HospitalInspections.org

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Based on interviews and review of the facility's Policy and Patient Guide Handbook, it was determined that the facility failed to demonstrate its reasons for the restriction or limitation on patient visitation rights.

Findings include:

On 09/04/13 at 8:50AM, this surveyor overheard several patients' family members complaining that they came to the facility in order to visit their family members but visitation was denied.

The wife of the patient in Room 251-2 was interviewed on 09/04/13 at 8:55AM. This spouse stated that her husband came to the Emergency Room last night (09/03/13) and he was admitted. Today (09/04/13) she came to visit her husband, but she was told that visiting starts at 11:00AM and she could not visit before that time.

The Security Officer, sitting at the desk, was interviewed on 09/04/13 at 9:00AM. The Security Officer reported that the visiting hours were 11:00AM - 8:00PM daily, for all inpatients, and he could not permit visitors to enter the facility before visiting time. The Security Officer stated that an exception can be made but the patient's visitor has to obtain a pass from either the patient's Doctor or from Nursing.

The Vice President of Administration was interviewed on 09/04/13 at 9:32AM. The Vice President reported that the visiting hours begin at 11:00AM because Nursing staff have to give medications.

The Nurse Manager assigned to the Unit (2 North) was interviewed on 09/04/13 at 10:45AM. This Nurse Manager stated that the Visiting Policy was 11:00AM to 9:00PM. She admitted that an exception can be made but she stated that the patient/patient's support person has to first speak to the patient's Physician.

The patient in Room 251-1 and his wife were interviewed at bedside on 09/04/13 at 10:55AM. The patient reported that his Nurse went over the visitation hours with him this morning around 10:00AM. He stated that he was told that the visiting hours were 11:00AM - 8:00PM daily. He was also told that if he needed to have visitors outside this time frame a pass may be obtained from his Physician. The patient stated that the Patient Guide Handbook was given to him this morning. He stated that his Nurse informed him that the Visitation Policy was located in the Patient Guide Handbook.

The Patient Guide Handbook was reviewed on 09/04/13 at 11:00AM. It was noted that the visiting hours were: "General Medical/Surgical Units - 11:00AM to 8:00PM, Critical Care Units (Petrie and Brooklyn) 11:00AM - 8:00PM & Petrie Neonatal Intensive Care Unit (NICU) - open visiting hours around clock. Visitors to Critical Care Units are requested to limit their visits to fifteen (15) to thirty (30) minutes at a time". There was no mention, in this Handbook, that there were exceptions to the visiting hours.

Beth Israel Medical Center Patient Care Services Policy No: V-5, revised 09/11, was reviewed on 09/04/13 at approximately 3:00PM. It was noted that the facility's Patient Visitation Rights Policy did not include a time frame for patients to receive visitors.
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Based on review of data, observations, staff interviews and review of facility documents, the facility failed to implement and maintain an effective, ongoing, hospital-wide, data-driven Quality Assessment and Performance Improvement Program. Furthermore, the facility failed to incorporate and involve all facility Departments and Services of its Quality Assessment and Performance Improvement (QAPI) Program, specifically Food and Dietetic Services and Infection Control Departments.

Findings include:

1. The facility failed to monitor the Department of Food and Dietetic Services Quality Improvement Program which resulted in ineffective monitoring and oversight of the provision of services provided to patients. Refer to Tag #s A 283, A 618 and A 620.

2. The facility failed to ensure that the Food Service Division of the Food and Nutrition Department had a Performance Improvement Program.

The facility failed to have Food Service Indicators, sufficient evidence of monitoring and surveillance in the kitchen and failed to correct deficiencies that had been identified in the Kitchen. Cross reference findings noted under Tag #s A 283 and A 620.

3. The Food and Dietetic Services failed to maintain safe and sanitary conditions in the Kitchen.

Refer to specific findings noted under Tag #s A 283, A 620 and A 749.

4. The facility failed to identify and take corrective actions on the scope and severity of findings noted in the areas affecting infection control. Cross reference detailed findings specified under Tag #s A 283, A 747 and A 749.

5. While there was evidence that Infection Control Committee Meeting Minutes on 03/26/13, 05/28/13 and 07/23/13 had identified ongoing problems in the Kitchen related to unsafe sanitation and practices related to food storage and handling, there was no follow up to ensure these deficiencies had been corrected. Significant findings related to the safety of food and infection control practices were observed during the survey as specified.

Cross reference specific findings noted under Tag #s A 283 and A 749.
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Based on review of data, observations, staff interviews, and review of facility documents, the facility failed to: 1. implement an effective program for Quality Improvement that identified prevalent problems, specifically in the Departments of Food and Dietetics and Infection Control; 2. maintain safe and sanitary conditions in the Kitchens; 3. identify and take corrective actions on the widespread findings observed in the areas affecting Infection Control; and, 4. integrate activities for Quality Assessment and Performance Improvement (QAPI) between Departments.

Findings include:

1a. The facility failed to monitor the Department of Food and Dietetic Service's Quality Improvement Program, which did not ensure effective monitoring and oversight of the provision of services provided to patients. Specifically, the Nutrition Quarterly Performance Improvement Report was submitted quarterly; however, this report only contained numbers without any explanation or analysis of the meaning of these numbers.

Refer to Tag #s A 618 and A 620.

1b. There was no evidence that the Food Service Division of the Food and Nutrition Department had a Performance Improvement Program.

At interview with the Food Service Director on 09/06/13, it was confirmed that Quality Assurance data is not submitted to Hospital-Wide Performance Improvement. Cross reference findings noted under Tag #A 620.

2. The Food and Dietetic Service failed to maintain safe and sanitary conditions in the Kitchen.

2a. The Food Service Director failed to monitor all areas of the Kitchen including sanitation, safety practices for food handling and food preparation, and to ensure the Emergency Food Supply Manual was adequate. (Refer to specific findings noted under Tag #s A 620 and A 749).

2b. Observations representing unsafe and unsanitary food handling, preparation, and maintenance were noted during a tour of the Kitchen conducted on 09/03/13 at approximately 10:00AM. The surveyor was accompanied by the Assistant Food Service Director and the Part Time Director of the Food and Nutrition Department. The following observations were noted:

The top frame of the salad refrigerator (#16) had many black round spots which appeared to be mold.

The doors and aluminum wall frames of all refrigerators were dirty and grimy.

A rack with seven (7) pans of brown film, sticky and grimy muffin pans were located in the pot washing area. The pot washer informed the surveyor that the muffin pans were cleaned.
The meat slicer was observed to be dirty. It was not properly cleaned.

Wet cooking pans were stored one on top of the other. When the surveyor unattached them the pans were dripping with water. These pans were not air dried.

Food carts in the meat box were dirty and had brown stains throughout the racks.

See specific findings under Tag #s A 620 and A 749.

3. The facility failed to identify and take corrective actions on the scope and severity of widespread findings noted in the areas affecting Infection Control across the hospital. Cross reference detailed findings specified under Tag #s A 747 and A 749.

Issues pertaining to the failure to monitor the environment to ensure the prevention of risk of infection includes, but is not limited to, the following examples:

3a. During tour of the Beth Israel Hospital (Kings Highway Division) Kitchen on 09/03/13 at 10:50AM it was observed that there was no separation between clean and dirty in the Manual Pot Washing and Dishwashing Room.

3b. Clean pots and pans were observed stored next to the pot washing sink that was filled with dirty pots, pans and coffee urns.

3c. Two (2) shelves stocked with clean meal trays were observed right across from the dishwashing machine. These clean pots, pans, and trays were inappropriately stored, which exposes these items to potential cross-contamination from splash from dirty water and food debris.

