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Based on staff interviews, and review of Grievance Files and Quality Assurance Committee Minutes to the Governing Body for Year 2013, it was determined that the facility's Governing Body failed to ensure that :
1. The facility had an effective grievance process which included prompt resolution of all grievances that the facility received. This was evident in lack of timely responses to grievances in twenty (20) of thirty five (35) files (#3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21 & #22);
2. In its resolution of grievances that it provided patients/patients' representatives with written notices of its decision that contained all the required elements. This was evident in ten (10) of thirty five (35) file reviewed files (#15, #23, #24, #25, #26, #27, #28, #29, #30 & #31).

Findings include:

Staff # 26 was interviewed on 4/9/14. This staff stated the facility does not have a Grievance Committee. Therefore, the hospital's governing body is responsible for the effective operation of the grievance process.

Forty (40) grievance files were reviewed on 4/10/14. It was noted that as an average the facility was not providing prompt resolutions to grievances. For example: Twenty (20) ( #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21 & # 22) of the forty (40) grievance files did not have final and written resolutions to patients/patients' representatives, within a time frame of 7 days, which is considered appropriate for the resolution of patients/patients' representative grievances. In addition, it was noted that ten (10) grievance files (#15, #23, #24, #25, #26, #27, #28, #29, #30 & #31) lacked the required elements such as : the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Quality Assurance Committee Minutes to the Governing Body Meetings Dated July 12, 2013 and December 20, 2013 were reviewed on 4/10/14. It was noted that timely resolution of grievances and the contents in the responses to complainants were not mentioned in either report.

Staff #27 was interviewed on 4/11/13. This staff stated that the Quality Assurance Committee Minutes to Governing Body for Year 2014 were not available. Therefore, it could not be determine if the Governing Body was currently addressing timely and prompt responses to all grievances.

Based on review of records, procedures, and staff interview, it was determined the facility failed to inform patients or their representatives about their rights due to: 1) failure to ensure provision of written notification of the Important Message from Medicare (IM), as required; and 2) lack of provision of the admission package informing the patients of their rights as hospital patients.

Findings include:

1a) The hospital failed to ensure that all patients /patients' representatives were provided the standardized notice, "An Important Message from Medicare" (IM), within 2 days of admission to inpatient Medicare beneficiaries. This was evident in MRs # (#1, #2, #11, #12, #13, #14, #15, #16 & #17).

During tour of the inpatient psychiatric unit, R5W at approximately 3 PM on 4/9/14, MR #1 and MR#2 were reviewed. Both patients were Medicare Beneficiaries. There was no documentation in the records of both patients to verify that the required written notice for the Important Message from Medicare was provided.

It was stated during interview with staff #2 that the notice is only given 24 hours prior to discharge to Behavioral Health patients. Staff #3 stated that the hospital is aware of the requirement to provide notification on admission and prior to discharge, and is working to resolve it.

Review of the hospital procedure titled: "Discharge Review Program - PC4.01.03 - 4.01.05" notes that Admitting staff shall deliver the IM notice to Medicare patients on admission and this process is implemented in the Comprehensive Emergency Psychiatric Department (CPEP). On a daily basis the Patient/Guest relations staff will identify patients who did not receive it on the date of admission and will follow up to deliver the notice to the Medicare beneficiary or their representative. The nurse also confirms receipt of the IM during the admission process and shall reissue a copy of the IM 24 to 48 hours before discharge.

The facility did not comply with this procedure.



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#1b) During the tour of the units ( A52 & A51), on 4/11/14 at 10:45 AM, a list of Medicare patient medical records was reviewed. It was noted that four of five selected had a patient unable to sign documented on the space for signature. The reason why the patients were unable to sign was not documented in MR #11, MR #12, MR #13 & MR #14. In MR #18, a copy of IM was not located for this Medicare Beneficiary.

MR # 13 was reviewed on 4/11/14. It was noted that the patient's mother signed an Informed consent forms for procedures on 2/2/14 and 3/7/14. There was no documentation in the record why this patient representative was given an IM form to sign on the patient's behalf or the reason why this was not necessary.

Three of five closed medical record for patients in MR #15, MR #16 & #17 reviewed did not have copies of IM located in the records.

2) The The hospital failed to ensure that all patients /patients' representatives were provided the admission package informing the patients of their rights as hospital patients. This was evident in one of two applicable medical records reviewed (MR #10).
The hospital did not consistently give patients the admission package, which includes the following mandated information:
"Your Rights as a Hospital Patient in New York" and Patient Guide (including information on additional patient's rights, responsibilities, advance directive and pain management). This deficiency was noted for the patient in MR #10.

During the tour of the unit (D4N), the patient housed in room D4N11-A was interviewed at bedside, on 4/11/14 at approximately 12:45 PM. The patient reported that she was not given the Patient Rights package containing information about Patient's Rights.

MR #10 was reviewed , in the unit , on 4/11/14. It was noted that the patient, 36 year old female patient, with history of severe anemia was brought to the Emergency Department (ED) by ambulance on 4/7/14 . The chief complaint was one week of vaginal bleeding, hypotensive and tachycardia. It was noted that while in the ED the patient became unresponsive. Given the patient's medical condition while in the ED, the patient was not presented with a Patient's Rights Package.

Staff # 28 was interviewed in the unit on 4/11/14. This staff stated that Patient Rights Information is given to the patients at admission. This staff did not know which staff is responsible for providing the Patient Rights information to patients who did not receive this information at admission.

Staff # 26 was interviewed on 4/14/14. This staff stated that if the Patient's Rights package was not given in the ED, then either the nurse or the Patient Relation staff, may give the Patient's Rights package to the patient.

Hospital Policy: Rights and Responsibilities of the Individual ( R) ; Subject: Patient Rights and Responsibilities - RI. 1.01.01 issued April 2011 was reviewed on 4/14/14. This policy indicated that patient or patient's representative receive Patient Rights information upon admission. This policy does not indicate a specific department to distribute this information to the patient/patient's representatives. This policy does specify which staff is responsible to distribute to Patient's Rights on the unit.

Based on staff interview, review of Grievance Files and Hospital's policy, it was determined that the hospital failed to ensure: (a) prompt responses to grievances in twenty (20) of forty (40) files (#3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21 & #22); and (b) a written response to all grievances in two (2) of forty (40) files (#1 & #2).
Findings include:

Staff #25 was interviewed on 4/9/14. This staff reported that this facility does not have a Grievance Committee. However, Patient Relations Department reports monthly to the Ambulatory Care Council, Specialty Care Council and Emergency Medicine Council. During these meetings, she reported to members on data for the total number of complaints, how many complaints were validated and the correction actions taken.

Grievance file #3 was reviewed on 4/10/14. It was noted that the patient complained to the facility's Patient Relations Department on 12/20/13. He alleged that he was given a test for STD (sexually transmission disease) on 9/12/13 and 10/2/13. In addition, he had a follow-up and he was given a clean bill of health. However, on 12/18/13, he was notified of a positive result. It was noted that an acknowledgement letter dated 12/20/13 was located in the file. However, a written response of the outcome of the investigation, was not located in the file.

Grievance file #5 dated 1/17/14 was reviewed on 4/10/14. It was noted that the complainant alleged that her, 76 year old mother was given an appointment for today ( 1/17/14 ), to have a colonoscopy performed. Her mother arrived for the appointment but she was told that the procedure could not be done due to financial clearance. It was noted that the facility investigated the grievance and the investigation was completed on 1/21/14. However, the complainant was not provided with a written response on the outcome of the investigation. It was noted that there was a notation in the file indicating that the staff called the patient for another appointment. The date and time of this intervention was not located in the file. In addition, all grievance required a written response.

Grievance file #4 dated 12/11/13 was reviewed on 4/10/14. It was noted that this patient was discharged from the ED on 12-6-13. The patient alleged that he was given discharge papers that belonged to another patient as the other patient's name and medical record number was on the discharge papers given. It was noted that an acknowledgement letter dated 12/11/13 indicated that "the facility have forward the complaint to the respective department for an investigation". The final response to the complainant was dated 3/31/2014, over three months after the complaint was received.

