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Based on observation, document review and interview, the facility failed to ensure that Security Officers who apply and monitor patients in restraints are trained in the following: 1) use of nonphysical intervention skills; 2) safe application of restraints 3); First Aid and certification in the use of Cardiopulmonary Resuscitation (CPR).

This failure may have placed patients at risk for harm.

Findings include:

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Based on document review and interview, the hospital's Governing Body did not ensure; 1) that the responsibility for grievance resolution was formally delegated to a grievance committee, 2) prompt resolution of all grievances received by the facility.

Findings include:
1. During interview with Staff C, Sr. Director of Chief Patient Experience Officer and Staff D, VP Quality & Patient Safety, on 5/11/2016 at 12:30 PM, Staff C stated that the Board of Trustees delegated Quality and Performance Improvement Committee, as the facility's Grievance Committee.
Review the Board of Trustees meeting minutes on 5/13/2016, noted that the Board delegated the resolution of grievances to a "Grievance Committee" on 5/13/2016, two days after proof of grievance committee delegation was requested.

2. Review of the Board of Trustees minutes of a meeting held on 2/25/16, noted that the resolution of grievances was not discussed in this meeting.
Review of the Quality Council Committee Minutes dated 4/27/16, noted a list containing the number of complaints and grievances and the departments where the complaint and grievances were generated.
The report did not document the status of complaints and grievances that were reported to the Quality Council Committee. There was no indication that the Board of Trustees was reviewing and monitoring complaints and grievances for prompt resolution.

During interview with Staff C, on 5/13/15 at approximately 12:30 PM, she confirmed that the Board of Trustees delegated the responsibility of reviewing and resolving grievances to a grievance committee on 5/13/16, and prior to the date, the Board of Trustees did not review and resolve grievances.

Based on document review and staff interview, it was determined that the facility did not have an effective grievance process to ensure the prompt resolution of all grievances.
This finding was evident in 16 of 21 grievance files reviewed (Files #s 1 through 16).

Failure to ensure prompt resolution of grievances denies all patients the assurance of having their complaints addressed in a timely manner.


Findings:

Review of grievance file # 1 noted the following: the facility received a grievance from the complainant on 12/2/15, alleging that on 12/2/2015 she was admitted to an ambulatory care area for a procedure. While in the ambulatory surgery holding unit, a physician stood at the corridor in front of the room and yelled, "Why wasn't the patient's HIV status on the computer." The written response to the complainant was dated 2/25/2016, over two months after the complaint was submitted.

Review of grievance file #2 noted that the facility received a grievance from the patient's wife on 3/3/2016 regarding her husband's immunosuppressive therapy while he was a patient in Surgical Intensive Care Unit. The complaint was forward to the Surgical Care Service for review. The response by the Surgical Care Service to the grievance was dated 3/16/2016; however, the written response to the grievance was dated 4/27/2016. The resolution of the grievance took over forty-five days after the receipt of the grievance.

Similar findings regarding delay in the resolution of grievances were noted in grievance file #s three (3) through 16.

Review of the facility's policy and procedure titled, "Complaint Grievance Management," last revised March 2016, indicated that on average, a time frame of seven (7) days for the provision of the response is appropriate. However, if the grievance is complex and/or involves multiple disciplines, a written response will be provided within 30 to 45 days.

It was noted that the facility was not resolving patient's grievances, on average of 7 days, even grievances that involves one discipline.

During interview with Staff C, Sr. Director of Chief Patient Experience Officer, on 5/11/2016 at approximately 12:45 PM, she acknowledged that the time frame for prompt resolution of grievances was not met.

Based on document review and interview, the facility did not establish a policy and procedure to ensure a written notice of its decision regarding the resolution of grievances is provided to the complainant. This finding was noted in one (1) of 21 files reviewed (Grievance file #17).

Findings include:

Review of Complaint Log on 5/11/16 noted that Grievance File # 17 was resolved via a phone call on 1/8/16.

