HospitalInspections.org

Based on record review, review of documents, and interviews it was determined that the governing body failed to exercise sufficient oversight of practices that have the potential for harm of infants and children.

Findings include:

Review of hospital policies and procedures on 9/2/14 found that the infant abduction system was implemented in a way that did not utilize appropriate features that would provide full protection for the patients in the high volume pediatric, nursery and neonatal units.

Several reports made in 2013 and 2014 identified issues with "gaps", and deficiencies in training which did did not result in any substantive action.

At interview with the Employee #10, on 9/2/14 it was stated that this situation with limited application of the features of the infant abduction system was in effect for the last 17 years with no adverse events.

Cross reference is made to Tag A 144.

Based on record review, interview and observation, it was evident that the hospital failed to implement a system to protect the rights of infants and children against unauthorized removal from the hospital's nursery, Neonatal Intensive Care Unit (NICU), and the pediatric unit.

Findings include:

Review of hospital policies and observations and interviews regarding infant abduction, quality assurance documents, and drills, found that the system in place was deficient in alarm volume, no elevator response, ineffective band system, and notification only at the nursing station which is not always staffed. Further no infants in the NICU were "banded" and therefore were not a part of the infant abduction system.

An immediate jeopardy (IJ) was called on 9/2/14 at 2 PM and abated on 9/2/14 at 4 PM. Immediate corrective action was implemented using Hospital Police officers placed in the halls at strategic locations to view both egress and entrance into units and observing activities on the elevators.

Cross reference is made to Tag A 144.

Based on observation, staff interviews, and review of procedures it was determined the facility did not ensure a safe environment for infants and young children.

Specific reference is made to findings related to the lack of an effective surveillance system in place for protection of infants and young children in order to minimize the potential risk for harm or abduction.

Findings include:

During the tour on the 5th Floor of the Pediatric Unit in the morning of 09/02/14, it was revealed that the facility used an electronic tag system to augment safety and tracking of Pediatric patients on the 5th Floor.

During observation on 9/02/14 it was noted that this Unit is accessed via employee swipe cards only, but exiting from the unit through these doors did not require employee identification card. Therefore, the egress from the unit was unrestricted and it was noted exits were not monitored by camera and/or staff. Interview with Staff Member #1 on 09/02/14 stated that the patient and family member/s are escorted by a staff member when departing from the unit.

However, the hospital did not provide sufficient safety monitoring of the environment of care for infants and children to minimize risk of harm or potential for abduction. The electronic infant protection system did not properly operate in three of three instances during system testing conducted in the pediatric unit 5B between 11 AM and 12 noon on 9/2/14.

This system is composed of an electronic device which is attached to a special bracelet placed around the wrist or ankle of the pediatric patient. There are two components of the system: the first involves the activation of locking the exit doors from the unit within 10 seconds when a tagged child is located in close proximity to the exit doors; and the second feature involves the immediate activation of an alarm (both auditory and visual alarms) when the bracelet is cut and/or loses skin contact. Upon testing the system, it was observed that the door locking function operated upon approach to the exit door. However, three (3) of three (3) tests performed found the second component of the system failed to activate the alarms and lock the doors immediately as required when the band was removed from the arm or leg. It was noted that there was a visual message display of "Tag . . . removal" appeared on a monitor connected to the Infant Protection System (IPS) in the nursing station. This alarm message did not display an audible or a visual signal in the unit. In addition, the monitor for the Infant Protection System was not being continuously monitored by staff in the nursing station. Therefore, it was concluded a potential risk existed for the removal of a baby from the Unit by easy removal of the security band from a infant/child and leaving it in the patient's room.

The feature of audio-visual alarm activation and egress door-locking mechanism of the Infant Protection System during security tag removal was also observed to not function during testing performed in the Well Baby nursery on the 4th floor of the main building between 12 and 1 PM on 9/2/14.

Inspection of the facility's infant security system was conducted on the Pediatric and Well Baby nursery located on the 5th and 4th
Floors respectively on 09/02/14 between 11:00 AM and 1:00 PM. Two (2) Surveyors and five (5) facility staff were present during these testing sessions (Staff Members # 1, 2, 3, 4, and 5).

