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Based on a review of personnel records, staff interview and medical records, the hospital did not ensure that personnel are properly licensed and qualified for their title and position.

Findings include:

The hospital has a Psychiatric Unit/Mental Health Services, which is required to meet both the general criteria for hospital units and the specific criteria for psychiatric units. The psychiatric unit must furnish, through the use of qualified personnel, psychological, social work, psychiatric nursing and occupational and recreational services.

1. A review of the hospital's job description for the director of psychiatric nursing services revealed that the person must be a registered nurse who has a master's degree in psychiatric and mental health nursing, or its equivalent, from a school of nursing accredited by the National League for Nursing, or be qualified by education and experience in the care of the mentally ill. The director must demonstrate competence to participate in disciplinary formulation of individual treatment plans; to give skilled nursing care and therapy; and to direct, monitor, and evaluate the nursing care furnished.

Review of the personnel record of Staff #14, who was recently promoted to a Director of Nursing in Mental Health Services, on 1/2011, revealed that the graduate degree was a Masters of Science in Nursing Administration, not in Psychiatric/Mental Health Nursing. According to the resume, Staff #14 had worked as a staff nurse in Psychiatric and Mental Health nursing from 2/1976 to 2/1978 and and as a Clinical Adjunct Professor from 9/1996 to 5/2002, which does not qualify her by education and current experience for care of the mentally ill.
Therefore, the newly designated Director of Psychiatric Nursing Services is not qualified in accordance with accepted standards of practice and established facility policies and procedures, including the facility's job description for this position.

2. Review of the credentialing record of Staff #15 revealed that the person the facility credentialed as a psychologist, is not currently licensed as a psychologist. However, Staff #15 is currently licensed as a registered nurse. According to Staff#15's credentialing record, she was approved, on 4/10/10, for the following delineation of privileges for psychologists: "Leader of Psychotherapy Group; Co-Leader Multi-Family Group; Family Therapy; and Individual Psychotherapy."

The Hospital's Medical Staff Bylaws, Article 14.1 Adjunct Staff state, "members of the allied health professionals ("AHPs"), including psychologists, physicists, physician assistants, special assistants, nurse practitioners, certified nurse midwives, doctoral scientists, and others as the Medical Executive Committee may from time to time recommend to the Board of Directors for appointment, shall be organized for administrative purposes only into an Adjunct Staff." "All members of the Adjunct staff whose areas of professional activity are governed by a licensing statue in the State of New York shall possess such a valid licensure, registry or certification as a condition for appointment or reappointment."

Based on observation, document reviews and staff interviews, it was determined the facility failed to construct a seclusion room to ensure patients rights to a less restrictive intervention than chemical and physical restraints in addressing patient behavior that is violent or destructive to self or others.


Findings include:

The facility stated in its Plan of Correction dated November 22, 2010, that the "space on the unit shall be evaluated and options shall be developed for appropriate seclusion space by the Director of Facilities and Director of Mental Health. A plan will be in place in 45 days. Construction will be completed by February 28, 2011." However, during a tour of the Mental Health Unit on March 7, 2011 at 11:30 AM, it was noted that the facility did not have a dedicated seclusion room.

This finding was verified by Staff #2 at that time.

The facility's "Seclusion" policy revised 11/10 references a seclusion room.

THIS IS A REPEAT CITATION FROM THE INITIAL SURVEY OF OCTOBER 22, 2010.

Based on facility documents reviews and staff interviews, it was determined that the facility Quality Assurance and Performance Improvement Program (QAPI) did not have an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes.

Findings include:

During the review of documents submitted by departments to the QAPI program from January 2010 to January 2011, it was noted that not all the departments at the facility were submitting data to the program. Departments critical to maintaining patient safety in the performance of their departmental functions, e.g., Dietary, Respiratory and Housekeeping, did not submit data regularly to the program. There was only one submission of data from Dietary department in the described period. During interview on 3/10/11 at 3:00 PM, Staff #25 stated that the department previously submitted data, but not to QAPI. The data submitted by Respiratory department was submitted to another program (Patient Care Services). The report from Patient Care Services did not mention the data from Respiratory department. On 3/10/11 at 3:05 PM, Staff #1 submitted a copy of the data from Respiratory department for review. Staff #1 also stated on 3/11/11 at 3:30 PM that, although housekeeping managers were always collecting data, a format for presentation of the data to QAPI needs to be developed. At 4:30 PM on 3/11/11 after the exit conference, Staff #1 stated that data from clinical departments are submitted to the Patient Care Services director whose secretary formulates the narrative summary submitted to QAPI.

