HospitalInspections.org

Based on review of personnel records and staff interviews, the hospital did not ensure that personnel are properly licensed and qualified for their title and position.

Findings include:

The hospital has Psychiatric Unit/Mental Health Services that is required to meet both the general criteria for hospital units and the specific criteria for psychiatric units. The psychiatric unit must provide through the use of qualified personnel, the following: psychology, social work, psychiatric nursing, occupational and recreational services.

A review of the hospital job description of the Director of Psychiatric Nursing services revealed that the person must be a registered nurse who has a master's degree in psychiatric and mental health nursing, or its equivalent, from a school of nursing accredited by the National League for Nursing, or be qualified by education and experience in the care of the mentally ill. The Director must demonstrate competence to participate in interdisciplinary formulation of individual treatment plans, give skilled nursing care and therapy, and to direct, monitor, and evaluate the nursing care furnished.

During interview with Staff #10 on 1/12/12 at 11:00AM, it was revealed that Staff #10 has worked as the Vice President of Patient Care Services from 2008 - 2009 for 13 months and returned to that position in April, 2011.

Staff #10, the Vice President of Patient Care Services, personnel records were reviewed. Staff #10 holds a Bachelors degree in Nursing and a Masters degree in Case Management. Staff #10 does not have a master's degree in Psychiatric or Mental Health Nursing or its equivalent. Therefore, the current Vice President of Patient Care Services of the Behavioral Health Program is not qualified in accordance with accepted standards of practice for Psychiatric Units.

Based on review of medical record, policies and procedures and staff interviews, the hospital failed to ensure patients the right to participate their plan of care. This was found in two (2) of two medical records reviewed, MR# 5 & 6.
Findings include:

Two (2) of two medical records reviewed in the Behavioral Health Unit had no evidence that patients participated in the development and implementation of their treatment plan of care. A review of the treatment plans revealed documentation from various disciplines, however there was no evidence that patients participated in the development of their plan. Additionally, the plans did not state whether or not the patients were mentally capable of participating or implementing the plan of care.

MR#5 is a 19 year old patient who was admitted to the hospital on 12/14/11 due to suicidal threats. The patient has a psychiatric history and is known to this hospital. The medical record revealed that a treatment plan was established on 12/22/11 and was updated 12/23/11-1/5/12. A review of the medical record revealed that various disciplines documented a treatment plan, but there was no evidence of any input from the patient. For example, on 12/16/11, the (RT) wrote that the patient will be able to identify at least 3 symptoms of her illness. On 12/23/11, the same RT wrote that the patient will participate in at least one life skill education or wellness group daily, stay focused task oriented, and be able to listen without interfering with others. There is no evidence that the patient participated in her treatment plans. There was no evidence by the team whether or not this patient was capable of participating or carrying out the plan.

MR#6 is a 59 year old patient with a long psychiatric history and multiple hospitalizations. She was admitted to the hospital on 12/24/11 via the emergency room. The treatment plan was established on 12/25/11, updated on 1/4/12 and 1/11/12. The treatment plan was developed and signed by all disciplines, however there was no evidence that the patient participated in the development of these plans. Additionally, there was no discussion by the staff regarding the patient's response to the plan. There was no evidence by the team whether or not this patient was capable of participating or carrying out the plan..

A review of the hospital policy for Behavioral Health Center titled "Comprehensive Treatment Planning" states the following:
The nature of the patient's participation in treatment planning is documented. The plan is explained to the patient in understandable language, and the patient signs and dates the treatment plan. Hospital staff failed to follow this policy.

Upon interview on 1/12/12 at 11:20 AM, social workers (Employees# 17&18) acknowledged the above information.

Based on review of facility documents and staff interviews the facility did not ensure that all departments were reporting data to the Quality Care Committee (QCC) as specified in the facility "Performance Improvement and Safety Plan 2010-2012."