Review of Grievance File # 17, noted that the patient's mother sent an e-mail to the facility on 1/8/2016, regarding several issues with the care and management of her baby with Down Syndrome. The complaint included allegation of neglect and lack of early assessment and evaluation of the baby. An acknowledgement letter sent to the complainant was dated 1/8/2016.

There was no documentation in the grievance file as that the complainant was provided with a written response on the steps taken to resolve the grievance.

The lack of written response was discussed with Staff C, Sr. Director of Chief Patient Experience Officer on 5/11/2016 at approximately 12:45 PM. The staff stated that she was not aware that all grievances required a written response.

The facility's policy and procedure titled, "Complaint Grievance Management," last revised March 2016, did not indicate that each grievance requires a written response.

Based on document review and interview, the facility failed to ensure that Security Officers, who assist with the application of restraints, are trained in the implementation of restraints.
This finding was evident in six (6) of six (6) Security Officers personnel files reviewed (Staff E, F, G, H, I, and J).

This failure may have placed patients at risk for harm.

Findings include:

Review of Security Department Incident Reports from December 2015 to May 2016, identified that in 24 of 51 Incident Reports; security officers applied physical hold and assisted nursing staff in the implementation of restraints.

Review of Incident #1 dated 3/2/16, authored by Staff E, Security Officer noted, Staff E and another security officer, Staff F, assisted a registered nurse to restrain an agitated and combative patient who required medication administration.

Review of Incident #2, dated 1/9/16, noted that security officers, Staff G and Staff H, were called to the Emergency Department where an intoxicated and combative patient was wrestling with an ED physician and a nurse. The two officers restrained the patient while the ED physician medicated the patient for agitation.


Review of the personnel files for Security Officers (Staff E, F, G, H, I, and J) identified that the officers had no training and competencies in the implementation of restraints.

During interview with Staff K, Director of Security on 5/9/16 at 2:30 PM, he confirmed that security officers have no training in the implementation of restraints.

Based on document review and interview, the facility failed to ensure that Security Officers who apply physical hold, and assist nursing staff in the implementation of restraints, are trained in the use of nonphysical intervention skills.
This finding was evident in six (6) of six (6) Security Officers personnel files reviewed (Staff E, F, G, H, I, and J).

This failure may have placed patients at risk for harm.

Findings include:

Review of six (6) of six (6) Security Officers personnel files for Security Officers, identified there was no evidence of training and competencies in the use of nonphysical intervention skills.

During interview with Staff K, Director of Security on 5/9/16 at approximately 2:30 PM, he confirmed that security officers have no training in the use of nonphysical intervention skills.

Based on document review and interview, the facility failed to ensure that Security Officers, who assist with the application of patient restraints, are trained in the use of First Aid techniques and certified in the use of Cardiopulmonary Resuscitation.
This finding was evident in six (6) of six (6) Security Officers personnel files reviewed (Staff E, F, G, H, I, and J).

This failure may have placed patients at risk for harm.

Findings include:

Review of six (6) of six (6) Security Officers personnel files for Security Officers identified there was no evidence of training and competencies in First Aid and in the use Cardiopulmonary Resuscitation.

At interview with Staff K, Director of Security on 5/9/16 at approximately 2:30 PM, he confirmed that training in First Aid and in the use of Cardiopulmonary Resuscitation, was not provided to Security Officers.

Based on observation, document review, and interview, the Pharmaceutical Department did not maintain oversight of medication inspection and removal of expired medications in patient care areas.
This finding was noted in one (1) one of five (5) medication carts inspected.


Findings include:

During tour of the "Main Operating Room Suite" on 5/11/16 at 12:30 PM, the following medications were found in the second drawer of the Malignant Hyperthermia Cart, located in nurses' station:

- 10 vials of Furosemide 100mg, expired on 4/1/2016.
- Four (4) vials of Sodium Acetate injection, 100mg, expired on 4/1/2016.
- Three (3) vials of Heparin 10,000 units, expired 10/2015.
- Two (2) vials of 2% Lidocaine, 100mg, expired on 9/1/2015.

Review of facility's policy and procedure titled "Disposal Medication," notes, "All medications known, or suspected, to be outdated, deteriorated, contaminated, partially used or otherwise unsuitable for patient administration shall be disposed of or returned to the pharmacy for proper disposition."

