'x6". This can also potentially become a looping hazard. The surveyors also noted exercise bars in the room.

· The surveyors noted a container (removable lid) with a cake of laundry soap. The lid of the container was capable of being easily removed and the soap cake was easily accessible with potential of causing harm.

· The door of the seclusion room was also observed to be installed with pivot hinges which can be potentially used to create ligature/s.

During an interview on 08/23/12 at approximately 11:30AM, the Chief Operating Officer informed the surveyors that the hospital did not have the authority to make the changes in the physical environment of the Forensic units (2 Forensic Psychiatric Units on 19W and 19N & 1 Forensic Medical Unit on 19S), as it was operated by the NYC Department Of Corrections.

See Tag A057


21204


During tours of the hospital at different times of the survey conducted in the period from 8/27/2012 to 8/31/2012, the following findings were identified and brought to the attention of the hospital staff who were accompanying the state surveyor (Director of Engineering, facility Operations and Building Efficiency).
Operative Suite (OR):
During a tour of the Operative Suite at approximately 12:05 PM of 8/28/2012, the following findings were identified in the presence of the Director of facilities and the Director of Operative Suite:
1. Two sterile carts that had five (5) sterile instrument trays were left in very near proximity to the scrubbing sinks which present potential of infecting the sterile instruments.
2. The frame of the door of OR #1 was noted to have multiple layers of adhesive plasters glued to the edge of the door frame and it was stained and dirty. When asked, the head nurse said that the staff may put this plaster to stop slamming of the door against the door frame.
3. Two sterile trays were observed being stored on the top of the soiled linen hamper by OR #1.
4. Two infusion pumps a stool and cart were observed to be obstructing the scrubbing area outside OR #3.
5. The OR ceiling tiles were not of the monolithic type and many of them had gaps between the tiles. This has potential to accumulate dirt and present risk of infections.
Examples include but was not limited to OR #3 which had stained and unclean ceiling tiles.
6. A medication cart was left in the scrubbing area between OR #4 and #5. When asked, the head nurse stated that they need that medication cart for special cases.
7. The floors of OR #10 and #11 were observed to be stripped of the covering layer (coating layer), and had black stains and were not easy to clean.
8. A supply cart was noted to be outside Cath Lab room and stairwell W11.
9. The housekeeping room in the OR Suite was cluttered preventing access to it.
Recovery Suite:
1. No exit signs were provided in the recovery suite to direct patients and staff in the event of fire or smoke.
2. The clean supply room of the recovery area did not have positive air pressure as required for this type of room.
3. Equipment (Ventilators, Balloon pumps, Blood Transfusion infusers, IV Poles, chairs, wheel chairs, etc.) were stored in the D bay CV001 next to patients in the recovery area.
4. No exit signs were provided in the Cath Lab suite to direct patients and staff to the outside of the suite in event of fire or smoke.
Adult Inpatient Psychiatric Unit (20th floor- East):
During a tour of the Adult Inpatient Psychiatric unit approximately at 3:00 PM of 8/27/2012 the following findings were identified in the presence of the Director of Engineering and the Assistant Director of Facilities Management who acknowledged the issues.
1. The electric outlet of the dayroom next to the ice machine was of the regular type not tamper resistant that is required to the psychiatric units.
2. The door handles of cabinets mounted to the wall at a level of four (4) feet above the floor presents looping hazard.
3. The TV wiring of the day room was exposed and not secured and presents looping hazard. There were six (6) electric outlets of the regular type not Tamper Resistant that is required for the psychiatric unit.
4. The wiring of the phone in the day room was loose. This wiring was more than six (6) feet long and presents looping hazard.
5. The faucet and water control knobs of the day room were of the regular type and present looping hazard.
6. The closet of patient room #34 and other rooms had piano hinges that were not extended to the top of the closet, leaving a gap about 2 inches between the door and the closet that presents looping hazard.
7. The outside cover of the drawer of the night stands in room #34 was broken leaving four (4) sharp pointing parts of screws which present a safety hazard.
8. Dried blood were observed on the linen on the bed of room #34.
9. Many patient beds were observed to have holes at the four sides of the beds. Those holes could be used for looping purposes and present a safety risk for the psychiatric patients. Example include but was not limited to room #34.