Findings include:
A review of the Performance Improvement and Safety Plan 2010-2012 revealed that the QCC shall meet at least quarterly or more frequently.
However, the annual calendar showed that departments were scheduled to meet less than quarterly. QCC meetings were not timely.

The Infection Control Committee (ICC) was scheduled to report tracked data and patient adverse events to QCC only once in the year, in February 2011. Consequently, an incidence of a significant cluster of infection that occurred at the facility involving 7 patients in the month of August 2011 was never reported to QCC.

During interview on 1/13/12 at 11:15 AM to 11:30 AM, staff #11 stated that although the ICC reported to QCC once that year, she also reported to the Medical Executive Committee monthly. However, the data related to the cluster of infection was not submitted to the Medical Executive Committee and was consequently not reported to the Governing Body.

Similarly, it was revealed during the review that the calendar with the schedule to report data to QCC did not include the Social Work Services Department. Therefore, that department failed to report patient related adverse events data to QCC.

A review of the Performance Improvement and Safety Plan 2010-2012 states "Department directors are responsible for the implementation of department quality improvement programs. Clinical departments shall meet at least ten (10) times per year and periodically report to the Quality and Safety Council ".

The facility failed to ensure that periodic reports were received from the departments and sent to the Quality and Safety Council. Some departments were ommitted from the calendar and some committees that were subject to "high volume, high variability, high risk/problem prone" were scheduled to report less than quarterly to the QCC.

Based on medical records, policy reviews and staff interviews, it was determined the facility failed to ensure that initial physical assessments were completed for 2 of 4 patients whose medical records were reviewed from the Hematotherapy Unit.
Findings include:
The nursing staff failed to conduct an initial history and physical assessment for MR #9. MR #9 is an 8 year old patient who was admitted to the center on 9/30/11 with a diagnosis of Neuroblastoma. The patient has been receiving treatment at the center since admission. A review of the patient's medical record on 1/13/12 revealed the members of nursing staff did not perform an initial history and physical assessment when the patient was admitted to the center. In addition, there was no evidence that the staff conducted any subsequent history and physical assessment after the patient began to receive treatment at the center.

The initial history and physical assessment was incomplete in MR #10. MR #10 is a 9 year old patient who was admitted to the center for blood transfusions for his diagnosis of Sickle Cell Anemia. A review of the medical record on 1/13/12 at 12:20 PM revealed the patient had received several units of blood since his admission in 2011. However, the initial history and physical assessment was incomplete.

These findings were witnessed by the Nursing Supervisor of the unit at the time of observations. This interviewee acknowledged that she had noted this issue in other medical records and she also stated that she had conducted audits to address this issue.This supervisor also acknowledged that it is the facility's policy for the nursing staff to perform a complete initial history and physical assessment of each patient upon admission.

It should also be noted that the facility's policy does not require a physician to perform a history and physical assessment upon admission, nor throughout the patients' treatments at the center. The nursing staff is only required to perform a history and physical assessment on admission. Therefore these records did not have any baseline data of the patient's history from any provider throughout the patients ' admission and treatments at the center.

Based on observations, review of policies and procedures and staff interviews the facility did not ensure that outdated, mislabeled, or otherwise unusable drugs and biologicals were not available for patient use.

Findings include:

During tour of the pharmacy department on 1/10/12 at 11:15 AM, it was noted that the following medications were expired .

1. Two bottles Guaifenesin Oral solution 100mg, 16 fluid ounces, expired 11/11.

2. One bottle Zyvox 150 mg expired 1/8/12.

3. One opened bottle Dexamethasone oral solution 0.5mg expired 08/11.

4. One bottle Plasma-LyteA, PH 7.4, multiple Electrolytes injection expired 05/11.

5. Nine bottles Phosphate laxative, Oral saline laxative, 1.5 ounces, expired 06/11.

Upon interview on 1/10/12 at 11:25 AM, the Director of Pharmacy (Employee #6), acknowledged the findings.


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6. A bottle 500 ml of 20% Dextrose with the expiration date of 12/11/11 was found stored
on a shelf.