During interview with Staff L, Staff Nurse on 5/11/16 at 12:35 PM, she acknowledged findings and stated the medication cart is inspected by nurses on the first day of each month.

There was no documented evidence that the second drawer of the medication cart was routinely inspected as described by Staff L.

Based on document review, observation, and interview, the facility did not ensure: 1) parenteral medication was accessed in accordance with facility's procedure, and the Center of Disease Control (CDC) 2007 recommendations for medication preparation, 2) facility's policy for labeling of multiple dose vials was implemented, 3) that the time, temperature and steam parameters are appropriately met during the high level sterilization process of surgical instruments, prior to the Load Release to the Operating Rooms.

Findings include:

1. During observation of medication pass on 5/10/16 at approximately 12:15 PM, Staff M, Registered Nurse, withdrew Furosemide (Diuretic) 40 mg from a single dose vial without first disinfecting the rubber septum.

Review of CDC 2007 recommendation for medication preparation noted, "Use aseptic technique to avoid contamination of sterile injection equipment ... rubber septum should be disinfected with alcohol prior to piercing it."

At interview with Staff N, In-service Educator on 5/16/16 at 2:15 PM, he stated Nursing Department implements the on-line Lippincott Nursing Procedures that prescribed the cleaning of vial's rubber stopper with alcohol pad before withdrawing medication from the vial.



2. During the inspection of a Medication Refrigerator located on 2N (Inpatient Unit) on 5/10/16 at 11:30 AM, an opened multiple dose vial of Novolin (Insulin) was not labeled with a "beyond-use" date.

Similar finding regarding the lack of assignment of a "beyond-use" date for an opened multiple dose vial was noted in the medication refrigerator located in the Post Anesthesia Care Unit.

Review of facility's policy titled, "Single dose/Multiple dose vials: Appropriate Use," last revised 6/2014, noted that "once a multiple-dose vial is punctured, it should be assigned a "beyond-use" date. The beyond-use date for an opened or entered multiple-dose container with antimicrobial preservatives is 28 days, unless otherwise specified by the manufacturer."

During interview with Staff O, Staff Nurse on 5/11/16 at 12: 45 PM, she acknowledged the failure to label multiple dose vials with beyond-use date as per hospital policy.



3. During the tour of the Central Sterile Processing Department (CSPD) on 05/10/16 at approximately 3:30 PM, the surveyors observed that some of the sterilized instruments were enclosed in metal cases secured with orange (used on metal cases sterilized in steam sterilizers) and pink (used on metal cases sterilized in sterrads) colored Tamper Evident Locks, containing Class 1 process indicator color tabs on them.

Observations made in the presence of the Assistant Nurse Manager on 05/10/16 at approximately 3:30 PM revealed that the indicator tabs changed color (blue to black post steam sterilization and magenta to blue post exposure to hydrogen peroxide in Sterrads) after exposure to sterilization process.

In addition, the surveyors observed that some of the sterilized instruments were wrapped in blue colored crepe and secured by an adhesive tape containing stripes of chemical indicator. The chemical indicator was observed to turn black in color after being exposed to steam sterilization.

Interview of the Director of Peri-Operative services on 05/10/16 at 3:35 PM revealed that the staff verified the color change in the color indicator tabs of the locks and on the adhesive tape for routine load release. However, review of documents revealed that the CSPD staff did not consistently document the verification of the color change on the locks and/ or the tape.

Review of the manufacturer's recommendations on process indicators, revealed that the tamper resistant seals with external chemical indicators were Class 1 process indicators that changed color upon exposure to sterrilant. The color change on these process indicators did not indicate that the time, temperature and steam parameters were met. Therefore, the manufacturer recommended (on pg 4 of 5) " For routine load release, one internal Chemical indicator (Class 3 or above) should be placed in the center of each tray or basket or in the most challenging location to sterilant penetration depending on the organization,density and configuration of the instrument sets, as determined by the user."