All three (3) of the three (3) tests performed on each floor (4th and 5th floors) found that the system failed to activate the alarms when the band was removed and lost skin contact.

The first simulation test inspection was conducted on the 5th Floor Pediatric Unit of the Main Building at approximately 11:00 AM. A staff nurse wore the bracelet over her finger during which it was observed that the auditory alarm failed to activate when the band was removed.

A second simulation test was then performed at approximately 11:15 AM on the 5th Floor of the main Building. The door at the entrance was propped open in an attempt to simulate an abduction where the door would be manipulated to remain ajar. When the band was removed from the finger, it was observed that it was possible to remove the infant from the Unit with no alarm activation. However, an audible alarm was activated when the door was propped open for more than 15 seconds.

A third simulation test was conducted between approximately 12 noon and 12:30 PM on the fifth floor Entrance/Exit Doors, where it was determined that the auditory alarms activated within one (1) second and the doors locked after the band approached the proximity of these Exit Doors. However, these doors failed to lock and alarms failed to activate upon removal of the band.

It was confirmed on interview with employee #6 that the electronic device system is not linked to the elevator system, so that if an abductor bypasses the lock feature of the double doors at the entrance of the Pediatric Unit, the elevators would not stop operating. This would increase the potential risk for infant/child abduction via elevators.


The Nursing staff of these Units were not aware of the features of the electronic security band system. For example, during interview with nursing staff #7, she was unaware that bands would expected to generate an alarm when tampered with or that the exit doors should lock. An interview with Hospital Police Staff #6, at approximately 12:45 PM, he stated that the feature of alarm activation upon removal of the "Infant Protection System" security bands was not available. He further stated that there were "gaps" in the current system, and the hospital police became aware of it during the month of May 2014 upon performing a test drill. Hospital management was notified of this concern.

On 9/2/14 at approximately 3:30 PM, the surveyor reviewed a 2013 report titled "Improving Infant Security and Alarm Management at MHC". This report noted that the facility "conducted infant protection drills and observations. An analysis of the outcomes has identified gaps with alarm response which is directly related to the Joint Commission's Sentinel Alert #50 and National Patient Safety Goal on the clinical alarm safety." The facility did not provide documented evidence of any corrections made to the "Gap" identified in this report.

For example, one of the "Gaps" identified was that the "Monitors are located in areas that do not allow for optimal viewing". There was no evidence in the units that this deficiency was corrected as these monitors were observed to be located behind the nurse and/or receptionist's desk and therefore was not being consistently monitored.

The Hospital, upon repeated requests from the surveyors, failed to provide a policy and procedure that described the specific details and the procedure involved in the installation, maintenance, and testing of the infant protection system. This procedure and drills failed to address all potential contingencies, e.g., instances where the door is manipulated to remain open and the band is removed from the infant.

Upon interview of the member of the hospital police Employee #6, it was stated that the Hospital Police became aware of the breach in the functioning of the system in May 2014 and the nursing staff was put on high alert since then.

In addition, upon tour of the NICU (Neonatal Intensive Care Unit) suite on the 4th floor on 9/2/14 at approximately 1 PM, it was revealed that the NICU babies were not protected by the Infant Protection System. It was also observed that the NICU unit had a back door that was unrestricted which connects with a common hallway shared with an outpatient clinic.

Finally, the facility did not consistently implement effective procedures for the prevention of infant and child abduction.

The facility did not have any policy and procedure on the frequency of the Code Pink Drills (designated code for an infant abduction). In the 2013 report titled "Improving Infant Security and Alarm Management at MHC", a "Gap Analysis" noted that: "Training is sporadic. No formal, ongoing training schedule".

Review of Code Pink Drills revealed that the facility conducted two drills in December 2013 and one drill in August 2014 on the 5th floor pediatric unit. There was no evidence to indicate that a Code Pink drill was conducted to simulate an event of tag removal from an infant.

