HospitalInspections.org

Based on document review, (Complaint Log) and staff interviews, the facility did not resolve grievances submitted by all patients.
This is evident in 5 of 9 patient grievances reviewed. MR# 12, 37, 38, 39 and 40.

Findings include:

1. On 4/29/09 the patient, medical record MR#12, filed a complaint with the patient relations director alleging poor care after her endoscopy procedure on 4/29/09. The complainant also alleged poor infection control practices by the nurse who attended her indicating that the nurse cleaned the surfaces and instruments in the room without wearing gloves and also gave her food without washing his hands.

On 3/24/10 the complaint was followed up and revealed that the complaint had not been fully resolved by the facility. Upon interview, Staff #19 stated that he was not interviewed by anyone in reference to the complaint. Staff #19 also stated that he wipes down surfaces without gloves but would wear gloves to wipe the post procedure areas as he is afraid of stool. Staff #8 does not remember the complaint being referred to her for follow-up. Staff #8 also searched the computer data base and said there is no specific policy and procedures for cleaning surfaces in the endoscopy procedure rooms.

Upon further investigation, in the response letter sent by Staff #12 to the complainant on 5/1/09 the facility wrote: "In discussing your comments with the charge nurse we feel that you have provided us with an opportunity to address the need for additional communication training with our staff." The letter continues: "Please be assured that your concerns have been shared with nursing administration for their follow-up with the staff involved in your care that day."

There was no documented evidence that the staff involved were interviewed in reference to the complaint, nor was any communication issues addressed with him.

On 3/25/10 at 10:12AM during a meeting with Staff #12 and #7, Staff #12 stated once the issues are referred to the individual departments for follow-up she does not require proof from the department that the follow-up was done. Staff #7 stated the follow-ups are being done in department meetings and individually as needed but may not have been sent back to Staff #12 to show evidence of resolution.

Staff #12 stated that the policy will be updated to require proof from the individual departments that the complaint was fully resolved. If the investigations are not completed, she will report to Quality Assurance that they are pending resolution.

2. The patient medical record MR #37 had a complaint about her birthing experience at the facility. This involved the nursing staff, medical staff, and hospital protocol for pain control. In the letter to the complainant, Staff #12 documented that "education has been provided to the Birthing Center Staff so as to ensure that issues of this nature do not arise again."
Upon review of the investigation of the complaint, there was no indication that education was provided to staff to prevent a re-occurrence. Issues raised regarding Dr .....have been referred to the Medical Director ......as well as the President of the Medical Staff, as required pursuant to our physician complaint protocol."
However, resolution of the complaint by the Medical Director and the President of the Medical Staff was not available for review as part of the facility complaint resolution process.

3) The patient medical record MR #38 complained about care provided by a Physician Assistant (PA) and a nurse in the Emergency Department (ED) on 4/12/09. Although statements were taken from the nurse on 5/12/09 and communicated to Staff #12 on 5/13/09, there was no interview about the care provided by the PA. The PA' s progress notes were the only references made in the investigation as evidence of care provided.
The facility investigation noted that Staff #12 would follow-up with the ED director concerning the physician assistant.

4) Patient medical record MR #39 complained about care provided in the Emergency Department. Staff #12 concluded that the care provided was appropriate but communication issues were identified as the reason for the patient's concern.
In the response letter sent to the complainant Staff #12 wrote: "we do agree that the staff who cared for you needed a review of the hospital's expectation of respect and caring. Our emergency department management team has performed that review and has plans to review with all of the staff at an upcoming staff meeting."
The ED director documented 4/09/09 to review the patient's chart with the PA, but there is no documentation that this occurred. There is also no documentation that the complaint was reviewed with all of the staff at the meeting as discussed.

Based on observation and staff interview, it was determined that the facility did not ensure that the family waiting area in the PT/OT unit (at Cornwall campus) was arranged to ensure privacy of the patient treated in the open gym area.

The findings include:

On 03/24/10 at 11:00AM during the observation of the facility, it was noted that the family waiting area in the PT/OT unit is arranged so that family members can directly see the patients being treated in the gym area. It was noted that a male patient was receiving a stretch muscle treatment/exercise of the legs on one of the gym's treatment beds which was visible to the waiting area.

Staff #25 stated that the facility does have some private rooms with screening. Screens are only provided if the patient requests it, otherwise the treatment is done out in the open since the facility considers it standard practice.

However, AIA 1996 9.1.H states that 'Each facility design shall ensure each patient audible and visual privacy and dignity during interviews, examinations, treatment, and recovery'.

Based on a review of policies and procedures, medical record review and from interview, the facility failed to ensure that policies and procedures with associated monitoring forms were developed for patients who receive medications used as restraints. MR #36
Findings are:

1. A review of the Policies for Restraint and Safety, PC0308, and Psychiatric Patients in the Emergency Room, 46161P-5, revealed that Medications used as Restraints (formerly Chemical Restraints) do not address monitoring of vital signs, and frequency of assessment. The monitoring form, "Restraint Device Nursing Flow Sheet" only addresses Physical Restraints.

2. From a review of medical record #36, the monitoring of vital signs did not occur with sufficient frequency to ensure prevention of patient injury or death.

The patient was seen in the ED 2/4/10 at 2020. According to the ED Patient Summary, the patient was medicated at 2035 and restraints applied to both arms at 2240. Diphenhydramine 50mg, Haldol, Haldol 10 mg, Lorazepam 2 mg were given at 2039. Response is documented as "effective". Vitals were only recorded at 2206. Additional Haldol and Ativan were given on 2/5/10 at 0153. Vital signs were recorded at discharge, 2/5/10 at 0157.

3. The Restraint Device Nursing Flow sheet indicates medication given as "alternative" before restraints. There is no monitoring of vital signs on the form for medications, only the record of monitoring the patients response to the physical restraint, every hour.

4. Since no policy was developed for monitoring medications used as restraints, vital signs were not recorded every 15 minutes as is the standard of practice for medications used as behavioral restraints.

5. Interview with the ED and Risk Managers on 3/29/10 revealed that there should have been more monitoring of vital signs than what was in the record. Staff #1 indicated a new policy and associated forms will be developed to address medications used as restraints.

Based on medical record review and staff interviews the facility did not ensure that registered nurses supervise and evaluate nursing care of patients who developed pressure ulcers after admission to the facility. MR#'s 11, 16, 28, 41.

Findings include:
1. On 3/24/10 at 12:00PM, the medical record for the patient MR #11 was reviewed and revealed that the Hourly Rounding sheet was checked for positioning, but it could not be determined what position the patient should be in, when observed in his room at 12:10PM. Staff #39 stated that the patient needs to be repositioned but when this is done, staff just applies a check mark on the form. Staff #2 stated at 12:10PM that the use of the form to document positioning of the patient has not been fully implemented as a policy, nor has the inclusion of the form as a part of the medical record been finalized.

2. On 3/25/10 at 2:45PM the patient, MR #16, was observed in bed on the 1st Floor patient care unit at the Cornwall campus. Hourly Rounding Documentation was checked under the section designated for positioning. It could not be determined what position the patient should be on when he was observed in his room at 2:45PM. Staff #13 stated that the patient needs to be repositioned but when this is done the staff just check off on the form as this is not a positioning record form. Staff #7 stated that she is not familiar with the use of the form as a positioning record form.

3. The patient, MR #41, had a complaint that was being investigated. Staff #2 stated that prior to the complaint investigation, the facility did not maintain a position record on patients that require positioning. She further stated that going forward the Hourly Rounding Document will be used to record the patient's positions. The document will then become a part of the medical record when the facility has finalized the document and educated staff.

