HospitalInspections.org

.
Based on observations, staff interviews, and review of procedures it was determined that the facility failed to comply with the Condition of Participation for Patient Rights due to failure
to comply with requirements for the protection and promotion of patients' rights as required.

Findings include:

The facility failed to implement an effective surveillance system for protection of infants and young children on the Maternal/Infant and Pediatric Units in order to minimize the potential risk for harm or abduction. In addition, ineffective monitoring of access to unlocked Pediatric Units within the facility was identified.

The electronic infant protection system did not consistently operate during system testing conducted at the facility.

Cross reference specific citations noted under Patient Rights, 482.13(c)(2), Tag A 144.

.
Based on review of medical records and policy review, it was determined the facility failed to implement its policy for acquiring telephone consents. This finding was noted in one (1) of two (2) telephone consents reviewed (Patient #19).

Finding include:

Review of the medical record for Patient #19 documented a 92-year-old female who was admitted on 11/14/13 with the diagnosis of Acute Respiratory Failure and required intubation.

Review of the patient record on 01/29/14 revealed that consents for procedures were obtained via telephone. The consent obtained on 11/19/13 did not list the procedure for which the consent was obtained and the risks and benefits of the procedure were not documented.

Similarly, there was no documentation for the telephone consent for Patient #19 obtained on 01/23/14 for the placement of a Peripherally Inserted Central Catheter (PICC). The risk and benefits of the procedure and the identity of person granting consent was not documented in the medical record.

The facility policy notes that when a surrogate is not available to grant consent in person, telephone consent may be accepted. The documentation of the telephone consent in the medical record will include the time the consent was obtained, content of the telephone discussion and the name of the staff who witnessed the discussion.
.

.
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:

On the morning of 01/29/14, observation of the 4th Floor (i.e. Maternity and Newborn Units) revealed that the facility did not provide sufficient safety monitoring of the environment of care for infants to minimize risk of harm or potential for abduction. The electronic infant security alarm system did not properly activate in three (3) of four (4) instances during system testing. Specifically:

On 01/29/14 during a tour of the 4th Floor Maternity and Newborn Units, the staff representing Security and Nursing Administration stated that an electronic tag system manufactured by "TPC Systems - HUGS" is used to augment safety and tracking of the the 4th Floor (i.e. Maternity and Newborn Units).

These units are accessed via employee card access only, which are located by the exit doors, and are unlocked for anyone who tries to depart using the exit doors of the Unit. This system operates when an electronic transponder tag is attached to a band placed around the ankle of all newborns. This device is linked electronically to a computer tracking system which activates a visual and audible electronic alarm during the following contingencies:

-The doors to the Unit lock and audible and visual alarm is activated when the infant wearing the device approaches the proximity of the exit doors to the Unit.

- The exit doors are locked and the visual and audible alarms are to immediately activate when the band is cut.

On 01/29/14 between 11:55AM and 12:18PM the electronic infant monitoring system was tested four (4) times and failed to consistently operate as designed during all four (4) of these tests.

Two (2) surveyors and approximately eight (8) hospital staff were present during these testing sessions, which included, but were not limited to, the following staff: the Director of Security, the Nurse Manager for Maternity and the Director of Nursing for Maternity and Child Health.

The first test inspection was conducted on the 4th Floor Newborn Unit at 11:55AM. Observation of a Nurse with a baby wearing a band passing through the Newborn Nursery exit revealed that the door lock failed to activate when the the baby with the band was passing through the exit door, and the audible alarm was heard at the Nurses' Station only and not throughout the Maternity and Nursery Unit and at the exit doors. The Nurse was able to pass the exit door without any obstruction.

A second test was conducted on the 4th Floor Newborn Unit at 12:05PM. Observation of a Nurse with a different baby band passing through the Main Entrance door revealed that the door lock failed to activate when the baby with another band was passed through the Main Unit's door, and there was low audible alarm. This alarm was only audible by the the Nurses' Station, not throughout the Unit or by the exit doors.

A third test was conducted on the 4th Floor Newborn Unit at 12:10PM. Observation of a Nurse cutting a baby band, revealed that the door lock failed to activate immediately when the band was cut.

A fourth test was conducted on the 4th Floor Maternity Unit at 12:18PM. Observation of a Nurse cutting a baby band passing through the Maternity Entrance doors revealed that the door lock failed to activate when the band was cut, and there was no auditory alarm. When the surveyor questioned the low volume of the auditory alarm, the Nurses went to the Nurses' Station and increased the volume.

It was also confirmed during interview with the Director of Security on 1/29/14 at 12:10 PM that the electronic device system was not linked to the elevator system or the emergency exit stairwells located directly outside the Units so that if an abductor bypasses the door lock feature, the elevators and the doors of the stairwells would not be deactivated / locked.