7. A bottle of 1000 cc Plasma Lyte with the expiration date of 5/11/11 was found on a
storage shelf.

8. A box containing 24 bags of 250mls of 10% Dextrose with the expiration dates 1/1/2012
was also found on a storage shelf.

9. A bottle of Zyvox premixed at 100mgs/ 5ml and dated "good until 1/8/12" was found
restocked on a shelf at 11:15 AM on 1/10/12.

Based on observation, staff interview, and review of the dietary policy and procedures, the facility failed to provide dietary and food services according to the current standards of practice.

Findings include:

1. a. During observation of the kitchen on 01/09/12 at 11:00 AM, it was noted that the hot washer for pots was running with a pre-wash temperature of 145*F, wash temperature of 147*F, and rinse temperature 180*F. On the hot washer it was posted that the wash temperature should be greater than 160*F. This finding was verified with Staff #12 and Staff #13.

1. b. During the review of policy and procedure titled 'Dish Washer/Pot Machine' revised on 12/2011, the policy stated that the wash temperature should be more than 160*F.

1. c. A review of the temperature logs for the pot washer for December 2011 and January 2012 revealed that the temperature log for January 2012 was different from the log of December 2011. The log in December 2011 stated that the water should be more than 160* F but in January 2012 the log states it must be more than 150*F. Also in the month of January the temperature was frequently below 160*F.

2. During observation of the pantry and the refrigerator, many of the stored food items were expired. For example, in the dry food pantry 14 boxes of 'Oat Bran Muffin Mix' expired between 2/2/2011 to 11/2620/11. Furthermore, 4 cartoons containing 6 boxes of 'Gluten Free Crackers' expired in 04/15/2011. There were other expired items and findings were verified with Staff #13.

3. Many bulk can items such as 'Butter Scotch Syrup' or 'Chocolate Flavoring' were not dated with received or expired dates. As per the policy titled "Expired/Recalled Products' revised on 11/15/2009, item # 4 states that 'Date cartons, boxes and cans with date received'. Thus it could not be determined the expired dates. Similar findings were noted on jugs/bottles of 'Worchestire Sauce' or 'Teriyaki Glaze'. These findings were verified with Staff #13 during the observation.

4. Various areas and equipment in the kitchen were dusty, greasy and with accumulation of garbage. The floors were also dirty with various areas of black greasy depositions. These included:

i. The convention oven was dirty and greasy.

ii. Below the meat cutting cart the floor was very dusty and dirty.

iii. The blade for cold cuts was dirty with residues of meat.

iv. Back of the open refrigerator was extremely dirty and dusty.

v. The grill next to the cafeteria freezer was very dusty and dirty.

5. The water in the hand washing sink in the Cafeteria was reading 130*F.

6. The gaskets of refrigerator #2 (Trausen 3 door) was torn, dirty and in disrepair.

All above findings were verified with Staff # 12 and Staff #13.

Based on observations and staff interview during the survey between 1/09/2012 and 1/13/2012, it was determined that the facility's physical construction was not equipped and maintained to provide a functional, safe and sanitary environment, free of hazards, for its patients, staff and family members.

The findings include:

1. During the tour of the Surgical Suite on 01/09/12 at 2:00 PM, it was noted that in OR #2 the operating table had a base with an excessive amount of tape and a thick adhesive residue layer that was accumulating dust. The corners of the OR was also dusty. Furthermore, the exhaust vents were dirty and dusty. Findings were verified with Staff #12.

2. During a tour of the Behavioral Health Center on 01/10/12 at 2:15 PM, it was noted that:

i. The floor corners/perimeters of the rooms in unit A1, A2, B1, B2 and B3 had accumulation of dirt.

ii. The air-conditioning vents were dusty and dirty in areas such as the dinning room of the B3 unit and in rooms such as B360, B359 and others.

iii. The mechanical vents of the toilet rooms of B351 and among others were dusty and dirty.

iv The toilet dispensers installed in toilet of B 351 and B355 had sharp edges which posed a risk of harm to patients.

v. Some of the chairs outside the rooms/near the lounge were observed with ripped upholstery.

vi. The shower curtains in the girls and boys bathroom in B1 unit had dirty stains.