On 3/29/10 at 11:40 AM, Staff #16 and #2 was interviewed regarding the facility's statistical report on pressure ulcers, which showed that unit 1W had a high prevalence of pressure ulcer. Both staff members explained that the patients on 1W were typical Skilled Nursing Facility patients and corrective actions are being worked on to ensure that pressure ulcers are better identified, responded to and cared for at the facility. They said a task force committee is addressing the issue.

Based on medical record reviews, policy reviews and interviews, it was determined that the facility did not ensure that its medical staff authenticated verbal orders. This was found in 6 of 41 medical records reviewed. This was found in MR's # 6, 8, 22, 23, 24, 35.

Findings include:

1. Verbal orders were not authenticated within 48 hours as required by the facility's policy. A review of MR # 6 on March 23, 2010, revealed verbal orders dated March 12, 2010 were not signed by a physician, 11 days after the order was written. This record also contained another verbal order written on March 17, 2010 which was not signed by the prescribing physician.

2. Review of MR #8 on March 24, 2010 revealed 3 verbal orders for dialysis treatments, written on March 17, 2010 for this patient who had Acute Renal Failure, were not signed by the prescribing physician.

Staff # 2 verified the findings at that time. Staff # 2 also stated during an interview on March 23, 2010 at approximately 3:05 PM, that the facility's policy requires that verbal orders must be signed within 48 hours.

3. Review of MR #23 revealed telephone order for 1 % Hydrocortisone Cream topically written on 3/22/2010 at 2020 that was not signed by the prescribing physician until 3/26/2010.

4. A review of medical records in the ICU on 3/23/2010, MR# 35, revealed that A DNR Form #4 (Adult Patient Without Capacity With a Surrogate) was not completed.
The section of Attending Physician Notice to Patient of DNR Order was not checked.
The Attending physician signed the form, but the date and time was not indicated.

5. MR #24 revealed that the transfer order on 3/19/2010 was not signed by the physician. A verbal Heparin order on 3/20/2010 at 12:45 PM and Dilaudid order on 3/19/2010 at 12:45 PM were not signed by the prescribing physician.
This was verified with Staff #36.

6. During medical record review in ICU on 3/23/2010 and 3/26/2010 of MR #22 revealed that a telephone order on 3/23/2010 for Kayexalate 30gm P.O. was not signed by the prescribing physician until 3/26/2010. A consultation on 3/22/2010 was not signed by physician.

Based on medical record reviews and staff interviews, the hospital did not ensure that medical records contained documentation of properly executed informed patient consents in 4 of 41 medical records reviewed. This was found in MR #6, #24, #27, #35.

Findings include:

1. A consent for surgery and/or diagnostic procedures and/or sedation was not signed by a physician. MR #6 was reviewed on March 23, 2010. The medical record contained a consent for Left Lower Extremity Revascularization, an operative procedure, which was signed by the patient on March 11, 2010. The patient underwent the procedure that day, but up to March 23, 2010, twelve days later, the consent form was not signed by the physician. This is particularly significant since the procedure involves laterality and the consent form was allegedly reviewed for the type and laterality of the procedure during a timeout in the OR.

This finding was verified during an interview with Staff #2 at 3:10PM on March 23, 2010.

2. Review of MR #27 revealed that a consent for surgery and/or diagnostic procedures form for a Central Line Placement was not signed, dated or timed by the physician. The form was signed and dated on 9/15/09 by the patient.

3. From a review of medical records in ICU on 3/23/2010, and 3/25/2010: MR #24 revealed that on 3/19/2010, a consent for Administration of Anesthesia was signed by a physician, but not dated and timed. This was rechecked on 3/25/2010, and it was not completed.
A consent for Operative &/or Diagnostic Procedures &/or Sedation was signed by a physician, but the date and time was not indicated. This was rechecked on 3/25/2010, and it was not completed.
A consent for transfusion of blood, plasma, and other blood component was not signed by a physician and date and time was not indicated. This was rechecked on 3/25/2010, and it was not completed.

4. During review of medical record in ICU on 3/23/2010:
MR# 35 revealed that DNR form #4, Adult Patient Without Capacity: With a Surrogate, was not completed. The section of Attending Physician Notice to Patient of DNR Order was not checked. The attending physician signed the form, but the date and time was not indicated.

Based on medical record review and staff interviews, the facility did not ensure that the medical record is complete. Reports of treatments, medication records, and positioning forms necessary to monitor the patient's condition were not promptly documented in the medical record. In the dialysis unit, manual conductivity of the dialysate was missing for one patient reviewed.
This was evident in 6 of 41 medical records reviewed. MR #10, 11, 16, 24 28 and 41.

Findings include:

1. On 3/24/10 at 11:25AM, the medical record for patient, MR #10, was reviewed and it was noted that the:
a) Nursing assessment was not completed for the patient who was admitted on 3/17/10 at 1735.
b) The medical record did not contain evidence that the patient or the patient's proxy was given a copy of the Patient Rights.
c) There were omissions in the Medication Administration Record (MAR). On 3/20/10 at 2100 the medication Amiodaron HCL 200mgs was due to be administered to the patient per oral route. A blank space was noted on the MAR. There was no explanation in the medical record why the nurse did not give the medication.
These findings were witnessed by Staff #2 who spoke with nurse who admitted the patient.

2. On 3/24/10 at 12:00PM the medical record for the patient, MR#11, was reviewed and it was observed that the:
a) Hourly Rounding Documentation was checked for positioning but it could not be determined what position the patient should be when he was observed in his room at 12:10PM. Staff #39 stated that the patient needs to be repositioned but when this is done the staff just applies a check mark on the form. Staff #2 stated at 12:10PM that the use of the form to document positioning of the patient has not been fully implemented as a policy, nor has the inclusion of the form as a part of the medical record.
b) A physician's order was written for MRI test procedure on 3/21/10, which was not picked up by the nurse. The MRI was performed.
c) There were omissions in the Medication Administration Record (MAR). On 3/20/10 at 1300 and 0500 on 3/22/10, the Intravenous (IV) site flush that was due to be administered to the patient at the IV site was not done. A blank space was noted on the MAR. There was no explanation in the medical record why the nurse did not flush the site. Similarly the medication Hydralazine HCL 25mgs per oral route every 8 hours was due at 0600 on 3/22/10 and was not documented as given to the patient.

3. On 3/23/10 at 11:45AM, the patient MR #24 was observed in the ICU during a dialysis treatment. The treatment record was reviewed and was noted not to have a record for the manual conductivity of the dialysate. During the interview, Staff #10 said the manual conductivity meter was broken and the test was not performed. Staff #9 was present and said the meter broke on Friday 3/19/10 and arrangements will be made for an immediate replacement of the meter.

A. Based on observations and staff interviews, the hospital failed to ensure that drugs and biologicals that are outdated or inappropriately labeled are not for patient use.

Findings include:

1. Outdated medications and biologicals were found in the hospital Emergency Department (ED) at the St. Lukes Cornwall Hospital - Newburgh campus.
a. On March 22, 2010 at 11:12AM, an opened bottle of Hydrogen Peroxide was not dated.
b. At 11:21AM on March 22, 2010, in the ED, a bottle of Alcon Tetracaine Hydrochloride eye drops was found opened, but not dated.
c. At 11:30AM on March 22, 2010, an opened bottle of Diatrizoate Meglumine and Diatrizoate Sodium Solution with an expiration date of February 20, 2010 was found in the ED.
d. On March 22, 2010 at 11:35AM, an opened bottle of Motrin elixir was not dated in the ED.
1A. Outdated medications and biologicals were found in the hospital Emergency Department (ED) Operating Rooms. On March 22, 2010 at 3:05PM, an opened bottle of Alcohol solution was found not dated in operating room (OR) #3 at the Newburgh campus. This finding was verified by the OR manager at that time.

