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Based on medical record review, policy and procedure review and staff interview, the facility did not ensure that verbal orders were authenticated by the prescribers within 48 hours per facility policy. This is evident in 4 of 55 medical records reviewed (MRs #7, 13, 14 and 15).

Findings include:

1. The MR for patient MR #7 was reviewed on 6/4/12 at 2:35 PM. During the review, it was noted that telephone order received by the nurse on 5/31/12 at 1:10:00 PM and on 5/31/12 at 5:30 PM were not authenticated by the physicians within 48 hours as required by the facility policy.

2. The MR for patient MR #13 was reviewed on 6/6/12 at 3:30 PM. During the review, it was noted that telephone order received by the nurse on 6/3/12 at 1:45 PM was not authenticated by the physician who ordered it within 48 hours as required by the facility policy.

3. The MR for patient MR #14 was reviewed on 6/6/12 at 3:40 PM. During the review, it was noted that telephone order received by the nurse on 5/30/12 at 6:45 PM, 6/4/12 at 11:45 AM and on 6/4/12 at 3:00 PM were not authenticated by the physicians who ordered them within 48 hours as required by the facility policy.

4. The MR for patient MR #15 was reviewed on 6/6/12 at 10:30 AM. During the review, it was noted that telephone orders received by the nurse on 4/27/12 at (time unstated), 4/28/12 at 11:20 (AM/PM not stated), 5/18/12 at 10:15 AM and 5/18/12 at 11:20 AM were not authenticated by the physicians who ordered them within 48 hours as required by the facility policy.

A review of the facility policy titled: "Acceptance and Transcription and Verification of Physician's/Practitioners Orders" revised June 2011, states in 3rd to the last bullet point on page 1 of 2; "The ordering physician/nurse practitioner shall authenticate telephone orders within forty-eight (48) hours."

During the medical record reviews with Staff #8 and the unit Charge Nurses these findings were verified.

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

Findings include:

During observation, staff interview and inspection of the kitchen, and food service areas in the Andrus, Park Care and Greenburgh Extension site conducted on 6/04/12 through 06/08/12, the following issues were noted:

a. On 06/04/2012 at 11:55 AM, during the tour of the refrigerator and store room it was noted that there were items present that were either not dated when it was open or did not have any expiry date on them. Items noted were:
i. A large bottle of cherries-date opened was 1/19. Staff #28 stated that this should have been discarded.
ii. Two large packs of Sun Dried tomato's had date received 9/2/11 and 12/7/11. Staff # 28 stated that there was no policy on when it should be discarded or how long is it good for. One of the bags was opened but there was no date or evidence of when it was open.
iii. A large bag of macaroni was found with the receive date of 4/22/11. Staff stated that there was no policy regarding how long it was good for.
iv. Furthermore, it was noted that some refrigerator in the kitchen had gaskets that were dirty or broken such as cold produce #1 and #2. The facility did not have any systemic schedule to ensure frequent and timely of monitoring to ensure proper maintenance of the refrigerator.
Finding was verified with Staff #25 during the observation.

b. On 06/07/12 at 1:45 PM during the tour of the kitchen in the Park Care it was noted that:
i. 10 buns stored in the refrigerator in a packet were not dated for when they were opened/received/placed in the refrigerator.
ii. A large bag of opened feta cheese was not dated and Staff #27 stated that she did not have any policy regarding how long to store it after it was open.
iii. A large open bottle of Posada Tasco sauce was not dated to show the date it was opened.
iv. The gasket of refrigerator #7 was noted very dirty.
v. A packet of French toast was also not dated for when it was receive/opened/placed in the refrigerator. There was no evidence to identify how old it was or when was it suppose to be discarded.

Findings were verified with Staff #18.
c. During the survey of the extension clinic in Greenburgh on 06/08/12 at 11:45 AM. it was noted that one of the refrigerator had a gasket that had white fluffy fungal/mold growth. The gasket of the other refrigerator was noted dirty.
Furthermore, there was a opened/used 1/2 gallon milk bottle that stated 'sell by June 7'. There was no opening date on this milk and no policy regarding if the milk is good to be used by the sell by date or needs to be discarded after that date. Also frozen pancakes/waffles were noted stored in the freezer that were not dated for expiry date or for when they were received.
Findings were verified with Staff #22 during the observations.

Based on observation, document review and staff interview, the hospital did not ensure that the physical plant and the overall hospital environment is maintained in such a manner that the safety and well-being of patients are assured.