3. The one hour rating of the seclusion rooms in A1, A2, B1, B2 and B3, could not be verified during survey as required by AIA 1996-97 7.6.D.

All above findings were verified with Staff #12

4. During the observation of Oncology Unit (7th floor-Main Hospital) on 01/11/12 11:15 AM, it was noted that when a nurse call was elicited from a patient room, it did not register in the medication room, clean utility room, soiled utility room and other areas as per AIA 7.32.G1.
Similar findings were noted in some other units of the building.

Finding was verified with Staff # 12.

5. The mechanical vent on 7S -Oncology unit was noted to be very dusty and dirty.

6. All the electrical closets surveyed in the Main Hospital were noted extremely dirty and dusty. Examples of electrical closets are including but not limited to the 7th floor, 5th floor and 1st floor.

7. During the survey of the Physical and Occupational Rehab unit/in-patient floor (Taylor Building), following issues were noted:

i. The upholstery of various examination/treatment bed and head rest were torn in the Physical Rehab area.

ii. Balancing boards were very dirty and made of a metrial that is impervious to thorough cleaning.

iii. The pulley system and the floor around the room was dusty and dirty.

iv. A wheel chair in the storage area had a large white tape on the hand rest.

v. The equipment storage area of the Physical Rehab/exercise place was very dirty.

vi. Toilet rooms in the in-patient Rehab area such as room #101,111 and among others did not have protection/insulation of hot water drain pipes under the sink as per ADA guidelines for protection of hot water pipes against contact.(ADA 4.24.6).

8. During observation of the Endoscopy unit on 01/13/11 at 12:30 PM, it was noted that endoscopy room #2 had un-flushed seams/opened joints. Therefore the floor was not mono-lithic as required by AIA 9.9. B 2.g.

All above findings were verified with Staff #12.


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9. The facility failed to comply with NFPA 101 Life Safety Code requirements to ensure the safety of patients and personnel.
(Cross reference to tags K11, K20, K21, K29, K32, K33, K147);

10. Many areas of the hospital are not protected from fire or smoke.
(Cross Reference tag K11, K20, K21, K29, K33);

11. The facility failed to comply with requirements to maintain the physical structure and facilities in good repair so as to ensure the safety of patients and personnel.
(Cross reference tag A724, K147)

Based on observation and staff interview, the facility did not provide proper storage for the red bag medical waste.

The finding is:

On the afternoon of 1/13/2012, observation of room AG-14 (i.e. the Housekeeping Closet) in the Cedarwood Hall building revealed that the red bag medical waste was being stored within the same space as the housekeeping equipment (i.e. drainage sink, mop/pail, etc.).


Concurrent interview with Staff #14 at the time of the observation confirmed this finding.

Based on observations and staff interviews, it was determined the facility was not maintained in working condition.
Findings include:
On 1/10/12 at approximately 2:00 PM, the light fixture in room 301 bed A in unit 3 South East was noted to be broken. This finding was witnessed by Staff #2 at that time.

The overhead light fixture was not in working order in room 437 Bed B on 4 North East Unit on 1/10/12 at 11:35 AM. This was witnessed by Staff #2 at that time.

At 3:25 PM on 1/10/12 the overhead light fixture was not functional in room 724 bed A on the Step-Down Cardiothoracic unit. This was witnessed by Staff #2 at that time.

At the 19 Bradhurst Avenue location in Hawthorne, NY, in the waiting area of the Advance Imaging Department, 5 light fixtures were noted to be not functional at 10:43 AM on 1/13/12. This was witnessed by Staff #1 at the time of the observation.