4. There was insufficient evidence of coordination and follow up between Departments in order to achieve Quality Improvement objectives. For example, while there was evidence that Infection Control Committee Meeting Minutes dated 03/26/13, 05/28/13 and 07/23/13 had identified ongoing problems in the Kitchen related to unsafe sanitation and practices related to food storage and handling, there was no follow up to ensure these deficiencies had been corrected. Findings related to safety of food and lack of safe infection control practices were observed. Cross reference specific findings noted under Tag #A 749.
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Based on interview, the review of Medical Records and Policies, it was determined that Nursing staff failed to implement the facility's Policies and Protocols to assure timely treatment of patients with pressure ulcers. Specifically, pressure ulcer treatment was provided without Physicians' Orders. This finding was noted in two (2) of four (4) applicable medical records reviewed (MR#6 and MR#7)

Findings include:

Review of MR #6 documents an 83-year-old female Nursing Home resident who was admitted on 08/23/13 for evaluation and treatment of chest pain and shortness of breath. The Initial Nursing Assessment on 08/24/13 at 17:01 (5:01PM) revealed a left heel community acquired pressure ulcer. The left heel ulcer measured 1.2cm x 2cm, unstageable with black eschar.

The Nursing Daily Assessment indicated that the left heel dressing was intact but there was no indication of the type of treatment or dressing used.

A Physician's Order for treatment of the left heel ulcer was not obtained until ten (10) days later on 09/03/13 at 11:52.

Review of the facility's policy titled: Pressure Ulcer Prevention and Treatment Protocol documents "Licensed Independent Practitioner should be notified when a pressure ulcer is identified and orders for pressure ulcer dressings, if indicated, should be obtained within 24 hours".

Review of MR #7 documents a 75-year-old male who was admitted on 08/30/13 for treatment of Pneumonia and Anemia. The patient had multiple pressure ulcers evidenced in the Initial Nursing Admission Assessment on 08/31/13 at 14:00 (2:00PM); a left heel unstageable ulcer, 6cm x 5cm with black eschar and erythema of the surrounding tissue; a sacral ulcer Stage IV, 2cm x 1cm x 1cm with light exudate and erythema of the surrounding tissue; a right trochanter unstageable ulcer, 1.5cm x 1cm; and a Stage I, left trochanter ulcer (no dimensions documented).

Review of the Nursing Daily Assessment and Treatment Record revealed Physician's Orders for treatment of pressure ulcers were not written within twenty-four (24) hours of admission. The initial treatment orders were written on 09/02/13 at 10:00. There was no evidence of dressing change to the left heel ulcer until 09/02/13, and to the sacral, and the left and right trochanter ulcers until 09/03/13.

At interview with the Unit Charge Nurse (3N) on 09/14/13 at 13:05, she confirmed the findings and stated the patient, upon Initial Nursing Assessment, should have been referred to the Physician for pressure ulcer assessment and treatment orders.
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Based on observation, staff interview, review of Policies, Quality Assurance, and Infection Control documents, it was determined that the facility's Food and Dietetic Services failed to be organized and directed in such a manner as to ensure that the environment of the Kitchen is maintained in a safe and sanitary manner.

Findings include:

The facility's Food and Dietetic Services failed to maintain safe and sanitary conditions in the Kitchen. (Refer to Tag #A 749)

The Food Service Director failed to implement effective oversight of the daily operation of the Dietary Services. (Refer to Tag #A620)

The Director of Food and Nutrition failed to be responsible for the daily management of Dietary Services. (Refer to Tag #620)

The Food and Nutrition Department failed to ensure that Physician prescribed diets meet the therapeutic nutritional needs of patients. (Refer to Tag #A 628)

The Food and Nutrition Department failed to ensure that the Physician prescribed diet was documented as prescribed on the patient's menu. (Refer to Tag #A 629)

The facility failed to ensure that the approved current Therapeutic Diet Manual is used as guidance for ordering and preparing patients diets. (Refer to Tag #A 631)
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Based on observation, staff interview, and review of documents, it was determined that the Director of Food and Nutrition failed to maintain responsibility for the daily management of Dietary Services as evidenced by:

1. The Food Service Director failed to monitor all areas of the Kitchen including sanitation, safety practices for food handling, and food preparation.

2. The Food Service Director failed to maintain a complete Emergency Food Supply Manual and centralized emergency food supply.

3. The Food Service Director failed to implement a Performance Improvement Program.

Findings include:

1. A tour of the Kitchen was conducted on 09/03/13 at approximately 10:00AM. The surveyor was accompanied by the Assistant Food Service Director and the Part Time Director of the Food and Nutrition Department. The following observations were noted:

a. The Hospital Master Menus were not posted in the kitchen.

b. The top frame of the salad refrigerator (#16) had many black round spots which appeared to be mold.

c. The doors and aluminum wall frames of all refrigerators were dirty and grimy.

d. Upon entering the Dry Food Storeroom a large number of gnats were flying around a food rack. In front of this rack were two hundred forty (240) boxes of pastry and three (3) boxes of Kaiser Rolls that had no dates. The Assistant Director informed the surveyor this area had a leak in the past and this may have brought the gnats to the Storeroom.

e. Large bins located in a rack in the Kitchen contained flour, sugar and cornstarch were not labeled. The content was difficult to assess since all had similar texture and color.

f. Condiment containers were not labeled or dated when opened. A container with clear fluid was not labeled. It was undetermined if the content in this container was vinegar, lemon juice, or another fluid.

g. The meat slicer was observed to be dirty with old pieces of food.

h. A rack with seven (7) pans of brown film, sticky and grimy muffin pans were located in the pot washing area. The pot washer informed the surveyor that the muffin pans were cleaned.

i. Two (2) chopping boards were discolored and with deep groves were found on a rack in the pot washing area.

j. Wet cooking pans were stored one on top of the other. When the surveyor unattached them the pans were dripping with water. These pans were not air dried.

k. The floor throughout the Kitchen was dirty.

l. Hand sink was dirty and one (1) of the sink was full of debris.

m. Standardized recipes did not define if they were regular or diet. The yield on the recipes did not define the standardized portion to be used to calculate the yield.

n. Food carts in the meat box were dirty and had brown stains throughout the racks.

o. Two (2) commercial can openers were rusty from top to bottom.

p. A cook was observed to throw his dirty gloves into an aluminum pan that had food garbage and clean red onions together.

q. The left side of the tilt kettle had accumulated dried, dark brown stains stuck on it.

r. A table stand Hobart mixer had accumulated dust on the head of the mixer and the plate where the attachments are placed was filled with dry food residue.

s. A commercial potato cutter located on a rack counter was filled with dust. The shelf below this counter was dirty and had food stains.

t. All entrance plastic curtains in the refrigerator and freezer were dirty and had food stains attached to them.

u. The intercom/bell on the wall above the sink was very dusty.

v. The molding at the bottom of the walls throughout the Kitchen was dirty and full of dust.

w. The surround acoustic tiles of two (2) ventilators were black. One (1) of these ventilators was located above the cook preparation station.

x. Scoop of ice machine was found on top of ice machine motor.

y. The Cafeteria refrigerator was observed to have a milk crate on the floor of the refrigerator. This crate was filled to the top with half and half milk in one (1) quart containers. Beside the crate were half and half milk quart containers. The floor of the refrigerator was completely covered with containers which prevents the cold air from circulating. The refrigerator was disorganized with food dumped on the racks. Saran wrap sandwiches appeared tossed in the refrigerator.

z. Temperature Logs from 08/06/13 - 08/17/13 were reviewed by the surveyor to assess the need of intervention. Surveyor found forty (40) freezer temperatures that were out of the normal range with no intervention. Review of freezer temperatures did not meet the standardized temperature of "0 degree Fahrenheit. Examples:
08/06/13 Meat Freezer #14 is AM - 8 degrees Fahrenheit.
08/07/13 Dairy Freezer #13 PM 10 degrees F.
08/08/13 Dairy Freezer #13 AM 10 degrees F.
08/08/13 # 30 Freezer AM 10 degrees F.