As a result of these findings, IMMEDIATE JEOPARDY was declared on 09/02/14 at approximately 2:00 PM. The hospital in response to the situation, posted Police officers in the elevator lobby of the 4th and 5th floors. New procedures for monitoring of entrance and egress activity was instituted in the infant and pediatric units. Training for all staff in the new monitoring procedures for increased awareness of unit activity was also initiated.

These actions taken by the hospital on 9/2/14 resulted in the abatement of immediacy of the immediate jeopardy situation at 4:00 PM.


After the decision was made to remove the immediacy of the first high-risk situation, another incident occurred that represented potential for infant/child abduction. On 09/04/14 during the tour of the Hospital Police command post in Room#805 on the 8th Floor, it was noted that there was only one security officer (Employee #8) who was assigned to visually monitor the activity of approximately 12 visual security monitors. At approximately 11:40 AM the surveyors, together with this employee, noticed a visual notification on the Infant Protection System monitor which displayed a message "Door Ajar". This message was activated while the camera displayed an infant and the mother being brought into the NICU area by staff. A simultaneous observation was made by the surveyors viewing this camera showing that another couple with an infant simultaneously exited out of the same NICU (4th Floor) area without being escorted or noticed by staff . This event was not noticed by the security officer viewing the camera with the surveyor. At this point, the surveyor verbalized this observation to the security officer. The officer contacted lobby security staff, security staff on the 4th floor, and the nursing staff in the nursing station of NICU. The officer activated "Code Pink" (a procedure to alert staff on the auditory overhead communication system of a possible infant abduction) at approximately 12:00PM, because there was no return communication received from the Police post in the lobby of the NICU. The nursing staff also did not respond to the phone call from the command post or to the activation of this Code Pink. The couple with the infant was apprehended in the lobby and investigation of the incident revealed that the staff were aware of the family's departure after returning a loaned breast pump.

At approximately 2:30 PM, employee #9, replayed a camera recording of the event, which showed the couple boarding the elevators. At this time, it was noticed that the police officer assigned to the post to monitor the elevator lobby of the 4th Floor was not visible on the tape recorded by this camera.

During a different observation by surveyors on the Well Baby nursery on the 4th floor on 09/05/14 at approximately 2:00PM, it was noticed that the Police officer assigned to monitor the elevator lobby of the fourth floor was inside the unit. The Officer was observed to be standing in the back of the unit, beyond the exit stairway, and was not present at the assigned post.

The hospital implemented subsequent corrective actions following these incidents, which included ongoing retraining of nursing and security staff to improve communication between them. In addition, procedures for heightened alertness and vigilance were implemented for patient security from 09/04/14 through 09/11/14. The hospital assigned additional police officers to monitor the infant and pediatric units on the fourth and fifth floors on 09/05/14. Additional officers were assigned to the halls outside these units adjacent to the elevators during visiting hours and during times of an influx of visitors and staff.

On 09/11/14, the hospital repaired the Infant Protection System to add the feature of audio and visual alarm activation and added a door locking system upon removal of the electronic security band from the infant/child. In addition, infant security tags were applied to babies hospitalized on NICU and the stepdown unit.

The IMMEDIATE JEOPARDY (jeopardy portion) situation was thus abated on 09/11/14 at approximately 3:50 PM.

Based on observations and staff interview, the facility failed to maintain the physical plant in a manner to provide a safe and sanitary environment for the treatment of patients.

Findings include:

During the tour of the operating rooms # 4, 6, 7, 8 and 10 on 08/29/14 the following were noted:

(1) All the operating rooms had marble tiled walls with grout filling in between the tiles.
(2) The tiled walls of the operating rooms appeared greasy. This was specifically observed in Operating room #6.
(3) The floor of OR #6 was observed to have some debris throughout the room.
(4) The perimeter of the wall behind the anesthesia machine was observed to be soiled in all the five Operating rooms inspected.
(5) A tile was observed to be broken on the wall below the exhaust vent. The tiles all along the exterior wall of OR #6 were chipped off.
(6) A broken tile was observed above the exhaust vent in OR #4.
(7) Crevices were observed around the mechanical exhaust vent in Operating Room #10.