Based on observations and staff interviews, it was determined that the facility failed to ensure that medical records were being stored in a secure location at all times.

Findings include:

On 3/10/11, during observations of the Rehabilitation facility in Pawling, the following item was noted and confirmed by Staff #6:

The medical records were stored in the receptionist's unlocked drawer near the entrance of the Rehabilitation facility. This is not a safe and secure location.

Based on medical records reviews on 3/7/2011 - 3/11/2011, it was determined that the facility did not ensure that all orders are dated, timed, and authenticated promptly by the ordering practitioners. This was found in 7 of 28 medical records. (MR #s 3, 14, 15, 18, 19, 27 and 28).

Findings include:

1. During observations and review of medical records, it was revealed that in MR #15 on 3/5/2011 the MD order to increase Risperdal to 3mg po bid was written and signed but the time it was ordered was not documented.
On 3/6/2011 the physician's progress note was signed and dated but the time was not indicated.
On 3/6/2011 the orders to start SA status and increase Seroquel to 100mg po BID were signed, but the time ordered was not indicated.

2. A review of MR #14 revealed that on 2/25/2011, Flexeril 5mg po tid, prn for pain x 3 days was ordered by the MD but the time it was ordered was not written.
On 3/1/2011 the orders for Flexeril 5mg po TID x 2 days, check O2 saturation every 6hrs, call if the patient feels SOB were dated and signed, but the time they were ordered was not indicated.
On 3/5/11, the order for Flexeril 5mg po, TID x 2 days, prn for lower back pain was dated and signed, but the time ordered was not written.

3. A review of MR #18 revealed that the MD progress note was written on 1/4/11 on two occasions and signed but the time each order was written was not indicated.
The MD orders on 1/1/2011 for Haldol 5mg, Ativan 2mg, Vistaril 50mg po now, if refuses, give IM were written, but the date and the time they were ordered, were not documented.
The MD orders given on 1/4/11 for Vistaril 50mg, Ativan 2mg, Haldol 5mg IM, stat orders and Seroquel 200mg po bid order were written and signed, but the time ordered was not written.

4. Similar findings were noted in MR #s 3,19, 27 and 28.

Based on observations made during the survey, the facility did not ensure that outdated, mislabeled, or otherwise unusable drugs and biologicals were not available for patient use.

Findings include:

The following expired items were found:
A. In the laboratory on 3/7/11 at 11:15 AM to 12:10 PM, witnessed by Staff #3 and #16, were:
1. Cytoseal expired on 07/07.
2. Microscope immersion high velocity expired 02/09.
3. Eight light blue Vacutainers expired 01/11.
4. Two red Vacutainers expired 02/11.
5. Thirteen red/black Vacutainers expired 01/11.
6. Four opened blood gas kits with heparinized syringe and kept in the storage.

B. In the Radiology Department on 3/7/11 at 12:15 PM to 1:00 PM, witnessed by Staff #3 and #17, were:
1. A bottle of 1000cc of sterile water opened and not dated or timed.
2. One pack of 200 gauze dressing opened and dingy looking.
3. Video camera drape expired 0/11 found in the ultrasound room #1.
4. Six red Vacutainers expired on 02/10.

C. In the oncology department on 3/8/11 at 2:25 PM to 3:00 PM, witnessed by Staff #23, were:
1. Eighty Providone Iodine cleaning pads expired 02/10.
2. One pack of 200 gauze dressing opened and discolored.
3. Twenty tongue depressors expired 04/10.
4. Three Accufoam cushions expired 05/10.
5. One Accufoam cushion expired 11/10.
6. One Betadine solution expired on 01/11
7. Fifty Providone Iodine cleaning pads expired 12/10.

D. In the wound care department on 3/8/11 at 3:00 PM to 3:10 PM, witnessed by Staff #s 19 and 23, were:
1. One pack of 200 gauze dressing opened and discolored.
2. Juices in the refrigerator expired 11/10.

Based on observations, the facility did not ensure that periodic inspection of equipment was made and hazards identified promptly corrected.

Findings include:

1) On 3/8/11 at 2:25 PM, it was observed that televisions in the Oncology treatment areas did not receive annual preventive maintenance inspection. The inspection stickers on 3 of 5 televisions were dated 6/1/09. This was witnessed by Staff #23 at that time.

2) Also noted on 3/8/11 at 2:35 PM, was a Camera RPM Gating located in the Simulator Room with a 7/24/09 due date for inspection.