2. The Emergency Food Supply Manual was reviewed on 09/03/13 at 1:00PM. This Manual was not easily accessible to staff. The Manual was in the computer. The Manual was reviewed with the Assistant Director of Food Service and Part Time Director of Food Service. This Manual contained a two (2) day generic menu that did not list the food portion to be provided on the tray. The menu was not specific as to what therapeutic diets were included in these menus. There was no menu for mechanical soft or pureed diets. The generic menu contain food items such as ready to eat cereals, sliced meat, beef stew, carrot sticks, lettuce wedge.

The Emergency Food Supply was not centralized and the manual did not have a diagram to locate food items on the menu.

Nonfat dry milk was on the menu however there were no instructions as to the conversion from dry milk to liquid milk. There was no evidence of enteral feedings on hand, no evidence of the location of either the water supply or the amount of water (bottles) to be provided per patient.

There was no evidence of the use of paper goods and other supplies (aprons, can openers, flashlights) necessary for the implementation of the emergency menu. There was no evidence that in-service on the Emergency Food Supply Manual was provided to employees.

3. There was no evidence that the Food Service Division of the Food and Nutrition Department had a Performance Improvement Program.

The Food Service Director upon interview confirmed this finding. The Food Service Director informed the surveyor that his Department only submits "Nutrition" Quality Assurance data and does not submit Food Service data to Hospital-Wide Performance Improvement. There was no evidence that sanitation and food safety audits were done.

There was no specific Food Service Indicators that were monitored or evidence of improvement when a deficiency in the Kitchen was noted. Example: Sanitation.

The Nutrition Quarterly Performance Improvement Report is submitted quarterly, however, this report only contained numbers without any explanation of what these numbers signify.

(Cross-reference findings noted under Tag #'s A 283 and A 749)
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Based on menu review, nutrient analysis of menu, and staff interview, it was determined that that the Food and Nutrition Department failed to ensure that Physician prescribed diets meet the therapeutic nutritional needs of patients.

Findings include:

The nutrient analysis of the facility menus was conducted on 09/05/13 at approximately 2:00PM. The Clinical Nutrition Manager was accompanied by the Food Service Director. The following issues were found:

1. The facility has a seven (7) day cycle menu. In addition to the regular diet, it also has approximately ninety (90) therapeutic diets available for the Physician to prescribe. The surveyor was informed by the Clinical Nutrition Manager that no menu (regular or therapeutic) has been analyzed for its nutrient content or validity of diet restriction. The facility's current menu has not been analyzed for nutrition adequacy; therefore none of the physician prescribed diets can be validated for accuracy. There is no evidence that the Physician prescribed restrictions are met.

2. The Pediatric menu is not age specific. The Pediatric menu states this menu is provided to children from the age of one (1) to eighteen (18) years old. All pediatric patients are provided the same amount of food regardless of age.

3. The Diabetic menu states the number of calories and not the amount of grams of carbohydrate per day. Based on the diet formulary provided by the Clinical Nutrition Manager the facility is providing the Diabetic diet by calories and grams of carbohydrates. This is inconsistent with the facility Diet Manual.

During interview with the Clinical Nutrition Manager on 09/05/13 at 2:00PM, the Manager failed to provide an explanation for the findings.
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Based on observation, dietary menu review and Physician's diet prescription, it was determined that the Physician prescribed diet was not documented as prescribed on the patient's menu.

Findings include:

1. Review of tray ticket (menu) on 09/05/13 at 4:00PM was conducted with the Food Service Director and Assistant Food Service Director. The Physician prescribed diet was not transcribed to menu as ordered. Facility menus require the identification of a Physician prescribed diet. Physician prescribed diets are abbreviated and do not document the diet prescribed. An example of this is the diet "Low Residue", which is noted as LOWRES on the menu.

2. Menu portions on the menu are not listed with standardized measurement. The tray menu states 1 port. Brisket of Beef w/Brown Gravy instead of 3 ounces Brisket of Beef w/2 oz. gravy; 1 port mixed vegetable instead of 4 oz. or 1/2C Mixed Vegetable.

3. On 09/03/13 at approximately 10:30AM a Food Service employee was observed in the Kitchen not using a standardized scoop for portion control. The Food Service staff was preparing salad using a spoon. During interview the surveyor asked the employee what scoop size would be used but the staff member was unable to answer.
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Based on observation and staff interview, it was determined that the facility failed to ensure that the approved current Therapeutic Diet Manual is used as guidance for ordering and preparing patients diets.

Findings include:

On 09/03/13 at approximately 3:00PM the Clinical Nutrition Manager was interviewed concerning the Adult and Pediatric Diet Manual. The Clinical Nutrition Manager informed the surveyor that the facility has the Adult Diet Manual on the computer. However, the facility does not have a Pediatric Nutrition Diet Manual.

The facility has a Pediatric menu non-specific to age but does not meet the Pediatric Nutrition Diet Manual Guidelines to validate the menu or to serve as a Pediatric nutrition resource to Dietitians and Medical staff.

Pediatric menus must conform to Pediatric Diet Manual Guidelines. The current Pediatric menu does not meet the Guidelines of the Pediatric Nutrition Diet Manual.
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Based on observations and staff interview, the facility failed to maintain the physical plant at Kings Highway Division and Bernstein Building on the Main Campus in a manner to provide a safe and sanitary environment for the treatment of patients. Similar issues were noted at the Petrie Division Campus and Philips Outpatient Building.

Findings include:

A 1. During the survey of the Kings Highway Hospital conducted on 09/03/12 to 09/06/13, it was noted that the facility did not maintain a clean environment in all the areas of the facility:

During the tour of the Emergency Department (ED) on 09/03/13 at approximately 11:00AM, it was noted in Room #15 (Isolation Room) was prepared and ready to receive a patient. Inspection of the ceiling revealed that the glass shade for the fluorescent light fixture had reddish brown dry residue resembling blood on it.

Tour of the Decontamination Room in the Central Sterile Department of the facility (Kings Highway Division) on 09/04/13 at approximately 12:30PM revealed the tiled wall adjacent to the decontamination sink was heavily stained and dirty. The perimeter of the floor was grimy and dusty.

During tour of the Medication Room in 2 North Medical Surgical Unit of Kings Highway Hospital on 09/04/13 at approximately 1:30PM, it was noted that the tiles on the walls of the room were dirty and dusty.

During the tour of the Kitchen of Kings Highway Division on 09/03/13 at approximately 2:00PM, the thermal insulation on the ceiling of the meat freezer was observed to be in disrepair. The freezer was observed to be filled completely to the ceiling with cardboard boxes containing raw meat and fish stored in a very disorganized manner. Upon interview of the Director of Dietary Services, it was stated that this employee was well aware of the contents in those boxes and that boxes stored at the entrance of the freezer would be removed out of the freezer while trying to access the boxes stored by the back wall of the freezer.

During the tour of the Histology Lab Room at the Kings Highway Division on 09/06/13 at approximately 2:30PM, it was noted that:

a. The floor of the room was heavily soiled and grimy.
b. The counter top used for inspection and testing of specimen was laden with dust.
c. The eye wash sink and the sink used for washing the specimen was dirty.
d. The plastic rack used for storing stain containers and the lid of all the individual stain containers were covered in dust; and
e. Four (4) sharp containers were observed to be stored on the floor and filled to the top with syringes and specimen samples. Interview of the Lab Director revealed that the facility staff removed the "filled sharp containers twice a week from this room".

II. Also, the facility failed to ensure that the Kings Highway Hospital was constructed in a manner to prevent cross contamination and spread of infections. Specific reference is made to the following findings identified during the survey dates of 09/03/13-09/06/13. (Cross-reference Tag #A 749)

1. During the tour of the Isolation Room(s) in the Emergency Department, ICU, Medical Surgical Units on 2 North, 3 North and 2 West, it was noted that the ceiling tiles were acoustical tiles and were of non-cleanable type.