On 1/11/12 at 10:25 AM, the thermostat censor in room 2322 in the adult trauma unit in the Maria Fareri building was noted to be broken and non-functional. This was witnessed by Staff #2 at the time of the observation.

During a tour of the Physical Rehabilitation Unit on 1/13/12 at 2:05 PM, it was noted that the closet handle in D142 was in need of repair. This finding was witnessed by Staff #4 at that time.

From 2:07 PM - 2:10 PM on 1/13/12 in the Physical Rehabilitation Unit, rust/brown residue was observed on the floor tiles below the hand-washing sinks in rooms 106A and 109 A. This finding was witnessed by Staff #4 at that time.


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On 1/11/12 at 1:45 PM to 3:15 PM the following observations, witnessed by Staff #9 and #10 were made in the behavioral units:

1. Room B324 was noted with a chipped bed frame.

2. Room B 328 (isolation room) was noted with a sharp edged air vent grill.

3. Room B 328 (isolation room) was noted with a 4" "U" shaped crack on the door.

4. Room B251 was noted with a cracked, sharp edged door label.

5. The tubing on the suction machine on the second floor treatment room was uncovered and lying on the floor.

6. Chairs with ripped covers were noted throughout the units.

7. The treatment room on the 2nd floor was noted to have a sharp edged, broken plastic container.

8. In room 231, the heating unit was observed with sharp edged grill covers.

9. The floor and shower in the female patient bathroom on the 1st floor was stained and dirty.

10. Room A233 (Treatment Room) the examination table was noted with a protruding cracking handle. The table was also missing a bar to hang the disposable examination table cover. Consequently, the roll of paper was placed on a step stool.


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Based on observation and staff interview, hospital medical equipment was not maintained to ensure an acceptable level of safety and quality. Specifically, there was multiple hospital grade equipment plugged into non-hospital grade outlets.

The finding is:

On the morning of 1/13/2012, observations of the medical equipment located in the specified Article 28 clinical space of the Bradhurst Center revealed that this equipment was plugged into non-hospital grade outlets. This equipment must be plugged into a hospital grade outlet. Specific equipment examples include the posturing equipment, the medical bikes, the patient tables, etc.

Interview with Staff #14 at the time of observation confirmed this finding.

Based on observation and staff interviews, the facility did not ensure that the air-pressures in various patient and non-patient areas were maintained as per code. Furthermore, monitoring for temperature and proper humidity levels was not done for sterile storage areas.

Findings Include:

1. During the tour of the Operating Suite on 01/09/12 at 2:00 PM, it was noted that multiple sinks outside the Operating Rooms did not have hot water, for example, OR #2, OR#5 and Sink #10 and Sink #7.

2. In the Operating Suite it was noted that the facility is storing sterile supplies in storage rooms and supply rooms in which there is no mechanism to monitor temperature and humidity. Facility was not aware of the requirement to ensure the appropriate humidity and temperature in areas that store sterile packages as required by AIA Table 2. Similar finding was noted in the sterile supplies storage room in the Dentistry Department.

3. During the tour of the Central Sterile Processing room on 01/10/12 at 10:45 AM, it was noted that there is a pass through carriage from the decontamination room to the clean sterile processing room. This pass through was open with no partition between the two rooms. When positive air pressure was checked by a simple tissue test for the Central Sterile Room, no movement of air was noted as required. Furthermore, the decontamination room also did not exhibit negative pressure. It was neutral. Thus this huge gap between the two rooms is not only compromising the air-pressure it is also a mean of cross contamination of both areas.

4. The janitorial closet in the Central Sterile Storage room did not have negative air pressure, did not latch positively and was very dirty. The soiled utility room on 7S floor also did not have negative air-pressure as required instead exhibited very strong positive air pressure during simple tissue test. Similar finding was noted in the soiled utility room of the Dentistry Department.