3) On 3/7/11 at 11:27 AM, a refrigerator in the Laboratory was noted without a handle to open the door. This was witnessed by Staff #3 at that time.

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

Findings include:

During observation and inspection of the kitchen, cafeteria, and food service areas conducted on 3/07/11 through 3/11/11, staff interview and review of the dietary policies and procedures manual, the following items were noted:

1. During the tours of the dietary areas on 3/7/11 through 3/11/11, cracked floors and walls were observed throughout the kitchen areas, creating a harborage for insects, and unsanitary and unsafe conditions.

2. During the tour of the kitchen on 3/7/11, the kitchen sink, located in the cooking area, did not have an indirect drain.

3. On 3/7/11, the concentration of the sanitizing solution in the buckets throughout the kitchen and pot sanitizing sink was checked using chemical test strips and was found to be excessively high. Chemicals used for sanitizing are not to have concentrations which will leave toxic residues on surfaces treated. On 3/11/11, the concentration of the sanitizing solution was checked again and found to be in an acceptable range.

4. On 3/7/11, the door to the outside delivery area and loading dock was observed to contain gaps and openings to the outside and was not protected against the entrance of insects and rodents.

Based on observations, staff interviews and document reviews, it was determined that the facility failed to maintain a safe, sanitary and comfortable environment to ensure that the safety and well-being of patients are not compromised.

Findings include:

1. During observations of the patient floors/areas from 03/07/11 to 03/11/11 between 10:30 AM to 4:00 PM, it was noted that the grills/heating elements of some heating/air-conditioning units in patient rooms (such as rooms in the Maternity Suite) exhibited accumulation of dirt and dust in the grills and around the floor perimeters beneath their edges. Trash (such as paper, candy wrappers and pencil) was found inside the air-conditioning/heating unit resting directly on the heating filament.

All findings were verified with Staff #5 and Staff #12 at the time of observation.

2. During observations from 03/07/11 to 03/11/11 between 10:30 AM to 4:00 PM, it was noted that the exhaust ventilation vents in different areas of the facility were very dirty, which leads to environmental contamination. Examples include but are not limited to:
i. On 03/08/11 at 11:00 AM during the tour of the Pharmacy, it was noted that the exhaust vent above the laminar hood used for preparation of drugs was very dirty with a thick accumulation of dirt and dust.

ii. On 03/08/11 at 11:30 AM during tour observation of the clean linen room, the exhaust vent in the room above clean linen was noted dirty and dusty.

iii. On 03/09/11 at 11:45 AM during tour observation of the OR suite, it was noted that the exhaust vent in OR #8 was very dirty and dusty with excessive dust accumulation.

iv. On 03/09/11 at 2:15 PM, during tour observation of the Med/Surge unit on 2nd floor Reed Building, it was noted that the exhaust vents of the patient room bathrooms (such as bathroom of room #255) were very dirty and dusty.

v. On 03/11/11 at 3:00 PM during tour observation of the Maternity unit, it was noted that the exhaust vents in the patient room bathrooms (such as bathroom of room #106) were very dirty and dusty.

vi. On 03/11/11 at 03:15 PM, during tour observation of the Maternity unit, it was noted that the exhaust vent in C-Section OR was very dirty and dusty with excessive dust accumulation.

The findings were verified with Staff #5 at the time of observation.

3. During the survey from 03/07/11 to 03/11/11 between 10:30 AM to 4:00 PM, it was noted that facility did not ensure that the environment around the premises and the equipment used were maintained in a sanitary condition, and free of dust and dirt to prevent transmission of infection and contamination. Furthermore, the facility did not ensure that the physical plant was kept in good repair to ensure a sanitary environment.

Examples, including but not limited to, are:

a. The floor in the Rad room behind the x-ray control box, was noted very dirty and dusty and had garbage such as gloves and paper. Findings were verified with Staff #5 and Staff #26.

b. In the X-ray core room/space, the floor around the perimeters of the desks/cabinets had sticky black material/dirt residue.

c. X-ray room #4 was noted dusty and dirty around its perimeters.

d. Elevator machine room in building 665 was noted very dusty and dirty.

e. The two hyperbaric chambers in the Wound center were noted dusty and dirty inside the chambers. Staff #23 stated that staff cleans the stretcher after every patient but the chamber itself is not cleaned after patients but is cleaned weekly.

f. Use of sticky tape was found in many places around the facility. Tapes were found stuck on stretchers, OR door, upholstery of chairs/mattresses and similar other places. If tape and its sticky residues are not cleaned properly, they are a means of cross-contamination.

