HospitalInspections.org

Based on observation and interview, the hospital does not provide the patient the right to make informed decisions regarding his or her care as related to the lack of disclosure to the patient that there is no doctor of medicine or osteopathy present in the hospital 24 hours per day, seven days per week.

Findings include:

Observation on 6/9/15 at 10:00 AM in the emergency department revealed no evidence the hospital had posted a notice conspicuously, in a place or places likely to be noticed by all individuals entering the dedicated emergency department, stating that the hospital does not have a doctor of medicine or a doctor of osteopathy present in the hospital 24 hours per day, 7 days per week, and how the hospital will meet the medical needs of any patient with an emergency medical condition at a time when there is no doctor of medicine or doctor of osteopathy present in the hospital.

During interview on 6/9/15, Patient Care Manager Staff #3 stated that the hospital does not have policies regarding this issue, and does not inform patients of this by having signage in the emergency department for emergency patients, or provide written notice with signed acknowledgement to inpatients, or outpatients who are under observation or having surgery or any other procedure using anesthesia. She stated that the hospitalist leaves the facility after morning rounds, and there is no longer a doctor of medicine or osteopathy present in the hospital, although one is on call.

During interview on 6/12/15, Medical Director Staff #21 confirmed that there is currently no system to notify patients that a doctor of medicine or osteopathy is not present 24 hours a day to provide medical care for patients.

Based on policy and procedure review, medical record review, and interview, the hospital does not ensure that all inpatient medications brought from home are verified by a pharmacist or provider before administration to patients, in order to ensure that medication inside the labelled medication container is the correct medication, as evidenced for 1 of 1 inpatients. (Patient #5)

Findings include:

Review on 6/11/15 of policy #31.50 "Medication from Home, Patient's Own" (last reviewed/revised 2/2014) revealed according to pharmacy procedure: "5.) Patient's own medications may be administered, if they are non-formulary, if ordered to do so by the physician. a) All patients own medication must be identified prior to administration. If pharmacy is closed the nurse may call the dispensing retail pharmacy for identification. If the dispensing pharmacy is unreachable, the physician or provider on duty may either choose to identify the medication or have the medication started in the morning after the pharmacy opens."

Medical record review on 6/11/15 for Patient #5 revealed:
- A physician orders document dated 6/9/15 at 20:15 (8:15 PM) revealed Patient #5 may take own medications from home, Breo Ellipta 100-25, 1 inhalation daily (typically used for chronic obstructive pulmonary disease).
- The Medical Administration Record (not dated) showed that Patient #5 received doses of Breo Ellipta 100-25, 1 inhalation, at 8:00 AM on 6/10/15 and 6/11/15.
- The "Verification Form for Home Medications" document (used by the pharmacist or provider to record verification that the correct medication is in the home medication container) revealed verification of Patient #5's home medication of Breo Ellipta 100-25 mcg by mouth once per day. The form did not have documentation of the date or time of verification.

Interview on 6/11/15 at 1:00 PM with Patient Services Manager Staff #3 revealed that verification of Patient #5's home medication Breo Ellipta 100-25 mcg was not completed until 6/11/15 at 12:00 PM, after Patient #5 had received two doses of the medication.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 7/15/11.

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Based on observation and interview, the hospital does not maintain the floors in the corridor near stairwell D, or the operating room on the left side of the operating suite, potentially leading to safety or infection control issues.

Findings include:

Observation during facility tour on 6/10/15 revealed that in the corridor near stairwell "D", five floor tiles had broken pieces, and many tiles had multiple cracks in them.
This finding was verified with Maintenance Staff #15 on 6/10/15.

Observation during tour of the operating suite on 6/10/15 revealed that when in the corridor viewing the operating room on the left side in the suite, the metal ceiling track was observed to have a large amount of corrosion on it. The surface was not a type that was a scrubbable surface. It was also observed that the exhaust grill had heavy corrosion on it, and was not a scrubbable surface.
This finding was verified with Patient Services Manager Staff #3 on 6/10/15.