Grievance file # 6, dated 3/5/14, was reviewed on 4/10/14. It was noted that the patient filed a complaint with the facility's Patient Relations Department regarding poor medical care and waiting time in the ED on 2/22/14. It was noted that an acknowledgement dated 3/5/14 was located in the file . It was noted that, a second letter dated 4/8/14, was located in the file. This letter indicated that "the complaint was still under investigation and upon receipt of the findings, a letter of response will be sent by May 8, 2014". There was no documentation in the file indicating the reasons for the delay.

Similar findings were noted for Grievance Files #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20 & #21) where patients / patients' representatives were not provided with prompt responses to their grievances i.e., beyond the required seven (7) day response.

Grievance file #1, dated 12/10/2013, was reviewed on 4/10/14. It was noted that the patient filed a grievance with the facility alleging that she was seen in the facility's ED on 12/6/13 and on 12/9/14 and she had an allergic reaction to the "clear liquid given prior to Cat Scan". The complainant alleged that she was not given a prescription for any medication for the allergic reaction. It was noted that the hospital's investigation dated 12/23/13 was located in the file. However, there was no written evidence that the complainant was provided with a written response on the outcome of the investigation. It was noted that the hospital investigation indicated that the patent was discharged to home with prescriptions for Benadryl. The record indicated that Patient Relations staff spoke to the patient on 1/8/14 and stated she was not prescribed any medications. There was no documentation that the patient was informed that if she was not satisfied with the facility's findings that she may contact the State agency.

Grievance File #2, dated 12/16/13, was reviewed on 4/10/14. In this grievance, the patient's daughter, of a 84 year old patient, alleged that the patient was discharged from the ED on 12/11/13 with Hep-Lock still attached. There was no evidence that a written response was sent to the complaint on the outcome of the investigation.

Hospital Manual - Category: Rights and Responsibilities of the Individual; Subject: Patient Complaint/Grievance Mechanism - date issued: December 2011 - was reviewed on 4/9/14. It was noted that the following statement "the hospital may use additional tools to resolve a grievance, such as meeting with the family". The hospital may use additional tools to resolve grievances. However, the facility is required to provide written responses to all grievances.

Based on staff interview and review of Grievance Files, it was determined that the facility failed to ensure that written notice of its decision on resolution of grievance contained all of the regulatory elements. This was evident in ten (10) of forty (40) files reviewed (#15, #23, #24, #25, #26, #27, #28, #29, #30 & #31).

Findings include:

Grievance #15, dated 8/22/13, was reviewed on 4/10/14. The patient complained to the facility that she received a bruise on her thigh due to heparin shots. The patient was to be discharged on 8/21/13. The patient alleged having difficulties in walking and would require help at home. It was noted that the written response to the complainant was dated 9/16/13. It was noted that the discharge issue was not mentioned in the response to the complainant. In addition, the date of the completion of the grievance was not included in the response to the complainant.

Grievance file # 23, dated 10/16/13, was reviewed on 4/10/14. It was noted that the complainant alleged that the patient, with dementia, was discharged from the hospital without prior family notification. The patient was found wandering on the side walk with hospital gown and no shoes. It was noted that the response to the complaint, dated 11/19/13, lacked the steps taken to investigate the grievance. In addition, the date of the completion was not included in the response.

Grievance file #24, dated 12/19/13, was reviewed on 4/10/14. It was noted that the complainant alleged that he was seen in the facility's ED on 9/18/14 for a broken arm and he was sent home without a cast. The written response to the complainant lacked steps taken to investigation the grievance, the completion date and the complainant was not informed that if he was dissatisfied with the facility's finding that he may contact the State agency.

Grievance file #25, dated 1/30/14, was reviewed on 4/10/14. It was noted that the parent of a child alleged that her daughter was brought to the ED on 1/13/14 for a severely painful swollen jaw. The complainant alleged that her daughter was misdiagnosed. The written response to the complainant dated 2/10/14 lacked the steps taken to resolve this grievance.

Grievance file # 26, dated 2/11/14, as reviewed on 4/10/14. It was noted that complainant alleged that she saw several specialist in the facility who missed the large tumor in her abdomen. The response to the complainant lacked the steps taken to resolve the grievance.

Similar findings noted for grievance files #27, #28, #29, #30 & #31 which lacked pertinent information in the responses to the complainant.


This was brought to the attention staff #26 on 4/10/14.

Based on review of documents and observation, nursing failed to provide adequate oversight over the non-licensed patient care providers, in that a patient care technician was observed performing a water treatment test incorrectly and independent of supervision of the responsible nurse. This was observed in 1 out of 1 hemodialysis machines prepared for patient care.

Findings include:

During demonstration of chlorine/chloramine tests on a Portable Reverse Osmosis Equipment by a Patient Care Technician (E #7) on 04/10/14 at approximately 3:00 PM, it was revealed that the facility was using E-Z RPC total chlorine test strips and this staff member did not follow the testing process as recommended by the manufacturer.

The following are the practice issues that were found to be contrary to manufacturer's recommendation:

(a)This staff member did not ensure the collection of 20 ml of water sample as recommended by the manufacturer.
(b) This staff member did not swirl the strip in the sample nor did the employee time the exposure of the reagent strip to the sample of water, as recommended by the manufacturer.
(c) This staff member did not compare the testing strip to the color chart on the bottle to determine the total chlorine level; instead raised it to the light bulb and determined that it was below 0.1 ppm

Interview of the Director of Dialysis, E #8, on 04/10/14 at approximately 3:10 PM, it was stated that a licensed nurse was responsible for the verification of the Total chlorine tests results and that this demonstration by the technician in the absence of the nurse was an aberration from the normal practice of the facility.

Review of the personnel file of this employee, it was noted that this employee did not receive training for chlorine/chloramine tests on-site. Upon interview, the technician stated that this staff member was trained at another facility.



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Based on observation, staff interview and review of medical records and documents, it was determined that the facility failed to ensure provision of nursing services by failing to comply with policy and procedures for: a) medication administration, b) continuous monitoring of patients as ordered to maintain patient safety and, c) pressure ulcer prevention and treatment.

Findings Include:

(A) Tour of the Labor & Delivery unit on 4/11/14 at 10:30 am revealed:

1) A double locked cabinet in the Medication Room had three (3) intravenous bags of solutions labeled Fentanyl with Bupivacaine and were dated 4/9/14. Staff #19 stated this medication is for Epidural administration and about five (5) packs are requested daily from the pharmacy for anticipated use, and the unused packs are returned to the pharmacy at the end of the day. Staff # 19 had no explanation why the medications dated 4/9/14 were still on the unit and stated these medications should have been returned within 24 to 48 hours.
There is no policy or process in place to ensure the timely return of Fentanyl medication to the pharmacy and there is no documentation or record to indicate the presence or monitoring of this medication on the unit.

Review of the facility's policy: Medication Administration: Nurses Responsibilities states: narcotics and other controlled substances shall be checked at the beginning and at the end of each tour and the count shall be recorded on Ward Record of Administration of Narcotics; and narcotics/controlled medications received from the pharmacy must record the date, time, and "Received from the Pharmacy."
The nursing staff has not implemented this policy for monitoring the Fentanyl on the unit.

This observation was acknowledged by Staff #18 who was present on the tour.


B) Tour of the Adult Primary Care & Specialty Practices Clinic on 4/14/14 at 11:15 am revealed:

1) The Medication refrigerator in the Admission Area had an opened vial of insulin dated 4/27/14 and an opened vial of PPD dated 4/9/14. Staff #20 stated these were multiple use medications and the dates written were when the vials were opened by the RN. The expiration dates should also be written and this was not done.
The facility's policy: Medication Administration: Nurses Responsibilities states: for multiple dose vials, once opened, the date of expiration is to be indicted on the vial.

2) The Medication refrigerator in the Specialty area had four (4) packets of Aranesp (used to treat Anemia) medication, each with a patient's name. The dates dispensed were 4/9/14, 4/9/14, 3/26/14 and 10/09/13. Staff #21 stated these medications were prescribed for the patients and if they were not picked up by the patient, would be kept for a week for patient follow-up. If there was no follow-up by the patient, the medication would be returned to the pharmacy. There was no explanation why two (2) of these medications remained for more than a week in the refrigerator and there is no policy to govern this practice.

