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Based on observation and interview the facility does not have sufficient safeguards in place to ensure that medical records are safely stored. This has the potential for patient confidentiality to be compromised, as well as loss of patient records.

Findings Include:

Observation of the medical record storage area adjacent to the laundry room on 3/2/16 at approximately 10:30am revealed two large rooms with shelving units. Boxes of medical records were stored on the floor, exposing the documents to the potential for water damage as the room is below grade and adjacent to the laundry area.

Interview with Staff #28 on 3/2/16 at approximately 10:30am revealed that staff other than medical record personnel have access to the room.

Observation of the medical record storage area in the morgue on 3/2/16 at approximately 11:30am revealed numerous boxes of medical records stored directly on the floor.

Interview with Staff #28 on 3/2/16 at approximately 11:30am verified the finding.

Observation of Room 201 on 3/3/16 at approximately 10:30am revealed a large number of patient x-rays. The area was unattended and accessible to all staff, as well as the public.

Interview with Staff #2 on on 3/3/16 at 10:43am verified that the room is used for record storage and that it is not secured.

Based on record review, policy review and interview, the facility did not ensure the medical record was complete and accurate for 1 of 2 Emergency Department (ED) patients (Patient #17) and 1 of 5 surgical patients (Patient # 42). This has the potential to negatively impact the patient's care.

Findings Include:

Review on 3/1/16 of the ED medical record for Patient # 17 revealed nursing triage was completed on 12/5/15 at 11:19am. No further nursing or physician documentation is present in the medical record.

Review of the billing transaction history for Patient #17 indicates the patient left without being seen on 12/5/15 at 1:54pm.

Review on 3/1/16 of facility policy "Patients Who Leave the Emergency Department Prior to Discharge", last reviewed 2/16, revealed that when a patient leaves following triage and prior to evaluation by a medical provider, a disposition of "left without being seen" is to be entered in the nursing discharge summary.

Interview with Staff #1 on 3/1/16 at 10:32am verified that there was no discharge note in the medical record to indicate patient disposition.

Review on 3/4/16 of the medical record for Patient # 42 dated 3/2/16 revealed the patient underwent a laparoscopic ventral hernia repair under general anesthesia. Review of the anesthesia record revealed the following sections were left blank: Under the Physical Assessment- the Mallampati Airway Classification, airway anatomy, teeth, blood pressure, oxygen saturation and heart & lung assessment. Under the Anesthetic Technique section- number of intubation attempts, Rapid Sequence Intubation (RSI) and breath sounds. Under the Phase I section- blood pressure and airway assessment.

Review on 3/4/16 of policy "Documentation Guideline for the Medical Record" last revised 1/16 indicates all entries should be complete and contain all significant information.

Interview on 3/4/16 at 1:15pm with Staff # 1 verified these findings.

Based on observation, document review and interview, the facility failed to maintain the medical gas system throughout the hospital. Deficiencies in the medical gas system identified both internally and by an outside vendor were not addressed and corrected. Failure to maintain the medical gas system has the potential to adversely impact patient care.

See findings under Tag # 0724.

Based on observation and interview the facility does not maintain all of the physical plant.

Findings include:

Observation on 2/29/16 at approximately 3:30pm, revealed that the roof, near the maternity unit and the exit stairwell that discharges in the vicinity of the laundry area, had dead vegetation and dirt on it. The area of vegetation and dirt was approximately four feet by ten feet.

Interview with Staff #66 on 3/3/16 at approximately 2:30pm verified the finding.

This is a repeat deficiency from the survey of October 07, 2016.


Observation on 2/29/16 at approximately 11:45am, on 3/1/16 at approximately 12:00pm, and 3/2/16 at approximately 11:45am revealed a large amount of standing water on the roof above dialysis and radiology. The roof drain was obstructed with leaves and plastic bags. In addition, there were two sheets of plywood and two four by fours, approximately ten feet in length sitting on the roof.

Interview with Staff #66 on 3/3/16 at approximately 2:30pm verified this finding.


Observation in the Emergency Department on 02/29/16 at approximately 10:45am, revealed that numerous dead insects were present in 2 of 2 light lenses in the medication room and 2 of 2 light lenses in bay #2.

Interview with Staff #11 on 2/29/16 at approximately 10:45am verified this finding.


Observation in the kitchen on 3/1/16 at approximately 2:30pm revealed two exhaust conduits did not appear to be functioning. The exhaust at both ends of the dish machine did not appear to be evacuating the steam from the machine.


Observation in the sterilizer room, adjacent to the operating room on 3/3/16 at approximately 11:00am revealed that the exhaust grate was heavily coated with dirt, the floor was dirty, and there was a piece of shelving on the floor behind the door. In addition, the paint on the sill of the pass-through window from the dirty side to the clean side, was chipped with raw wood exposed.

Interview with Staff #52 on 3/3/16 at approximately 11:00am verified this finding.


Observation of the sterilizer room located near the pharmacy on 3/2/16 at approximately 1:00 pm revealed that the room was in disrepair. Floor tiles were damaged and missing, walls were damaged and drywall was missing. In addition, the room was cluttered with boxes, pipes and blue towels.

Interview with Staff #52 on 3/2/16 at approximately 1:15pm verified this finding.