On 01/29/14 observation of the 5th Floor (i.e. Pediatrics and Pediatric Intensive Care Units) revealed that the facility did not provide sufficient safety monitoring of the environment of care for children to minimize risk of harm or potential for abduction. The electronic infant security alarm system did not properly activate in three (3) of four (4) instances during system testing. Specifically:

On 01/29/14 during a tour of the 5th Floor Pediatrics Unit with the staff representing Security and Nursing Administration stated that an electronic tag system manufactured by "TPC Systems - HUGS" is used to augment safety and tracking of young children on the 5th Floor (i.e. Pediatrics and Pediatric Intensive Care Units). These Units are accessed via employee card access only, which are located by the exit doors, and are unlocked for anyone who tries to depart using the exit doors of the Unit. This system operates when an electronic transponder tag is attached to a band placed around the ankle of all newborns. This device is linked electronically to a computer tracking system which activates a visual and audible electronic alarm during the following contingencies:

-The doors to the Unit lock and the visual and audible alarms are to immediately activate when the child wearing the device approaches the proximity of the exit doors to the Unit.

-The doors to the Unit lock and the visual and audible alarms are to immediately activate when the band is cut.

On 01/29/14, between 1:55PM and 2:15PM, the electronic infant monitoring system was tested four (4) times and failed to consistently operate during three (3) of these tests. It was determined that the electronic door lock, the auditory alarm, and the visual alarm did not consistently operate in a manner that ensured the safety and security of young children. Two (2) surveyors and approximately eight (8) hospital staff were present during these testing sessions, which included but were not limited to the following staff: the Director of Security, the Director of Engineering and the Director of Nursing.

The first test inspection was conducted on the 5th Floor Pediatrics Unit at 1:55PM. Observation of a Nurse cutting a baby band and walking through the 5th Floor Pediatrics Entrance doors revealed that the door lock failed to activate when the band was cut.

A second test was conducted on the 5th Floor Pediatrics Unit at 2:04PM and the door locked and auditory alarm was activated.

A third test was conducted on the 5th Floor Pediatrics Unit at 2:09PM. Observation of a Nurse wearing a baby band passing through the 5th Floor Pediatrics Entrance doors revealed that while the door lock activated, the auditory alarm did not activate.

A fourth test was conducted on the 5th Floor Pediatrics Unit at 2:15PM. Observation of a Nurse wearing a baby band passing through the 5th Floor Pediatrics Entrance doors revealed that while the door lock activated, the auditory alarm did not activate.

It was also confirmed during interview with the Director of Security on 1/29/14 at 12:10 PM that the electronic device system was not linked to the elevator system or the exit stairwells located directly outside the Units so that if an abductor bypasses the door lock feature, the elevators or the stairwells doors would not be deactivated / locked.

The written Policy #C-456 titled "Critical Response Plan In The Case of Infant/Child Abduction", that was reviewed on 01/29/14, stated that "the Hospital's Newborn Nursery and Pediatric Units are equipped with electronic detection devices which will alert the Nursing Staff and Hospital Security of someone's attempt to remove an infant / child without authorization or attempts to cut the electronic tag's band which is affixed to the child". However, this policy did not describe the specific details and testing of the system to include potential contingencies, including instances where the door is manipulated to remain open, the visual and auditory alarm is displayed / heard throughout the Unit.
.

.
Based on tour, review of documents, and interviews, it was determined that the Environmental Services failed to collect, aggregate, and analyze data for the quality indicator measures, monitor the effectiveness of the action plan, and monitor the performance of the staff to ensure compliance with daily rounds conducted in the facility.

Findings include:

Review of the Quarterly Statics Reports and Quality Management Staff Meeting Reports on 01/31/14 revealed the following:

Environmental Services presented Quarterly Statistics to the Quality Council on June 14, 2013; September 13, 2013 and December 13, 2013. For each quarter, the measures not achieved under the Press Gainey Survey were presented as follows: (1) Room Overall Score, (2) Room Cleanliness, and (3) Courtesy of Person Cleaning Room.

The Action Plans for these measures were repeated each quarter and there was no documentation to support implementation of the plan. There was no data collection, tracking, trending and analysis to determine outcomes and identify areas for improvement.

Departmental Management Meetings were recorded monthly but there were no meeting agenda and no minutes/reports generated after these meetings.

Departmental Staff Meetings were recorded monthly but there were no minutes, reports or documentation to validate discussion of the items on the agenda or training materials distributed.

During an interview with Staff #10 on 01/31/14 at 10:35AM, it was stated the activities in the Action Plan were implemented, but no data was kept. There is no tracking, trending and analysis to determine the outcomes and identify areas for improvement and there was also no process to provide ongoing monitoring of staff to ensure compliance with the Action Plan. These findings were acknowledged by Staff #10.