These observations were acknowledged by Staff #22, who was present on the tour.


(C) Tour of the A5 Medical Surgical unit on 4/8/14, at 10:45 am, the surveyor observed:

1) Patient MR#6 was admitted from the Emergency Department 2/20/14, Diagnoses: Abnormal Gait, Dementia, and Seizure Disorder. A sign, " Close Watch Safety " was posted by his bed and Staff #13 stated this patient receives q15minutes check by the nursing staff and this is documented on the Observation Record. Close check q15minutes for safety, was ordered by the physician on 3/13/14.
The surveyor noted gaps in the q15minutes record of observation, and review of the Observation Record 4/4/14 through 4/8/14 revealed no observations were recorded for the following dates and time periods:
(a) On 4/4/14 from 6:45 pm to 9:45 pm
(b) On 4/5/14 from 4:00 pm to 6:00 pm
(c) On 4/6/14 from 12:00 pm to 7:45 am
(d) On 4/7/14 from 3:00 am to 3:35 am, and 5:15 am to 5:45 am.
(e) On 4/7/14 from 5:15 pm to 11:45 pm.

Staff #13 acknowledged the Observation Records were incomplete.


2) Patient MR#7 was admitted on 2/7/14 with a Diagnosis of Dysphagia and there is a physician order for 1:1 Observation for safety on April 1, 2014, which was changed on April 2, 2014 to Close Watch Observation, q15minutes check. Review of the Observation Records revealed there were no q15minutes observation recorded:
(a) On 4/2/14 from 12:45 pm to 1:30 pm
(b) On 4/3/14 from 12:15 pm to 12:45 pm; from 1:15 pm to 1:45 pm; from 3:15 pm to 3:45 pm.
(c) On 4/4/14 from 12:00 midnight (12:00 - 7:00 am Tour I) to 3:45 pm. (8:00 am -3:45 pm
Tour II).

Staff #17 stated the observations may not be documented on the Observation Record, but the nurses will document the close check in the notes. This statement is not in compliance with the facility's Policy: One To One -Constant Observation And Close Observation, which states; nursing staff assigned to Close Observation must round on the patient for safety and location check at 15 minutes intervals and the "Patient's Observation Record" is utilized for documentation of constant or close observation.

The Observation Records for the periods of 4/4/14 through 4/7/14 could not be located for the surveyor.

D) Tour of the D2North Medical Surgical unit on 4/10/14 at approximately 3:00 pm revealed:

1) Patient MR#8 was admitted on 4/7/14 with Diagnosis Bipolar Disorder, Suicidal multiple attempts and 1:1 Observation was ordered.
There was no documented observation from 12:45 pm to 1:30 pm on 4/9/14.
This is not in compliance with the facility's policy which states that constant (24hours) observation requires documentation of the patient's activity by one nursing staff every 15 minutes.

The nursing staff failed to comply with this policy to provide a safe environment for all patients.


(E) Tour of the A5 Medical Surgical unit on 4/8/14, at approximately 12:00 noon revealed:

1) Patient MR#6 was admitted from the Emergency Department 2/20/14, Diagnoses: Abnormal Gait, Dementia and Seizure Disorder. The Initial Nursing Assessment, completed on 2/21/14, identified the patient at high risk for pressure ulcer development, and the skin assessment revealed intact skin. Review of the EMR revealed:

(a) The nursing care plan was developed on 2/21/14 but the patient's risk for pressure ulcer was not identified and there was no documentation that interventions for prevention were implemented.
(b) The patient's Skin Assessment conducted on 4/2/17 recorded a Stage II Pressure Ulcer, Lt. Buttocks (hospital acquired), but the nursing care plan was not updated and there was no documentation that treatment interventions were initiated.
(c) There was no documentation of treatment interventions on 4/3, 4/4, 4/5, 4/6 and 4/7/14.
(d) There was no physician order for PU treatment in the EMR.
A physician order for wound care was entered on 4/8/14 at 12:50 PM when the surveyor was present.

At interview, Staff #15 stated a physician order is needed within 24 hours to use Duoderm, which is the protocol for treating a Stage II PU. Review of the facility's Pressure Ulcer Prevention And Management Protocol confirmed Duoderm dressing for Stage II PU, to be changed q3 days and prn. The protocol also states: all patients who are identified at risk for pressure ulcers will have the nursing care plan for PU Prevention and Treatment initiated and documented in the EMR and this plan is to be updated on a regular basis. Ongoing Pressure Ulcer Treatment Interventions are to be documented with each dressing change.

(F) Tour of the D4N Medical Surgical unit on 4/9/11 at approximately 10:45 am revealed:

1) Patient #9 was admitted to the facility from a nursing home on 2/22/14, and the Initial RN Assessment revealed Community Acquired Pressure Ulcers (PU), (a) Stage II Sacrum and (b) Deep Tissue Injury (DTI), Rt. Heel. Review of the EMR revealed:

(a) The nursing care plan to implement interventions for the PU was documented on 2/26/14, four days after the initial assessment.
(b) The physician order for wound treatment was documented on 2/27/14, five days after the initial assessment, and the facility's policy states orders for pressure ulcer dressings, if indicated, should be obtained within 24 hrs of when a pressure ulcer is identified.
(c) Wound treatment was not documented in the EMR 2/23, 2/24, 2/25 and 2/26/14.
(d) The RNs documentation from 2/27/14 to 4/9/14 does not specify the PU interventions with each dressing change, as required by the facility's protocol.
(e) There was no documentation in the EMR relating to the DTI, Rt. Heel, after the initial assessment on 2/22/14. Staff #23 checked the patient's Rt. Heel and informed the surveyor that the DTI was resolved and stated the care and description would be documented as needed and also if there is a change.
This statement is not in compliance with the facility's protocol for DTI which requires "treatment as per the presenting stage of the DTI" and ongoing Pressure Ulcer Treatment Interventions are to be documented with each dressing change.


The nursing staff failed to comply with the facility's policy for the prevention and treatment of pressure ulcers.


This observations were acknowledged by Staff #18 who was present on the tour.

Based on observation, staff interview and document review, the facility failed to develop and implement a policy to govern the timely return of the unused controlled substance dispensed from the pharmacy. Specifically, the Pharmacy Department does not have a policy to ensure timely return of unused/expired Fentanyl from Labor & Delivery.


Findings Include:

Tour of the Labor & Delivery unit on 4/11/14 at 10:30 am revealed:

A double locked cabinet in the Medication Room had three (3) intravenous bags of solutions labeled Fentanyl with Bupivacaine and were dated 4/9/14. Staff #19 stated this medication is for Epidural administration and about five (5) packs are requested daily from the pharmacy for anticipated use, and the unused packs are returned to the pharmacy at the end of the day. Staff #19 had no explanation why the medications dated 4/9/14 were still on the unit and stated these medications should have been returned within 24 to 48 hours.
There is no policy or process in place to ensure timely return of the Fentanyl medication to the pharmacy and there is no documentation or record to indicate the presence or monitoring of this medication on the unit.

Review of the facility's policy: Medication Administration: Nurses Responsibilities states: narcotics and other controlled substances shall be checked at the beginning and at the end of each tour and the count shall be recorded on Ward Record of Administration of Narcotics; and narcotics/controlled medications received from the pharmacy must record the date, time, and "Received from the Pharmacy."
The nursing staff has not implemented this policy for the monitoring of Fentanyl on the unit.

This observation was acknowledged by Staff #18 who was present on the tour.

At interview on 4/14/14 at 10:30 am, Staff #24 stated the Fentanyl pack is used for Epidural administration in the Labor & Delivery only. This preparation is compounded in house, upon demand, and has a 48 hours expiration date. The RN picks up the Fentanyl from the pharmacy and returns the unused/expired Fentanyl. The RN on the floor is responsible for pick-up, monitoring and return of Fentanyl.
The pharmacy does not monitor this medication on the unit and has no system for prompt return of the unused/expired Fentanyl. There is no policy in place for this process.

Based on review of records, observation and staff interview the food service director did not take responsibility for the daily management of the service to ensure that (a) proper safety practices for handling food are maintained and (b) proper sanitary environment is maintained in the kitchen.