These broken tiles in the Operating rooms posed an infection control risk caused by microbial growth in the crevices due to high humidity and the collection of dust in the crevices.

During interview of employee #2 on 08/29/14 at approximately 11:00 AM, it was stated that this employee was not aware of the disrepair in these operating rooms.

It was also observed that the metal ceiling tiles in the sub-sterile corridor of the Operating room suite were unclean and discolored.

During the tour of the inpatient unit on 8B on 09/04/14 at approximately 10:15 AM, it was noted that the nursing staff was using a physician on-call room to provide stair navigation training to patients. It was noted that the stairs used for patient training were unstable and the stair platform moved when surveyor attempted to step up. No handrails were found on the perimeter of the entire room and the floor consisted of hard tiles. There were no chairs observed in the room. The room was not equipped with a nurse call system. During an interview with a Physical Therapist employee #17 it was stated that only one patient at a time is in the room and that patient is continuously monitored by a Physical Therapist. The room was also observed to be used for storage of Physical Therapy equipment such as walkers, canes, crutches, wheelchairs, and other miscellaneous. This practice potentially poses a risk for cross contamination.

During the tour of the infusion center on the 6th Floor C wing, it was noted that there 8 treatment chairs in the room. It was evident that the facility did not maintain the minimum 80 square feet per patient cubicle as required by American Institute of Architects (AIA) 7.9 C2 1996-97 Edition. Interview of employee #16 revealed that this unit began operation in that location in 2001. Review of the Operating certificate of the hospital on 08/29/14 at approximately 3:30 PM, and review of NYSDOH records revealed that there was no documented evidence that this service was being provided with NYSDOH approval.

During the tour of the Critical care units [Surgical Intensive Care Unit (SICU) and Medical Intensive Care Unit (MICU)] on the 6th floor on 09/03/14 at approximately 2:00PM, it was observed that the patient rooms (except isolation rooms) did not have a patient bathroom inside them. However, each unit had a patient bathroom which had only 32 inches clearance at the door and therefore was not accessible when using a wheelchair. Also the bathroom in each unit did not have handrails for handicap patients.

During the tour of Gastrointestinal (GI) suite on the 11th Floor on 08/29/14 at approximately 10:30 AM, a test of the nurse call system was performed. It was observed that the nurse call system in the recovery area, upon being pulled at the patient's bedside, did not activate a visual and /or audio signal in the clean and soiled workroom.

During the tour of the kitchen on 08/28/14 at approximately 3:00 PM, it was observed that the housekeeping closet of the kitchen did not have a mechanical exhaust.

During the tour of the Emergency Department on 08/28/14 at approximately 11:00 AM, it was observed that the airflow of the soiled utility room in relation to the corridor was neutral, and not negative as required.


Additionally, the facility failed to maintain the inpatient psychiatric units (on the 5th, 6th, 7th, 8th and 9th floors of the mental health building) free of physical hazards to ensure a safe environment for the treatment of patients.

Specific reference is made to the following observations made during the inspection of the units on 09/03/14 and 09/04/14.

(1) During the tour of the inpatient psychiatric unit on 8 West, it was noted that the two sides of the patient beds were open and that they could be used to create ligature. This observation was also made in other inpatient psychiatric units located on 5 West, 6 West, and 9 West. Upon interview, the Administrator of these units stated that the facility had purchased captain beds (a platform bed with drawers and storage compartments built in underneath) for the units on 7 South and 6 South.

(2) During the tour of the patient bedrooms in all Psychiatric units, it was noted that the reading lights for each bed had a flat top plastic encasement, that was capable of forming ligature for looping.

(3) The surface mounted paper towel dispenser, bathroom tissue dispenser, and the hand soap dispenser in the patient bathrooms in all psychiatric units had a flat top surface, and therefore was noted to be a looping hazard.

(4) The handwashing sink in the same bathrooms were observed to be protruding out of the wall approximately 18 inches and therefore provided opportunities of looping.

(5) The shower head and the shower knob were observed to be protruding from the wall and having a flat top surface, allowing ligatures to be formed.