g. In the Pharmacy it was noted that the perimeter of a table/desk on the 'Oral Preparation' side had excessive accumulation of dust, dirt and debris.

h. A portable air-conditioner 'R2D2' in the Clean linen room was noted laden with heavy accumulation of dust and dirt.

i. The walls of the Clean linen room were noted in gross disrepair
(broken/ revealing underneath structure) with accumulation of dust, dirt and debris.

j. Clean linen room has an attached ex-laundry room which is not in commission, is very dusty, in disrepair and is used as storage area. It was noted that there was an approximate 10 x 10 inch hole in the wall communicating between the two rooms. This arrangement leads to cross contamination.

k. In the Laboratory, a portable a/c unit was noted installed in the office area with dirty, dusty filter.

l. In the Phlebotomy collection section of the laboratory, excessive amount of dust and dirt was noted in the track of the window opening to the outside.

m. Pulmonary function test equipment in the Respiratory therapy department was noted dirty and dusty.

n. The wall outside OR #6 and OR #7 was noted in gross disrepair. The wall was broken, had punch holes, and revealed the structure within.

o. The nitrogen pipes in OR #6 were noted grossly dirty with sticky adhesive (remnant of tape) and dirt filaments.

p. The med gas room in the OR suite had cob webs, dust, and dirt all around the room. Furthermore, there was a pool of water under the gas tank.

q. Many wooden doors of the patient rooms/areas around the facility were noted in disrepair and exhibited splinters. Examples, including but not limited to, are patient room doors of the Behavior unit, C-section OR in Maternity unit, and Room #12 in Emergency Department.

r. The glucometer kit in the Emergency Department was noted very dusty.

s. The floor of the C-section OR was noted stained with orange/red and yellow stains.

t. The wall behind the bed of room #112 in maternity suite, was noted in disrepair with holes.

All findings were verified with Staff #5 and other unit staffs at the time of observation.

4. During a tour of the Behavioral Health unit on 03/10/11 at 11:45 AM, it was noted that:
i. The handles of drawers in the bed were dusty.
ii. Bed mattresses were noted damaged/discolored or dirty with stains in the rooms, including but not limited to, Quiet room and room #402. Also, the bed sheet in patient room #402 was noted ripped.
iii. Looping hazards were noted in the patient bathrooms such as:
(a) Door handles of the patient room/Quiet room bathrooms in the unit were not the approved type, and pose risk for looping hazard.
(b) The mixing valves for the showers in the bathrooms were not the approved type and pose a risk for looping hazard.
iv. The art supply cabinet in the Day room was noted very dirty and dusty.
v. The dining room chairs in the Day room were noted made of very heavy metal. They were not fixed to floor and could be picked up. This type of chair may be used by disruptive patients as a means to harm other patients, and thus poses a risk for safety hazard.

Findings were verified with Staff #5 and Staff #19 at the time of observation.

5. During the survey from 03/7/11 to 03/11/11 between 10:30 AM to 4:00 PM, it was observed that several ceiling tiles on different floors of the hospital showed signs of old leaks. Examples include, but are not limited to:
a) On 03/07/11 at 12:30 PM, during tour observation of the Central Sterile Supply room, two ceiling tiles were noted stained in the clean work area.

b) On 03/08/11 at 11:30 AM, during tour observation of the Pharmacy, three ceiling tiles were noted dirty/stained in the area.

c) On 03/08/11 at 2:45 PM, during tour observation of the Laboratory, two ceiling tiles were noted dirty/stained in the area.

d) On 03/09/11 at 11:30 AM, during tour observation of the OR suite, one ceiling tile was noted stained in the sterile supply storage room.

e) On 03/07/11 at 11:45 AM, during tour observation of the Radiology suite, one ceiling tile was noted stained in the storage room by the x-ray rooms.

All findings were verified with Staff #5 at the time of observation.

NOTE: If ceiling tiles are not replaced and stay humid/wet, they may harbor the growth of mold/fungi and contribute to environmental contaminants. Also, stained ceiling tiles need to be investigated for potential leaks above, as it may be an indication of a problem with the plumbing/sprinkler system or of insufficient insulation around the steam pipes supplying heating to the facility.

6(a). On 03/11/11 at 12:00PM during the survey of the Emergency Department, it was noted that when a nurse call bell was elicited from a patient room, it did not register in the medication room, clean utility room, soiled utility room and other areas as required by AIA 7.32.G1.

The findings were verified with Staff #5 at the time of observation.

6(b). On 03/07/11 at 11:30 AM, it was observed that the patient toilet in the waiting room of the Radiology department had no emergency call bell as required per AIA 7.32.G7.