Findings include: During tour of the main kitchen on 4/8/14, the following observations were made.
1. Food items were observed not labeled with the name of the food item, day or date the food was prepared and day or date the food must be discarded. No labels were observed on diced pear cups and puree pear cups that were on the on tray line.
2. A dietary aide in the light production area was observed doing her duties, after making sandwiches she removed gloves from her hand and lifted the cover of a large garbage can with her bare hands. She then took paper towel and wiped the table down, the worker then moved to the other side of the room and started to put rubber gloves on without washing her hands.
This was brought to her supervisor's attention who then instructed her to wash her hands.
3. A large uncovered card board box lined with plastic and filled with garbage was observed near the tray line area.
4. An outer wear coat was observed hanging on a rack next to clean pots and pans in the manual pot washing area.
5. A cage with emergency food supplies was observed stored in close proximity next to the dishwashing machine. These items were exposed to splash from dirty water and food debris. This represent a high risk for cross- contamination.




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6- Freezer #1 had a build-up of ice on the condenser. There was pot roast on a rack beneath the condenser.
7- There were many food items in the freezer as well as the refrigerator that had been opened, re-wrapped and not labeled for its content, date when the item was wrapped and date of expiration.
Some of these items were a chunk of butter, loose pancakes, American cheese, pan of cooked chicken, multitude of cold cuts and employee ' s food in brown bag, individual packs of wrapped spinach, flour and red tortillas with no label, a covered plate with waffles had no label,
8- A pan covered with saran wrap contained a creamy white food item. There was no label identifying the food. When the surveyor asked staff # what was this food; she responded I do not know - let ' s ask the cook. It was unknown if the food was pureed rice or cooked cereal.
9- Three hand sink were observed not to have a waste basket beneath them to discard wet paper towels.
10- There were two large plastic garbage receptacle containing garbage in the kitchen which were not in use and were uncovered.
11- A plastic sanitizer bottle was cut in half and the solution was pink. This container hung on the wall. There was no label for its use. Staff # 11 was shown the bottle and was unable to identify its purpose or its content.
12- A pan of cooked white rice was uncovered and placed in the dairy refrigerator.
13- Milk refrigerator box on the tray line was covered yet the cover had a nickel size hole through it. Temperature is lost despite the refrigerator being covered.
14- Freezer Temperature Log titled " #2 Reach-in " noted on 4/1/14 an opening temperature of 10.6 degree Fahrenheit (F) and a closing temperature of 8.0 degrees, 4/2/14 the opening temperature was 8.6 degrees F, 4/3/14 the opening temperature was 19.6 degrees F, 4/4/14 the opening temperature was 22 degrees F and the closing temperature was 5.0 degrees F, 4/5/14 opening temperature was 7.4 F and closing temperature was 4 degrees F, 4/6/14 opening temperature was 22.8 degrees F and closing was 2 F degrees and on 4/7/14 the opening temperature was 30.6 degrees F and the closing temperature was 1.2 degrees F. All of the above temperatures were out of range yet there was no corrective action documented on the log sheet. Freezer standard temperature is 0 Fahrenheit degrees.
15- Four additional brown bags containing food was found in the food warmer at the kitchen. Staff # 11 informed the surveyor that these bags of food were employees ' lunches.
16- A dirty radio was sitting on the counter in the cold prep area.
17- There was no rubber mats on the floor in the dishwashing area.
18- The clean pans were place bottom down however when you separated the pans they were dripping water. The pans were stored wet and stacked.
19- A bottle of bleach was found in the pot washing area. When staff was interviewed concerning the use of bleach she informed the surveyor that the bleach was used to whitened the melamine plates. Staff # was informed by the surveyor that bleach cannot be used in the food service department.
She was informed that she had to read the manufacturer recommendation on removing stains on dishes.

B. A review of the Emergency Preparedness manual was conducted on 4/8/14 at approximately 1:00 PM in the presence of staff #11 . The manual was not user friendly for non-food service staff. It was bulky and did not contain the information warranted should an emergency arise. The following was observed:
a) The menu was generic. It did not state the food items to be provided. The menu read- 4 oz juice, 1 cereal instead of 4 oz canned apple juice, 1 small box of Cheerios.
b) The menu did note state what diets would be covered by the menu.
c) There was no diagram as to the location of the emergency food supply. The foods for this menu were not centralized in the kitchen. Staff # informed the surveyor that some foods such as desserts and juices were in metal cages in the kitchen. The cages were not label for emergency use only. The paper on the cage noted, " Cage 2 " .
e) There were no amounts of water listed to be provided for each unit.
f) Menu did list the amount of staff to be fed on each unit.
g) Equipment such as aprons, can openers or food utensil was not listed.
h) Paper good were not listed (plates, cups, napkins).

C. A review of the form titled " Evaluation of Tray Assessment " was conducted on 4/9/14 at 9:15 AM.
Staff #11 was interviewed as to the frequency these tray assessment are done. Staff # informed the surveyor that three tray assessments are done per week. These tray assessments are very important since they address tray accuracy, food temperature of trays arriving on the unit and the quality of food.
Review of tray assessment was done from 4/02/13 thru 10/24/13. There were 25 tray assessments done
None of the assessments had a menu attached to the form to assess food items. 24 of 25 menus assessed only the foods on the Regular diet. Foods provided on therapeutic diets were not assessed.
The overall quality of the tray assessment was not documented on any of the forms. This information is required by the form.
Many of the tray assessment had a Xerox pre-printed signature of the employee performing the assessment.
Temperatures that did not meet the standard did not have a corrective action -example 3/3/14.
The overall review of these form determined that the forms were incomplete in documentation and evidence of a management reviewer was not evident.

D. A review of Food and Nutrition Department Quality Improvement Program was done on 4/9/14 at approximately 11:00 AM. The nutrition division of the department had evidence of a quality assurance program however the Food Service division of the department had no quality assurance program instituted. Staff # 11 informed the surveyor that she did not have a formal quality assurance program in place.

Based on staff interview, review of hospital master menus and nutrient analysis of menus, it was determined the Food and Nutrition Department failed to ensure that physician prescribed diets met the therapeutic nutritional needs of patients. This finding was noted in 10 of 34 menus.

Findings include:

A review of hospital master menu and nutrient analysis was conducted on 4/8/14 at approximately 10:00PM. This review was done in the presence of staff #12. The surveyor interviewed staff #12 on the hospital Master menu and their nutrient analysis.
1-It was observed that the hospital has 34 diets on the physician ' s diet formulary however there are only 10 menus in print available for all these diets. Staff #12 informed the surveyor that the software the hospital has for printing menus is limited to 10 diets.
The outcome is that 24 diets have to be modified by hand on 10 menus.
2- Nutrient analysis for 34 diets was available for review however due to the lack of menus for these diets it is unknown if the patients are receiving the portions and restrictions the physician prescribes. Diets analyzes by the hospital cannot be substantiate since there is no menu to confirm that the amount of food, type of food and restriction prescribed meet what is written on the analysis.
3- It was observed that all hospital menus were generic. The food item listed on the Master Menu and or nutrient analysis is not listed on the menu. Example: The hospital Master menu states 3 oz. Roast Chicken, ? cup Rice, ? cup Broccoli instead the menu the patient receives reads 3 oz Meat, 1/2 cup Starch, ? cup Vegetables. The patients are not aware of what they are receiving on their trays neither can they use these menus as an education tool since the actual name of foods is not listed on the menu. Therefore samples of menus patient usually takes home to follow is not possible since this menu is generic and does not list the foods they should have on their prescribed diet.