B. Based on observations, the facility did not ensure that expired drugs, instruments and biologicals were removed from storage areas where they could be used for patient care.

Findings include:

1. On 3/22/10 between 11:05AM and 11:30AM, the following were observed on patient care Unit 2 at the Newburgh campus:
a) At 11:05AM, one opened sterile instrument tray was found in a storage cabinet in the clean utility room.
b) At 11:20AM, one opened and undated 1000cc sterile water bottle was found on the shelf in the clean storage room.
c) At 11:25AM, an opened and undated container of Apple Sauce was found in the medication refrigerator. This was stored with other medications e.g. Insulin. Staff #2 confirmed that the nurses use this to give medications and should have been dated.
d) At 11:45AM, a Percutaneous Sheath Introducer Kit with an expiration date of 11/2009 was found in the storage cabinet in the medication room.
e) At 11:50AM, an opened Yankauer Suction Catheter package was found in storage cabinet in the medication room.
f) At 12:02PM, the crash cart in front of room 207 was observed unlocked. The plastic lock was applied to the bottom of the cart but the drawers were not locked. Included in the one of the unlocked drawers was a tube of Topical Anesthetic which could be accessed by patients or unauthorized individuals. Staff #2 said sometimes the drawers jam and the cart does not lock properly.

A2. On 3/22/10 at 1: 45PM during an observational review of patient care Unit 3 at the Newburgh campus in room 307, it was observed that a bottle of sterile water for inhalation therapy was attached to the O2 delivery port in the room. The bottle of sterile water was unlabelled with a date. On further review, it was revealed by Staff #2 that the sterile water belonged to the previous patient in the room and should have been discarded before the new admission was admitted into the room. It could not be determined if the room was terminally cleaned before a new admission was placed in the room. During interview with Staff #15 at 2:30PM on 3/26/10, it was confirmed that nursing staff should have removed all used clinical care items from the room before housekeeping cleans the room in preparation for the next admission.

2. During observation of the Radiology department on 3/22/10 at 2:40PM on the Newburgh campus the following was found:
a. One box of Single Hole Latex Free Nipples with about 50 nipples in the box, all with the expiration date of 1/11/09, was observed in the storage cabinet. The nipples are used to feed babies with radiological mediums as needed in test procedures. This observation was witnessed by Staff #21 and #7.
b. A tube of SurgiLube with the expiration date of 3/09 was also found in a mobile cabinet kept in the X-Ray room.

A3. Laboratory observations revealed that on 3/23/10 at 3:15PM a bottle of opened and undated 1000cc of sterile water was observed on the processing counter in the laboratory. Staff # 17 explained that the staff pours the water from the container into other containers to process lab tests. On 3/26/10 at 11:35AM, Staff #17 was interviewed and stated that a policy will be developed to date and time the opened bottle of sterile water and discard after 24 hours.

3. On 3/25/10 at 2:20PM, an observation of the 1st floor in-patient unit at the Cornwall Campus was conducted with Staff #13, #7 and #22. The following were found in the unit's medication room storage area:
a. 18 gauge 1 ¼ Angiocath with expiration dates of 01/2010.
-1 gauge 1 ¼ Angiocath with expiration dates of 12/2009.
-4 gauge 1 ¼ Angiocath with expiration dates of 1/2010.
b. 3 bottles of green Vacutainer containers with expiration dates of 11/09.
-2 bottles of blue Vacutainer containers with expiration dates of 01/2010.
c. At 2:40PM, the emergency box was observed with a Temporary Pacing Catheter with shrouded pins introducer kit that expired on 11/2009.
d. Also inside the emergency box were 4 Monitoring Electrodes with expiration dates of 06/06, 11/05, 12/09 and 12/09. An Angiocath with expiration date of 05/07 was also observed. There were also 15 sachets of lubricating jelly, each with the expiration date of 10/07 in the emergency box.
Upon the discovery of these expired items on the unit, Staff #13 stated that the staff must be reading the expiration dates incorrectly.

4. On 3/25/10 between 3:00PM and 3:25PM, an observation of the Laboratory Department at the Cornwall campus was conducted with Staff #7 and #14. The following expired items were found:
a. 9 expired Sample Probe Cleaner bottles with expiration dates of 1/1/10 were found on the shelf in the storage room. One of the bottles was marked with the word, "Expired." Another set of the cleanser which Staff #14 said was still good had a bottle that had expired on 1/8/09 mixed with the stock.
b. 8 containers of Certified Blood Bank Saline 4 liter size with expiration dates of 02/10 were found in 2 boxes in the storage room.
c. 14 yellow and 1 green Vacutainer specimen containers with expiration dates of 11/09 were also found in the storage room. Also found were 3 red Vacutainer specimen bottles with expiration dates of 9/09.
d. On a work station counter inside the lab was found a bottle of opened 1000cc of sterile water dated 2/25/10 and timed 2PM which should have been discarded 24 hours after opening.

5. During observation of the ICU (including Coronary Care Unit) on March 22, 2010 at the Newburgh campus:
a. Outdated Triadine was found in the Catheterization Laboratory with expiration date of 8/2009.
b. Inside of the Difficult Intubation red box, two outdated Cricothyrotomy Catheter sets were found with expiration date of 2/2010.
c. In the Crash Cart, outdated Easy Cap II Co2 detector was found with expiration date of 2/2010.

6. During observation of the X-ray/CT department on March 22, 2010, at the Newburgh campus:
a. Outdated "X-ray Cut Down Tray" was found with expiration date of 9/15/2000.
b. Outdated Flexible Tube Disposable was torn and was found with expiration date of 2009/07.

7. During observation in the ED at the Cornwall campus at 3:30PM on March 25, 2010, a box of outdated suture mixed with 5-0/4-0 Chromic Gut and one outdated Ethyl Chloride Spray were found in the suture set cart:
a. 5-0 Chromic Gut had an expired date of 2007-01,
4-0 Chromic Gut had an expired date of 2009-02,
b. Gebauer's Ethyl Chloride Spray, mist spray (Topical Anesthetic Skin Refrigerant) which temporarily controls pain was opened and dated on 3/21/2010 at 2130 which had an expired date of October 2009.

Based on observation and review of the dietary policy and procedure manual, it was determined that the facility did not provide dietary and food services in a sanitary manner.

Findings include:

A) During observation and inspection of the kitchen and food service areas at the Newburgh campus conducted on 3/22/10 and 3/25/10 and review of the dietary policies and procedures manual, the following items were noted:

1. On 3/22/10, potentially hazardous cooked food (turkey breasts weighing 8 to 11 pounds) were not cooled by an adequate method to ensure that every part of the turkey product reached the desirable temperature within the required timeframes.

2. On 3/22/10 at approximately 2:30 PM, the operation of the dishwashing machine was observed. The temperature of the final rinse cycle was noted to be below 135 degrees Fahrenheit. The manufacturer's required temperature for the final rinse is 180 degrees Fahrenheit. There was no other sanitizing solution in use with the dishwashing machine at that time. Review of the Hospital's, "Dish Machine Area Temperature Log" for the month of March 2010, showed recordings of Final Rinse temperatures of 102 degrees Fahrenheit on March 13, 120 degrees F on March 21, and 131 degrees F on March 9-12.