Findings include:

Park Care Pavilion:
Five of Five (100%) of patient emergency call bells located in the bathrooms of the examination rooms of the Hope clinic (Park Care pavilion) was not functional. This was discovered on 6/7/12 at 2:45 PM, when the call bells were tested in each of the patient's bathroom.
The Director of Social Services (Staff #17) for The Hope Center observed and confirmed the findings.
Operative Suite:
During a tour of the Operating Suite on the morning of 6/4/2012, the following findings were identified in the presence of Staff #19 who acknowledge them and promised the proper corrections:
1- A biohazard plastic container that was 5 ' x 3 ' x 4 ' and a clean linen container were stored on the elevator bank of the main elevator. The storage of clean linen next to the biohazard container pose a potential for infections and storing both containers in the elevator lobby is a fire hazard.
2- A wired cart that was 4 ' x3 ' x3 ' was stored at the entrance door of the OR which obstructed the exit way.
3- No exit sign was provided at the exit door of the OR Suite on the second floor of the hospital (Andrus Pavilion).
4- The corridors outside the Operative Rooms were used for storage of medical equipment, surgical, medical and anesthetic supplies.
5- The scrub sinks outside the two ORs in the Andrus Pavilion that were referred to by the hospital staff as the Dobbs Ferry ORs, did not have hot water for hand washing and scrubbing before surgery. The staff did not know that there was no hot water at the scrub sinks and there was no mechanism in place to check the water temperature at the scrub sinks.
6- The porter closet in front of OR #3 had a positive airflow, instead of the required negative airflow for this type of room.
7- There was no solid utility room provided to the Operative Suite.
8- There were lots of medical equipment and supplies stored in three cubicles of the PACU area known as Dobbs ferry PACU of the Andrus Pavilion which has a potential of causing fire.
9- There were two penetrations around conduits and electrical wirings in the wall above the door in the electric closet on the PACU electric closet (E6), in addition to a vertical penetration around conduit in the same room.


Critical Care Unit:
During a tour of the Critical Care Unit of the hospital on the afternoon of 6/4/2012, the followings were identified in the presence of the Director of Engineering who acknowledged the findings:
1- There is no isolation room provided for the Critical Care Unit of the hospital.
2- The corridor which is also the (exit way) of the second floor of the hospital was observed to be obstructed by four (4) night stands, and two (2) clean linen hampers.
3- A linen cart was found stored on the corridor outside ICU #7 next to an oxygen cylinder which is a potential for fire hazard.
4- The soiled utility room of the ICU unit had a positive air flow instead of the required negative air flow.
5- The electric closet in front of room 9 had penetrations at the perimeter of the ceiling and the walls that were sealed with foam instead of the required fire stops.
6- Penetrations were observed around two conduits on the fire wall on the second floor elevator lobby outside the OR Suite.


Ambulatory Surgery Unit:
1- There was no negative isolation room provided for the 13 beds Ambulatory Surgery Unit.
2- The soiled utility room of the Ambulatory Surgery Unit had positive air flow instead of the required negative air flow for this type of rooms.
3- Eight (8) oxygen cylinders were stored in the Endoscopy Suite near the emergency exit door and adjacent to the soiled linen hampers which is a potential for a fire hazard.
4- Penetrations were observed around air duct and around conduits on the wall above the door of the electric closet of the Endoscopy Suit. Those penetrations were sealed with foam spray, instead of the required fire stops.


The Emergency Department (ED):
During a tour to the ED area on the morning of 6/5/2012, the followings were identified in the presence of the Director of Engineering:
1- Four (4) stretchers were found obstructing the corridor in front of the exit door of the ED.
2- The smoke barrier wall next to the staff locker room had multiple penetrations around electric and data wirings.
3- The electric closet next to the discharge desk had multiple large penetrations in the smoke barrier and in the corridor walls.
4- The soiled utility room of the ED had positive air flow, instead of the negative air flow required for this type of rooms.


Radiology Department:
During a tour to the Radiology Department on 6/5/2012 at 11:10 AM, the followings were identified in the presence of the Director of Engineering:
1- The patient bathroom near to the nursing station did not have a nursing call bell.
2- The smoke/fire rated wall of the electric closet in the Radiology Department was not extended to the deck above, leaving a penetration of approximately 4 inches above the upper end of the wall that was not sealed by fire stops.