Below is an incident in which two toddlers received a menu with diet restrictions not prescribed by the physician and a menu not modified to meet the needs of the toddler age groups. Food portions provided on their trays were adult size portions.
The surveyor tours the Pediatric unit on 4/11/14 at approximately 12:30 PM with a hospital Risk Manager employee. The following was observed:
a) Two toddlers age 1-2 years old (MR# 2602080 & MR# 265482) received trays with menus noting Soft/Bland diet. Both patients received adult size portions of foods. A review of both patients ' physician prescribed diets on hospital ' s diet census read " Toddler 1-2 yr Diet " These patients were provided the wrong diets since their menu read Toddler 1-2 yr Soft/Bland Diet. The diet order by the physician did not contain the diet restrictions of Soft/Bland.
b) These menus were provided to these children ' s because there are no menus for the pediatric population with the exception of adolescent.
c) The menus had no food preferences on them.
d) A pediatric patient approximately the age of five was asked how he liked his food. The child stuck out his tongue twice. The surveyor look at his tray and his entree was a large portion of elbow macaroni with brown meat sauce splattered on the plate. The food appeared unappetizing.
The staff nurse present during the tour informed the surveyor that the children hate the food - it is not pediatric friendly food.

Based on staff interview, review of hospital's menus and physician diet prescription formulary, it was determined that the prescribed physician diet orders were not being accurately transcribed on patients menus.
Findings include:

An interview with staff #12 was held on 4/8/14 at approximately 12:00PM concerning diet abbreviations found on menu was discussed. Staff #12 informed the surveyor that due to the lack of menus diet not on menu would have to be hand written. It was observed that physician diet orders were abbreviated on the patient menus. Physician diet orders were not transcribed on to the menus as prescribed by the physician. Physician's diet orders were abbreviated and not legible. Examples of abbreviations used on menu are as follows:
Prescribed Diet: Abbreviation noted on patient menu:
Diabetic 1800 kcal. 2 gm. Sodium Diet 1800 kcal DB/Lo Na
Diabetic Renal 60 Gm Protein Diab/Renal 60 gm

The surveyor informed the Clinical Nutrition Manager these abbreviations are unacceptable since the purpose of the diet printed on the menu is to identify the physician prescribed diet to the patient and staff.

Based on observation, staff interview and other document, it was determined that the hospital failed to ensure that hospital prescribed diets are in accordance with hospital approved diet manual.
Findings include:

Review of physician diet order formulary contained diets not listed in the Adult or Pediatric Diet Manual approved by the hospital. Staff #12 was interviewed on the physician diet order formulary. She informed the surveyor that she will be updating the diet formulary however no time frame was provided.
These diets are:
1- (Pediatric) Junior Food - 6-12 months
2- Pediatric General - 6-10 years
3- Bland
4- Diabetic (NO calories) listed under Miscellaneous
The physician diet order formulary needs to be updated to meet hospital's diet manuals standards.

Based on staff interview and documents reviewed, it was determined that the hospital failed to meet the UR plan requirements.

Findings include:
Staff # 37 was interviewed on 4/14/14. The staff stated that the Utilization Management Committee Meetings are held quarterly (on the third of the month following each quarter). However, the meeting for February 2014 was cancelled. She also stated that there has been no Utilization Management Committee Meeting yet for this year 2014.

Staff #37 submitted a document dated 4/14/14 which stated the following: "The Utilization Management meeting which was scheduled for February 6, 2014 was postponed because there was not a quorum of two physicians from the Medicine or Osteopathy as stipulated in the Condition of Participation". This document did not include schedule for the next meeting.

The facility's Utilization Review Plan was requested from the staff #37 on 4/14/14. The staff submitted the facility's Utilization Review/Case Management Plan for 2012-2013. She stated that the facility was still working on the facility's Utilization Review plan for 2013-2014.

Based on observations and staff interview, emergency department environment was not maintained to ensure the safety and well being of patients. Specific reference is made to the nurse call system installed in this department.

Findings include:

During the tour of the Emergency Department on 04/08/14 at approximately 11:00 AM,the nurse call system was activated for testing by a staff member on the request of the surveyor at bay #25. It was noted that there was no audible alarm. Upon further investigation and interview of the Asst. Director of facilities (E# 9), it was revealed that the nurse call was hooked up to an on call phone located at the nurses' station, which was left unplugged.

This finding was again observed in the diagnostic radiology section of the Emergency Department. The nurse call system in the patient changing room was activated by the surveyor and there was no response from the staff as it did not emit an audible alarm. The director of the radiology department acknowledged that the on call phone was unplugged and therefore the system did not emit an audible alarm upon activation.

The facility plugged in the on call phones in the presence of the surveyor. The system was tested and found to be fully functional.

In addition, during the tour of the Mother and Baby unit on D South 5 on 04/09/14 at approximately 3:30 PM, it was noted that there was one electrical duplex emergency outlet for each bed and that there was no provisions for equipment to be hooked up to an infant basinet during a power failure emergency. Therefore the facility failed to ensure the safety and well being of both mother and baby in an event when both required life saving equipment during a power failure emergency.


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

The findings include:

1. On the morning of 4/8/2014 observation of the Comprehensive Psychiatric Emergency Program (CPEP) Unit revealed that:

a) there were miscellaneous boxes that were stored on the floor of the Wheelchair Storage Room.

b) the Seclusion Room was being used as a storage room. Specifically, there were CPEP beds, restraint beds, wheelchairs, etc. were stored in this room. Although the facility does not currently utilize the Seclusion Room, this room must be kept clear in case it has to be used.

c) a light motion sensor was not tightly secured to the ceiling in the Patient Bathroom within Room R1071. This was a looping hazard.

d) the monolithic ceiling was stained in the Extended Observation Unit Female Shower Room.

2. On the morning of 4/8/2014 observation of the Behavioral Health Primary Care Clinic revealed that:

a) there was a wheelchair being stored in Supply Closet, Room R1211.

b) the shower curtain in the Patient Bathroom within Room R2226 was in disrepair. Specifically, it had a hole in it. This is not considered a looping hazard.

c) the door to Room R2219 was damaged.

d) the light sensor escutcheon was missing in Room R216, the Tub Room.

e) medical tape was used to seal an exhaust duct in Room 2215, the Laundry Room.

3. On the afternoon of 4/8/2014 observation of the 3rd Floor Adult Impatient Services revealed that:

a) the monolithic ceiling was stained in the Bathroom.

b) two stacks of boxes with paper in them were stored on the floor of Room 3231, the Storage Room.

4. On the afternoon of 4/8/2014 observation of the 5th Floor Adult Impatient Services revealed that the monolithic ceiling in the Room R5208 was stained.

5. On the afternoon of 4/8/2014 observation of the Dental Suite revealed that there were three stained ceiling tiles in Room E1139.

6. On the morning of 4/9/2014 observation of the Medical/Surgical Progressive Care Unit revealed that there were two stained ceiling tiles in Room D7N34, the Equipment Room.

The above findings were concurrently verified by Staff #1.

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

Findings include:

During the survey of the facility from 03/24/14 - 03/27/14, 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 17 (Corridors are separated from use areas by walls constructed with at least ? hour fire resistance rating. 19.3.6.1, 19.3.6.2.1, 19.3.6.5)

K 29 [One hour fire rated construction (with ? hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas].

K33 (Exit components (such as stairways) are enclosed with construction having a fire resistance rating of at least one hour, are arranged to provide a continuous path of escape, and provide protection against fire or smoke from other parts of the building. 8.2.5.2, 19.3.1.1)

Based on observation, staff interviews, policy review, and review of medical records and documents, the facility failed to: 1) implement measures for maintenance and surveillance of equipment with potential for infection transmission; 2) maintain a safe and sanitary environment to minimize the transmission of infections; 3) comply with its infection control practices to avoid potential sources of cross contamination which increase risk for spread of infection; 4) maintain proper airflow in rooms which require negative pressure to mitigate risk of infection; and 5) ensure compliance with isolation procedures to decrease the risk for spread of infection.


Findings include:

1. The hospital did not implement effective measures for maintenance of equipment which pose risk of infection transmission, in order to maintain a safe patient environment on a behavioral health service unit. This observation was made in one of two treatment rooms observed on inpatient behavioral health units.

During tour of inpatient Behavioral health unit R5W at 3:40 PM on 4/9/14, observation of the locked treatment room revealed a red sharps waste container was mounted to the wall which contained disposed used needles and sharps. These sharps had risen above the established fill line limit marked on the container.

During interview at the time of observation with employee #s 13 and #14, it was reported that the nursing staff will contact Facilities management staff for pick up when the sharps containers are filled. When asked if there was a maintenance surveillance schedule for environmental rounds, staff indicated there is no known monitoring schedule and it is the responsibility of the nursing staff to call for removal of filled containers and replacement.