7. During the survey from 03/07/11 to 03/11/11, it was noted that the water cooler/ice dispenser unit on different patient areas/floors such as ICU, Maternity and Med/Surg unit had greenish/white residue (most probably hard water residue) around the end of the water dispensing pipes. Also, the filters of the water cooler/ice dispenser machines and the areas around the dispenser were noted especially dusty and dirty.

All findings were verified with Staff #5 and other unit staffs at the time of observation.

8. During the survey on 03/07/11 and 03/09/11, it was determined that the facility failed to ensure that the patients' environment remains free from accident hazards. The facility did not ensure that the temperature of hot running water at the hand wash sinks accessible to patients and staff, were maintained at acceptable levels [not to exceed 110 degrees Fahrenheit (F)] to prevent potential burns. Hot water temperatures of 117?F-116*F were noted in the Ambulatory surgery unit and Pharmacy Department.

Findings were verified with Staff #5

9. The kitchen and dietary area were not maintained to ensure an acceptable level of safety and quality for the patient and staff.
See A 620.

Based on observations, record reviews and staff interviews, it was determined that the facility did not meet the applicable provisions of the Life Safety Code, NFPA 101, 2000 edition.

Findings include:

During the survey of the facility from 03/07/11 to 03/11/11, Life Safety Code deficiencies were noted in multiple areas of the Code requirements and were cited under the following Fire/Life Safety Code tags:

K-12 (Structural elements not completely protected /fire proof);
K-17 (Corridor walls not maintained for its rating;
K-18 (Corridor doors not kept free of impediments);
K-25 (Fire/Smoke barrier not constructed/maintained for its fire rating);
K-46 (Emergency Battery power backup lights maintenance for off-site clinic locations could not be verified);
K-50 (Fire drill not performed under varying conditions);
K-52 (Fire alarm system maintenance for off-site location clinics could not be verified);
K-62 (Sprinkler Alarm system not maintained as per NFPA);
K-73 (Decorations/Artifical trees not fire proof);
K-104 (Penetrations in smoke/fire barrier not completely sealed/protected);
K-130 (Business occupancy and Health care occupancy separation not maintained/built);
K-160 (Fire fighter recall not installed on all patient-serving existing elevators);
K-211(Alcohol Based Hand Sanitizers not installed away from ignition source).

Based on observation and interview, it was determined that regulated medical waste was not secured and handled in a manner to prevent unauthorized access (as required by State law, thus Federal).

The findings are:

On 03/08/11 at approximately 11:45 AM, the storage/loading area for the medical waste was inspected. Numerous plastic bins labeled regulated medical waste were noted in the storage room. These bins were full and waiting to be loaded/transported. This area was unsupervised at the time of inspection. It was noted that the loading area was accessible for unauthorized access from outside since the door was not locked and one leaf did not latch positively. Findings were verified with Staff # 5.

Based on observation, it was determined that the facility did not ensure that all facilities/areas and equipment were maintained in such a way to ensure safety and quality for the patient and staff.

Findings include:

1. During survey of the Ambulatory Surgical Unit on 03/09/11 at 11:00 PM , it was noted that blanket warmer was reading 167?F. Staff were unaware of the required temperature at which the blanket warmer should be maintained, however temperature range posted by the manufacturer on blanket warmer was not more than 150*F. To avoid any injury/burns to the patient, the temperature must be maintained at the required ranges as per the manufacturer's recommendation .

2. On 03/09/11 at 11:45 am, during the observation of OR suite, it was noted that the positive pressure ball/indicator installed outside OR #9 was not moving when the door was being opened or shut. It was stuck in outward position. The purpose of the ball is to provide visual verification of positive pressure. The ball is supposed to move inwards when the door is open and outwards when it is closed. The room exhibited positive pressure after a simple tissue test; however, as per Staff #5, the ball was not functioning. Finding was verified with Staff #23.

3. On 03/7/11 at 11:00 AM, during survey observation of the Radiology department, it was noted that 'Safety shut off switch' of the CAT scanner was blocked by a cart of clean linen supplies. Staff present acknowledged that such arrangement hinders prompt access to the switch in case of emergency.
Finding was verified with Staff #5 and Staff # 26.

4. On 03/11/11 at 11:55 AM, during the observation tour of the Emergency department, it was noted that shut off panel for the facility's main HVAC system was located in the janitorial/housekeeping closet. The shut off panel was not secured from unauthorized access. The closet was noted to be very small and contained janitorial supplies and bucket. Such unprotected arrangement of the shut off panel may lead to accidental shut off of the HVAC system.

