HospitalInspections.org

Based on medical record review and staff interview, in 2 (two) of 5 (five) applicable medical records reviewed, the facility did not establish policies and procedures to ensure that patients admitted to the hospital are asked if they want the hospital to notify their family/representative and physician of their admission (Patient #s 2 and 3).

Findings include:

Review of medical record for Patient #2 identified a 68-year-old with multiple medical conditions who was admitted to the hospital on 2/16/2017 due to mechanical fall. The physician admission assessment on 2/16/2017 at 3:09 PM indicated that the patient had a primary care physician.

There was no documentation in the medical record that the admitting physician enquired if the patient wanted her primary physician notified of her admission. There was no documentation of the patient's response to the enquiry, and if the patient's primary physician was contacted.

Review of medical record, for Patient #3, noted there was no documentation in the record that the patient's family/representative and physician were notified of the patient's admission.

During interview with Staff Y, Director of Regulatory on 3/23/2017 at approximately 10:30 AM, the staff acknowledged that the facility does not notify patients' family/representative and physician upon their admission. Staff Y stated that the facility does not have a written policy and procedure for such notification.

Based on document review and interview, in 3 (three) of 3 (three) security personnel files reviewed, the facility did not ensure that security staff that assist with restraints and perform manual holds are trained in the use of First Aid techniques and are certified in Cardiopulmonary Resuscitation (Staff A, B, and C).

Findings include:

Review of security incident #005204 dated 02/21/2017 at 1:27 PM, notes that a security officer documented that he was called to assist in the restraint of a patient that required medication administration.

Review of security incident #007857 dated 03/18/2017 at 12:39 PM, notes that a security officer documented that he responded to the Emergency Department (ED) where he used a manual hold to restrain a patient at the instruction of the ED staff.

Review of personnel file for Staff A, Security Officer, noted that the staff has no training in First Aid and no certification in Cardiopulmonary Resuscitation.

Similar findings regarding the lack of training in First Aid and Cardiopulmonary Resuscitation were noted in personnel files of Staff B, University Police Officer and Staff C, Security Officer.

During interview with Staff J, Assistant Director of Nursing on 03/24/2017 at 11:50 AM, Staff confirmed that Security Staff and Hospital Police have no training in First Aid and Cardiopulmonary Resuscitation.

Based on observation and interview, the hospital did not ensure that medical records are protected from water damage.

Findings include:

On 3/22/17 at approximately 10:30 AM, a tour of the Medical Record Department, which is located in the basement of the hospital, revealed more than one thousand medical records were stored on open shelves beneath sprinklers.

On 3/22/17 at 10:35 AM, during interview with Staff V, Director of Medical Record, she stated that she is not aware that medical records needs to be protector from water damage.

Based on observation and staff interview, the facility did not maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured.

Findings include:

During tour of the hospital from 3/21 to 3/24/2017, the following findings were identified in the presence of the Staff T, Safety Director, and Staff U, Associate VP of Ancillary Services.

During a tour of the Neonatal Intensive Care Unit - 3-574 (NICU) on 3/21/2017 at approximately 10:30 am, the ceiling tiles of the NICU and the Continuing Care Unit were found to be of the regular type and not the washable ceiling tiles that is required for NICU units for infection control purposes.

There were stained ceiling tiles with signs of water leak at the Sonographic room (A3-412) located in the Medical Surgical ICU.

The shower room of the Med -Surg ICU was used for storage of bottled water, card boxes, microwave and security shredding bin.

During a tour of the Labor and Delivery Suite (L&D) on 3/21/2017 approximately at 11:15 AM, there were 5(five) light fixtures of one of the two Operating rooms that were not working properly; some light fixtures were dim or had a flickering wave of light.

There were two (2) broken floor tiles that had dirt around their periphery, at the entrance of one of the Operating Rooms of the L&D suite.

There were more than 24, 5(five) gallon water bottles stored in the back corridor of the Labor and Delivery suite.

The medication room 2-370 was found to have a negative airflow instead of the required positive airflow for this type of room.

The door of isolation room 2-374 failed to positively latch when allowed to self-close. Upon closing, the door latch did not allow the door to close completely, leaving a gap between the door and the frame.


The hand-wash sink of the admission testing area of the Ambulatory Surgery Suite was blocked by the Clerk Desk and was not accessible for staff members to wash their hands.

During a tour of the Pediatric Unit 42 on 3/22/17 at approximately 11:00 AM, the bathroom of the isolation room of the pediatric unit 42 did not have a hand-wash sink.

The storage closet A4-419 was noted to be cluttered with items that included 5 (five) blood pressure monitoring machines, 2 (two) measuring scales, clean supplies, and other equipment. There was no clear space to enter the room.

The tub room A4-375 of the pediatric unit was used as a toy storage room and it did not have a label to identify the room.

The step down room of the pediatric unit was noted to be cluttered and had many items stored in it including 5 (five) seating chairs, one (1) recliner, 4 (four) beds, 4 (four) Neonatal Vents and Computer on Wheels.



Pediatric Oncology:

The infusion room was observed to be very crowded and the patient's chairs were almost touching each other, which poses a risk of transmission of infections.

6th Floor - Internal Medicine:

During a tour of the Internal Medicine unit on the 6th floor of the hospital, on 3/23/2017 at approximately 10:00 AM, the following were observed:
There was a missing ceiling tile above the door of room 608.

The medication room A6-367A did not have a positive airflow as required for this type of room.

The isolation room 609 was found to have a positive airflow in relation to the anteroom, contrary to the required negative air pressure for this type of room.

During interviews with Staff T and Staff U at the time of the tour, staff acknowledged these findings.

Based on observation and staff interview, the facility did not ensure proper ventilation in an outpatient extension clinic.

Findings include:

During a tour of one of the hospital's extension clinics located at 840 Lefferts Avenue, on 3/23/2017 at approximately 1:45 PM, the followings were identified in the presence of Staff T, Director of Safety and Staff W, Facility Management Coordinator:

The clean utility room of the extension clinic exhibited a neutral air pressure instead of the positive air pressure required for this type of room.

The soiled utility room was found to have a positive air pressure instead of the required negative air pressure for this type of room. The exhaust vent of this room was not working.

There were fans observed in different offices. When the staff of the clinic were asked about the need for these fans, they said that they use the fans to moderate the temperature during the summer months when it is hot.

During an interview with Staff T on 3/23/17 at approximately 2:15 PM, he stated that the motor of the building exhaust fans burnt out and has not been repaired.