2. The ceiling tiles over the twelve (12) ICU beds on 2 East were also observed to be of acoustical and non-cleanable/washable type.

3. During the tour of the patient rooms on 2 West and 3 East, it was noted that the patient bathroom did not have a handwashing sink.

4. During the tour of the 2 East on 09/05/13 at approximately 3:00PM, it was observed that five (5) out of twelve (12) patient rooms on this unit (Room #s 203, 206, 208, 215 and 213) did not have a handwashing sink in the patient room, as required by AIA 1996-97 Edition.

5. During the tour of the Histology Room, it was observed that the staff did not have a separate handwashing sink to wash hands.

6. During the tour of the Pharmacy Department on 09/06/13 at approximately 3:00PM, it was noted that the Medication Preparation Room did not have a handwashing sink.

7. The Clean Utility Room in the Emergency Department and Sterilization Room of the Central Sterile Department was noted to have negative pressure instead of the positive pressure in accordance with AIA 1996-97 Edition.

III. Additionally, the facility failed to maintain a safe environment, free of physical hazards for the treatment of psychiatric patients in the Bernstein Building (Petrie Division). The following observations were made on two (2) Psychiatric Inpatient Units (Bernstein) on 09/09/13 at 1:00PM and 2:30PM respectively:

· All the inpatient rooms on the 4th Floor and the 8th Floor had loosely hanging fabric curtains, which were easily removable and potentially could be used for looping and/or suffocation.

· During the tour of the inpatient rooms on the 4th and 8th Floors, it was noted that each bed had side tables that were not bolted to the ground and each one of them had three (3)drawers that could be pulled out completely.

· The handrails along the corridors on both of the units was observed to be open on the top and bottom sides, allowing the possibility to create a ligature.

· At least two (2) regular strobe lights jutting out of the wall with a flat top were noted on front and back corridor of both units. These strobe lights have the potential of creating a loop around the device.

· At least two (2) pay phones were observed installed in the front and back corridor of both floors. The cord of each these phones was approximately three (3) feet long, and represent the potential of creating a ligature.

A tub room was observed on the 4th Floor, with a two and one half feet (2½') deep tub and star shaped faucets jutting out of the wall and length of the stem was approximately three (3) inches long.

· A moveable shower chair was observed to be in shower rooms on both the floors and this object posed a risk of being used as a weapon to cause harm.

· The smoke barrier door and the Soiled Utility Room door had metallic door closures that could be used to create a ligature.

· The patient closet in the Dining Area on the 8th Floor has regular hinges and this is determined to be a looping hazard.

· The dining/living area on both floors had moveable tables and light weight chairs which could be used for barricading and as weapons to cause harm.

IV. Moreover, the facility failed to maintain its premises in a manner to ensure safety of patients. Specific reference is made to the following:

a. During the interview of the Emergency Department staff at Kings Highway Hospital on 09/03/13 at approximately 11:00AM, it was revealed that the Emergency Department provided service to Pediatric patients. Inspection of the low lying electrical receptacles in the Waiting Area of this Department revealed that there were at least four (4) duplex electrical outlets that were not tamper resistant.

b. During the tour of the Waiting Area and corridor of Child Psychiatric Outpatient Clinic on the 2nd Floor of the Bernstein building (Petrie Division) on 09/09/13 at approximately 12:00 Noon, it was noted that there were two (2) duplex electrical outlets in the Waiting Area and two (2) duplex electrical receptacles in the corridor that were not tamper resistant.

c. During the inspection of three (3) bathrooms for the Outpatient Psychiatric Clinic on the 2nd Floor of the Bernstein Building (Petrie Division) on 09/09/13 at approximately 12:30PM, it was noted that these bathrooms were not equipped with a call bell system to notify staff when patients required assistance from staff in the bathrooms.



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B. During the tour of the Petrie Division Campus and Philips Outpatient Buildings from 09/03/13 to 09/10/13 between 10:30AM to 4:00PM, the following issues were noted which were verified with the staff accompanying the surveyor.

EMERGENCY DEPARTMENT

1. During the tour of the Emergency Department on on 09/03/13 at 11:00AM, the Director of Engineering was interviewed at the time of observation to provide information regarding the maintenance of the Hazmat Showers in the Decontamination Area. He stated that the preventive maintenance was done, however there was no documentation nor verification provided indicating that such preventive maintenance schedule existed in the facility.

2. The computer area (near the entrance to the blue pod) was noted to have very dusty and dirty computers and CPUs. Additionally, the floor and perimeter were dusty.

3. In the Trauma Room, patient bed #1 was noted to have a dusty and dirty bed sheet. This bed was clean and ready to be used for the next patient as per the Nursing staff.

4. The perimeters of the bays in the Emergency Room were noted to be dusty and dirty. In particular, the EKG Room had a hole in the wall and was noted to be very dusty. Room #19 in green zone of the Emergency Department was also noted having a portion of the wall in disrepair.

5. The Ambu bags were noted hanging on oxygen flow meters around the Department and in other parts of the facility which may cause damage to flow meters and leaks.

CPEP EMERGENCY DEPARTMENT

During the tour of the CPEP Emergency Department on 09/04/13 at 2:00PM, it was noted that the screws of the floor drain and door hardware in the CPEP toilet were not tamper proof/Psychiatric Unit approved and were of the regular kind.

LINSKY 11 TH FLOOR-MEDICAL UNIT

1. During the tour of the Medical Unit on 11th Floor Linsky, it was noted that there were many ceiling tiles stained in corridor entering the unit. Furthermore, ceiling tiles of Room #10 were noted to be dirty.

2. The mechanical exhaust vent of clean utility unit was noted to be dusty and dirty.

3. The gasket of the refrigerator in the Pantry/Nourishment Room was noted to be broken and dirty.

LABORATORY-12th Floor

1. During the tour of the Laboratory Department on 09/03/13 at 3:15PM, it was noted that the corners, floors and perimeters of the Laboratories were dirty and dusty, specially the area of "Special Hematology".

NICU-4TH FLOOR DAZIAN

1. During the tour of the NICU Department on 09/04/13 at 11:15AM, the hot water temperature at the hand wash sink was noted to be very hot on skin contact. The staff later notified the surveyor that the temperature was 116* F. The maximum allowable temperature at hand end wash sink is 110* F.

2. The mechanical vent by the bassinets and the perimeters of the floor in NICU were noted to be very dirty and dusty.

LABOR & DELIVERY-4TH FLOOR DAZIAN

1. During the tour of the Labor & Delivery Unit on 09/04/13 at 11:30AM, it was noted that the floors of the C-Sections ORs (including but not limited to OR #1 and OR #2) were dented and in disrepair. These floors thus were not monolithic to ensure proper cleaning to avoid cross contamination. Furthermore, in OR #3 the floor was observed to have tape and tape residue.

2. Scrub sink #3 next to OR #2 was observed not to be working.

3. The mechanical exhausts on the walls were noted to be blocked by equipment and carts in the C-Section ORs.

4. Two (2) out of three (3) ORs did not have a phone or emergency call button to summon help in case of medical emergency or fire as required by AIA 7.32.G4.

5. There were two (2) thermostat devices installed in OR #1. As per staff, one (1) was for temperature and the other one (1) for humidity. The two (2) thermostats were identical and did not have any label or units (such as Fahrenheit or Celsius or percentage for humidity). Therefore it could not be verified which thermostat was assigned for which measure and if these were accurate for temperature and humidity.

PSYCHIATRIC UNIT-6TH FLOOR KARPAS

1. During the tour of the Psychiatric Unit on 09/04/13 it was noted that the light fixtures in the Shower Room (6K-34) were loose and detached from the light frame. Furthermore, the frame has protruded screws that may cause a patient safety hazard.