10. The floor of the clean linen room was dirty and there was a urine collecting cup on the floor.
11. The soap dispenser in room #200E26 was removed and multiple holes were left unsealed on the wall.
12. The faucet and the flusher of the patient bathroom and shaving room #20E41 was of the regular type not the safety type required for the Psychiatric units and presents looping hazard.
13. The door handle of room #20E41 was of the regular type not the safety type required for the Psychiatric units and presents looping hazard.
14. The seclusion room #20E44 was not padded and presented a safety hazard.
15. Blood were observed on the floor of the bathroom #20E50.
16. The air supply vent of room 20E50 was covered by layers of paper and adhesive tape.
17. The water control of the shower at bathroom # 20E52 was of the regular type, not of the safety type required for the psychiatric unit and presents looping hazard.
18. The cabinets of the activity room have protruded metal lockers that present a safety hazard for the psychiatric patients.
Adolescent Inpatient Psychiatric Unit - Floor 21West:
1. The TV, the cabinets and the video cable of the activity room present safety risk and looping hazard.
2. The bed of room #21W56 has holes and metal hooks on the four sides of the bed. That is a potential for a looping hazard.
3. The thermostat of the dining room was noted to be loose and not secure and presents safety and a looping hazard.
4. The corner beam of the Conference room #21 W44 was broken.
5. The door on the exit near the nursing station and the conference room was observed to have a protruding metal bolt instead of the original safety bolt.
Child Psychiatric Unit - Floor 21 South:
1. The faucet and the shower head of patient restroom 21S86 was of the regular type not the safety type and present a looping hazard.
2. The cable of the TV set on the dining room was loose and not secured and presents looping a hazard.
3. The wiring of the microwave was not secured and present a looping hazard.
4. All the patient beds have restraining metal hooks that present looping hazard. Interview with the supervisor of the Psychiatric unit revealed that the children in this unit are not to be restrained.
5. The electric outlet in the child's play room was not tamper resistant. There were many electrical wires observed in that room, which present a safety and a looping hazard.
6. There was a metal cabinet stored in an alcove of the corridor next to room 21 S57 and that cabinet had a metal protruding lock which presents a safety hazard.
7. The patient's bathroom # 23S1 had a goose neck type of faucet, regular water control and regular door handles. All of which were not of the safety type and present a looping hazard.
10th floor - ICUs:
1. Many rooms of the Medical ICU and Neurological ICU were observed to be dirty especially around the perimeter of those rooms. Examples included but were not limited to room # MICU3 and # NICU4.
2. The clean utility room 10W34A was found to have negative air pressure instead of the required positive air pressure for this type of room.
3. The Janitor closet (10W33C) was found to have positive air pressure instead of the required negative air pressure.
4. The soiled utility room of the step down surgical ICU (room 10N54) did not have negative air pressure as required for this type of room.
Endoscopy Suite:
1. The draining pipes underneath the sinks of the ADA bathrooms # 10 N14 and #10N10A of the endoscopy suite were not insulated or otherwise configured to prevent abrasion and / or burns that could occur to wheel-chair bound patients.
2. The mirrors of the above two rooms were mounted at a level more than 40 inches from the floor, contrary to the ADA requirement.
3. The Data Jack cover outlet of procedure room 2 was observed to be loose and broken.
Rehabilitation Department (Rehab) and Gym - 6th floor North:
During a tour of the rehab unit on the 6th floor on the morning of 8/29/2012, the following issues were identified in the presence of the Director of Engineering and the Director of Facilities Management.
1. No illuminated exit signs to direct patients and staff to outside the unit in the event of smoke or fire. Examples included but were not limited to the waiting area and the outpatient Gym 6N16.
2. All of the bathrooms in this department did not have a nursing call bell. Examples included but were not limited to: room 6N14A (ADA bathroom, 6N17, 6N18, 6N19A, 6N19B and 6S33.
3. All the bathrooms of the Rehab Department and the Gym area including the ADA bathrooms did not have fire Alarm strobe lights.
4. No fire alarm strobes lights were provided in patient areas that included but limited to the hydrotherapy area, female locker room.
5. Three Hydrocholators (two in the Outpatient Gym and one in the Inpatient Gym) were found to have rusted surfaces especially the upper part of the inside of the hyrocholators.