Review of the procedure titled: "Management of Regulated Medical Waste-EC. 2.02. 01" finds that users (staff) of sharps containers should monitor these containers to ensure they are not filled to capacity. The staff must request replacement if the container has been filled to 3/4 or greater of its capacity.
This policy also describes the role of the contracted vendor Technician , floor Housekeeping/Institutional aide, and the Environmental Services Supervisor. The vendor technician is required to remove the filled sharps containers, hospital wide, per a schedule and "transport to waste management platform for processing". The housekeeping/institutional aide must provide support services during tours I and II when the technician is not onsite, shall provide empty sharps containers, and transport filled containers to soiled utility rooms. The Environmental Services supervisor is to notify the waste manager during tour II and at other times including weekends will provide empty sharps containers from the waste management platform and inform the waste manager.

The facility did not follow its policy and procedure. The availability of used needles that exceed the fill line on sharps containers could present a risk for transmission of infection in the event a patient is able to is able to remove these items to cause harm or injury while undergoing examination in the treatment room.


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2)a. During tour of the Operating Room #6 on the 3rd Floor of hospital on 04/09/14 at approximately 10:30 AM, it was noted that the perimeter of the Operating Room floor was heavily soiled. The floor was strewn with pieces of tapes, plastic caps, paper wrappings etc.
A metal supply cart located in corner of the room (at the entrance of the room) was observed to be covered in dust.
Similar findings were noted in OR#8. A medication vial was observed underneath a supply cabinet and floor of the Operating room was strewn with debris, including a shoe cover that was found lying underneath the supply cabinet. A rusty IV pole was also observed in this operating room. A microscope was observed in this room and the arm of the equipment was observed to be dusty and stained.

2)b. During the testing of temperature of water of scrub sinks in the Catheter Lab in the S building of the hospital on 04/11/14 at approximately 11:45 AM, it was noted that the water in the two scrub sinks were cold. CDC recommendations on pg 49 under 3 b regarding Water Temperature and Pressure of the topic D-Water in Part 1. Background Information: Environmental Infection Control In Health-care facilities states "the hot water temperature in hospital patient-care areas is no greater than a temperature within the range of 105 F-120F".

2)c. During the tour of the Emergency Department of hospital on 04/08/14 at approximately 11:00 AM, it was noted that the facility stored 2 portable C-arm (portable X-ray equipment)in an alcove outside the emergency department. Both the equipment were identified by radiology staff as clean equipment, but were observed to be collecting dust and uncovered.

2)d. On 04/09/14 at approximately 2:30PM, during the tour of an unoccupied isolation room of the ICU on the third floor of the hospital,the room was identified by staff as cleaned and ready to accept the next patient by the nurse-in charge. However the nurse in charge was not sure whether a flowtron equipment lying on the countertop of this room was cleaned after use on the previous patient. This equipment was observed to be left uncovered on the countertop.

2)e. During the tour of the MICU on 04/09/14 at approximately 3:35 PM, the surveyor noted that flooring of all the rooms in this suite had embedded black and brown stains,especially along the perimeter of the wall. It was also observed that the flooring at the entrance of room #3S29 was chipped off.


3)a. During the review of the reprocessing logs for the sterrads on 04/10/14 at approximately 3:30 PM, it was noted that the facility does not have a process in place to identify the specific failed load when they are re-done due to sterrad failure. For example:
100S Sterrad failed on cycle 4 on 04/07/14 failed and the load consisted of Cylinder Oncology. Further review of the logs and interview of E#4 revealed that the Plastic Cylinder was reprocessed on 04/08/14 on the 5th cycle, but there is no documented evidence to indicate that the re-done load was actually the load that had failed. Upon interview of the Director of Central Sterile (E#4) and the Manager (E#5) revealed that the facility does not have unique identifiers for the instruments/load that are re-processed, but tracking of re-done loads are done by the sterilization record that indicates the reason for the load being re-done.
Similar findings were noted on the load consisting of flexible ureteroscope which failed on 04/04/14 and re-done on 04/07/14.

3)b. Again on 04/09/14 at approximately 11:00 AM the surveyor noted a steris re-processing equipment in the central core of the Operating Suite. Review of the cycle strip on the equipment revealed that the equipment failed on 04/08/14 at 1:42 PM. Interview of the Equipment Technician (E#6)for GI revealed that the endoscope involved in the failed cycle was re-processed in the central GI core. There were other endoscopes reprocessed in the central core on 04/09/14 and the facility does not have a mechanism in place to identify the particular endoscope that failed reprocessing among the ones that were reprocessed in the central core.
During interview with employee # (E 38) on 4/11/14 at approximately 3:30 PM, it was stated the Infection Control Department did not establish and implement a mechanism for tracking instruments that are cleaned in the Steris machines located in the Central core of the Endoscopy suite.


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4)a. The facility failed to ensure that the facility's environment was maintained to prevent the spread of infections.

- On the afternoon of 4/9/2014 observation of the Medical/Surgical Progressive Care Unit revealed that the Soiled Utility Room and Housekeeping Room had positive pressure to the corridor. These rooms are "dirty" rooms and are required to have negative pressure to the corridor.

The above findings were concurrently verified by Staff #1.

4)b. During the tour of the ICU suite, it was noted that the soiled utility rooms in the NICU and PICU had air flow with positive pressure and not negative pressure as required.



32522

5. Observation, staff interview, and review of documents,found that the facility failed to ensure compliance with isolation procedure to decrease the risk for spread of infection. This was observed in 2 of 2 applicable patients who had orders for Contact Isolation.

During a tour of the A5 Medical Surgical unit on 4/8/14, at approximately 11:45 am, the surveyor observed:

a. Patient MR#4 in Room 5102 had Contact Precautions signs posted outside the door. A female, identified as a visitor, was standing by the bedside and was not wearing a gown. At interview, the visitor stated she announced herself to the staff at the Nursing Station and was not informed she had to wear a gown and she did not observe the signs posted outside the door. Staff #15 confirmed Contact Precautions was ordered for this patient.

b. Staff #16 was completing blood glucose test for Patient MR#4, in Room 5102 and was not wearing a gown. Signs for Contact Precautions were posted outside the door. Staff #14 admitted to the surveyor that she did not wear a gown while in contact with this patient and this patient is on Contact Precautions.

c. During a tour of the 7S Medical Surgical unit on 4/8/14, at 1:4, a visitor was observed seated at the bedside of Patient MR#5, Room 715A and was not wearing a gown. This patient had signs posted for Contact Precautions which was confirmed by Staff #17 who stated that the visitor should be wearing a gown.

The facility's protocol for Contact Precautions states: visitors should report to the nurse before entering, gowns should be worn " upon entry into the room whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. " This is in addition to Standard Precautions and gloves.

These observations were confirmed by Staff #18 who was present on the tour.

Based on staff interviews and review of medical records, it was determined that the hospital failed to ensure that each patient who needed discharge planning has a discharge planning evaluation which entails, individual post-discharge needs, in order to identify the specific areas that must be addressed in the discharge plan. This deficiency was noted in four (4) of nine (9) applicable medical records reviewed ( MRs #: #15, # 16, #21 & #22)

Findings include:

1. During the tour of the unit, (D4S) , on 4/11/14 at approximately 1:45 PM, the staff #33 & Staff # 34 stated that the patient in MR # 21 was to discharged today, (4/11/14). The discharge plan was home with home care services.

The patient was off the unit and could not be interviewed.

Staff # 35 was interviewed on 4/11/14. She stated that the patient was newly diagnosed with cancer. She also stated that the patient will be discharged today after MRI (Magnetic Resonance Imaging) is done.
MR # 21 was reviewed. It was noted the patient, 51 year old female with medical history including hyperthyroidism and CHF ( Congestive Heart Failure,) was admitted on 4/04/14 due to dyspnea. On 4/11/14 at 1343 (1:43 PM), the SW noted "according to the medical team, the patient is medically cleared for discharge home today. Patient resides in the community with her family will receive follow-up care from VNS (visiting nurse service) of NY for CHF management in the community". It was noted that on 4/11/14 at 2:28 PM, the physician assessment indicated that the patient "has right breast mass - adenocarcinoma state III" .
It was noted that the patient's diagnosis of cancer was not included in the discharge planning evaluation. It was noted that patient ' s insurance Medicaid was currently pending for approval. It was noted that the evaluation did not include how long the home care services would remain in the home. The discharge evaluation did not include if these services would continue until the insurance was approved. The discharge planning evaluation did not address the patient's cancer diagnosis.