Based on observation, interview and policy review, the facility does not ensure biohazardous waste, specifically sharps containers, are properly secured and stored. Failure to properly secure sharps containers place patients, staff and visitors at risk of injury and/or infection.

Findings Include:

Observation on 3/1/16 at 2:30pm in the outpatient Gastrointestinal Department revealed that 2 out of 3 procedure rooms (room #1 and # 3) had sharps containers sitting directly on the floor unsecured.

Review of policy "Disposal of Used Disposable Needles and Syringes/Sharps" last reviewed 10/11 indicated each area where disposable needles and syringes/sharps are used will have a red, rigid, leak proof, puncture resistant container which is designed specifically for the purpose of needle and syringe/sharps disposal. These containers shall be maintained in an upright position and will be secured to preclude loss of contents.

Interview with Staff #1 and Staff #24 on 3/1/16 at 2:30pm verified these findings.

Based on observation, document review and interview, the facility does not maintain the medical gas system throughout the hospital. Not maintaining the medical gas system has the potential to negatively impact patient care.

Findings Include:

Observation in the Emergency Department (ED) on 2/29/16 at approximately 10:25am revealed that the digital display on 2 of the 4 medical gas panels located at the nursing station were not readable. On panel " Triage 1-3 " the vacuum digital display was not readable. On panel " Resuscitation psy 1-3 " the vacuum and the oxygen were not readable. In addition, a free-standing coat rack with four coats on it was obstructing the medical gas panels.

During interview with Staff #24 on 3/1/16 at approximately 10:15am it was stated that the vacuum in the Gastrointestional Suite, procedure room # 1 was disconnected and that at times suction is low.

Observation in the Gastrointestinal Suite, procedure room #1 on 3/3/16 at approximately 11:00am revealed that 2 of the 3 vacuum outlets were not functional.

Interview with Staff #66 on 3/3/16 revealed that the finding of 2 out of 3 vacuum outlets were not functioning was verified with Staff #18, who stated that when equipment that uses vacuum is in use, it is fed into the one functional outlet.

Review of the " Annual Testing of the Medical Gas Distribution System at Niagara Falls Memorial Medical Center " dated August 22, 2015 and conducted by Medical Gas Technologies Inc. revealed that the panel " resuscitation psy 1-3 " vacuum had a " Bad Display Module " ; that the panel " Triage Fast Track 5-6 " (noted above as Triage 1-3) vacuum and oxygen had a " Bad Display Module ". The Annual Testing report noted that the panels " Fast Track 1-4 Acute Care 5-12 " and " Triage Fast Track 5-6 " are " Not Labeled " and that "at the time of the inspection it was found the low pressure vacuum switch, located in the Heart Center mechanical room does not sound at the master alarms." Additional findings noted in the report include no apparent area alarm servicing the ICU, the master alarm panel in Engineering and at the switchboard has no alarm for vacuum "Main Pressure Low" and vacuum system leaks in the following ED rooms: Resuscitation, PSY 1, PSY 2, PSY 3, Triage #1, Fast Track #1, Fast Track #2, Fast Track #4, Fast Track #6, Acute Care Room 1, Acute Care Room 2, Acute Care Room 4, Acute Care Bed 5, Acute Care Bed 7, Acute Care Bed 8, Acute Care 10.

Review on 3/2/16 at 3:00pm of Corrective Work Orders from 1/16/15 to 3/1/16 revealed that no work orders were generated to address the deficiencies noted in the Annual Testing of the Medical Gas System report.

Interview with Staff #2 and Staff #66 on 3/3/16 at approximately 2:30pm verified these findings.

Based on document review, interview and policy review staff did not document temperatures in the Emergency Department (ED) medication refrigerator/freezer for 7 of 29 days in February 2016. This could result in medications not being stored at the appropriate temperature.

Findings include:

Review of the daily medication refrigerator/freezer log in the ED on 2/29/16 at 11:00am revealed no documentation of temperature check for February 17-20, 26, 28 and 29, 2016. The log includes instructions for staff to check and document the refrigerator/freezer temperatures daily.

Interview with Staff #11 on 2/29/16 at 11:00am verified that there was no documentation of the medication refrigerator temperatures for the above noted days.

Review of the policy "Monitoring Refrigerator Temperature" last reviewed 10/09 indicated a daily temperature reading will be taken and documented on the refrigerator monitoring form and initialed by the person performing the reading.

Based on observation, interview and document review, the facility does not maintain infection control practices to promote infection prevention or maintain an active surveillance program for the identification of postoperative infections. This has the potential to place staff and patients at risk for infection.

Findings Include:

During observation on 3/2/16 at 9:00am on medical/surgical unit S-2 Staff # 38 was observed administering heparin 5000 units/1 ml subcutaneous to Patient # 34 without wearing gloves. This observation was verified with Staff #29.

Interview 3/4/16 at 9:20am with Staff # 2 stated the facility uses Lippincott 's Nursing Procedure textbook for nursing interventions, which includes the administration of subcutaneous injections. Review of Lippincott 's Nursing Procedure textbook, page 680 indicates staff are to perform hand hygiene and put on gloves when administering a subcutaneous injection.

Interview with Staff # 66 on 3/3/16 at 1:00pm revealed that the facility does not have a process for active surveillance of post operative infections.