6. More than seven hydrotherapy Tubs /and or tanks were found to be dust laden and not clean.
7. The lockers of all the patient bathrooms on this floor did not have an easy mechanism to open the door from outside to rescue patients who might need assistance in the event of emergency. The Supervisor of the Physical Therapy and the Director of Facility management could not open the door upon locking them from inside and acknowledged the need to correct this issue.
8. The smoke barrier above smoke door near 6N5 was found to have penetrations around electric wirings, cable wirings and conduits wirings that were not sealed by the proper fire stops.
9. The smoke barrier above the smoke door that is next to 6N14B was found to have penetrations around conduits and cable wirings that were not sealed by the proper fire stops.
10. The smoke door next to 6N5 was kept closed and its magnetic mechanism that holds the door open was removed. Most of the patients passing through that door were outpatients with wheel chairs who did not have companions, and it was difficult for them to go through that door without help.
Inpatient Rehabilitation 6th Floor South:
1. The bi-swing doors of the patient bathrooms did not have locking mechanisms to lock the door from the inside to ensure privacy of the patients in semi - private rooms.
2. The soiled utility room 6S24 was found to have positive air pressure instead of the required negative pressure for this type of room.
Pulmonary Unit- 7th floor west:
1. The exit door next to room 7W51 did not have an illuminated exit sign.
2. The exit door next to room 7S37 did not have an illuminated exit sign.
3. The soiled utility room 7W42 was found to have positive air pressure instead of the required negative pressure for this type of room.
4. The activity room/Day room and lounge room did not have a hand-wash sink.
Radiology Suite:
During a tour of the radiology suite on the morning of 8/30/2012, the following issues were identified in the presence of the Director of Engineering and the Director of Facilities Management.
1. Nursing call bells were not provided in the patient bathrooms of the radiology suite. Examples included but were not limited to Bathrooms 3W8, 3W9, 3W10D, 3E16, 3E18, 3S11 and the patient bariatric bathroom.
2. Nursing call bells were not provided in the patient changing rooms in the radiology suite. Examples included but were not limited to changing room of the mammography suite, changing room 3E21, 3E23, 3E24, changing room 3E49, 3E51and the changing room of the echocardiogram.
3. There was no illuminated exit sign provided on the work service corridor of the nuclear medicine and the ultrasound unit.
4. The electrical closet 3W11 in the mammography suite had penetrations that were sealed by insulation foam and not the proper fire stops. The staff said that that foam might have fire rating, however they could not provide documentation to support that claim.
5. The floor and wall of closet 3N49 next to the exit door was in disrepair and the floor was full of debris and very dirty.
6. The fire barrier above the fire door next to room 3E15 had a penetration that was not sealed properly by the fire stops.
7. X-ray room 3E4 was converted to a storage room and it was found to have hundreds of boxes full of medical records. This is a fire hazard and HIPPA violation issue because those medical records were accessible to unauthorized individuals.
8. Ten (10) 5-gallon plastic containers full of barium were stored on the floor outside room 3E45 and the floor was not clean.
9. No clean supply room was provided for the radiology suite. Additionally, many shelves of clean supplies (12 feet long x 7 feet high) were stored on the floor by the waiting area. This practice of storing clean supplies next to patients on the open floor presents an infection control and fire hazard concern.
10. Some floor tiles of the interventional radiology were found to be broken which presents an infection control problem.
11. No illuminated exit sign was provided at the exit door of the CT scan suite.
12. The CT scan rooms #1, # 2 and #3 as well as the two Gama Camera rooms did not have emergency electric outlets.
Laboratory Department:
1. The floor of the tissue processing area of the histology was observed to be dirty and broken.
2. No exit signs were provided in the hematology lab.
3. No exit signs were provided at the corridor of the chemistry lab and by the exit door next to 4S12B.
4. There were two penetrations at the two-hour fire rated ceiling of the electric closet 4S7.
MRI Suite:
1. The dressing room GE56 did not have a nursing call bell.
2. The carriage of the oxygen tanks were from ferrous material and not from the MRI compatible material whish presents a safety risk.
3. The floor of the corridor and around the emergency exit door of the MRI suite was found to be broken and presents a tripping hazard.