Physical Therapy Area:
During a tour of the Physical Therapy area at 10:50 am, the followings were identified in the presence of the Director of the facilities who acknowledged the findings and promised to correct them as follow:
1- No fire alarm strobe was provided in the patient bathroom of the waiting area outside the physical therapy area.
2- No fire alarm strobe was provided in the handicapped bathroom of the of the physical therapy area.
3- The storage room of the Physical Therapy area was observed to have a toaster, coffee machine, microwave, and refrigerator. This practice of using the storage room as lounge room has the potential for fire hazard and infection control problems.
4- The corridor outside the Physical Therapy area was obstructed by chairs on each side of the corridor. The corridor was observed to be used as a waiting area with two lines of seats (6 seats on each side of the corridor).
The corridor of the Occupational Therapy was partly blocked by six (6) seats and was used as a waiting area.


6th Floor West:
During a tour of the Andrus Pavilion on 6/6/3012, at 2:30 pm, the followings were identified in the presence of the Director of Facilities:
1- The soiled utility room had positive air flow, instead of the negative air flow that is required for this type of room.
2- The fire/smoke barrier above the smoke door between the Ambulatory Surgery unit and the elevator bank had multiple penetrations that were not sealed with fire stops.


6th Floor South:
1- The nursing call bells of patient bathrooms were mounted at approximately 3 feet from the floor and did not have cord that make them inaccessible for patents on the floor.
2- The lock of the door on room 601 was removed and its place was left empty.
3- The electric closet (6SE) had multiple penetrations that were sealed by insulation material and not the proper fire stop.
4- The soiled utility room of the 6th south had positive air flow, instead of the negative air flow required for this type of room.
5-The nursing call bell of patient bathroom of the Physical Therapy areas on that floor were mounted at approximately 3 feet from the floor and did not have cord which made them inaccessible for patents on the floor.


7th floor:
The nursing call bells of the patient bathrooms of the 7th floor were found without cords and were mounted at a level approximately 3feet from the floor, which made them inaccessible for patients that need help during emergencies.


Roof and Mechanical Floor:
The paint house and mechanical area on the 8th floor did not have exit signs to direct the staff to the exit doors in the event of fire or smoke conditions.


Central Sterile Supply:
During a tour of the central sterile supply unit the followings were identified in the presence of the Director of facilities:
1- Five boxes were observed being stored on shelves very close to the ceiling tiles, not leaving 18 " of space in the sprinkled room.
2- There was no hand washing sink provided for the staff to wash hands in the clean preparation area.
3- There was no hand washing sink provided for the staff to wash hands in the decontamination area.
4- The decontamination area had positive air flow in relation to the corridor, instead of the negative air flow that is required for this type of room.
5- A small room inside the contamination area of the central sterile supply unit was used as a staff lounge room. This is not a safe practice and has a potential for spreading infection from the staff food.
6- There were no exit sign provided at the clean preparation area.


Dobbs Ferry
During a tour of the Dobbs Ferry Hospital on 6/7/2012 at 11:30 AM, the followings were observed and verified by hospital Staff #19 as follow:

1- The Endoscopy processing room did not have a hand washing sink as required by AIA guidelines.
2- The hospital had 11 patient rooms and did not have an isolation room.
3- The Cardiology and Respiratory office was used as storage for the clean supplies. Six (6) shelves contained cart that measured 4x2x8 feet in dimension, in addition to 8 oxygen cylinders, 3 (Diffusion tanks) carbon dioxide cylinders in the room.
4- The patient bathroom in the Emergency Department (ED) of the Dobbs Ferry Hospital was mounted at 3 feet from the floor and did not have a string; therefore, it is not accessible for patients that need help during emergencies.

5- The exit and fire door from Ashikari Breast Center did not have positive latch.

6- The facility stored the file shelves very close to the ceiling tiles in the file room of the Dobbs Ferry Hospital, not leaving 18 inches in the sprinkled room.

7- Three huge plastic containers full of linen were observed being stored near to the exit door of the south Washington Ave. This is a fire Hazard.

8. The Annual test of the GE MRI machine was overdue by two month. The previous annual Quality Assurance report was performed in April 2011 and was due in April 2012



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Kitchen
On 06/04/2012 at 11:30 AM, during the tour of the kitchen in the Andrus Pavilion it was noted that there was no hot water in the hand washing sink by the entrance of the kitchen. An employee was noted washing hand in this sink.
Finding verified with Staff #18 and Staff #25.