(6) The door handles of patient bedrooms, seclusion rooms, day /dining rooms were L shaped and were determined to be looping hazards.

(7) The patient bedside table was not bolted to the floor. The drawers of these bedside tables were removable and could be potentially used as weapon to harm others.

(8) The Fire Alarm pull boxes in all the inpatient Psychiatric units were observed to be enclosed inside a flat top metal boxes that were located approximately 53 inches above the floor. These alarm boxes were also noted to be looping hazards, as they could potentially be used to form ligatures for looping.

(9) The facility was observed to be using light weight chairs in the day/dining rooms. These chairs were capable of being lifted off the floor and could be used to inflict harm on others.

(10) The hinges on the shower room door, laundry room door and patient lockers were of the regular type which allow looping. The hinges of all doors in a psychiatric unit must be piano hinges, which would not provide an opportunity to create ligatures.

(11) The phone cords on the public phone installed in the hallway of the Psychiatric units were approximately 17 inches long. These cords were capable of forming ligatures and therefore were looping hazards.

(12) In each of the psychiatric units, the floor, the metal radiator on the back wall and the door surface of the seclusion room were not padded and therefore were capable of causing injury to a patient or person that might fall and /or hit against them.

Moreover, the Preparation Room (2B23) in the Pathology Laboratory did not have a handwashing sink. Interview with the Director of the Laboratory revealed that the staff were using the existing sink to drain stains and handwashing. The floor surface and the counter top of this laboratory was observed to be heavily soiled and grimy. An encrusting of brown color residue was observed around the sink used to drain stains.

During the tour of the dental clinic on 09/10/14 at approximately 2:30 PM, it was observed that the airflow in the dental laboratory (2D 3L) was neutral and not negative as required.

During the tour of the Audiology clinic on 09/10/14 at approximately 2:00 PM, 3 ceiling tiles were noted to be wet and heavily stained. Employee #2, upon interview, did not explain the reasons for the ceiling tiles to be wet, but stated that the tiles would be replaced immediately.

Based on observation and staff interview, the facility failed to comply with all provisions of Life Safety Code as recommended in NFPA101 2000 Edition.

Findings include:

(1) The facility did not ensure all interior finishes for flame spread rating in rooms or spaces not used as a corridor have a flame spread rating of class A or B. Specific reference is made to the fact that the facility failed to ensure that the flame retardancy of the 100% polyester cubicle curtains is maintained after they are repeatedly laundered and /or dry cleaned.
Refer to Tag K 015

(2) The facility failed to ensure that smoke barrier walls were constructed to have at least a one-half (½) hour fire resistance rating in that unsealed penetrations around wires and conduits, cut holes, improperly sealed, and unfinished wall assemblies were observed in smoke barrier walls in the basement and on the 5thand 8th Floors.
Refer to Tag K 025

(3) The facility failed to ensure that exit access is so arranged that exits are readily accessible at all times.
Refer to tag K 038

(4) The facility failed to comply with Life Safety Code and ADA recommendations. Specific reference is made to the audiology clinic, where patients hard of hearing are diagnosed and treated.
Refer to tag K 051

(5) The facility failed to ensure that all sprinkler control valves were electronically supervised to sound an alarm at a continuously monitored location. This was evidenced by electronic supervisory devices noted not being provided on sprinkler control valves in-line of a sprinkler pipe located in various locations throughout the building.
Refer to tag K 056

(6) The facility failed to ensure that the required monthly inspections of the ANSUL system (the range hood fire extinguishing system) in the kitchen were conducted.
Refer to tag K 069

(7) The facility was not provided with a Type 1 Essential Electrical System that was divided into separate Critical Branch, Life Safety Branch and Equipment Systems in accordance with NFPA 99. This was noted in the distribution panels located in the basement, kitchen, 8th, 9th, 10th, 11th and 17th Floors.
Refer to tag K 145

(8) The facility failed to ensure that a minimum of six (6) outlets served by the Emergency System were provided at the bed location in the Post Anesthesia Care Unit (PACU) in the Labor and Delivery Suite.
Refer to tag K 145