5. On 03/07/11 at 11:45 AM during tour of the Radiology Department, it was noted that supplies such as wood shelves, cardboard boxes and other combustible items were stored in Electrical room of the CAT scanner. Such arrangement not only hinders easy accessibility to the electrical panels but also creates a fire hazard.

6. On 03/07/11 at 2:30 PM, during the tour of the bulk storage area it was noted that a big cart was stored in front of the mechanical room door. This arrangement compromises easy accessibility by the staff to the door in case of an emergency.

7. On 3/10/11 during observations of the Rehabilitation facility in Pawling, the following items were noted:
a) The two fire extinguishers in the Rehabilitation facility did not have documented evidence on the attached tag to show that they were inspected monthly, as required.

b) The Temperature and Cleaning Log for the Hydrocollator, Paraffin equipment, and freezer failed to show documented evidence that these equipment items were cleaned monthly between October 2010 and February 2011, as per the facility's cleaning log instructions.

Based on observation and staff interviews, it was determined that the facility did not ensure that proper humidity levels were provided and monitored in the ORs and that proper ventilation was provided to other areas of the building.

Findings include:

1. (a) On 03/08/11 at 2:00 PM, it was brought to the surveyor's attention by another survey team member that the humidity of
OR #8 was 15%.

On 03/08/11 at 2:15 PM, Staff # 5 was interviewed regarding the mechanism of monitoring the temperature and humidity. Staff #5 stated that the system of monitoring temperature and humidity of the ORs is such that only Staff #5's computer monitors and shows 'real time temperature and humidity' and that Staff #5 is responsible to notify the surgical department if any discrepancies occur. The software system is such that it cannot generate paperwork output and therefore no logging or trending is done for the values. Since Staff #5 was with the surveyor at that time, he could not verify if the temperature was out of range earlier in the day.

1 (b) On 03/09/11 at 11:00 AM , Staff #5 stated that the humidity of OR #8 was 28% yesterday and on the morning of 03/08/11. During observations of the ORs on 03/09/11 at 11:15 AM, it was noted that the ORs have a monitoring device installed on the walls of all ORs. When the humidity was checked for OR #8, the monitoring device was still reading 15%. Staff #5 stated that he was unsure if the sensors reporting to the computer were transmitting an inaccurate reading or if the devices on the wall were not functioning properly.

1(c) Staff #8 was interviewed regarding if the temperature and humidity of the ORs were monitored by any other method or by OR staff. Staff #8 stated that the engineering department was responsible for central monitoring and no monitoring was done in the OR itself before or during an operation.

Therefore, it could not be determined if the values of temperature and humidity were routinely maintained as per CDC guidelines, how often they fell out of compliance, and if they fluctuated during surgery.

2. On 03/09/11 at 11:30 AM during the tour of the OR suite, it was noted that the room used for storing sterile packages did not have any monitor/gauges installed to ensure that the temperature and humidity were as per CDC guidelines and AIA Table 2. Finding was verified with Staff #8 and Staff #5.

3. (a) On 03/09/11 at 11:45 AM during the tour of the OR suite, it was noted that one out of two exhaust vents in OR #8 did not have any suction and the other one had a weak suction. This situation compromises the per hour air exchanges required as per AIA Table 2.

3 (b) Mechanical exhaust vents in C-Section OR were noted blocked by the storage of equipment.

4. During the survey from 03/07/11 to 03/11/11 between 11:00 AM to 4:00 PM, it was noted that non-patient areas that may contribute to infection control/contamination did not have the required ventilation/air-pressure as per AIA 1996-97 Table 2.
Examples include, but are not limited to, the following:
a) Soiled Utility Room and one housekeeping closet in the OR suite were neutral pressure instead of negative.
b)One housekeeping/soiled utility room (that had clean scrubs and other soiled items stored) had positive air-pressure instead of negative.
c) Clean utility room in the Recovery area of the Ambulatory Surg was neutral pressure instead of positive.
d) Soiled Utility room in the Ambulatory Surg was neutral pressure instead of negative.
e) Housekeeping closet in the Mental Health unit was positive pressure instead of negative.
f) Soiled utility room in the Emergency Department (by the fast track) was positive pressure instead of negative.

5. During the tour of the Intensive Care unit on 03/10/11 at 12:45 PM, it was noted that a refrigerator used for storing patient food was reading a temperature of 53*F. This was brought to the attention of Staff #19. No range for correct temperature was posted anywhere to alert staff regarding the correct temperature.
Also, it was noted that in the log posted on the refrigerator no temperature was written for March 8 and 9, 2011. Also, staff had documented values up to 56*F in the log for the month of January 2011.