LABORATORY
On 06/04/12 at 2:15 PM, during the tour of the Laboratory Department it was noted that the desk top counter in the Blood bank (by the hand wash sink) was broken and put in place by a duct tape. Such arrangement contributes in the harboring of germs and prevents infection control.
The hand wash sinks in the general laboratory area were noted lacking wrist blades that are important to operate the handwash sink to prevent cross contamination of infection.
Finding verified with Staff #18.

EMERGENCY DEPARTMENT (Andrus Pavilion)
On 06/04/12 at 3:15 PM it was noted that the electrical closet in the emergency department was very dirty and dusty.
The storage closet next to the electrical/telecommunication closet in the department was noted having office supplies stored close to the ceiling and thus blocking the sprinkler.
Sixteen oxygen tanks were noted stored in an un-protected room in the emergency department (room # 11 A) . Furthermore, 3 oxygen tanks were noted stored directly on the floor and not on any cart.
There was no self-closure on the door of the soiled utility room. .
Room #5A, 4 and 10 had no hot waster in the hand wash sink or the scrub sink present in the room.
Finding verified with Staff #18.

RADIOLOGY DEPARTMENT
On 06/04/12 at 3:30 PM during the tour of the Radiology Department in the Andrus pavilion it was noted that the floor perimeters and corners of the x-ray room #9 were dirty and dusty.
The ceiling tile in the MRI control room had blackish mold growth on the ceiling tile.
Finding verified with Staff #18 and the supervisory staff present at the time of survey.

Dialysis Unit
On 06/06/12 at 11:00 PM, during the tour of the dialysis unit following issues were noted:
1. A review of the culture reports for the dialysis machines indicated that all the culture reports never reported the number of the culture growth in the sample. The reports also did not have the range written indicating the reference. The report only stated' No growth after 24 hours of incubation' or 'no growth after 48 hours of incubation' in all the reports of the previous year. It is very important to know the growth (even if it is zero,one, two or more ) to ensure proper trending is done and prompt action is taken even if the culture is within limit but is of action level.
2. Staff #26 did not document the steps of disinfecting the RO in a log. There was no information if the RO membranes were dwelled with the appropriate strength of disinfectant for the proper length of dwell time as indicated by the manufacturer and by the policy and procedure. Furthermore, there was no documented evidence that the staff #26 checked for residual testing after rinsing the machine free of disinfectant.
3. Staff #26 indicated that he does not perform hardness test for the water. His explanation was that the water of City of Yonkers is soft. Staff # 19 was asked to provide any documentation or exception provided by the City and approved by the facility/hospital.
During the interview with the engineering staff (Staff #20) looking at the boiler areas of the hospital, it was brought to the surveyor's attention that the facility has a softener installed for the main water supply since the water of the City of Yonkers is ' Hard ' . This boiler is providing water for the mechanical/heating part of the facility.
On 06/08/12 at 1:45 PM , a document was provided to the surveyor from City of Yonkers regarding the water quality but this report did not have any information regarding the ward being hard or soft. Therefore, there was no official answer or justification that the facility is not required to perform hardness test for dialysis.
Maternity
On 06/06/12 at 11:45 AM, during the maternity suite tour of the Andrus pavilion it was noted that the soiled utility room had a very strong positive air pressure instead of the required negative air pressure.
The breast milk refrigerator in the Nursery was noted having dirty gasket.
6th floor Park Care
During the tour of the 6th floor Park Care on 06/07/12 at 12:15 PM, it was noted that the soiled utility room had a strong positive air pressure instead of the negative air pressure.
On 06/07/12 at 11:45 AM, during the survey of the 6th floor it was noted that the electrical closet was very dusty and had penetrations.
The refrigerator gasket was dirty and it had was used for patient food/milk
5th floor Park Care
The Soiled Utility room on the 5th floor of Park Care campus exhibited strong positive air pressure.
During the tour of the patient rooms it was noted that the baseboard and perimeters of the patient rooms were dusty. Few example including but not limited to are room #565 and room#570.
ATS GREENBURGH
During the tour of the extension clinic in Greenburgh on 06/08/12 at 11:45 PM, it was observed that the unit had dirty perimeters and corners in the waiting area and in the group rooms.
Ceiling tiles were noted stained in various areas of the unit. Examples including but not limited to are 5 ceiling tiles stained closed chart room, 2 tiles in conference room and 3 ceiling tiles in the Group room.
Findings verified with Staff #22 and Staff #21.