(9) The facility failed to ensure that flexible cords and cables were not used as a substitute for the fixed wiring of a structure. This was noted in the outpatient Ophthalmology Clinic.
Refer to tag K 145

(10) The facility failed to ensure that all Emergency Power Panels were provided with Panel Directories. This was noted on the 9th, 8th, 3rd, and Ground Floors.
Refer to tag K 145

(11) The facility failed to ensure that Ground Fault Circuit Interrupters (GFCIs) were provided for hydrocollators (a device that consists of a thermostatically controlled water bath for placing cloth heating pads - the pads are removed from the bath, are placed in covers and then placed on a patient). This was noted in the Physical Therapy Suite.
Refer to tag K 145

Based on review of documents and staff interview, the facility failed to ensure that all equipment used in the treatment of patients are maintained according to the facility established preventative maintenance program, based on manufacturer recommendations and/or Alternate Equipment Management (AEM) Program.

Findings include:

Review of the Preventative maintenance records for the critical equipment in the hospital on 09/09/14 at approximately 2:00 PM, it was noted that the Equipment maintenance activities were conducted through a combination of hospital personnel and contracted services. It was also noted that the facility had chosen to to employ alternate maintenance activities and schedules which were developed by a contract vendor, for all of their equipment, except for lasers, radiological equipment and the anesthesia machines.

Interview of staff determined that the clinical Engineering Department of the hospital was managed by or through a contract service since May 2014, and that the hospital was following the AEM program developed by the resource center of the contract service.

Review of the hospital's policy and procedure and interview of employee #4 on 09/10/14 at approximately 2:30 PM, revealed that the hospital does not have a mechanism in place to evaluate the effectiveness of the AEM program being implemented in the facility.

Review of the Preventative Maintenance records for the equipment inspected and tested by hospital personnel noted that the staff were using an existing check list for Qualitative Tests to record the activities conducted during a Preventative Maintenance check. It was observed that the check list did not include documentation of all the PM activities specific to each type of equipment.

For example :

(1) Review of Preventative Maintenance record for an incubator #2554-637931 dated 07/01/14, revealed that there was no indication that the oxygen flow rates were being checked and verified to manufacturer specifications.

AEM policy for this Equipment required verification that the achieved oxygen flow rates were within the manufacturer's maximum and minimum specifications.

Interview of employee #13 on 09/09/14 at approximately 11:00 AM, he stated that the technician does not check the oxygen flow rates for the incubators. He stated that the technician was not aware of the manufacturer's specified maximum and minimum flow rates. He also stated that the hospital biomed technicians have not received training on every specific equipment maintenance protocol.

(2) Review of the Preventative Maintenance record for a Defibrillator, Pacing #2554-689172, dated 08/01/14, revealed that there was no record of the measurement of output energy, as required by the Quantitative tasks of the AEM policy.

According to the AEM policy, the technicians are required to "measure output energy at minimum, intermediate" . . . (e.g., 50J or 50 joules; a joule is a derived unit of energy, work, or amount of heat in the International System of Units) . . . "and maximum energy settings".

Interview of the Employee #11, identified that there was a lack of training for all the three hospital biomed technicians (one lead and 2 other technicians), and that he was in the process of training all of the technicians.

In addition, the hospital, through the contract managing company, failed to ensure that the preventative maintenance on the lasers, which is conducted by a sub-contractor, was and is in conformance with the manufacturer's specifications.

For example:
Review of the Preventative Maintenance (PM) record for a Yag Laser console #648203 dated 06/20/14, revealed that all the accessories and cooling fluid components were not regularly inspected. Out of the nine(9) accessories only the hand piece was recorded as "checked". Out of five(5) Cooling Fluid components, only the Fans were recorded as "checked:".

Similarly, review of the PM for a Diode Laser console #648211, revealed that two [fiber and extended superframe (ESF - consists of twenty-four consecutive 193-bit frames of data)] of the nine (9) accessories were inspected. Only two (System and Laser Head) out of the five (5) cooling components were recorded as "checked".