3. On 3/22/10, five out of five cutting boards observed were noted to have excessive wear and were not easily cleanable.

4. On 3/22/10, clean pans, being stored on shelves, were observed stacked and wet and not properly air-dried.

5. On 3/22/10 and 3/25/10, at least four sinks used for food preparation or food service were observed without indirect drains. There is to be no direct connection between the sewage system and any drains originating from sinks and equipment used for food or drink preparation.

6. On 3/22/10 and 3/25/10, at least four sinks used for food preparation or food service were observed without strainers.

7. On 3/22/10, chemical test strips were not available to test the efficacy of the sanitizing solutions used in the kitchen. Therefore, there was no method available to assure that adequate chemical concentrations were achieved to provide for proper sanitation of the dishwashing machine, potwashing, counter tops, etc.

8. On 3/22/10 and 3/25/10, garbage containers in the food preparation and utensil washing areas were observed uncovered when not in use.

9. On 3/25/10, live ants were observed on the floor of the food storage room.

10. On 3/22/10, the door to the loading dock area was observed to contain gaps and openings to the outside and was not protected against the entrance of insects and rodents.

11. On 3/25/10, at least five food trays were observed to be chipped, and therefore, were not easily cleanable, as well as, a potential safety hazard to the patients.

12. On 3/22/10, an open metal food cart was observed having shelving that was cracked and broken, and therefore, was not easily cleanable.

13. On 3/22/10 and 3/25/10, the covers on the bins containing rice, flour and bread crumbs were observed cracked and broken, and therefore, not adequately protecting the food items from contamination.

14. On 3/22/10 and 3/25/10, broken, cracked and/or missing floor tiles were observed throughout the kitchen and food service areas.

15. On 3/22/10 and 3/25/10, soiled and stained ceiling tiles were observed throughout the kitchen and food service areas.

16. Two dented food cans (#10) were noted stored on the shelves in the kitchen area.

17. On 3/22/10 at 12:15 PM, four scoops being used on the patient tray line were missing a bottom cap on the handle, therefore, they were not easily cleanable.

B. On 3/22/10, in the 7th Floor Kitchen Pantry on the Newburgh campus, the following was observed:
1. The ice machine was broken and did not provide ice.
2. The microwave was soiled and needed to be cleaned.

C. During observation and inspection of the kitchen and food service areas at the Cornwall campus conducted on 3/22/10, and review of the dietary policies and procedures manual, the following items were noted:

1. On 03/22/10 at 12:15PM, during observation of the kitchen at Cornwall Campus, it was noted:

a. Several closed cheese bulk rolls stored in the refrigerator, were dated as 3/6, 3/8, 3/9 and 3/11. As per Staff #23, the items were dated as when they were received. Staff #23 was asked regarding the time period for storage of perishable items. Staff #23 stated that all the items in the refrigerator are to be stored for 10 days after they are received/dated. He also stated that the items are to be dated when they were opened.

b. It was noted that in another refrigerator, two 8 lbs tubs of fruits were noted open and they did not have a date when they were opened. Staff #23 later stated that the facility goes by expiration date on the product. No policy was available indicating what is the policy to store the items after they are opened/seal is broken.

c. The facility provided a newly developed policy and procedure on 03/24/10, however no evidence was provided to show that all staff were in-serviced or educated on the new policy.

2. On 03/22/10 at 11:45AM during observation of the kitchen in the Cornwall campus, it was noted that the janitor's closet (which was opening directly into the kitchen washing area) had an approx 15x 20 inches hole in the wall. This situation may lead to insects/rodents infestation. Furthermore, it was noted that the floor and walls were very dirty and were not kept in good repair which may also contribute to insect infestation. It is to be noted from observation many mouse/insect traps were beneath the kitchen sinks and around the kitchen area. Findings verified with Staff #22, Staff #28 and Staff #29.

3. It was found that the preparation area's sink was leaking from beneath.

4. Garbage such as food, paper, and gloves were found under all the sinks and on the floor.

5. Doors of the two main refrigerators in the kitchen did not latch positively when released. This situation does not enable the doors of the refrigerator to seal properly until manual/staff intervention is done. The refrigerator not sealing properly will result in the unit not being able to maintain the required temperature for cold food storage.

6. Inside lid of the ice-cream deep freezer was broken with the underlying insulating material visible. Staff #23 stated that a new one was in order and till then the facility is using this unit.

7. The gasket of the refrigerator in the cafeteria was noted broken and dirty. Several other refrigerators on other floors of the hospital (both sites) had a similar issue of broken and dirty gaskets.

8. The burger grill in the cafeteria (Cornwall campus) was noted dirty on 03/22/10 at 12:20PM. At 4:00PM when the cafeteria was closed and the cafeteria staff had left, the grill was still noted to be dirty with thick accumulation of grease and grime all around it on the top and its periphery. At 12:20PM, the lettuce holder at the Taco station was noted to be dirty also. These findings were shared with Staff #22.

9. On 03/22/10 at 12:15PM during the observation of the kitchen (Cornwall campus), it was noted that 8 bottles (gallons) of cooking oil, sauce, vanilla extract and similar items were stored under one of the sinks opposite the stove. Storing clean supplies under the sink increases the chances of contamination from the drain pipe.

D. The facility did not ensure that the temperatures of the food refrigerators at both sites were monitored accurately. The temperature logs had instruction that the temperature range of the refrigerators is to be maintained between 35 degrees Farenheit to 41degrees F.

As per Staff #36, the Dietary department is responsible for monitoring and recording the temperature in the morning and afternoon of all the nourishment refrigerators.

It was noted that the temperature logged in the morning and the actual temperature noted at the time of survey, differed by 5-6 degrees and was above or below the required range. Therefore, it was unclear how facility ensures that the required temperature range of 35-41degrees F is maintained at all times.

1. On 03/22/10 at 11:50AM, during observation of the kitchen (Cornwall Campus), it was noted that the temperature in the refrigerator used for juice bottles/cold drinks was reading 28 degrees F. The temperature log on the refrigerator indicated that the morning temperature recording at 5:30AM was 34 degrees F. Staff #23 was unaware if there was any problem with the refrigerator. It was further noted that the AM temperature for this refrigerator was 34 degrees F since 03/16/10 and in PM it was 30 degrees F-34 degrees F from 03/17/10 to 03/19/10. Finding was verified with Staff #23.

2. On 03/26/10 at 11:50AM, it was noted that the refrigerator for patient food in the nourishment room of ICU (Newburgh Campus) indicated the reading to be 45 degrees F. The morning temperature log indicated that the temperature was 39 degrees F. On all temperature logs, the policy is written to notify the supervisor if the temperature is above 41degrees F.

3. On 03/26/10 at 12:10PM during the observation of the Stepdown ICU unit (Newburgh Campus), it was noted that the refrigerator for patient food in the nourishment room was reading 35 degrees F, however the morning temperature was 30 degrees F. Staff #36 was not aware if any action is taken when the temperature is below the required range. This refrigerator had semi-solid food items (such as jelly, pudding and cream) stored. Staff #36 confirmed that the dietary department is responsible for monitoring and recording the temperature in the morning and afternoon

E. Review of the Food and Nutritional Policies and Procedures manual revealed that there were inadequate policies and procedures available to address safety practices for food handling and kitchen equipment. Many food and nutritional policies needed revision and some were last reviewed in 1998. In addition, there was no evidence available that a nutritional analysis of the menus was conducted to ensure that the meals provided to the patients meet the current national standards for the recommended dietary allowances.