2. During the unit tour (D4S), on 4/11/14, MR #22 was reviewed on 4/11/14. It was noted that the patient, 72 year old with history of HIV (human immunodeficiency virus), ESRD (End Renal Stage Disease) presented from home with 2-day history of dyspnea and weakness. The patient was admitted on 4/8/14 with diagnosis of systemic lupus erythematosus. It was noted that on 4/11/14 at 1317 (1:17 PM), the social worker (SW) noted "according to the medical team, the patient is medically cleared for discharge. The patient was referred to Village Care for CHHA (certified home health agency) and home care services. Patient resides in the community with her family and will be escorted home". It was noted that this discharge evaluation did not include the patient's post-hospitalization needs or the services to be provided by the home care agency. It was noted that this patient did not have a complete discharge evaluation during this admission.

Staff #36 was interviewed on 4/11/14. This staff stated that, as per policy, if a patient is readmitted within six months, an assessment is not required, and the worker is only required to write a progress note. It should note that the staff #32 interviewed on the unit (D4N) who gave similar response regarding a complete discharge planning evaluation.

The Staff #36 submitted a copy of a previous discharge assessment from MR # 22 , dated 11/15/13 at 1335, for review. It was noted that in the 11/15/13 admission the patient was discharged to home with home care services from HHC Home Care. In this admission, the patient was to be discharged to home with home care service from Village Care Home Care Agency. The reason for the change in home care agency was not addressed in the current discharge evaluation.

MR# 16- was reviewed on 4/11/14. It was noted the patient, 78 year old with past history Hypertension , human immunodeficiency virus, diabetes and Dementia presented to the facility ' s Emergency Room with complaint of non-bloody emesis and poor oral intake on 2/7/14; triaged on 2/7/14 at 1052 AM. The patient was admitted on 2/7/14 at 2054 (8: 54 PM) with diagnosis hyposmolality and hyponatremia. The patient was discharged on 2/13/14 in stable medical condition. The disposition was home with home health attendant and son ' s care
The Social work initial assessment was dated 2/12/14, over five days after, admission and the day before discharge. It was noted that the social worker (SW) noted that the patient has home care services with VNS (visiting nurse service) 712 and the discharge plan is to reinstate the home care services with VNS.
It was document in the record that the patient becomes markedly confused at nights. It was noted that patient was on 1:1 observation for safety while in the hospital. The discharge planning evaluation did not include if the current home care service was still adequate and appropriate for this patient . It was noted that, in the discharge summary, the physician indicated that patient needed supervision. It was noted the that type and frequency of supervision was not included in the discharge planning evaluation. It was noted that the nursing assessment and physician's assessment indicated that the patient lives alone. However, the social work assessment indicated that the patient's son lives in the same address. The house hold arrangement and supervisor for the patient during nights was not addressed or discussed with the patient's representative prior to discharge.

MR # 15 was reviewed on 4/11/14. It was noted that the patient, 78 year old male with history of bronchitis, COPD (chronic obstructive pulmonary disease) and Coronary disease, was brought to the facility's Emergency Department (ED) by ambulance on 2/11/14 with complaint of shortness of breath. The patient was admitted .
On 2/12/14 1037, the - attending adult admission notes indicated that the patient was non-complaint with his chest clinic appointments; patient has been admitted numerous times for COPD exacerbation. It was noted that the discharge plan was discharge to home with reinstated of his home care services. The discharge planning evaluation did not address with the patient or the caregiver the issues with the patient's noncompliant with appointments and numerous admissions.

Based on staff and patient ' s interviews, and review of medical records and hospital policy, it was determined that the hospital personnel failed to ensure that all discharge planning evaluations were timely so that appropriate post-hospital care services were made before discharge. This was noted in three (3) of nine (9) applicable patient records reviewed (MRs: #17, #19 & #20) .

Findings include:

Staff #29 was interviewed on 4/9/14. This staff stated that it is the social worker, on the unit, responsibility to develop and implement an appropriate discharge plan for all patients. This staff also stated that although Department of Social Work has a time frame for assessing and reassessing patients, the facility's discharge planning evaluation policy does not addresses time frame for discharge planning assessment and reassessment.

1. During the tour of the units ( AA51 & A52,) on 4/11/14 at approximately 10:45 AM, the staff on the unit (Staff # 30 & Staff # 31) stated that the patient housed in room A5216-02 (MR # 19) was scheduled for discharged today (4/11/14).
It was observed that the patient was dressed. He had his belongings with him and he was waiting on a seat in front of the nursing station.

Patient # (19) was interviewed. The patient stated that he was told by the physician that he was discharged so he is waiting for his discharge papers. The patient stated that he was admitted after heavy drinking and he felt like he was having a seizure. The patient reported that he has a drinking problem and he would like to stop drinking. The patient's discharge plan was discussed with the patient. The patient stated that a "five minutes ago he was told by a gentleman that once he is finish in this building then he should go to the R building". The patient stated that no further instruction was given.

MR # 19 was reviewed was reviewed on 4/11/14. The admission history and physical section of the medical record, dated 4/10/14 at 1434 (2:34 PM) was reviewed. It was noted that the patient , 27 year old male with history of alcohol abuse and no other significant medical history, presented to the facility ' s Emergency Department (ED) with right upper quadrant pain and swelling ; the pain started after he drank heavily. The patient had one previous admission on 9/12 with similar complaints. The patient was admitted on 4/10/14 with the diagnosis of alcohol withdrawal. The patient was treated with thiamine, folic acid, Librium , fluid and pain management. The discharge Summary indicated that the discharge date was 4/11/14. The discharge disposition: to home; follow-up appointment: behavioral health clinic: " to be scheduled, Medicine Clinic to be schedule"

It was noted that there was no discharge planning evaluation located in the record. Staff # 31 was interviewed , in the unit, on 4/11/14. This staff stated that he did not get a chance to speak to the patient. This patient was discharge before the discharge planning evaluation was completed.

2. During the tour of the unit (DN4), on 4/11/14 at approximately 12:35 PM, the medical record for the patient in MR # 20 was reviewed. It was noted that the patient was admitted to the facility on 2/22/2014. It was noted that this patient, 57 year old female with history of meningioma , cerebral vascular accident x2, diabetes, hypertension, pulmonary embolism, s/p PEG (Percutaneous Endoscopic Gastrostomy), bed bound and nonverbal since November 2013, was sent from a nursing home for altered mental status and hypotension. While in the hospital, the patient developed respiratory distress and she was intubated; she was placed on a mechanical ventilator. It was noted that the patient was hemodynamically stable and she was awaiting placement since 4/1/14.

It was noted that the first social work discharge planning noted was dated 2/27/14 at 1904. This assessment was not timely as it was over seven (5) days after admission.
The social worker noted 'met with patient's daughter who expressed that she want the patient to go to a rehabilitation facility for short term and then be discharge home" . The Social worker also stated that the patient's daughter does not want the patient to return to River manor. It was noted that the discharge planning evaluation did not include if the patient's post discharge needs could be met in short term rehabilitation or if the patient's daughter's request were practical. The reason the patient's daughter did not want the patient to return to River Manor nursing home was not included in the assessment.
On 4/09/14, the social worker noted "Concord SNF ( skilled nursing facility) is in network and will accept patient now". This patient was still in the hospital on 4/11/14. The reason why the patient's daughter did not accept this nursing home was not documented. On 4/11/14 at 1256, The Social worker noted "spoke with daughter who will visit Four Seasons this afternoon and follow up with social worker for final decision". This assessment did not include what would happen if the patient's daughter refused this skilled nursing facility.

Staff #32 was interviewed ,in the unit, on 4/11/14. This staff reported that one of the obstacle, causing the delay with the discharge plan, was that the patient is now a ventilator dependent and few nursing homes have ventilator beds. It was noted that there was no documentation that this was discussed with the patient's daughter.