Based on observations the facility did not ensure that supplies and equipment were maintained to ensure an acceptable level of safety and quality.

Findings include:

On 8/28/12 observations of the patient units on the 10th floor: 10N, 10NE, 10 NW, 10SE, 10SW, 10E and 10W were performed between 11:45AM and 1:15PM, witnessed by the DNS of the unit. During interview with the Infection Control Coordinator on 8/30/12 at 12:15PM to 1:00PM, the observations of dusty and dirty conditions of the facility equipment were verified.


1. It was observed that each patient room on the 10th floor had a column
that had additional electrical outlets. The electrical outlets were noted with expired inspection due dates of 02/2009.

2. It was observed that each patient room on the 10th floor units had dialysis ports enclosed behind an open stainless steel covered mini cabinet. During observation, it was noted that the stainless steel covers were clean but the inside of the cabinet where the dialysis ports were located were dusty and filled with embedded grimy black materials.

3. It was observed on the Neuro ICU unit at 1:00PM that the Emergency Box was dusty on the outside. Staff verified that this dusty cart was an exchange cart brought to the unit that morning from the pharmacy.

Based on observation, review of documents and staff interview, the facility failed to ensure that the sterilization of surgical equipment were performed and recorded by staff in accordance with CDC recommendation and AAMI standards.

Based on observation the ceiling tiles in this area are not cleanable /washable.

Findings include:

1. During the tour of the Central Sterile Department, it was noted that the facility was using the three sterrads (low temperature sterilizer) to sterilize surgical instruments. Review of the sterilization records revealed that the facility did not consistently perform and record the test results of the biological indicator on a daily basis as recommended by CDC under "Guideline for Disinfection and Sterilization in Health-Care Facilities."

For example: Review of the sterilization records for the month of August, 2012 for loads sterilized by Sterilizer #3 (NX Sterrad), it was noted that 21 days out of 27 days of last month (August 1-27, 2012), the facility did not perform and read the test results of the Biological Indicator (BI).

The facility did not have a consistent practice of incubating the BI for 48 hours. During the tour of the central sterile department on 08/30/12, it was noted that the facility only had one incubator and had three BI vials from the three sterilizers for the first load of instruments sterilized that day. Upon interview of the Associate Director of Central Sterile regarding the incubation period, it was revealed that the facility did not consistently incubate for 48 hours. Review of records for Sterilizer #3 for the month of August 2012, revealed that the 48 hour BI test results were read only on three of the six days and that the tests were actually performed for the month. Test results of the control was also not being consistently recorded either.

During observation, it was noted that the temperature of the incubator was at a temperature of 65 degree centigrade. Review of the manufacturer (Sterrad Cyclesure 24) Directions For Use revealed that the "incubator temperature should be between 55 C and 60 C." The facility policy states " Should the device fall out of this range an alternative incubator must be used." The Central Sterile department did not have another incubator, and there was no documented evidence that the department staff were monitoring the temperature of the incubator on the days that the BI tests were actually performed and read.

During an interview with the Associate Director of Central Sterile Department, it was revealed that this employee was not aware of the recommended temperature required by the manufacturer of the incubator.

Review of the sterilization records also revealed that the facility did not track the release of instruments. The avenue to document the release of the "Load released by .....Date..." were left blank on almost all the days and on every load cycle. Interview of the Associate Director of Central Sterile revealed that the facility did not track the release of the sterilized instruments

During an interview of the hospital Epidemiolgist on 08/31/12, revealed that the facility policy was to release the instruments to operating rooms based on the Chemical Indicator (CI) test results.