The Condition of Physical Environment is not met since the hospital is not constructed arranged and maintained to ensure safety of it's patients and staff.

Findings are:

1. The facility did not maintain its premises in a safe, sanitary and comfortable environment to ensure that the safety and well-being of patients are not compromised.
See 0701

2. The facility did not ensure that all facilities/areas and equipment was maintained in such a way to ensure safety and quality for the patients and staff.
See A 0724

3. The facility did not ensure that proper ventilation was provided and monitored in patient care areas and other areas of the building.
See A 0726

4. The facility did not ensure that dietary and food services were provided in a sanitary manner, and that food preparation areas and related equipment and supplies were adequately maintained.
See A 0620, 0726

Based on observation, it was determined that the facility did not maintain its premises in a safe, sanitary and comfortable environment to ensure that the safety and well-being of patients are not compromised.

The findings include:

1. During the survey of the kitchen in Cornwall Campus on 03/22/10 at 11:45AM and survey of an off-site Rehabilitation Center (at Newburgh 9W) on 03/24/10 at 1:30PM, 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 kitchen fixtures, and temperature of hot water at the handwash 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 118°F was noted in the kitchen at the hand wash sink (by the exterior exit door).
The temperature at the off-site Rehabilitation Center could not be measured since a thermometer was not available, however the water was very hot on skin contact. Findings were verified with Staff #28, Staff #29 and Staff #31.

2. On 03/29/10 at 11:00AM, during observation of the Birthing Center (maternity suite) in Newburgh campus on 6th floor west wing, it was observed that in rooms (including but not limited to) #625 and #604, the heating units in patient rooms (including but not limited to above referenced rooms), exhibited accumulation of dirt and dust in the grills and around the floor perimeters beneath their edges. Also many heating units exhibited red brown stains on them. Exhaust vents above patient beds were noted to have thick accumulation of dust. Findings were verified with Staff #35, Staff #29, and Staff #33.
Similar findings were noted on 03/23/10 at 12:15PM in the Cornwall campus, 1st floor (1 west unit patient med/surg rooms) where pencil, straws and paper were found on top of the filament of the heating units and dirt was found around the perimeter of the heating units. These findings were found in rooms, including but not limited to, rooms #127 and #128.

3. On 03/23/10 at 12:00PM during the tour of 1st floor (1 west unit patient med/surg rooms) in the Cornwall campus, it was noted that the exhaust vents of the bathrooms in patient rooms were extremely dirty with very thick layers of dust accumulation. Examples include, but not limited to, rooms #124, #127, #132.
Similar finding was noted at the off-site Rehabilitation Center (at Newburgh 9W) on 03/24/10 at 1:30PM where also the vent in the bathroom was noted to be very dirty.
On 03/25/10 at 11:30AM, one of the bathrooms in Emergency Department (Newburgh campus) was noted to be unsanitary/dirty and had a 'sanitary pad' stuck on the wall. Findings were verified with Staff #35, Staff #30, Staff #28.

4. During the survey between 03/22/10 and 03/29/10, it was observed that several patient and visitor bathrooms on different floors of both hospital campuses and bathroom in outpatient areas, did not have appropriate emergency nursing call bell pull cords as required by AIA 7.32.G2. The emergency pull cords were either short in length, were tied up to a grab bar or were bunched together. This practice does not provide easy access for patient's safety. Also it was noted that the emergency call bell cords were dirty with accumulation of dirt. The examples include but are not limited to:
i) The emergency nursing call bell cord, in the patient bathroom in the endoscopy procedure room in Newburgh Campus 2nd floor, South Circle, was tied around a grab bar, thus not providing an easy access to a patient who might collapse on floor.
ii)The emergency nursing call bell cord in the patient bathroom in room #168 at Cornwall campus was tied up together thus not giving the required length to pull for the patient who might collapse on the floor.
iii)The emergency nursing call bell cord in the patient bathroom in the Rehabilitation Center in Newburgh (at 9W), was tied around a grab bar thus not providing an easy access to a patient who might collapse on floor.
Findings were verified with Staff #22, Staff #8 and Staff #28.

5. On 03/24/10 at 1:45PM during the survey of the off-site Rehabilitation Center at Newburgh (9W), it was noted that the drain pipe underneath the handwashing sink in the handicap accessible patient bathroom was not protected/insulated to prevent patient leg contact against hot water pipes. (ADA 4.24.6).

6. On 03/22/10 at 2:00PM it was noted that cold pack unit in the OT room (Cornwall campus) had ice/frost build up/accumulation and indicated that it had not been defrosted.

A similar finding was noted on 03/24/10 at 1:45PM at the off-site Rehabilitation Center at Newburgh (9W). The cold pack unit was noted to have excessive ice/frost build up. Frost buildup increases the amount of energy needed to keep the motor running and may put more load on the engine which in turn decreases the efficiency of the unit. The unit is to be frost free. This build up indicates the possibility that the heater element has failed. Therefore, it is a sign that the unit is not maintained and cleaned frequently to avoid contamination or infection control issues.

7. On 03/22/10 at 1:50PM Splint Therma unit in the PT/OT unit (Cornwall campus) was noted to be dirty around it's inside perimeter and the drain appeared to be clogged with black/grey type of accumulation.
It was also noted that the Paraffin bath unit had some type of dirt/inclusion floating in it. The bottom part of the unit was in disrepair and appeared melted and wrinkled.

The Splint tub unit in the outpatient Rehabilitation Center (Newburgh 9W) was noted to have a rusted drain on 02/24/10 at 2:15PM.

8. On 03/23/10 at 10:45AM it was noted that the water cooler/ice dispenser unit in the Emergency Department (Cornwall campus) had white residue/corrosion around the end of water dispensing pipe.
Similar finding was noted on 03/26/10 at 2:45PM at the Step Down ICU water cooler/ice unit (Newburgh campus, 2nd floor) where the water and ice dispenser in the nourishment room was found corroded and had a white residue around the water dispensing pipe. The ice dispensing part was also noted dirty with brownish and greenish accumulations.

9. During observation of the basement at the Cornwall campus on 03/23/10 at 11:45AM, it was observed that the facility has a room designated as a morgue. The body is held in the refrigerator in an alcove next to the room. The area/room was labelled as 'Pathology,' however, Staff #22 stated that a postmortem or any kind of procedure is not done in the facility, and that the refrigerator is used to hold the body until release.
The room had a toilet adjacent and directly opening to the alcove area where the morgue refrigerator is stored/kept. It was noted that the toilet was in disrepair and in unsanitary condition (with signs of dried urine on the toilet bowl). It was also noted that insects were crawling on the floor. It is to be noted that there was a gap between the floor and the refrigerator holding the body. Therefore, this might lead to an unsanitary environmental condition.

10. On 03/23/2010 at 10:30AM, it was noted that the floor in front of the cafeteria was broken and had missing tiles. This situation may lead to a fall/tripping hazard.
A similar finding was noted on 03/25/10 at 11:45PM on the Dialysis/Endoscopy floor (Newburgh campus). It was noted that the floor joint was broken thus creating a patient or staff tripping hazard.