The facility failed to maintain a sanitary physical environment to minimize the risks for transmission of infections and failed to monitor the performance of the staff to ensure compliance with daily rounds that are conducted in the facility.

Refer to Tag A 748 (Infection Control: Organization and Policies).
.

.
Based on observations, staff interviews, and review of medical records and other documents, it was determined that Nursing staff failed to implement the facility's policy and procedure to assure the prevention and treatment of pressure ulcers. Specifically, Nursing staff failed to; develop care plans that addresses identified care needs; consistently document skin assessment and care of pressure ulcers as directed by the facility's policy; and identify post hospital care needs regarding treatment of pressure ulcers to assure continuity of care. These findings were noted in three (3) of eight (8) patient records reviewed (Patients #1, #2, #3).

Findings include:

1. Patient #1 is a 77-year-old female who was evaluated in the Emergency Department on 01/7/14. She is status post fall at home and diagnosed with a Left Hip Fracture for which she underwent left hip Open Reduction Internal Fixation on 01/09/14.

The Initial Nursing Assessment on admission identified the patient as a risk for developing pressure ulcers as evidenced by a Braden Score (assessment tool used to predict the risk for pressure ulcers) of fifteen (15) (mild risk). The patient was noted to be dependent in ambulation, transferring, toileting, bathing, and dressing. The patient's skin however was documented on admission to be "clean, dry, and intact".

Review of the Repositioning Record in the Electronic Medical Record (EMR) on 01/28/14 revealed the patient had not been consistently repositioned every two (2) hours as indicated in the facility's Pressure Ulcer Prevention and Treatment Policy. The policy requires that pressure ulcer prevention protocol is initiated for all adult patients who score eighteen (18) or less on the Braden Risk Assessment Form and care of such patients should include turning and repositioning every two (2) hours in order to redistribute pressure. The documentation of position change should be entered into the EMR.

The Repositioning Record for Patient #1 indicated the patient was turned once on 01/08/14, 01/09/14, 01/10/14 and 01/12/14 and not every two (2) hours as directed by the policy.

Review of the EMR lacked documentation of a daily comprehensive skin assessment to promote skin integrity and prevent skin breakdown in accordance with the Pressure Ulcer Prevention Policy. A pressure ulcer on the patient's coccyx was first identified on 01/13/14 as a Deep Tissue Injury (DTI). At discharge on 01/28/14, the patient's coccyx ulcer was described as unstageable, 7cm x 4cm.

Review of the patient's Discharge Instructions on 01/29/14 at 11:30AM noted care for patient's surgical wounds but there was no post hospital care instruction for the treatment of her pressure ulcer.

At interview with Staff #1 on 01/29/14 at 11:32AM, she stated the patient was discharged to a nursing home and the Physician is responsible for communicating the care needs of the patient to the nursing home. However, these needs were not identified in the Interdisciplinary Care Plan and documented in the patient's Discharge Instructions.

2. Patient #2 is a 43-year-old female presented to the Emergency Department on 01/11/14 and was triaged at 8:46PM. The patient was transferred from a long term care facility for evaluation of Fever, Rule Out Sepsis. The patient is ventilator dependent, responsive to deep pain and stimuli only, with a past medical history of Intracranial Hemorrhage. The patient was admitted on 01/12/14 at 02:59AM and the Admission History and Physical completed by the Physician documents a history taken from the nursing home record. This history included skin care treatment to buttocks twice daily and a dressing treatment to the sacrum.

The patient was transferred to the Cardio Pulmonary Care Unit (CPCU) on 01/13/14 at 21:11 (9:11PM) and the Registered Nurse (RN) Admission Assessment was completed at 1:36AM on 01/14/14.

The documentation of skin assessment and treatment in the medical record from 01/11/14 to 01/28/14 revealed the following:

a. The medical record lacked documentation that pressure ulcer (PU) treatment was provided during the first thirty (30) hours when the patient was admitted to the facility.

In addition, the Admission Assessment that was completed by the RN in the critical care area lacked documentation of a comprehensive skin assessment.

The facility's policy for Pressure Ulcer Prevention and Treatment requires a comprehensive skin assessment upon admission and daily thereafter in all critical care areas.

b. PU to the Left Buttock, Sacral Spine, Stage II was first documented by the RN on 01/14/14 at 15:33 (3:33PM) and there is no documentation that treatment was implemented and provided as per protocol.

The facility's protocol states that topical wound treatment may be initiated by the RN for Stage II and to notify the Medical Doctor. The treatment is to be provided daily.

c. The Care Plan was not updated to include a plan for pressure ulcer management.

d. The PU wound assessment, which is required at least weekly, did not document the findings as per protocol. Specifically, the size of the PU on the sacrum and description of the Periwound was not documented.

e. The patient's PU was evaluated by the Wound Specialist RN on 01/23/14 and the wound was described as "L. Sacrogluteal Stage III wound with slough, red tissue, drainage, and an area of DTI (Deep Tissue Injury) from 11-12 o'clock". Wound treatment with application of Allevyn foam Q 3-5 days PRN (as needed) was recommended by the RN.