In addition, based on the manufacturer's (3M) directions for use on the adhesive tapes, the color change on the tape (which was also a Class 1 process indicator) post steam exposure is not adequate for determination of routine load release.

AAMI and AORN recommendations stated that routine load release must be determined by the results on a Chemical Integrator (Class 5- indicating the time, temperature and steam parameters were met) test results.

The facility did not provide any written policies and procedures for Sterilized Instrument Load release.

Therefore, it was determined that the facility failed to follow manufacturers' and AAMI recommendations for routine Load Release.

Based on medical record review, and interview, the facility did not ensure the initial implementation of each patient's discharge plan.
This finding was evident in one (1) of six (6) medical records reviewed. (Patient #6).


Findings include:

Review of medical record for Patient #6 noted, a 56-year-old patient with a medical history of hypertension, who presented to the Emergency Department (ED) on 5/10/2016 with a complaint of pain to her left hand, left back and groin pain. Radiology report revealed a left distal radius fracture, requiring an open reduction internal fixation of the left distal radius, on 5/11/2016. The patient was discharged on 5/12/2016.

During interview with Patient #6, a Mandarin speaking patient using an interpreter on 5/12/2016 at approximately 11:00 AM, the patient stated that she was admitted to the hospital because she fell and hurt her wrist and her discharge plan was to return home and come back to the hospital for the removal of her stitches. The patient stated she did not know the date and time for the follow-up visit.

The discharge instructions (written in English), indicated that the patient was to follow up with the attending physician in two weeks and the Wound/Ostomy care in two weeks. It was noted that the patient was not given an initial referral to this specialized ambulatory care services to ensure continuity of care.

During interview with Staff P, Registered Nurse assigned to the patient's care on 5/12/2016 at approximately 11:30 AM, she acknowledged that the referral to the specialized ambulatory care services was not arranged.

At interview Staff D, Director of Quality on 5/13/2015 at approximately 10:30 AM, she stated that the hospital is not required to set up patients' appointments as part of the implementation of their discharge planning.

Based on medical record review, document review, and staff interview, the facility did not consistently implement its policy to inform patients or their representatives of their freedom to choose post-hospital home care services. This finding was evident in two (2) of six (6) medical records reviewed. (Patient #s 7 and 8).


Findings include:

Review of medical record for Patient #7 noted, a 56-year-old patient who was admitted to the facility on 5/5/2016 and discharged on 5/12/2016. The Case Management Assessment note dated 5/6/2016 at 12:50 PM, indicated that the patient declined offered home care services. A reassessment of the patient by Case Management and the discharge planning final note on 5/10/2016 11:18 AM, indicated that the patient was discharged with home care services. The Case Manager noted, "You have been referred to VNSNY for registered nurse assessment, teachings, pain management and for Home Health Aide to assist you with personal care."

There was no documentation in the medical record that a list of Home Health Agencies (HHAs) was provided to the patient, or the reason why the provision of a list was not necessary.

Review of facility's policy and procedure titled, "Direct Referrals for Home Care Services to include HHA, Hospice, Special Care," last revised 2/2014, states, "Case manager/social worker to establish with family/family agency choices in order of preference." This policy indicated that the agency choices should be documented in the medical record. This policy was not consistently implemented.


Review of medical record for Patient #8 noted, a 97-year-old patient who was admitted on 5/11/2016 and discharged on 5/13. The Case Management High Risk Assessment note dated 5/12 1:46 PM, indicated the patient had prior home services for 12 hours daily. On 5/13, the day of discharge, Case Management Reassessment and final note dated 5/13 2:07pm, indicated the following: "discharge plan: home with managed long term care, home care certified home care agency. You have been referred to Metropolitan Jewish Home Care Services (MJHS) for an initial assessment."

There was no documentation in the medical record that the patient had home care services with MJHS before admission, or that the patient's family/representative requested these services reinstated. There was no documentation in the medical record that the patient made a choice of home care agency.

During interview with Staff Q, Sr. Director Case Management/Social work on 5/12 at approximately 11:30 AM, she stated that all patients requiring services are given a list of home care provider but staff failed to document this information in the patients' medical record.