Review of the test results of the chemical indicator test results for January-August 27, 2012 revealed that the staff did not consistently perform that test on a regular basis.
For Example: Review of the Chemical Indicator test results for January on Sterrad #3 revealed that the test was not performed on 7 days (01/16/12, 01/19/12, 01/20/12, 01/28/12, 01/29/12, 01/30/12 and 01/31/12)

The findings of inconsistencies in the performance and reading of the BI and CI test results were noted in the sterilization records of all three Sterrads from January-August,2012 and the facility was noted to run 4-5 load cycles on each of these Sterrads everyday.

According to the CDC, the BI is the only indicator that provides evidence of the "Microbial Killing Power of the sterilization process". Furthermore, according to ANSI/AAMI ST79 Table 8: Types and Applications for Sterilization Monitoring Devices use of CIs alone are not sufficient in many instances to "release" a load. CIs respond to one or more sterilization cycle parameters/changes to the physical conditions within the sterilization chamber. While use of a CI can help spot potential sterilization failures, a "pass" response of a CI does not prove that items monitored by the indicator are sterile. CIs are used in conjunction with BIs and physical parameter read-outs.

2. Specific reference is made to the fact that the ceiling tiles in this area are not cleanable /washable. The ceiling tiles were observed to be pitted and therefore not easily cleanable.

Based on review of medical records and hospital policy, it was determined that the facility did not consistently ensure that the personnel responsible for the discharge plans completed discharge planning evaluations in a timely manner and that the assessments were complete and accurate. This was noted in four of twelve medical records reviewed (MRs # 11, 12, 13 & 15.)
Findings include:
During tour of the unit (16 N) on 8/28/12, at approximately 11:30 AM, MR #11 was reviewed. It was noted that this 73 year old patient with history of esophageal cancer came to the hospital after having increased chest pain and fall at home. The patient was admitted on 8/21/12 with diagnosis of failure to thrive. Review of the psychosocial assessment dated 8/27/12 at 0945, noted that the patient was a navy veteran and the patient was known to the VA (Veteran Administration). The assessment did not include why the patient was not referred the patient to the VA hospital.
Review of MR # 12 on 8/31/12 noted that this 88 year old patient with history of liver cancer was admitted on 7/1/12. On 7/2/12, the attending physician noted "patient requesting inpatient placement hospice, is OK with St. Albans other VA facility or private hospice. Will contact VA for transfer and placement."
The attending physician faxed over medical records from his hospitalization. VAH working on transfer so that the patient can have the option of VAH hospice at St. Albans. The physician noted that the patient agreed to a transfer or hospice placement, whatever comes first. On 7/5/12 at 1532, the discharge summary documented that the patient was transferred to the Midway Nursing Home.
On 7/5/12 at 1656, the social worker (SW) noted, "per team patient is medically cleared for discharge. Plan at this time is for patient to be discharged to a long term SNF for hospice." The SW noted "patient has been accepted by Fairview Nursing Home. Patient and family in agreement of placement at this facility." It is unclear where the patient was placed.
The SW Referral and Assessment policy documented if patient meets moderate risk criteria, the patient should have a psychical assessment within 72 hours. This patient fits this criteria. It was noted that this patient was admitted on 7/1/12 and discharged on 7/5/12. The only SW discharge assessment located in the record was dated 7/5/12, the day of discharge.
MR #13 was admitted on 8/24/12 and placed on alternate level of care (ALOC) status on 8/28/12, but there was no psychosocial assessment or social work assessment located in the record reviewed on 8/28/12 at 3:45 PM.
MR #15 was reviewed on 8/31/12 and noted that this 68 year old patient had medical history of depression, DMII, non-obstructive CAD, HTN & asthma/COPD was admitted on 7/8/12 for COPD exacerbation. It was noted that on 7/9/12 at 1149 that the MD noted Disposition " intact home lives alone has services HHA and social work informed to reinstate when discharged ". On 7/10/12 at 1637, Social Work (SW) notes " case reviewed and discussed with the medical team, per PA patient will be discharged tomorrow want worker to reinstate patient's home care services. Worker called and informed NY foundation to reinstate patient's home care services".
On 7/11/12 at 1429 SW noted as per PA (physician assistant) noted discharge plan was placed on hold for observation. Patient may not be ready until Friday. Worker called and informed NY Foundation Home Care Agency.-On 7/11/12 at 1437, SW noted HA (home attendant) came late and transportation (ambulette 2:36 PM still has not showed up, it was set up for 12 pm) also late. The SW noted patient's niece notified. On 7/11/12 at 1442 the SW noted DC home today. It was noted that the discharge plan was changed from 'observation' to 'home' in less than ten minutes. The reason for the change was not addressed in this assessment.
On 7/11/12 at 1528 SW DC note: Pt. was transferred from ER. SW noted that case was reviewed and discussed with medical team in rounds. Per PA and MD, patient is being discharged today. Patient will benefit from home care services. The case was referred to VNS. It was documented on 7/10/12 that the patient had home care services with NY Foundation. The reason for the change in home care agency was not addressed in this assessment. The SW noted that the patient stated that there is no SW barrier for him regarding discharge. This documentation suggested that this assessment is for a different patient as the patient in MR # 15 was a female patient.
On 7/13/12 at 1635, the Social Work Note documented, initial/discharge note, patient is new to SW today 7/13 and is medically ready for discharge. SW spoke to patient's daughter who stated that patient receives home care services with New York Foundation. NY Foundation confirmed that patient home attendant will come to patient's home on 7/14/12. This documentation is inaccurate as this patient had an initial assessment on 7/10/12.
It was documented that the patient was discharged on 7/11/12.