Note: As per standard of food safety, food should be stored at a temperature of 32*F-46*F.

Based on observations, policy reviews and staff interviews, it was determined the facility failed to implement its policies to ensure that a clean and safe environment was maintained to minimize the spread of infections. Staff #s 9, 10,11 and 22.

Findings include:

1. Equipment was not maintained in manner to prevent the spread of infections. A code cart in the ED was noted to have an excessive accumulation of dust on March 7, 2011 at 12:15 PM in the storage bracket. A glove and a suction canister were also observed in this bracket.

2. Observed in operating room (OR) #1 at approximately 10:30 AM on March 8, 2011, was an excessive amount of debris on the floor prior to the beginning of the surgical procedure. This included at least twelve pieces of of caps, paper, and other objects on the floor.

In addition, equipment that was not used during the procedure was stored in the OR #1. When interviewed at 11:00 AM on March 8, 2011, Staff #8 acknowledged that some of the equipment has been stored in the OR. Staff #8 also stated at that time that only the equipment that was used during a procedure was cleaned after each surgical procedure as indicated by the facility's policy. Therefore, the equipment that was stored in the OR was not cleaned between surgical cases per the facility's policy.

2. The staff failed to carry out proper hand hygiene after their hands became contaminated to prevent the spread of infections. On March 8, 2011 at 10:47 AM, Staff # 9 was observed picking up a towel from the floor. Staff #9 then proceeded to pick up a packet containing sterile equipment without sanitizing her hands.

3. Staff #9 who was wearing a pair of gloves, was observed on March 8, 2011 at 11:09 AM picking up an item from the floor in OR #1. Staff #9 removed the gloves but did not carry out any hand hygiene before continuing the preparation for the next procedure.

4. On March 8, 2011 at 10:53 AM, Staff #10 was observed picking an object from the floor but did not sanitize or wash her hands before proceeding with other tasks.

5. Staff #11 was observed at 10:55 AM on March 8, 2011 picking up a chux from the floor in OR #1. Staff #11 placed the chux on top of the headrest on the OR table on which the patient's head was later placed.

6. Staff #11 was also observed at 11:25 AM on March 8, 2011, lifting and rearranging a machine's electrical cord which was lying on the floor while wearing a pair of gloves. Staff #11 proceeded to re-position the patient's head without changing gloves or performing hand hygiene.

The facility's hand hygiene policy approved 11/10 states hand washing was must be performed before applying and after removing gloves.

7. Observed on March 9, 2011 at 3:48 PM at PHC-Outpatient Rehabilitation Services offsite location at Yorktown, were twelve rolls of toilet tissue and 5 rolls of hand towels stored in the dirty utility room, which also had a mop, cleaning agents and a sink. The twelve toilet rolls and 2 of the 5 rolls of hand towels did not have any protective covering, therefore posing an increased risk of contamination from splatters. This finding was witnessed by Staff #6 at that time.

8. On March 7, 2011 at 2:20 PM on the maternity unit, two nasal cannulaes in rooms 102 and 105 which were attached to the oxygen outlets, did not have any protective covering. It could not be determined if the cannulaes had been used. The findings in the maternity unit were witnessed by Staff #12 at that time.


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9. On 3/8/11 at 10:00 AM to 10:30 AM, a patient with a central venous cannulae in the dialysis room was observed being treated by Staff #22 while witnessed by Staff #3. Staff #22 was observed changing the dressing at the access site. Staff # 22 removed the old dressing with gloves and was seen covering the site with a gauze swab without changing the gloves.
After this, Staff #22 was observed taking off the soiled gloves and donning sterile gloves without sanitizing or washing her hands. Staff #22 failed to use proper technique in cleaning the area.
Staff #22 was observed cleaning the wound in a circular motion outwards but occasionally went back inwards to the exit site to clean with the same q-tipped swab.
After the completion of the procedure, the noted infection control violations were discussed with Staff #s 22 and 3, noting the critical steps in the procedure omitted by Staff # 22.

Based on observation and staff interview, it was determined that the facility did not ensure a safe environment consistent with recognized infection control practices, prevention of cross contamination by keeping clean supplies separate/away from dirty areas, and ensuring that all patient care equipment is in good repair to prevent infection control.