Based on observations, record reviews and staff interviews, it was determined that the facility failed to meet the applicable provisions of the Life Safety Code, NFPA 101, 2000 edition.

The findings include:

During the survey of the facility from June 04-June 08, 2012, Life Safety Code deficiencies were noted in multiple areas of the Code requirements and were cited under the following Fire/Life Safety Code K-Tags:

K-12 (Structural elements not completely protected /fire proof);
K-46 (Maintenance of Emergency Battery power backup lights for off-site clinic locations not done annually);
K-50 (Fire drill not performed under varying conditions);
K-62 (Sprinkler system not tested as per NFPA);
K-64 (Portable fire extinguishers not easily accessible in all areas);
K-67 (Fire dampers not maintained in operational condition);
K-104 (Penetrations in smoke/fire barriers not completely sealed/protected);
K-145 (The TYPE 1 EES not divided into three branches);
K-147(Facility using extension cord/multi plug adaptor to plug multiple items in OR).

Based on medical record review, policy and procedure review and staff interview, the facility did not ensure that a patient who was discharged from the facility was referred to an appropriate facility for appropriate follow up care. This is evident in 1 of 55 medical records reviewed (MR #16).

Findings include:

On 6/7/12 at 11:50 AM MR #16 was selected for review after it was revealed that the patient was administratively discharged on 6/6/12 from the Park Care Pavilion Behavioral Health Services.

According to the medical record the patient was admitted on 6/4/12 for detoxification of alcohol and crack cocaine. The patient's medications include Seroquel, Trazodone, Inhalers and Cardiac meds. A prescription form stated that the patient required Level 4 care. The patient has a history of cardiac syncope, chest pain at times lasting greater than 12 hours (last episode was 48 hours ago), seizure disorders, emphysema with multiple episodes of shortness of breath, poor memory, and bipolar disorders with psychotic gestures. The patient has no medications and would require a high level of medical involvement while receiving treatment for substance abuse.

A review of the patient's medication record revealed that since his admission to the facility, the patient was not administered medication for cardiac conditions and was on active detoxification regimen with tapering doses of Librium per detoxification protocol. The effects of the Librium doses administered were noted to be of partial effect.

On 6/5/12 at 22:41 the patient displayed irritable behavior and at 07:22 on 6/6/12 the patient was still irritable and was medicated with Librium 25 mg with minimal effect. At 16:41 on 6/6/12 the patient was described as angry, cursing and demanding to be medicated, the patient was medicated again with partial effect. At 7:15 PM on 6/6/12 a telephone order was obtained from the physician to discharge the patient and at 19:28 on 6/6/12 the patient was escorted off the unit by security for aggressive and belligerent behavior towards another female patient which resulted in a fight.

A review of the facility's policy and procedure titled Early Discharge stated that "Patients will not be discharged from the unit without medical clearance from the attending physician."

Further review of the facility's policy and procedure titled Patient Behavior and Safety Issues states that " The attending physician will be notified. Physical violence is cause for termination of treatment. An evaluation of the incident will determine, if early discharge, with referral, is warranted."

The covering physician failed to ensure that the attending physician was consulted prior to the patient discharge and failed to assess the patient prior to discharge.

During interview with Staff #11 on 6/8/12 at 11:30 AM, it was stated that he did not examine the patient prior to discharge. The physician also stated that he relied on the nurse input that the patient was stable and he was not the physician responsible for the patient.

There was no evidence that any consideration was given regarding referral for further follow up care.

During interview with Staff #3 on 6/7/12 at 2:00 PM it was verified that the patient was administratively discharged without medications or referral.

Based on document review and staff interview, it was determined, the facility failed to maintain a complete operating room log.

Findings include:

The operating log was incomplete. The OR log for 5/29/12 - 5/30/12 was requested and reviewed. The log only listed the date, patients' names, medical record and account numbers, duration of surgery, anesthesia MD, anesthesia type, type of surgery, and the name of the surgeon. The log does not have the age of the patient, pre and post-op diagnosis, name of nursing personnel (scrub and circulating) and the name of assistant (s) if applicable. Although this information is documented in the patient's medical record, it is not documented in the OR register as required.

This finding was observed by Staff #13 on 6/5/12 at 10:50 AM.