5.a. On 01/11/12 at 11:00 AM during the survey of the Oncology Unit-7th Floor (Mian building), it was noted that rooms #710 and #704 had negative air pressure instead of positive air-pressure which is required for Oncology Positive pressure rooms. Furthermore, rooms #705 and #701 had neutral air pressure.

5.b. During review of the air pressure check logs on 01/12/12 at 11:30 AM, it was noted that in the past week most of the rooms had CFM of about 225 or more, whereas room #710 had CFM of 75. This itself indicates that in comparison to other rooms this room does not have the required CFM to make it positive air pressure, thus during simple tissue test it exhibited negative air pressure. The reports submitted for the month of January 2012 did not have information on room #704, and #701. The information for room #705 indicated a CFM of 275 but it could not be explained why during simple tissue test this room was not exhibiting any movement of air.

It was also noted that this log did not record information for MICU rooms #10 and #11.

A. Based on observations and staff interviews, it was determined the facility failed to provide and identify conditions that pose a risk of contamination and infections.
Findings include:
The following conditions which pose a risk of infections were observed during a tour of the facility. The glucometer machine was dusty and dirty in the ED on 1/9/12 at 11:00 AM. This finding was witnessed by Staff #3.

At 11:05 AM on 1/9/12, the cupboards and drawers in the Emergency Department were in need of proper cleaning. This was witnessed by Staff #3 at the time of observation.

On 4 North East on 1/10/12 at 11:35 AM, the covering for the cart used to store clean linen had an excessive amount of dirt. This finding was witnessed by Staff #3 at the time of observation.

On 4 North East on 1/10/12 at 11:35 AM, there was a used glove on the floor and a dirty pulse oxymeter probe on a cart in the clean storage room. These findings were witnessed by Staff #3 at that time.

The patients' privacy curtains in room 2322 in the Adult Trauma Unit had a large soiled or stained area measuring at least 3" x 4" and 6 smaller areas which appeared soiled on 1/11/12 at approximately 10:45 AM. This was witnessed by Staff #3 at that time.

On 1/11/12 at 2:50 PM there was at least 3 inches of the patient privacy curtains lying on the floor in the ultrasound room in the Cedarwood Outpatient Clinic. This was witnessed by Staff #1.

A refrigerator in the medication room in the Cedarwood Outpatient Department was dirty and dusty on 1/11/12 at 3:03 PM. This was witnessed by Staff #1 at the time of observation.

The inner sections of each armrest of the chair in nursing station #1 at the Bradhurst Avenue, Hawthorne location, had areas each measuring at least 2" x 2" of dried brown/red substance on 1/13/12 at 10:47 AM. Patients sit in these chairs while staff access their IV sites. This was witnessed by Staff #1 at that time.

A chair was observed stored in the patient's bathroom in the Diagnostic Imaging Department at the Bradhurst Avenue, Hawthorne location at 10:57 AM on 1/13/12. This was witnessed by Staff #1 at that time.

The Body Box equipment in the Pulmonary Pediatric Lab at the Bradhurst, Hawthorne location was heavily soiled and in need of cleaning at 11:23 AM on 1/13/12. This was also observed by Staff #1 at that time.

The windowsill in room 107 in the Physical Rehabilitation Unit was dusty and in need of cleaning on 1/13/12 at 2:15 PM. This was witnessed by Staff # 4 at that time.

There were 5 potted plants in the patient lounge in the Physical Rehabilitation Unit on 1/13/12 at 2:20 PM. Each potted plant had a dirty towel below each pot. This finding was witnessed by Staff # 4 at the time of observation.

The above conditions pose a risk for contamination and infection for patients and staff.


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B. Based on observations from 1/9/12 to 1/13/12, staff interviews and policy and procedures reviews, the facility did not ensure that the infection control officer developed a system for identifying risks that may cause healthcare-associated infections.

Findings include:

On 1/9/12 the following observations were noted and witnessed by Staff # 5.

1. Radiology Department:
Three blue anesthesia carts were noted with unwrapped stack of mouth gags and discolored 4 x 4 gauzes.