3. MR # 17 was review on 4/11/14. It was noted that the patient, 75 year old female, with medical history of hypertension, diabetes Hyperlipidemia, and obesity who underwent total knee arthroplasty of left knee(TKA) on 1/6/14. The patient was admitted on 1/15/14 due to dislocation of TKA components. The patient was transferred to another hospital on 2/3/14. It was noted that this patient did not have reassessment of her discharge planning evaluation during this admission.

It was noted that the patient was advised by the orthopedic that due to the instability of the TKA she would need a second procedure. However, the procedure would be done at another hospital. It was noted that the patient agreed with the discharge plan to home and to follow-up as an out-patient. On 2/3/14 at 0931 ( 9:31 AM), the patient informed the physician that she would like to go home but she has no one to take care of her. It was noted that this patient was admitted on 1/15/14 with anticipate discharge date of 2/1/14. The patient was forced to accept a transfer to another facility instead of discharge to home.

Hospital Manual (HM) # 120-05-10; Category : Provision of Care, Treatment and Services - Subject: Discharge Planning - PC 15.20 reviewed 3/1/14 was reviewed on 4/11/14. Discusses the profession involve in the discharge planning. However, this policy does not specify a time frame for discharge planning screening and timeframe for completing discharge planning evaluations.
- The Hospital manual ( HM) 3 120-05-133 ; Category : Provision of Care, Treatment and Services (PC)- Subject: Psycho-Social Screening and Assessment - PC 1.02.01 reviewed 3/1/14 was reviewed on 4/11/14. It was noted that although the patient in MR #19 did not fit the criteria for the psycho-social screening and assessment as stated in the policy. This patient required a discharge planning evaluation before discharge.

- It was noted that under this policy "General Care - Admitted Patients" Patients readmitted within 14 days due to discharge planning problems fall under the social work moderate risk criteria. The purpose of adequate discharge planning is to prevent readmission. Therefore, the social psycho-social screening policy cannot be substitute for discharge planning evaluation - assessment and reassessment policy.

Based on staff interviews and review of medical records, it was determined that the facility failed to provide patients with a choice of home care agencies (HHAs) and not to limit which qualified providers the patients may choose from HHA agencies.

Findings include:

Staff # 29 was interviewed on 4/9/14. This staff stated that facility has contract with three home care agencies , Village Home Care, HHC Home Care and VNS (visiting nurse service) and the patients are referred to these agencies. This was noted in two (2) of three (3) applicable medical records reviewed.

Staff # 34 and staff #36 were interviewed, in the unit, on 4/11/14. They stated that if the patient was admitted with home care services then the patient will be referred back to that agency. However, new home care referrals are made to one of the following home care agencies: HHC Home Care , Village Care and Visiting Nurse Service agency .

MR # 21 was reviewed on 4/11/14. It was noted that this 51 year old patient was admitted to the facility on 4/4/14. It was noted that 4/11/14 on at 1314 (1:14 PM), the social worker noted that the patient will return home with "CHF management from VNS of NY". It was noted that the patient was not provided with a choice of home care agency. The reason why the patient was not given a choice of home care agencies was not documented.

Similar finding note for a patient who was given choice in home care agency or the reason for this decision was noted in MR #22.

Based on staff interview and review of documents and procedure, it was determined the hospital failed to confirm arrangements for home health care agency services for one of two behavioral health patients with identified home care needs upon discharge.

Findings include:

During tour of unit on R3W on 4/9/14 at approximately 12:15 PM, MR #3 was reviewed. The patient had been discharged home at approximately 12 PM. Review of the medical record revealed this 46 year old female had been admitted on inpatient psychiatry on 3/24/14 following a suicide attempt in which she had taken an overdose of norvasc (a medication used to lower blood pressure). The patient was initially treated on inpatient Medicine where she was also receiving continuous oxygen for chronic obstructive pulmonary disease. Patient was noted to have a past history of schizophrenia as well as hypertension, asthma, chronic obstructive pulmonary disease (COPD), and substance abuse.
A physical therapy assessment (PT) on 3/22/14 at 2 PM indicated a need for ambulation training and transfers due to bilateral knee pain and recommendation for home care and continued home physical therapy after discharge.
The patient was assessed by a Social work intern, on 3/26/14 where it was indicated the patient will return to scatter site apartment housing and Personal Recovery Oriented Services (" PROS") program for outpatient mental health services. It was noted that Visiting Nurse Services would be explored. On 4/1/14, the social work intern noted the patient wanted information about Access-A-Ride and Visiting Nurse Service (VNS). (Access- A-Ride is a resource for transportation for persons with physical disabilities) The patient was encouraged to follow up after discharge with Access-A-Ride application due to need to obtain a photograph. It was noted at that time an application would be placed for VNS.
On 4/7/14, a physical therapy note (PT) indicated she was able to ambulate 100 feet with rollator. It was noted no further PT is needed but the patient could be discharged to home with recommendation for home care services when medically cleared.
On 4/8/14, the Social Work intern noted that after discussion with the patient's Health Plus caseworker, the patient would need VNS after discharge. However, two family members would need to be involved with her care due to suicidality and the day schedule program would need to be rearranged to accommodate VNS once per week between the hours of 9 AM and 4 PM. After a family meeting with the daughter, agreement was noted with the plan, and the worker noted a referral was made for these services. On 4/9/14 a follow up social work note from the intern indicated the caseworker, therapist, mother, and daughter were all in agreement with the plans. This note indicated a referral to VNS is "pending".
The nursing discharge note of 4/9/14 indicated the patient left the unit with a walker and would also be followed by an intensive case manager (ICM) worker and has a Monitoring, Referral, and Linkage unit (MRLU) worker post discharge to monitor progress in the community. There was no evidence of written coordination for the VNS referral.
Review of written Inpatient discharge and aftercare plan instructions dated 4/9/14 determined these were signed by the patient but this document lacked written details about Visiting Nurse Services referrals and home care arrangements. The instructions also lacked documented follow up plans to refer for Access-A-Ride transportation needs and did not document a medical follow-up appointment.
The inpatient psychiatric discharge summary dated 4/10/14 indicated the patient had been treated for bipolar disorder and borderline personality disorder. She returned to the medical unit for weaning from continuous oxygen and following clearance was returned to the psychiatric unit the day prior to discharge. She had been receiving Bilevel positive airway pressure (BIPAP) machine therapy at night. (BIPAP is a machine which maintains airway and ventilation for persons with respiratory conditions). The patient was noted to have no functional limitations following provision of a rolling walker and that she was referred to Behavioral health Medical Suite for outpatient primary medical care. However, review of discharge instructions provided to the patient did not contain a written appointment for medical follow up.
During interview with the staff #25 on 4/14/14 at approximately noon it was reported a referral was made to Visiting Nurse. It was also reported that a Monitoring Referral and Linkage unit (MRL) maintains a separate database of post discharge follow up with the patient. These documents, titled "Discharge Follow up abstract" was provided to the surveyor on 4/14/14. This document noted that during contact on 4/10/14, the patient reported "Health first" would assist with a home health aide and a nurse to assist her in the apartment.
The issue noted in the medical record prior to discharge regarding the time conflict between the outpatient mental health services and hours of availability of home care had not been resolved.
The hospital's discharge plan was prospective, and did not confirm that home care services had been arranged nor document a validated date of home visit. The hospital deferred arrangements for home care to be made by an outside entity, "Healthfirst".
Review of procedures on 4/14/14 for discharge planning in Behavioral Health titled: "Aftercare Planning and Discharge Protocol" indicates that 24 hours before discharge the inpatient social work staff must enter complete aftercare information into the medical record including outpatient and housing provider details. The responsibilities are described for each professional and indicate that psychiatrists are responsible for orders and referrals for placements, entitlements, and other continuing care applications as needed. This policy found no reference or details to describe how arrangements are made for behavioral health patients who require skilled nursing or home care visits post discharge.
Review of hospital wide Social Work procedure titled "Discharge planning, PC.04.01.03" on 4/14/14 finds there is no reference to the hospital's process for home care agency referrals.