2. During the survey of the 6th Floor Karpas Psychiatric Unit, the Nursing staff/Nurse Manager acknowledged using the Seclusion Room for the purpose of time-out/quiet room when Seclusion Room is not in use. As per AIA 1996/97 Section 11. 2.B26, facility is required to have a separate "Quiet Room" which must measure a minimum eighty (80) square feet. The Seclusion Room is a separate requirement under 11. 2.C and may be of sixty (60) square feet. Thus, using the same room for "Quiet Room" does not comply with the two (2) separate rooms requirement.

Note: The use of a Quiet Room is a programmatic need thus it is regulated under Chapter 11 of AIA 1996-97 rather than Chapter 7, where the use and configuration of only seclusion room and no quiet room is provided.

PHILIPS OUTPATIENT-AMBULATORY SUITE

1. On 09/06/13 between 11:00AM to 1:00PM, during the tour of the Ambulatory Surgical Suite/Center (ASC) on 4th Floor, it was noted that:

i. The electrical outlets/receptacles in the Waiting Area were not tamper proof.

ii. OR #6 in the ASC was noted to have a dirty stretcher, dented floor, and a large amount of tape and tape residue on the operating table.

iii. The exhaust grills in the ORs of ASC were noted to be dusty and dirty.

iv. The ASC serves Pediatric patients in the facility. However during the survey no separation/separate room for Pediatric from the Adult section was noted for Post Recovery Room/Area in the post-recovery bay as required by AIA 9.5.F3.

v. One (1) of the patient chairs in post-recovery bay of ASC was noted to have a streak of red stain/possible blood on the underside of the hand rest and on the sides of the chair.

vi. The door by Exam Room #5 of ASC was noted to be very dirty with streaks of black stains and dirt.

2. On 09/06/13 during the tour of the Urology Suite at 2:00PM, a big dead fly was noted inside of a bug trap in the corner of the Urodynamic Room.

3. On 09/06/13 during the tour of the Dermatology Suite at 2:30PM, it was noted that the Dermatology Lab/Decontamination Room did not have a self-closing door and did not exhibit negative air pressure.

4. On 09/06/13 during the tour of the Dental Suite at 2:45PM, it was noted that:

i. The Waiting Room had a surge protector with computer and electrical equipment attached. This surge protector could not be verified for being hospital grade. Furthermore, the use of surge protector/power strip instead of using a permanent electrical receptacle was not explained.

ii. The electrical outlets/receptacle plates were noted getting detached from the wall.

iii. The Decontamination Room did not exhibit negative air pressure.

iv. No preventive maintenance records were provided for the eyewash in the Decontamination Room.
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Based on review of documents and staff interview, the facility failed to ensure that an established program for Preventive Maintenance (PM) of the dialysis machines used in the treatment of patients at Kings Highway Hospital was implemented in accordance with the manufacturer's guidelines and acceptable standard of practice.

Findings include:

Review of the manufacturer recommendations documents that the Preventive Maintenance (PM) for Fresenius K machines be performed and documented on the checklist every six (6) months and an Annual Preventive Maintenance (PM) be performed and documented on the checklist every year or every 4000 hours which ever comes first. Review of the PM records for the five (5) dialysis machines in the Unit on 09/06/13 at approximately 10:00AM revealed lack of documented evidence of all the required PM checks conducted on four (4) out of five (5) machines reviewed, which #s KA, KB, KC and K3.

Machine #K3 - The last Annual PM conducted on the machine was performed on 02/10/11 at 33,120 hours. A Semi-Annual PM check was conducted on 05/22/13. There was no further documented evidence of AM checks.

Machine #KA - During the review of the PM records on 09/06/13 at approximately 9:30AM, there was no record of any PM checks conducted on this machine in 2012. A Semi-Annual PM check was dated 03/20/13. There was no further documented evidence of PM checks.

Machine #KB - Review of the PM checks performed on this machine revealed that there were two (2) Semi-Annual PM checks performed on 02/07/12 and 08/28/12 for the year 2012. There were two (2) Semi-Annual PM checks performed on 03/11/13 and 08/20/13. There was no documented evidence of PM checks in 2012 or 2013.

Machine KC - Review of the PM checks on this machine revealed that there was only one (1) Semi-Annual PM check performed on 08/30/12. In the 2013, there were records that indicated that two semi-Annual PM checks were performed on 03/20/13 and 08/10/13. There was no documented evidence of an Annual PM check for 2012 or 2013.
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Based on observations and review of documents, it was determined the facility failed to: 1. monitor and implement infection control plans to address risks related to the environmental design of the facility; 2. ensure accountability by the Infection Control Officer and coordination with Food and Dietetics staff; and, 3. provide a safe environment consistent with recognized Infection Control Practices and prevent risk of cross contamination.

Findings include:

1. Tours of the facility conducted at both sites determined the lack of infection control surveillance and strategies in place to prevent the risk of transmission of infections posed by the environmental construction and design of the facility.

Examples observed include the following issues:

-Ceiling tiles installed throughout the facility in high risk areas were non cleanable.

-Handwashing sinks were not available in high risk patient and staff work areas at both sites, such as in the Endoscopy Decontamination Room at the Petrie site, in accordance with AIA requirements.

-Improper air flow/pressures were widespread and noted in critical areas, including but not limited to, Emergency Department Clean Utility Rooms and the Sterilization Room of the Sterile Central Department at the Kings Highway Division.

-Proper temperatures were not maintained in the Central Sterile Processing Room at the Petrie site.

-There was a lack of installed audible and visual alarms for exhaust systems in sterilizer work area.

-There was lack of humidity monitoring devices in Central Sterile Processing Department.

-There was no surveillance and monitoring of temperature and humidity of Operating Rooms in the Ambulatory Surgery Outpatient Building.

-Exit doors were not equipped with self closing devices in Petrie MICU and ED.

-There was lack of Isolation Rooms in the NICU and Newborn Nursery at the Petrie site and lack of procedures developed to handle this need if airborne isolation is indicated. Additionally there was lack of dedicated room for processing of equipment in the Endoscopy Suite at the Petrie Campus.

Refer to specific findings noted under Tag #A 724.

2. Inadequate coordination between Infection Control activities and Food and Dietetics functions was evident in the failure of the facility to properly monitor and correct widespread unsanitary conditions identified in the Kitchens.

Unsanitary practices were observed related to the storage, maintenance, and handling of foods or equipment used in preparation that have potential for food borne infections if strict sanitary guidelines are not followed. Examples are:

-Freezer temperatures at the Petrie Division were found to not be within an acceptable range and were not "0" degrees Fahrenheit as required.

-Soiled equipment used in food storage or preparation: i.e., dirty meat slicer, equipment in the salad refrigerator displayed black round spots which resembled mold.

Further, while there was evidence that Infection Control Committee Meeting Minutes on 03/26/13, 05/28/13 and 07/23/13 had identified ongoing problems in the Kitchen related to observations of unsafe sanitation and practices related to food storage and handling, there was no follow up to ensure these observed deficiencies had been corrected

Cross reference findings noted under Tag #s A 263 (QAPI) and A 724 (Infection Control).

3. The facility failed to maintain a clean and safe environment in order to adhere to Infection Control Standards that reduce risk of infection transmission.

Examples of inadequate surveillance and practices in place to mitigate cross contamination risks were observed.

There was lack of established practices for separation between dirty and clean instrument cleaning procedures. For example, in the Dental Suite in Philips Outpatient Building, it was observed a sink was being used for placement of dirty instruments before being cleaned and then were returned to the same sink after being washed in the ultrasonic washer. This practice may lead to cross contamination.

Additional widespread instances were observed for soiled and dusty conditions and equipment in the facility and in the Kitchens at both Campuses.