2. Diagnostic Immunology:
Two opened bottles of Normal Saline 1000 cc solution dated 1/3/12 and 1/6/12 were observed at the work stations. The bottles containing the liquids were not closed systems and were subject to contamination from multiple access and uses once opened.


3. Stat Lab:
On 1/9/12 , a bottle of 1000 cc of Normal Saline opened and dated 11/14/11 with the manufacturer expiration date of 12/14/11 was noted at a work station.


4. Automated Chemistry:
Detergent solutions in bottles which were scheduled for disposal were found stored on shelves.


5. Hematology:
An open bottle of 1000 cc of Normal Saline was not dated.


6. HDL Room:
One red Vacutainer with expiration date of 12/11, 3 tan colored Vacutainers with expiration dates of 02/11. 07/11 and 12/11 were observed among the stack of supplies in carry caddies.


7. Pharmacy:
See citations at V0505 for similar findings.


8. Nuclear Medicine:
A bottle of rubbing Alcohol was opened 8/15/11 had a manufacturer expiration date of 9/15/11 was observed stored on a shelf.


9. Behavioral unit:
On the second floor treatment room, a suction machine tubing was observed uncovered and lying on the floor.
In room A233 (Treatment Room), the examination table had a protruding handle that posed a risk for harm. The table was also missing a bar to hang the disposable paper cover. The roll of paper was placed on a step stool.


10. Endoscopy:
An blue anesthesia cart had unwrapped mouth gag/airways and stacks of open discolored 4 x 4 gauzes.
In the Endoscopy Room, a basin was observed with 4 x 4 gauzes, an emesis bowl, and an opened 20cc syringe. Staff # 7 stated during interview at 3:30 PM that the gauzes are used to set up for the endoscopy procedures. Staff # 7 further stated that she uses her bare hand to obtain the gauzes for the procedure and lay the gauze on the prepped field for the surgeons.


The facility policy and procedures for setting up for endoscopies was reviewed. The procedure; "EGD/CARE OF PATIENTS" revised January 2009, failed to instruct staff about hand hygiene prior to set up for procedures.

During interview on 1/13/12 at 2:00 PM Staff #11 stated: "I have seen that some policies lack the essential requirements to perform hand washing and donning gloves in the procedural statements as required by CDC."


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11. The janitorial closet in the Kitchen (LLD4) did not latch positively and did not have negative air-pressure.


12. a. Many of the janitorial closets and soiled utility rooms in the facility did not latch positively and had missing self-closures. An example of a soiled utility room door not latching properly was in the PACU of OR (Main Hospital).


12.b. The janitorial closet in the OR suite also did not latch positively. Furthermore, this closet was located in a room/area that the door was open. The room had supplies such as filters/cartridges and suction tubings stored uncovered. The filters were for the equipment Neptune which is used in suction in ORs. This condition may lead to cross-contamination of the clean supplies. Similar finding was noted in the PACU of the main hospital where a Neptune machine was stored in an un-named room that also stored dirty housekeeping items.


13. On 01/10/12 at 11:00AM, during observation of the Central Processing area (Clean & Decontamination room), it was noted that the perimeters of the rooms were very dirty and dusty. The floor was also noted dirty , had broken patches that were temporary sealed with cement and the seams in the Decontamination room were not flushed.


14. It was noted that some ceiling tiles in the Central Sterile Room (especially the tiles with devices such as smoke detectors) were porous/had holes that may retain dirt (they were not monolithic) and did comply with AIA 7.28.B8. These porous ceiling tiles compromise thorough cleaning of the ceiling.


15 . As per AIA 7.9.D22, at least one airborne infection isolation room should be provided complying with the requirements of Section 7.2. Furthermore Section 7.2.C4 states that 'air borne infection isolation room shall have self-closing devices on all room exit doors'. During observations of the Main Hospital from 01/09/12 to 01/13/12 from 11:00 AM to 4:00 PM several air-borne isolation rooms in the facility did not have self-closure or self-closure mechanisms installed at the exit doors. Some examples include but are not limited to the isolation room in the PACU, 7th and 5th floor.