11. The floor outside the Dialysis unit was also noted dirty with a trail of brown/reddish orange stains.

12. During the survey between 03/22/10 and 03/29/10, it was observed that several ceiling tiles on different floors of the hospital and outpatient clinic were stained and showed signs of old leaks. The examples include but are not limited to:
a) On 03/23/10 at 3:00PM three stained ceiling tiles were found in the corridor opposite the blood gas room on the 1st floor Cornwall campus.
b) One Stained ceiling tile was found inside the blood gas room on the 1st floor Cornwall campus.
c) On 03/24/10 at 1:30PM one ceiling tile above the nurse's station was noted stained at the off site Rehabilitation Center (Newburgh 9W).
d) On 03/25/10 at 12:15PM in Emergency Department of Newburgh campus, it was noted that two ceiling tiles in the corridor were stained.
e) On 03/26/10 at 11:45PM in ICU 2nd floor (Newburgh campus) one ceiling tile was noted to be stained.

If ceiling tiles are not replaced and stay humid/wet, they may harbor growth of mold/fungi and contribute to environmental contaminants. Also, the ceiling tile stain needs to be investigated for potential leaks above, as it is an indication of a problem with the plumbing/sprinkler system.

13. On 03/25/10 at 12:00PM, on the Dialysis/Endoscopy floor (Newburgh campus) it was noted that two-three lady bugs were on the floor outside the endoscopy procedure room and about 10-14 lady bugs were noted inside the bathroom of this endoscopy procedure room.

14. On 03/25/10 at 11:45AM, in the fast track room #6 of Emergency Department-Newburgh, 3-4 holes were noted in the wall.

15. On 03/23/10 at 3:30PM, a leak from the ceiling was noted in the corridor of the sleep center (Cornwall campus) and a water pail/bucket was placed beneath the ceiling. Staff #28 stated that the facility is aware about the leak and is working on it.

16. The kitchens and dietary areas, at both sites (Newburgh and Cornwall), were not maintained in a safe and sanitary manner.
See A 620.

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 the observation of the sub-basement (Cornwall campus) on 03/23/10 at 12:00PM it was noted that 2-3 inches of stagnant/standing water on the floor. This area houses components of the HVAC system. It was noted that wires were floating in the water. The floor was in disrepair. Big pieces of fabric were found floating near the drains which might lead to further clogging of the drains. Findings were verified with Staff #28 and Staff #29.

2. On 03/23/10 at 2:55PM, it was noted that the pump room door situated in the main clean linen storage room (Cornwall) was blocked by a cart of clean linen and thus was not readily accessible to the engineering staff if emergency repairs were needed. As per Staff #29, this pump is especially important during summer when the air conditioner (a/c) is working and any kind of repair or monitoring of the a/c unit is required.

3. On 03/25/10 at 11:55AM, it was noted that a blanket warmer in the Emergency Department (Newburgh campus) had instructions posted on the warmer that the temperature should not be more than 135°F. At the time of survey it was noted that the temperature of the blanket warmer was reading 147°F. Finding was verified with Staff #35 and Staff #8.

Similar findings were noted for the blanket warmer on 03/29/10 at 11:00AM, during a tour of the Birthing Center (Newburgh campus on 6th floor west wing). It was noted that the temperature of the blanket warmer was at 157°F. No range of temperature was posted on the blanket warmer and Staff #38 was unaware of the required temperature the blanket warmer should be maintained. It is important to maintain these temperatures at the required ranges as per manufacture's recommendation to avoid any injury/burns to the patient.

4. On 03/24/10 at 2:20PM during observation of the off-site Rehabilitation Center (at Newburgh 9W), it was noted that the power cord of the refrigerator in the phlebotomy room was resting and passing the hand wash sink installed in the room. This arrangement may lead to electric shock hazard to the staff.

5. Light fixtures were not in working condition. These findings include but were not limited to the following: At (Newburgh campus): In room #1 in the ED on March 22, 2010 at 11:10AM, the light fixture was not in working condition. This finding indicates lack of sufficient lighting to perform assessments and evaluations of patients. This finding was verified by Staff #41 at that time.

b. The light fixture on the wall in room 8 in the ED on March 22, 2010 at 11:16 AM (Newburgh campus), was not in working condition. This finding was verified by Staff # 41 at that time.

c. Similarly, light fixtures on the walls of rooms 9 and 11 in the ED (Newburgh campus) were not in working condition at 11:18 AM and 11:20 AM respectively, on March 22, 2010.

6. Equipment was not inspected to ensure that they were safe for patient use.
a. On March 23, 2010, Bed 1 in room 403 on the 4th Floor, a medical/surgical unit at St. Lukes Cornwall Hospital - Newburgh campus, was due for an inspection in August 2007, more than 2 years overdue. This poses a potential unsafe condition for patients and staff.
This finding was verified by Staff #2 at that time.

b. Inspection of bed 1 in room 503, a medical surgical unit on the 5th Floor at the St. Lukes Cornwall Hospital - Newburgh campus, at 2:35 PM on March 23, 2010, revealed it was due for an inspection in 2007.

c. A similar finding was noted at bed 1 in room 513 on the 5th Floor (Newburgh campus) on March 23, 2010 at 2:40 PM, where an inspection was due in 2007.
These findings were verified by Staff #2 at that time.

7. Based on record review and interview there was no system in place for recording humidity in the NICU at the Newburgh Campus.
During an interview with Staff #29 on 3/29/10, it was found that the computer system indicates the percent of humidity added to the units, but there is no method for monitoring the actual humidity in the NICU.

8. The kitchens and dietary areas, at both sites (Newburgh and Cornwall), were not maintained to ensure an acceptable level of safety and quality for the patient and staff.
See A 620.

Based on observation and staff interview it was determined that the facility did not ensure that proper ventilation was provided and monitored in patient care (such as the isolation room) and other areas of the building.

Findings include:

1. On 03/26/10 at 11:15AM, during observation of the ICU (Newburgh campus) Staff #36 stated that the unit has one isolation room (room #13) which is converted to negative pressure only when a patient requires air-borne isolation. Staff #36 was unaware how the negative pressure is attained and maintained in the room. Nursing staff indicated a toggle switch by the nurse's station turns the negative pressure on. Nursing staff were unaware of the continuous negative air pressure monitoring of the room, which was verified with Staff #36, Staff #33 and Staff #8.

Staff #29 was interviewed on 03/29/10 at 12:45PM regarding how the engineering staff monitors the isolation room's negative air pressure. He stated that all isolation rooms have monitors installed outside the room to monitor the negative pressure. He also stated the that toggle switch has been removed from the system and thus no nursing staff can turn on the air-pressure. It is to be noted that the isolation room of ICU did not have a monitor installed outside the room, which was verified by Staff #29. Therefore it was unclear how this particular isolation room was monitored.

2. On 03/29/10 at 11:00AM, during observation of the Birthing Center (maternity suite) (Newburgh campus) on 6th floor west wing, it was noted that 3 exhaust/returns in OR #2 appeared to have no suction, since manual verification could not be obtained. Findings was verified with Staff #38.
It was also noted that after manual verification, the exhaust return on the mother/baby floor was not working. Finding verified with Staff #29.

3. During the survey of the facility from 03/22/10 to 03/29/10, 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, including but not limited to, are:
a)The soiled utility room on 1st floor (1 west-Cornwall) did not have required negative pressure.
b)Soiled utility room in the Pain Management unit 3rd floor (Cornwall) exhibited positive pressure instead of the required negative pressure.
c) Janitorial closet in the Emergency Department (Newburgh) exhibited air pressure to be neutral instead of the required negative pressure.
d) Soiled utility room on the Stepdown ICU (Newburgh) had neutral or slight positive pressure instead of the required negative pressure.
e) Clean utility room on the Stepdown ICU (Newburgh) had neutral pressure instead of the required positive pressure.