Based on review of documents, procedures, and staff interview, it was determined that the hospital did not implement an effective process for the safe discharge arrangements of minors living in group home residences.
Findings include:
The hospital failed to identify a safe arrangement for the initial implementation of a pediatric patient's discharge plan to a group home residence.
During a tour of the inpatient pediatrics unit on 8/29/12 at approximately noon, it was observed that a 16 day old infant was admitted for fever and a sepsis work up. The infant was in the process of being discharged with her 16 year old mother for pending return to a group home residence for adolescents and their babies. The facility did not confirm the identity of the group home escort who arrived to accompany the patient and the adolescent mother for return to the shelter.
It was observed that the facility escort was not wearing identification and when asked to provide it, she stated that she did not have it in her possession and that the hospital could contact the agency.
Review of the infant's record, MR #1, on 8/29/12 identified that the patient and the adolescent mother were living in a group home residence for teen mothers. The physician documented on 8/26/12 "to contact the mother and child floor at the residence upon discharge to obtain an escort", however, no contact name was listed.
The social work assessment dated 8/27/12 documented that the patient was living in the residence for nine months. This assessment did not confirm the history with ACS and establish collateral contact with officials at the maternal shelter.
Staff was interviewed about discharge policies of minors to shelters, who are also known to ACS. The nurse stated at interview that she recognized the staff member from the residence who had visited during the weekend. During an interview with the Social Work Manager on the unit on 8/29/12 at noon, it was stated that there was need to confirm with shelter officials about the escort's identity, and to establish the validity of the information provided by the mother regarding residential placement and ACS case. This follow-up contact was reportedly confirmed following discussion with the physician after departure from the unit.
The hospital did not have a consistent policy for discharge of minors to only authorized agency officials besides ACS. The main hospital A-1 policy for Reporting of Suspected Abused or Maltreated Children specified where arrangements were made for direct ACS transfer.
On 8/31/12 a policy titled, V-8 Security and Visitation Guidelines for Children in care of Administration for Children's Services was provided dated 3/11. This policy specified situations for visitation and security for children under protective custody or under jurisdiction of Administration for Children's Services, and specified that the child protection team will consult with hospital staff about special procedures for ACS children.
However, the policy did not specifically address situations for safe disposition of children with minor parents for discharge to only authorized persons and agency personnel, other than ACS. The policy did not detail procedures to be followed for escort identification from authorized residences, including verification of placement and identity of the escort.

Based on review of medical records and staff interviews, it was determined that the facility did not ensure that discharge plans included necessary referrals for evident patient post-discharge needs. This finding was evident in two (2) of five (5) inpatient medical/pediatric records reviewed.

Findings include:

MR #8, an elderly female underwent surgery for a left open distal radius fracture on 7/7/12. The patient was assessed by occupational therapy (OT) and physical therapy (PT) prior to discharge on 7/9/12. PT noted the patient ambulated with a cane, but did not require PT services. The patient was noted to reside at home in Florida with her son.