16. During observation of the Main Hospital form 01/09/12 to 01/13/12 between 11:00 AM to 4:00 PM, it was noted that many Janitorial Closets had an abundant amount of storage of clean supply, such as toilet paper rolls, paper towels and other clean supplies. Furthermore, in the Physical Rehab Center (Taylor Building) many clean items such as towels and clean supplies were stored in the tub room which is open to the toilet area. Thus due to aerosol from the commode of the toilet, these items have the potential to be contaminated.



17. As per AIA 1996-97 section 7.28.B9 'Rooms used for protective isolation shall not have carpeted floors and shall have mono-lithic ceilings'. On 01/11/12 at 11:45 AM, during the tour of 7S-Oncology Unit it was noted that the ceiling tiles inside the patient rooms were not in compliance with the code. The room had ceiling tiles which were porous and may retain dust and dirt thus posing harm to the patients in protective isolation.


All above findings were verified with Staff #12.

Based on facility documents reviews and staff interviews, the Chief Executive Officer, the medical staff, and the Director of Nursing did not ensure that the hospital-wide quality assurance program addressed problems identified by the infection control officer.

Findings include:

SEE CITATIONS AT A0286

Based on review of medical record, policies and procedure, and interview, the hospital failed to ensure that all members of the interdisciplinary develop or supervise in the development of the discharge plan. In addition the hospital failed to implement an initial discharge plan. There is no evidence that the patient was involved in the discharge plan. This was found in two (2) of two medical records review, MR # 5 & 6.

Findings include:

Two (2) of two medical records reviewed revealed there was no evidence that the interdisciplinary team participated in the development of patients discharge plan. MR# 5 & 6.

1. A review of medical records revealed that the discharge plans were completed by the social workers. There is no evidence that any other members of the interdisciplinary participated in the discharge planning evaluation/process. For example:

MR # 5 is a 19 year old patient who was admitted to the hospital on 12/14/11 via the emergency room for suicidal threats. The patient has a history of psychiatric hospitalizations.
A review of the medical record revealed that on 1/5/12, three weeks after admission the social worker (employee #17) wrote an "Action/Intervention" regarding the patient's discharge plan.

Review of this plan showed no evidence that any other member of the interdisciplinary team participated in this discharge plan. There is no evidence in the medical record that the interdisciplinary team approved the plan. There was no evidence if there were indicators from other disciplines that might impede or expedite the discharge.

2. MR # 6 is a 59 year old patient with a history psychiatric disorder. She was brought into the hospital via the emergency room on 12/24/11. The patient is known to the hospital and was previously discharged on 12/19/11. A review of the medical record revealed that on 12/27/11 the social worker (employee #18) wrote an assessment and on 1/12/12 she wrote an addendum to this assessment. The addendum erroneously states the following: "The d/c plan is for patient to be placed in an adult home or residential placement. St Vincent's was referred to St. Vincent's out-patient latina program."

The social worker assessment and discharge plan did not mention the previous discharge on 12/19/11. There was no evidence of any collaboration with any member of the interdisciplinary team. A review of the medical record revealed no evidence of a discharge evaluation prior to the above addendum. The addendum (discharge plan) was written three weeks after the patient was admitted to the hospital.

A review of the hospital's policy and procedure for Behavioral Health Center, titled Discharge Criteria that was last reviewed 12/11, does not state the role of the multi-disciplinary team in the discharge planning process. It states that the patient progress toward meeting discharge criteria is reviewed at the interdisciplinary team meeting. There was no evidence of this meeting in the medical record.

Upon interview on 1/12/12 at 11:20 AM Social Workers (employees # 17& #18) acknowledged the above documentation. They acknowledged that they were responsible for the patients discharge plan. They did not state whether or not other disciplines were involved in the discharge process.