Refer to specific findings noted under Tag #s A 620 and A 724.

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Based on observations during tours of the facility and staff interview, it was determined: a. facility failed to monitor and implement Infection Control practices related to the environmental design of the facility, in order to prevent the potential for cross contamination and spread of infections; b. the Infection Control Officer did not ensure that proper sanitary environment is maintained in the kitchen to prevent the possibility of cross contamination and transfer of infection; and, c. facility did not ensure a safe environment consistent with recognized Infection Control Practices and prevention of cross contamination in its Petrie and Kings Highway Campuses.

AI. Specific reference is made to the following deficiencies identified at Kings Highway Hospital Division between 09/03/13 and 09/06/13 between the hours of 9:00AM and 4:00PM are noted below:

1. During the tour of the Isolation Room(s) in the Emergency Department, ICU, Medical Surgical Units on 2 North, 3 North, and 2 West, it was noted that the ceiling tiles were acoustical tiles and were of non-cleanable type.

2. The ceiling tiles over the twelve (12) ICU beds on 2 East were also observed to be of acoustical and non-cleanable/washable type.

3. During the tour of the patient rooms on 2 West and 3 East, it was noted that the patient bathroom did not have handwashing sink.

4. During the tour of the 2 East on 09/05/13 at approximately 3:00PM, it was observed that five (5) room (#s 203, 206, 208, 215 and 213) out of twelve (12 ) patient rooms on this Unit did not have a handwashing sink in the patient room, as required by AIA 1996-97 Edition.

5. During the tour of the Histology Room, it was observed that the staff did not have a separate handwashing sink to wash hands.

6. During the tour of the Pharmacy Department on 09/06/13 at approximately 3:00PM, it was noted that the Medication Preparation Room did not have a handwashing sink.

7. The Clean Utility Room in the Emergency Department and Sterilization Room of the Central Sterile Department was noted to have negative pressure instead of the positive pressure in accordance with AIA 1996-97 Edition.

II. The facility did not develop and implement an Infection Control Risk Assessment for all of the above noted deficiencies. A risk assessment for item (1) was provided to the surveyor on 09/06/13 at approximately 12:00 Noon, but was not yet implemented.

The lack of a Risk Assessment Plan for the remaining findings (2) through (7), was confirmed during interview of the Director of the Kings Highway Division on 09/04/13 at approximately 2:00PM. It was stated at that interview the facility did not currently have a Risk Assessment for the issues referenced for (2) through (7), but Risk Assessment Plans were in process of being developed to address these issues.

These findings noted above were also cited under Physical Environment for failure to ensure the construction of a safe environment. Cross reference citations written under Tag #A 701.

B. During tour of Beth Israel Hospital (Kings Highway Division) Kitchen on 09/03/13 at 10:50AM it was observed that there was no separation between clean and dirty in the Manual Pot Washing and Dishwashing Room. Clean pots and pans were observed stored next to the pot washing sink that was filled with dirty pots, pans and coffee urns. Two (2) shelves stocked with clean meal trays were observed right across from the dishwashing machine. These clean pots, pans and trays were inappropriately stored, which expose these items to splash from dirty water and food debris. This represents a high risk for cross-contamination.

The findings as noted above were confirmed during interviews with the Network and onsite Food Service Directors, who were all present during the inspection tour.
(Cross-reference Tag #A 620)




26934


C1. On 09/09/13 between 11:25AM to 12:30PM during survey of the Central Sterile Processing Department /CSPD in the Basement of the Karpas Building and 1st Floor near OR Suite, it was observed that:

a. The ceiling tiles in the Clean Sterile Processing Room-Karpas were porous and had holes that may retain dirt (they were not monolithic) and thus were not in compliance as per AIA 7.28.B8. Such porous ceiling tiles compromise cleaning which is required to keep the environment of the Central Sterile Processing Room as clean and sterile as possible.

b. The Central Sterile Processing Room-1st Floor exhibited negative air-pressure from the OR corridor. Furthermore the Decontamination Room-Karpas was also positive Central Sterile Processing Room and to the corridor.

c. The vinyl coved by the sterilizer and around the perimeter of the Central Sterile Processing Room-Karpas exhibited dirt and dust.

d. The temperature of the Central Sterile Processing Room on 1st Floor was noted to be above the required 75*F. At the time of survey it was 78*F. In reviewing the past Records/Logs since June 2013 it was noted that the temperature was always between
80*F to 76*F. As per Central Sterile Processing Room staff, the Engineering Department was notified of the high temperature. No documentation or follow up was provided regarding the communication of the issue and resolution.

e. In the sterilizer work area no audible and visual alarm was noted for exhaust system which is intended to alert the staff for the loss of air-flow as required by AIA 1996 7.31.D19.

f. The sinks of the Central Sterile Processing Room in Karpas did not have wrist blade handles.

g. During the survey of the Decontamination Room in Karpas, the staff working in the area indicated that the sink used for decontamination of the instruments is also used as the handwashing sink. It is to be noted that using the decontamination sink also as a handwashing sink may contribute to cross contamination.

h. No humidity monitoring device/mechanism was present in the rooms/areas used for storing sterilized items from CSPD. The issue was noted on both floors of the CSPD and in the OR Suite.

2. During the tour of the Ambulatory Surgical Center/Suite in the Philips Outpatient Building on 09/06/13 between 11:00AM to 1:00PM, it was noted that:

i. There was no monitoring or assurance that the temperature and humidity of the ORs in ASC.

ii. The ceiling tiles of the Central Sterile Processing Room were not cleanable type and were porous.

iii. The air flow of the Central Sterile Processing Room was not positive on both sides of the corridor and the decontamination room was positive to clean side of processing room.

iv. The sterilizer was noted dusty and dirty around its edges and corners in the Clean Processing Room. A similar finding was noted for the washer in the area.

The carriage/loader for loading clean instruments in the sterilizer was also noted to be dusty and dirty.

3. During observation of the Isolation Room on the 7th Floor Dazian-Medical Intensive Care Unit on 09/10/13 at 12:30PM, it was noted that the Isolation Room did not comply with the requirements of AIA Section 7.2.C4 for Isolation Rooms.

The requirement states that "air borne infection isolation room shall have self-closing devices on all room exit doors". The Isolation Room in the unit did not have self-closure or self-closure mechanism installed at the exit door. Similar issue was noted in the Isolation Room of Emergency Department Room #IS-ED-27.

4. During the survey of 11 Linsky-Medical Unit on 09/03/13 at 1:45PM it was noted that the ceiling tiles in the Isolation Room were porous/had holes that may retain dirt (they were not monolithic) and thus were not as per AIA 7.28.B8

5. During the survey of the NICU-4th Floor Dazian and Newborn Nursery-5th Floor Dazian on 09/13/13 and 09/10/13 between 11:00AM to 2:15PM, it was noted that the facility does not have any Isolation Room provision for the newborns at any level of Nursery care (as per AIA 7.3.E9) nor was any Policy provided regarding how the facility will handle a baby with an air-borne disease.

6. During the survey of the Endoscopy Suite-8th Floor Dazian on 09/09/13 at 3:15PM, it was observed that the Decontamination Processing Room did not have a free standing hand washing sink (as per AIA 9.9.B2). A dedicated processing room for cleaning (as per AIA 9.9.B1) was also not present for the Endoscopy Suite.

7. During the tour of the Emergency Department on 09/03/13 at 11:45AM, Nursing staff stated that in the Emergency Department patients with any immunocompromised disease are placed in a private room. The facility in its census does receive patients with immunocompromised disease who come to the Emergency Department. One (1) of the private rooms in the Emergency Department (ED) was identified by the staff which is used for such patients. During survey it was noted that this room exhibited "negative" air-pressure.