4. During the survey of the facility from 03/22/10 to 03/29/10, it was noted that most of the toilet/bathroom doors were kept open in the facility. This practice compromises the per hour air-exchange of the toilet as required by AIA, Table 2.

It was also noted on 03/24/10 at 1:35PM that the patient bathroom/toilet at the off-site Rehabilitation Center (at Newburgh 9W) had its exhaust attached to the light switch. This arrangement means that the exhaust can only be functional if the light of the toilet is on otherwise it will be off. This situation means that the exhaust is unable to provide per hour air exchange.

5. The facility did not ensure that the temperatures of the food refrigerators were monitored accurately and consistently.
See A 620.

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 area and ensuring that all patient care equipment are in good repair to prevent infection control.

Findings include:

1. During observations of the operating room (OR) suite on 3/23/10 from 11AM to 2PM the following deficiencies were noted:
a. Air flow in four of eight ORs was negative rather than positive as required. Air from the corridor was pulling into ORs #3, #5, #6 and #7.
b. An HVAC performance test was conducted in October 2009. The report, dated October 19, 2009, showed that ORs #2, #5, #6 and #7 had greater CFM on the exhaust side than on the supply side. Documentation to show that corrective action was taken was requested but not provided.
c. Air flow in the decontamination room in the OR suite was positive rather than negative as required.
d. There was no hot water at one of two scrub sinks between ORs #3 and #4. Temperature at the scrub sink was 60 degrees Farenheit.
e. The scrub sinks between ORs #7 and #8 were in disrepair. The knee pedal at the sink on the left hand side did not stay on. The surgeon would have to keep his/her knee on the pedal during the entire handwashing procedure to keep the water flowing. The sink at the right hand side was not working at all.

2. On 03/23/10 at 3:00PM, observation of the laboratory (Cornwall campus), it was observed divided in areas for different tasks. In the area where urine analysis was done, it was noted that 12 cups urine samples and clean supplies such as 4-6 agar plate, multiple empty clean urine tubes, wipes, stains for fixing slides and various reports/papers were stored together in the same proximity. It was also noted as per interview with Staff #14, there was no distinct demarcation of clean and dirty area or flow to go from dirty to clean area in the various areas of the lab. The Centrifuge machine for blood was noted stored among clean supplies.

3. On 03/25/10 at 2:30PM during observation of the Dialysis/Endoscopy floor (Newburgh campus), it was noted that 4-5 IV poles were stored in the endoscopy procedure bathroom. Finding was verified with Staff #8.

4. Six disinfecting machines in the endoscopy processing room were noted to be dirty, had broken edges inside and some of them were missing drain covers/strainers. The machines are used for high disinfection of the endoscopes/instruments and due to the status of the equipment, may interfere with optimum functionality.

5. On 03/26/10 at 11:45AM, it was noted that one ceiling tile in the clean utility of ICU (Newburgh Campus) was removed. Structure and elements above the drop ceiling were exposed. This clean utility room is used to store clean supplies and may lead dust and dirt contamination from above the ceilings.

6. On 03/23/10 at 2:45PM during observation of the main clean linen storage area (Cornwall campus), it was noted that the clean linens were stored directly beneath the water and chiller pipes going along the ceiling. The pipes indicated old evidence of leaks. There was no barrier between the pipes and the clean linens. This condition may lead to contamination since the water condensation may contaminate the clean linens stored beneath the chiller and water pipes.

7. On 03/29/10 at 11:45 AM, it was noted the blood suction machine in OR #2 (Newburgh-Birthing Center) had red pipes that were held together by masking tape and cotton balls. The pipes had sticky residues and filaments of cotton around the sticky area. Similar issue was noted in the OR #1 on the unit.

8. On 03/23/10 at 11:15 AM, it was noted that the upholstery of the stretcher/bed in the nuclear medicine room (Cornwall campus) was torn, imposing a risk of cross contamination due to difficulty in cleaning.

Similar finding was noted on 03/24/10 at 1:45 PM at the Rehabilitation Center (Newburgh-9W) where treatment table 1 & 2 had torn upholstery and had dirt accumulation in between the cervices and hinges.

9. During the survey from 03/22/10 to 03/29/10, it was noted that many sinks in the facility (and off-site) had handwashing sinks which were not trimmed with valves that can be operated with the use of hand (wrist blade handles) AIA 7.31.E. By not installing handwash sinks with wrist blade handles, there is a risk that staff/patient will operate the valves with soiled hands and thus contribute to cross contamination. Examples, including but not limited to, are:
a) Some of the sinks in the kitchen (Cornwall campus) did not have the required wrist blade valve.
b)Wrist blade valves were not installed on some of the hand wash sinks in PT/OT unit (Cornwall campus).
c)Wrist blade valves were not installed at the hand wash sink in the Rehabilitation Center (Newburgh-9W) patient bathroom and at the hand wash sink by the nurse's station.

10. On 03/26/10 at 12:00PM during observation of the Stepdown ICU unit (Newburgh Campus), it was noted that a janitorial/housekeeping bucket was stored in the soiled utility room. Janitorial bucket is to be stored in janitorial /housekeeping closet and should be kept separate since the soiled utility room is considered less dirty than a janitorial closet.

11. On 03/23/10 at 11:45 AM, it was noted that the isolation room in the Emergency Department (Cornwall) did not have self-closure installed on the door as per AIA 7.2.C4. 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. Similar finding was noted on 03/26/10 at 11:35 AM for the isolation room #13 in the ICU unit (Newburgh campus).

12. During a observation of the central storage room located off the loading dock, at the Newburgh campus, on 3/22/10 it was noted that the hospital did not ensure that its medical supplies were stored in a safe manner.
a. Medical supplies that would likely come into direct contact with patients were stored in open boxes on the general storage rooms shelves. Some supplies, including bladder bags, were stored loose on the shelves. Supplies included, but were not limited to, pediatric feeding tubes, pediatric oxygen masks, suction catheters, surgical clipper blades, sponge gauze. The storage shelves, the blue plastic storage bins and the floor in the area were dust laden.
b. Holes were noted in the wall separating the medical supply storage area from ongoing construction on the other side. Air flow from the construction site was positive rather than negative as the facility's construction policy requires.
c. The plastic sheet separating the construction work area from the medical supplies at the rear was torn.
d. The door at the rear was open to the outside loading dock area.
e. The filter on the HEPA unit on the construction side was clogged with dust. According to the construction manager the filter is changed when the gauge on the unit reads greater than 1.5 inches water column. The reading was then checked and was found to be 1.75 inches water column.
f. The filter on the HEPA unit in this construction area was checked again on 3/25/10 at approximately 3:00PM. It was again found to be dust laden. The reading on the gauge was at an unacceptable 1.8 inches water column.