Based on policy and procedure review, document review and interview, the hospital failed to ensure the availability and reliability of needed supplies for emergency situations, as evidenced for 1 of 2 pediatric crash carts in the emergency department. (treatment room #2)

Findings include:

Review on 6/10/15 of policy #2.7 "Crash Cart, Checking Of " (last reviewed/revised 10/2010) revealed " 'The Nursing Department Check for Locked Crash Carts' checklist will be completed every 24 hours. . . The checklist is to be completed and signed by the assigned RN, LPN, PCA (patient care assistant), and U.S. (unit secretary)."

Review on 6/10/15 at 9:20 AM of the "Nursing Department Check for Locked Crash Carts" documents for the 2 pediatric crash carts in the emergency department revealed that the pediatric crash cart in treatment room #2 had not been checked daily; there was no documentation that it was checked from 6/1/15 through 6/6/15.

This finding was verified by Patient Services Manager Staff #3 on 6/10/15.

Based on interview, personnel file review, policy and procedure review, observation and document review, lapses in generally acceptable infection control practices were identified in the documentation of endoscope reprocessing, and in staff qualifications and education related to infection control.

See findings under Tags #A748 and A749.

Based on interview, personnel file review, and policy and procedure review, the hospital does not have evidence that the infection control officer is qualified and maintains qualifications related to infection control.

Findings include:

Interview on 6/11/15 with Patient Services Manager Staff #3 revealed she is the hospital's infection control officer, but she has received no additional training beyond standard infection control training as required by New York State Education Department for her registered nurse licensure, and routine yearly inservices per hospital policy.

Review on 6/11/15 of the "Course Completion" training portion of Staff #3's personnel record revealed she received the hospital training "Annual Mandatory Safety Update" on 11/4/13 and 10/13/14, which contained some components for infection control and is required for all nursing staff. No evidence of specialized infection control education was noted in the file.

Review on 6/10/15 of policy #2.19 "Mandatory Inservice and Education Requirements" (reviewed/revised 10/2010) revealed "1. All nursing associates are required to complete the annual hospital wide mandatory inservices. This includes, but may not be limited to: . . b. Infection Control - includes personal hygiene, personal protective equipment, maintaining a healthy environment, and overviews on bloodborne pathogens and tuberculosis."

This finding was verified with Staff #3 and Administrative Assistant Staff #24 on 6/11/15.

Based on observation, document review, interview, medical record review, and policy and procedure review, the operator does not have a process to monitor and track cleaning, disinfection and patient identification related to the use of endoscopes.

Findings include:

Inspection on 6/9/15 at 9:00 AM of the endoscope reprocessing area revealed 3 Pentax scopes that were reported to be disinfected and ready for use. The surveyor was unable to determine when scopes had been processed and there was no evidence to show if scopes were clean or dirty.

Review on 6/9/15 of Steris endoscope reprocessing "print outs" for the past year revealed no identifiers of individual scopes to indicate which were cleaned and mechanically reprocessed.

Interview on 6/9/15 with Licensed Practical Nurse Staff #20 revealed that scopes are cleaned manually, then processed via the Steris machine. Scope numbers are not documented when the scopes are processed, and the scopes are not identified or dated when processing is completed. Staff #20 also reported that the facility has no process to routinely reprocess scopes when patient volume is low and scopes are not used as frequently as usual.

Medical record review on 6/10/15 for Patients #1-3 revealed no documentation of which scope was used on the patient for the endoscopy procedures they underwent, for tracking purposes in the event infection control or other issues were identified afterward.

Review on 6/10/15 of the Steris operator's manual revealed a patient and device ID option is available in which to enter the patient identifier number and scope identifier number for the results "print out."

Review on 6/10/15 of policies related to scope reprocessing revealed no evidence of a policy related to the ability to track a scope from the "clean" storage area, to patient use, or through the disinfection process. There was also no evidence of any policies on the reprocessing of clean scopes that remain unused over a period of time.

These findings were verified with Patient Services Manager Staff #3 and Staff #20 on 6/11/15.