Findings include:

1. On 03/07/11 at 3:15 PM, during observation of the bulk storage area it was noted that the clean items in open boxes were stored beneath the water and chiller pipes going along the ceiling in the room. The pipes indicated old evidence of leaks. There was no barrier between the pipes and the clean items. This condition may lead to contamination since the water condensation may contaminate the clean supplies stored beneath the chiller and water pipes.

2. On 03/07/11 at 3:30 PM during survey of the Central Sterile supply room, it was noted that the ceiling tiles in the room were porous/had holes that may retain dirt (they were not monolithic) and thus were not as per AIA 7.28.B8. Such porous ceiling tiles compromise thorough cleaning of the ceiling which is required to keep the environment of Central Sterile as clean/sterile as possible.

3(a) As per AIA 7.2C1, at least one isolation room is required for the nursing/surgical unit (and more may be required as per the infection control committee). The facility has 2 isolation rooms on med/surg units. During observation of these units on 03/09/11, it was noted that the two isolation rooms did not comply with all requirements of Section 7.2.C4 for isolation rooms that states that 'air borne infection isolation room shall have self-closing devices on all room exit doors'.The ceiling tiles were porous and were of such material, that they would not minimize the retention of dirt as required by 7.28.B8 and would not be thoroughly washable/cleanable.

Similarly the isolation room in the ICU and Emergency department lacked non-porous ceiling tiles and also did not have self-closure on the sliding exit doors of the room.

Note:
By not having a self-closure at the door, the room will not to be able to maintain optimum negative pressure as required, and may contribute to contamination of the corridor outside the isolation room.

All findings were verified with Staff #5 at the time of observation.

3 (b) It was also noted that there is no room/arrangement for patients who are immunocompromised/Neutropenic and require protective environment/positive air-pressure room on the Med/Surge floor. As per the nursing staff, the facility does treat such patients/community and the procedure has been to use a regular room and use HEPA filters.

Note: As per AIA 7.2.D, the Infection department needs to assess the community's need for such room based on the frequency/ volume of treatment to such patients, and if the numbers are high enough, should at least provide one such room.

3 (c) As per AIA 7.4.A6, an airborne infection isolation room is required in or near at least one level of nursery care. During the survey, nursing staff stated that the one isolation room present in nursery may be used for air borne isolation purposes. However, it was noted that the ceiling tiles in this isolation room were not of non-porous material as required by AIA 7.28.B8 for an airborne isolation room.

4. During the survey of the Surgical Suite and Emergency department(ED) on 03/09/11 and 03/11/11 respectively, it was noted that a room identified as Housekeeping closet/ Environmental Service room by Staff #23 (the room was not labeled) in OR, and the Housekeeping room in ED, had clean scrubs and clean linens stored in the room.

5. During survey of the facility from 03/07/11 to 03/11/11 between 10:30 AM to 3:45 PM, it was noted that many Soiled Utility rooms had an abundant amount of clean supplies (such as toilet rolls, paper towels, and other clean supplies) stored in the same room. This was noted in the Soiled Utility room of the Emergency Department, Med/Surg area and ICU.

6 (a) On 03/09/11 at 11:45 AM during the tour of the OR suite, it was noted that the air pressure indicator/ball outside OR#7 did not indicate the room to have positive air pressure. A simple tissue test was used to verify the flow of air and the tissue exhibited no outward movement which is typical for a positive air pressure ( all other ORs were positive at the time of survey). A procedure of 'Percutaneous Nephrostomy recess' was being performed in this room. Staff #8 stated that nobody paid attention to the positive air indicator/ball not being in its correct position. The OR #7 air pressure was neutral at the time of survey.

Staff #5 requested his engineering staff to check at that time regarding what the problem might be. A few minutes later, Staff #5 stated that the staff had found some problem with the belt and other components of HVAC system which needed maintenance. Staff #5 was asked how the facility ensures that positive air pressure is always provided in the OR. Staff #5 stated that apart from regular preventive maintenance and visual indicator of the pressure ball installed above the OR doors, there was no other way to ensure the positive air pressure.

Preventive maintenance record for the OR HVAC system was requested on 3/8/11 but not provided to the surveyor.

(b) Air flow in the Clean Sterilization workroom was neutral rather than positive as required.

7. On 03/08/11 at 11:30 AM, during the survey of the Main Clean linen room/laundry in the basement, it was noted that the floor and ceiling of this room was very dirty with an accumulation of dust and dirt all around its perimeters. This may lead to cross contamination of the clean linens that are washed and stored here and are ready to be used by the patients

All findings were verified with Staff #5

8. Many areas of the facility were dusty and dirty which may contribute to cross-contamination of infection. Refer to Tag 701.