As per AIA 1996-97 Section 7.2.D-Protective Environment Room "Many facilities care for patients with an extreme susceptibility to infection e.g immunosuppressed patients that are extremely susceptible to infection, with prolonged granulocytopenia, most notably bone marrow recipients; or solid organ transplant recipient, and patients with hematological malignancies who are receiving chemotherapy and are severely granulocytopenic." These patients are required to be put in a room that has positive air pressure.

As per the Director of Engineering, this private room is a "negative air-pressure room" and these rooms cannot be converted to positive air pressure rooms.

8. During the survey of the Petrie Division and Philips Outpatient Buildings from 09/03/13 to 09/10/13 between 11:00AM to 4:15PM, many areas of the facility were noted not exhibiting the correct air-flow. The examples include the following but are not limited to:

i. The Morgue and Autopsy Room on 11th Floor Silver exhibited strong positive air-pressure instead of negative air pressure.

ii. The Microbiology Lab did not have the required negative air-pressure and had positive air pressure. Also during survey the Main Entrance door to the Lab was noted open to the corridor.

iii. 4th floor Dazian-Soiled Utility Room exhibited positive air flow instead of negative air flow.

iv. Urology Suite-Philips Outpatient-Soiled Utility Room and Clean Utility Room did not have the correct air flows as required.

v. 11th Floor Linsky-Soiled Utility Room exhibited neutral air flow instead of negative air flow.

vi. 6th Floor Dazian-Pediatric Floor-Soiled Utility Room exhibited positive air pressure.

vii. 6th Floor Dazian-Pediatric Floor by PICU-Medication Room was negative instead of positive.

9. During the tour at 12:30PM, the following issues were noted in PICU on 09/09/13:

a. The perimeters of the rooms were noted to be dirty and dusty. Furthermore, the vinyl base cover was observed to becoming detached from the wall.

b. The tracks of the door of were noted to be very dusty and dirty in the designated negative air pressure room.

c. The Soiled Utility Room was noted to be exhibiting positive air pressure.

10. On 09/06/13 at 3:00PM during the tour of the Dental Suite in the Philips Outpatient Building it was noted that the room used for decontaminating the instruments did not have a work flow established to ensure proper separation of tasks from dirty to clean activity. As per the staff the dirty instruments are placed in the sink and after being washed/cleaned by the ultrasonic washer they are again placed in the same sink to be rinsed off. This practice may lead to cross contamination.

11. During the tour of the Newborn Nursery-5th Floor Dazian on 09/10/13 at 10:45AM, it was noted that there was no exclusive Housekeeping Room for the unit as required by AIA 7.4.G. The Nurse Manager interviewed identified another housekeeping closet which as per staff is for the use of the whole 5th Floor. Furthermore, this assigned housekeeping closet did not exhibit negative air-pressure as required.

12. During the tour of the 6th Floor Dazian-Pediatric Floor PICU on 09/09/13 at 2:00PM, it was noted that Dedicated Isolation Room ICU #5 did not exhibit negative air pressure. As per the Nurse Manager of the floor, this Isolation Room is always negative. The Director of the Engineering Department went in the room and turned on the exhaust fan and after being turned on the room exhibited negative air-pressure. The Nurse Manager acknowledged not knowing anything about a switch or turning the room exhaust fan on before placement of an air-borne isolation patient in this room.

All above findings were verified with Director of Engineering, Vice President of Facilities Operation, Director of Facilities and other Nurse Managers of the Units and staff escorting the surveyor at the time of observation/survey.
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09995

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Based on interviews, review of Medical Records and facility Policy, it was determined that the facility failed to ensure that for each patient, who was identified as needing discharge planning, received a complete assessment. This deficiency was noted in five (5) of five (5) applicable Medical Records reviewed (MR #1, MR #2, MR #3, MR #4 and MR #5).

Findings include:

During the tour of the unit (2 North at Kings Highway Division), the patient housed in Room 254/1 was interviewed on 09/04/13 at 11:20AM. The patient stated that he was discharged and he was waiting for his daughter to transport him home. The patient stated that he met with the Social Worker yesterday (09/03/13) who suggested that he may need some help at home. This patient stated that his post-hospitalization needs and the agency to provide the services were not discussed.

The Social Worker (SW) assigned to the patient was interviewed on 09/04/13 at 11:30AM. The SW reported that the Social Worker is responsible for discharge planning. The SW stated that the patient was referred to her on 09/03/13 and the discharge evaluation was conducted on that date. She stated that the patient was referred to Revival Home Care Services. She also stated that the discharge plan was discussed with the patient and his daughters.

The patient's daughters arrived at the hospital and they were interviewed on 09/04/13 at 11:35AM. The patient's daughter stated that the Social Worker suggested home care services for their father, but the agency or the appropriate services to fit his needs were not discussed.

The SW was re-interviewed on 09/04/13 at 11:45AM. She was informed that the patient/patients' daughter had concerns regarding home care services.

While still in the Unit, on 09/04/13 at 12:30PM, the SW reported that she spoke to the patient's daughters and she has updated her notes.

MR #1 was reviewed on 09/04/13. It was noted that the patient, a 79-year-old male, was admitted on 08/30/13 with the diagnosis of Hematuria. The Discharge Assessment information dated 09/03/13 12:02PM was reviewed. The Discharge Planner indicated that the patient appeared alert, oriented and ambulatory. As per patient, resided alone in a three (3) family house and prior to admission was independent in most ADLs (Activities of Daily Living). Patient has two (2) involved daughters. They live in the same house upstairs and able to assist patient as needed. The Post Discharge Needs: CHHA (Certified Home Health Agency).

The Discharge Plan notes dated 09/04/13 12:01 was reviewed. The SW noted patient to be discharged today with family. Patient was referred to Revival Home Care as per patient's daughters' request.

It was noted that the Discharge Evaluation did not include: the patient's function in ADLs at discharge, services the patient would need after discharge, and if the patient's financial resources/ insurance would cover these services.

MR #2 was reviewed on 09/6/13 at approximately 11:00AM. It was noted that this 91-year-old patient was admitted to the facility on 08/26/13 with complaint of leg pain. The patient was discharged on 09/04/13 with diagnosis of DVT (Deep Vein Thrombosis).

The Initial Discharge Assessment information dated 08/27/13 at 5:00PM was reviewed. The Discharge Manager indicated that the patient lived with his wife in a private home. The patient was ambulating independently and able to take care himself prior to admission. The SW noted that the patient had no prior home care services. The assessment noted patient will be discharged home with home care service or transferred to a SNF (Skilled Nursing Facility) for rehabilitation when medically stable. The SW noted that the patient/rep (representative) was offered choices of SNF. Patient/rep was offered choices of CHHA.

The Discharge Plan note dated 09/02/13 10:28 was reviewed. It was noted that the SW indicated that the patient would like to go home with RN (Registered Nurse) services when medically stable and the patient is known to VNAB (Visiting Nursing Association of Brooklyn).

On 09/04/13 12:37, the SW noted patient was transferred to Unit 2E, he is medically stable and will be discharged home with his daughter and VNR (Visiting Nurse Services) home care will follow-up. The home care agency's assessment and decision was not included in the Discharge Plan Evaluation. The home care agency's decision and its assessment prior to discharge were not included in the assessment.

The Discharge the Follow-Up Care Instructions were reviewed. This document indicated: "I certify that the patient is confined to his/her home and needs skilled nursing care, physical therapy and or continues to need occupation therapy". There was no documentation in the Medical Record that this patient had Occupational Therapy services prior to admission. There was no documentation that the patient had Occupational Therapy evaluation while as an inpatient or on the day of discharge.

MR #3 was reviewed on 09/06/13 at approximately 11:45AM. It was noted that this 93-year-old patient with history of Hypertension, Seizure and Brain Surgery was brought the Emergency Department on 07/28/13 with complaint of right arm pain after a fall.