13. Based on observations at the Newburgh Campus, the hospital did not ensure that there was an active program for the prevention, control and investigation of infections. Staff #2 was present during the observations to validate the findings.
a. On 3/22/10 at 10:55AM, a pair of crutches was found in the dirty utility room in Unit 2.
b. At 11:25AM on 3/22/10, a telephone used for "language line" communication was found under the sink in the medication room.
c. At 11:50AM on 3/22/10, an intravenous (IV) primary line labeled to be changed on 3/19/10 at 12:00PM, was still in use for the administration of IV fluids for the patient in room 214.
d. A face mask used for the delivery of oxygen was found hanging on the O2 delivery port on the wall without any cover, in room 214 at 11:55 AM.
e. At 11:56AM on 3/22/10, an intravenous (IV) primary line labeled to be changed on 3/21/10 at 21:00 was still in use for the administration of IV fluids to the patient in room 217.
f. At 11:58AM on 3/22/10, an intravenous (IV) primary line labeled to be changed on 3/21/10 at 11:30 was still in use for the administration of IV fluids to the patient in room 209.
g. On 3/22/10 at 1:45PM, during environmental survey of patient care Unit 3 at the Newburgh campus in room 307, it was observed that a bottle of sterile water for inhalation therapy was attached to the O2 delivery port in the room. The bottle of sterile water was not labeled with a date and time. Further investigation revealed that the sterile water belonged to the previous admission to the room and should have been discarded before the new admission was admitted. Also, it could not be determined if the room was terminally cleaned before the new admission was placed in the room.

During interview at 2:30PM on 3/26/10, staff #15 stated that nursing staff should have removed all used clinical care items from the room before housekeeping cleans the room in preparation for the next admission.
h. During observation of the laboratory on 3/23/10 at 3:00PM, a chair with an armrest used for blood drawing was noted with several layers of cloth tape covering the armrest where it was torn. Staff #17 said the chair was no longer in use. The chair was not removed. The torn part of the chair did not allow for proper cleaning and disinfection of the armrest part of the chair and was noted stained with dirt.
i. At 1:50PM on 3/22/10 an intravenous (IV) primary line labeled to be changed on 3/21/10 at 1300, was still in use for the administration of IV fluids to the patient in room 309.
j. On 3/23/10 at 3:15PM a bottle of opened and undated 1000cc of sterile water was observed on the processing counter in the laboratory. Staff # 17 explained that the staff pours the water from the container into other containers to process lab tests. On 3/26/10 at 11:35AM, staff #17 was interviewed and stated that a policy will be developed to date and time the opened bottle of sterile water and discard after 24 hours.
k. On 3/25/10 at 4:00PM, it was observed in the laboratory department that the automatic hand towel dispenser dispensed the towel into the sharp container that was located in close proximity.
l. On 3/25/10 at 3:57PM, on the workstation counter inside the lab was found an opened bottle of 1000cc of sterile water dated 2/25/10 and timed 2:00PM which should have been discarded 24 hours after opening.

14. The following observations made of the ED at St. Lukes Cornwall Hospital - Newburgh campus increases the potential for the spread of infections.
a. The supply cart in the clean utility room in the ED at the was noted to be dusty on March 22, 2010 at 11:05AM.
Staff # 41 verified this finding at that time.
b. The TV remote was lying on the floor in room #8 in the ED at the St. Lukes Cornwall Hospital - Newburgh campus on March 22, 2010 at 11:16AM.
c. There were 3 IV poles stored in the soiled utility room in the ED at the St. Lukes Cornwall Hospital - Newburgh campus at 11:40AM on March 22, 2010. This findings was verified by Staff #41.

15. The following observations were made on the 4th FloorMed Surg Unit at the Newburgh campus.
a. In room 403, bed #1 at 11:05AM on March 23, 2010, the patient's Foley bag with a large amount of urine was touching the floor. This was brought to the attention of Staff #2 at that time.
b. At 11:10AM on March 23, 2010, the belongings for a patient that had been discharged from the facility on the 4th Floor were observed in a bag in the dirty utility room.
c. In room 415, bed #2 on the 4th Floor at approximately 11:40AM on March 23, 2010, a urinal with a small amount of urine was observed on the window ledge.
d. Staff # 40 was observed picking up a piece of paper from the floor in room 404, bed #2 at 11:13AM on March 23, 2010. Staff #40 touched the patient's belongings at that bedside before exiting room and before using the hand sanitizer mounted outside the door of the room.

16. The hospital failed to provide a sanitary environment in the kitchen and dietary areas at both sites (Newburgh and Cornwall).
See A 620

Based on observations, document review and staff interviews, the infection control officer did not develop a system to fully investigate and control incidents of infection among patients who had surgical procedures.

In addition, the Infection Control office was not aware of abnormal environmental values in pressure, temperature and humidity in the hospital operating rooms.

Findings include:

A review of the hospital statistics of the Newburgh campus on infection rates related to surgical wounds show evidence that procedures performed by Orthopedic surgeons were prone to developing infections. In the period 2/10/09 to 12/22/09 (2010 data was in draft form), there were a total of 22 incidences of infections status post surgery. Fifteen of the 22 surgical procedures requiring review due to infections resulted in a return to surgery for incision and drainage of the affected areas.

During interview with Staff #15 on 3/26/10 at 2:30 PM it was revealed by Staff #15 that orthopedic surgeries are done in operating Rooms #7 and #8. Staff #15 also stated that there have always been problems with cleaning these operating rooms as the verification documents of cleaning are sometimes left blank, and staff have been reeducated on proper cleaning.

Staff #15 also stated that there are 2 main orthopedic surgeons using the operating rooms. Staff #15 also revealed that she just became aware that operating room #7 had abnormal findings related to pressure gauge and humidity measurements and abnormal humidity measurements in operating room #8.

Further interview with Staff #15 indicated that she does not review the pressure gauge and humidity measurement readings for the operating rooms, has never performed a random culture of the sterilized the instruments used by the orthopedic surgeons, and has never observed any of the surgeons or operating room staff during scrubbing procedures. Nor has she observed the housekeeping staff clean the operating rooms in question.

Based on these statements, the infection control officer failed to fully investigate potential sources of infection of either the techniques of the orthopedic surgeons, the procedures used to scrub before surgery, maintenance of the ORs and/or the housekeeping practices used to terminally clean the ORs.

Based on a review of medical records, a patient was not transferred to an appropriate facility, as needed, for ancillary care. MR #26

Finding is:

A review of MR #26, revealed the patient came from an assisted living facility and was admitted to the hospital on 9/18/09 with a diagnosis of pneumonia. According to the physician's orders, dated 9/20/09 and the nurse's progress notes, dated 9/23/09, the patient had a foley catheter ordered and in place during the patient's hospitalization. The last nurse's progress notes, dated on the discharge date of 9/24/09, stated that a foley is still in place. There was no documented evidence in the medical record that the physician ordered removal of the foley catheter, or that the nurses removed the foley prior to discharge, or that the patient was educated on how to care for the foley catheter.

The patient was discharged to an assisted living facility. Assisted living facilities do not accept patients who require assistance with the care of foley catheters, therefore, the patient was not discharged appropriately.

Based on medical record review, facility documents and staff interviews, the hospital failed to assess and render appropriate care for Patient MR #26.

Findings include:

Based on review of MR #26, this 3 year old patient, with a previous medical history of asthma, presented to the Emergency Department on 4/26/2009 at 0630 with a fever of 102.9 and a cough for the last 2 days. A chest x-ray was performed. The chest x-ray was read by the emergency department physician as being normal. The patient was discharged home on 4/26/09 at 0936 with a diagnosis of upper respiratory infection and given a prescription for antibiotics and instructions to take Tylenol and Motrin, drink liquids and rest.

A review of the x-ray report interpreted by a radiologist on 4/27/09 at 0954, revealed that the impression was of a "suspected right upper lobe infiltrate"; therefore, the x-ray was initially misinterpreted as normal by the emergency physician. There was no evidence that the patient's family was notified in a timely manner. It wasn't until a certified letter, dated May 6, 2009, was sent to the patient's home describing the correct results of the x-ray. This included the possible pneumonia diagnosis, and a recommendation for follow up with a pediatrician. Interview with Staff #1 confirmed these events.