OT determined the need for instruction, which was provided for immobilization with orthotics. It was noted that "no OT follow up due to patient living in Florida". At that time, it was recommended to have medical follow up in her home state. Medical discharge instructions noted that the patient's family advised she will have follow up orthopedic care in Florida.
A social work note dated 7/9/12 documented that the social worker conferred with the team but was unable to interview the patient because the patient had been discharged prior to the interview attempt. It was noted that there was no request for social work intervention and patient is clear for discharge.
The patient was discharged prior to arrangements being made to assess the psychosocial situation and to arrange follow up of presumptive needs related to her functional deficit. The patient was also improperly screened. On 7/7/12 it was noted that a social work referral was not indicated. The discharge plan was incomplete for explanation for how needs would be met prior to receipt of follow up care out of state.

MR #9 is a six year old child was admitted from the ED on 7/19/12 for traumatic injuries following a 6 foot fall on concrete steps, did not receive adequate discharge planning assessment or referrals for evident needs. Child slipped and fell approximately 6 feet onto concrete while playing with friends outside home. She slipped between bars of gate and fell down the side wall of concrete steps from street level onto a concrete landing beneath. The child sustained injuries including lower lip laceration, forehead hematoma, and nondisplaced frontal bone fracture. Possible associated small contusion or subdural hematoma was noted.
The Admission Assessment dated 7/20/12 at 0100 found no social work referral was indicated. There was no Social work assessment as required by the G-1 policy that assigns suspected child abuse/neglect as a high risk criteria requiring assessment within 24 hours of admission. Neurosurgical consult noted fall was witnessed only by playmates and that no adults were present. Oral surgery note on 7/20/12 indicated mother was used as a translator for the child. Assessments did not rule out potential for inadequate adult supervision.
The child was discharged home with the parent on 7/20/12 at 3:28 PM with a clinic appointment.
The record lacked an assessment to determine if the child was being discharged to a safe environment. The procedure G-1 for Social work referral and assessment did not clearly identify a process for those meeting high risk criteria but whose stay is less than 24 hours.
.

Based on review of reports and staff interviews, it was determined that the hospital's review of its discharge planning process did not include quality review analysis of the appropriateness of discharge plans provided to patients in all relevant clinical service areas.

Findings include:

1. At interview with the Directors of Social Work and Case Management Departments on 8/31/12, it was reported that clinical quality improvement reviews for discharge planning adequacy was not performed for emergency department, inpatient pediatrics, and obstetrical and GYN units, including mother-baby units.

Review of Social Work Department report to the Quality Council dated 7/19/12 included comprehensive chart reviews for up to 151 records and 32 indicators that measured discharge plans for inpatients in psychiatry, medicine, and surgery.
However, this report did not include reviews of indicators or records for additional service areas as noted for pediatrics, emergency (ED), and mother and baby services.

At interview with the Social Work Director on 8/31/12, it was stated that the supervisors of each of the remaining units in the ED, Pediatrics, and Women and infant health would review charts and discuss findings requiring improvement with their respective staff. However, no reports documenting this process of record review and staff remediation for deficient findings was evident.

2. It was determined that the Social Work Department meeting minutes did not include a formalized structure to discuss the findings resulting from quality assurance reviews and corrective actions taken with staff.

Review of Social work departmental monthly in-service training and monthly meetings found that there was no systematic review of quality assurance data and findings. The content of meeting records reviewed focused mainly on training, education, and reminders about policies and procedures.

Records were reviewed for meetings related to:
· In-service training for different topics dated 8/22/12, 8/8/12, 6/20/12.
· Monthly staff meetings dated 7/18/12, 8/15/12, 4/18/12, 5/16/12.
· Social Work Grand Rounds dated 7/25/12, 5/30/12, and 3/28/12.
These meeting records had no formalized approach to discussion of quality reviews and meeting content consisted mostly of training, process related or administrative issues.

At interview with the Social Work Director on 8/31/12, it was confirmed that the review of quality assurance data was not formalized.