Interview of a technician from the sub-contracting company on 09/11/14 at approximately 11:00 AM, revealed that this employee inspects only the accessories that are made available at that time.

Therefore, there is no documented evidence to indicate that all the other accessories and the cooling components are "checked" on a regular basis, as required by the manufacturer.

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

Findings include :

(1) During the tour of the Operating Room suite on 08/29/14 at approximately 10:30 AM, the surveyors observed the operating room had tiled walls with grout filling in between. It was also observed the several of the tiles were broken or chipped off in three different Operating Rooms. The condition of the tiled walls in the Operating Rooms is an infection control issue as it may promote microbial growth. Refer to Tag A 701

The perimeter of the floor in the Operating Rooms inspected were also observed to be dirty. The floor of OR #6 was observed to have some debris throughout the room. Therefore the facility failed to maintain a clean environment for patient surgeries. Refer Tag A 701.

Interview of Employee #2 on 08/29/14 at approximately 11:00 AM, it was stated that the Operating Rooms were in place since the early days of the hospital and have not at any time undergo renovation.

(2) The facility was observed to store clean Physical Therapy equipment in the room 8B on the 8th Floor Medical surgical Unit. This room was also used to provide stair negotiation training for patients. This arrangement of storing clean equipment in patient treatment area is potential of causing cross-contamination. Refer to Tag A 701.

Interview of the Director of Rehabilitation Nursing Employee #18 on 09/04/14 at approximately 2:30 PM, it was stated that the clean Physical Therapy Equipment will be removed from the room.

(3) During the tour of the Operating Room suite, it was noticed that there were sub-sterile rooms with flash sterilizers in between two Operating Rooms. The airflow of all 5 sub-sterile rooms was tested by surveyor and indicated positive airflow in relation to the corridor and not negative as required.

(4) (a) During the tour of a 4 bedded patient room 8B-14 on the med-surg unit on 09/04/14 at approximately 10:00 AM, the surveyors observed a staff nurse, Employee #14, draining used saline in the handwashing sink. This practice is potential of causing cross contamination.
(b) During the tour of the pediatric unit on the 5th Floor on 09/02/14 at approximately 10:00 AM, the surveyors observed a service aide Employee #19 wiping surfaces and cleaning patient room #5B-11. It was observed that a caution sign for Droplet precaution was posted on the door. It was also observed that the service aide cleaning the room did not put on a protective gown while cleaning the room. Interview of the staff on the unit revealed that the infection control policy did not require the service aide to put on a protective gown while cleaning patient rooms. This practice of wearing inadequate personal protective equipment (PPE) represents a potential of causing cross contamination while the service aide moves from one patient room to the other.

During the interview of the Hospital's Director of Infection Control Program Employee #20, it was stated that the infection control policy will be changed to reflect that all service aides must don full PPE (Personal Protective Equipment) while cleaning patient rooms.

(5) The hospital's respiratory therapy department was found to have formulated and implemented a policy and procedure regarding the terminal cleaning of ventilators that directs respiratory therapists to disassemble used ventilators in the patient room and to dispose of the non-reusable parts in the patient's bedside garbage cans. This may include "contaminated tubing." This was evidenced by interview of Employee #12, on 9/5/14 at 2:00 PM and a policy given to the survey team at the same time.

Based on review of policies and interviews it was determined that the respiratory therapy department developed a policy that created a risk of spread of infection during the disassembling and cleaning of used ventilators.

Findings include:


Review of hospital policies for Respiratory Therapy found a document dated 9/5/14 that made reference to the Respiratory Therapists role in the disassembling of the Ventilator after patient use. The procedure to be followed when the ventilator is to be cleaned after patient use is to disassemble the machine in the patient's room at the bedside and to dispose of these "contaminated parts" in the garbage can next to the patient's bed. This included the soiled tubing circuit. The respiratory therapy director Employee #12 stated this document reflects the practice currently in effect.

At interview with the Employee #12, on 9/5/14 at 2:00 PM, it was stated that the disposable parts are placed in the regular garbage can in the patient's room, not in red bag waste which identifies the items as potentially contaminated.