Discharge Assessment information was reviewed. It was noted that on 07/30/13, the SW noted anticipated that the Discharge Plan was home with resumed care services. It was noted that the patient did not have a discharge reassessment in order to determine if return to the same home care agency and services were still appropriate for this patient.

The Department of Social Work and Home Care Services Policy, revised on 08/13, was reviewed on 09/05/13. It was noted that this Policy indicated that "the social worker make home care referral to the home care agency. The social worker will document the outcome of the home care agency's assessment and referral decision in the medical record". The facility was not following this policy.

Similar deficiencies were also identified in MR's #4 and #5.
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Based on patient interview and Medical Record review, it was determined that the facility failed to ensure that each patient's Discharge Planning Evaluation included an assessment on whether or not the patient could be cared for in environment from which he or she entered the facility. This was noted in one (1) of five (5) applicable Medical Records reviewed (MR #4).

Findings include:

During the tour of the Unit (2 West), the patient (MR #4) was interviewed on 09/04/13 at 11:55AM. This patient reported that she was discharged today and she was waiting for transportation. The patient reported that prior to admission she resided at home. The patient stated that she was admitted because she was walking on the street; she felt dizzy and blacked out. She stated that her Discharge Plan was to a rehabilitation facility and she chose Sheepshead Nursing Home. The patient stated that she felt anxious about residing in a nursing home.

MR #4 was reviewed on 09/04/13 at 1:45PM. It was noted that this 94-year-old patient was admitted to the facility on 08/27/13. The reason for the admission was dizziness and giddiness. It was noted that the Initial Discharge Screen was conducted on 08/28/13 at 11:00AM. The Discharge Manager noted that the patient lived alone and the discharge need was CHHA (Certified Home Health Agency).

On 08/29/13 at 09:31, the Discharge Planner noted MD (Medical Doctor) "contacted worker and is recommending in-patient rehabilitation". It was noted that the Discharge Planning Evaluation did not include the reason why the Discharge Plan was changed from home with home care services to a skilled nursing facility.

The patient had had a Physical Therapy (PT) Evaluation on 09/03/13 at 12:18PM. It was noted that the Physical Therapist recommended continued PT to improve stability and strength. The Discharge Evaluation did not include the reason why patient's post-discharge needs could not be accomplished in the patient's community for example home physical therapy.

The patient had a consultation on 09/02/13. The reason for the consultation was due to Depression and Anxiety. The Consultant noted that the patient wanted to leave the facility as soon as possible; she was missing her dancing and club she was involved with. The Discharge Evaluation did not include if there was a discussion to address the patient's goals and if or when the patient's discharge goal may be achieved. The assessment did not include if there was a discussion with the patient in order to prepare her for a change from home to living in a skilled nursing facility.
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Based on interviews, observation and the review of Medical Records and other documents, it was determined that the facility failed to implement Policies and Procedures in the Emergency Department (ED) as evidenced by the following: 1. there was no process to ensure timely evaluation and treatment of patients assessed at triage with severe pain; 2. staff failed to respond timely to cardiac monitor alarms; and, (MR#11) 3. staff did not ensure that the content of Code Carts are complete as established by the Cardiopulmonary Committee.
The finding regarding delay reassessment and management of severe pain was evident in three (3) of seven (7) applicable records (MR's #8, #9 and #10).

Findings include:

1. During the tour of the Emergency Department Waiting Area at the Beth Israel - Kings Highway Division on 09/03/13 at 10:24, it was observed that the facility did not have an established system for timely management of patient's pain upon triage. A patient identified as MR #8 was heard moaning with facial grimacing and clinching to her abdomen in the ED Waiting Area. At interview with the patient at 10:25, she stated she had been triaged over one (1) hour ago and was waiting to be called into the Treatment Area for Physician assessment. The patient was then immediately escorted by the ED Physician to the Treatment Area at 10:32 on 09/03/13 and evaluated.

Review of the patient's record on 09/05/13 at 12:00 revealed she was triaged on 09/03/13 at 09:23 with a chief complaint of abdominal pain that she rated to be nine (9) out of ten (10) on a scale of ten (10). The pain was described as throbbing, associated with nausea and vomiting. The Medication Administration Record revealed Morphine 2mg IVP was administered at 11:00 on 09/03/13.

At interview with the ED Director on 09/05/13 at 13:45 regarding the Emergency Department procedure for timely assessment and treatment of pain, he stated the goal of the Emergency Department is to respect the patient's right to optimal pain assessment and management. He added that patients with severe pain during triage assessment are immediately referred to the Physician for timely evaluation and management.

Review of the facility's Policy titled "Pain Assessment and Management in the Emergency Department" revised on 08/13 documented procedures for pain assessment/ reassessment, patient/family education and involvement in treatment plan. However, the Policy failed to establish a protocol that assures timely assessment and management of pain upon triage.

MR #9 is a 57-year-old male who was triaged on 07/26/13 at 13:27 with complaint of severe right arm pain rated at ten (10) on a scale of ten (10). The patient was assigned an acuity level of "3". The Triage Nurse notes at 13:32 indicated the patient was calm with facial grimace. Physician assessment at 15:46, over two (2) hours later revealed a three (3) day history of right arm redness, pain, swelling and chills after an insect bite. Physician's Orders were written for antibiotics, Ampicillin and Vancomycin at 15:30; however, the patient's pain was not reevaluated and treated until 16:24 on 07/26/13.

MR #10 was triaged in the ED on 08/28/13 at 15:17 with chief complaint of generalized pain. The patient indicated her pain level was nine (9) out of ten (10). The patient's medical history was significant for Sickle Cell Disease and Anemia. The Initial Physician Assessment of the patient was over three (3) hours later at 18:23 with a final diagnosis of Sickle Cell - Pain Crisis. Physician's Orders for Hydromorphone (Opioid Analgesic) 2mg, intravenous push (IVP) and Benadryl (antihistamine) 25mg IVP written on 08/28/13 at 18:22 prior to the initial assessment of the patient were not administered until eighty-five (85) minutes later at 19:47.

2. During tour of the Emergency Department on 09/03/13 between 10:20 and 10:50, it was observed that staff members failed to respond to cardiac monitor alarms timely. For example, on 09/3/13 at 10:26, the surveyor witnessed the cardiac monitor in Bed 9 alarming continuously for two (2) minutes without intervention by staff members. Review of the patient's Medical Record, #11, revealed a 70-year-old male who presented to the ED on 09/03/13 at 03:44 with chief complaint of Syncope. Physician's Orders were noted on 09/03/13 at 04:32 for continuous monitoring of cardiac, blood pressure and oxygen saturation. However, the review of the patient's heart rhythm from 08:00 to 10:58 showed no cardiac rhythm was recorded for five (5) minutes from 10:22 to 10:27. This finding was validated by the Nurse responsible for the care of the patient and the ED Nurse Manager.

At interview with the patient's Nurse on 09/03/13 at 10:30, he stated artifacts in the patient's heart rhythm was due to movement by the patient, and the lack of heart rhythm for five (5) minutes was caused by displacement of cardiac leads. The Nurse did not offer explanation for the failure to timely review the nature of the alarm, interpret and provide appropriate intervention.

3. During tour of the Emergency Department on 09/03/13 at 10:45, it was observed that three (3) of the four (4) Code Carts did not have an oxygen tank; however; the review of the Code Cart Checklist revealed oxygen tank was checked daily to be present on each of the Code Carts.

The facility's Policy #C-2 titled "Checking of Emergency Equipment", that was reissued 06/13, noted a staff member is assigned daily to conduct daily checks of the Code Carts and all unlocked items that includes but not limited to oxygen tank, bag/valve/mask and airways.

This finding was verified by the ED Nurse Manager on 09/03/13 at 10:47. At interview at 10:47, she stated oxygen tanks are readily available but are not attached to the Emergency Department Code Carts as prescribed in the Policy.