There was no documentation in the medical record that wound care with Allevyn has been implemented by the RN. It was noted that the Wound Specialist's recommendation for application of Allevyn foam Q 3-5 days PRN was not consistent with the facility's protocol for application of Allevyn gauze every two (2) days and prn to a Stage III PU.

f. The RN documents a Stage II Pressure Ulcer on the patient's left elbow on 01/13/14 and 01/14/14 but there was no documentation that treatment was initiated and that the MD was notified as per protocol. In addition, there was no documentation after 01/14/14 relating to the PU on the left elbow.

g. The documentation in the "Assessment and Cares" notes does not validate that this patient was turned and repositioned every two (2) hours as per protocol.

h. The Physician ordered the use of a Cooling blanket for this patient effective 01/21/14 and the RN documents that the blanket was applied on 01/21/14. The facility's policy for Hypo / Hyperthermia Blanket use requires the documentation to include the presence of skin lesions, pressure areas, and pressure ulcers prior to placing the patient on the blanket but this documentation was not included in the RN's note.

The protocol for Hypo / Hyperthermia Blanket use also states the patient's temperature should be monitored every two (2) to four (4) hours or more frequently as the patient's condition warrants and documented in the "Assessment and Cares" notes to validate compliance with this requirement. The record lacked documentation of compliance with the protocol.

3. Patient #3 is a 52-year-old female who presented to the ED on 01/21/14 at 10:30AM for Pneumonia and was triaged by an RN. Patient was transferred from a long term care facility with past medical history of Huntington's Chorea, Gastro Esophageal Reflux Disease, Hypertension, Psychosis, Chronic Obstructive Pulmonary Disease, and Chronic Respiratory Failure. Patient is nonverbal, ventilator dependent, and has severe contractures of the extremities.

Patient was admitted to the facility on 01/21/14, at 15:14 (3:14PM) and was transferred to the CPCU on 01/23/14.

The medical record included documentation of a Wound Care consult on 01/23/14 at 8:25AM and the Wound Care Nurse documents the presence of (1) Sacral, Unstageable wound, (2) Left Sacrogluteal Stage II wound and (3) Left Ischium shearing wound. Wound treatment was recommended to all three (3) wounds, along with elevate / float the patient heels and reposition the patient Q 2 hours. Treatment of the PU's was documented by the RN on 01/23/14, at 8:30AM.

There was no documentation, however, that this patient received PU treatment after being admitted to the facility on 01/21/14 and prior to 01/23/14.

It was noted that the Wound Specialist's recommendation for application of Allevyn foam Q 3-5 days PRN is not consistent with the facility's protocol for application of Allevyn gauze every two (2) days and prn to a Stage III PU.

The documentation in the "Assessment and Cares" lacks evidence that the elevation of the patient's heels was implemented and does not validate reposition of the patient Q 2 hours.

These findings were confirmed with Staff #7 on 1/29/14 at 1:35 PM.









16399

Based on observation of the Medical Record Department and interview, it was determined the facility failed to ensure that medical records were promptly completed. Specifically, Operative notes and discharge summaries of patients were not completed thirty days after discharge as prescribed by the facility's policy on medical record completion. This finding was noted in three (3) of three (3) records reviewed (Patient #20, #21, #22).

Findings include:

During tour of the Medical Record Department on 01/28/14 at 12:30PM, it was observed that several medical records were incomplete after thirty (30) days of discharge. The review of a sample of outstanding medical records was requested and upon review, it was noted that several Physicians were not compliant with timely completion of medical reports within thirty (30) days of discharge. One Physician had thirty (30) deficiencies that included incomplete Operative Notes and Discharge Summaries. For example:

Patient #20 was discharged 06/12/13; the patient's Operative Report was completed six (6) months later on 01/02/14.

Patient #21 was discharged on 08/08/13 and the Discharge Summary was not completed until four (4) months later on 12/11/13.

Patient #22 was discharged on 02/13/13; the Operative Note was completed four (4) months later on 06/21/13.

At interview with Staff #11 on 1/28/14 at 1:15 PM, she stated that incomplete records past 30days are delinquent. She added that the Medical Record Department tracks incomplete records and works aggressively with physicians to ensure timely completion of records.

.
Based on observation, interview, and review of documents, it was determined that the Department of Pharmacy Policies and Procedures related to labeling of multi-dose vial were not consistently implemented. This finding was noted in two (2) of four (4) Outpatient Clinics visited.

Findings include:

1. During observation tour in the Ortho/Pulmonary Clinic on 01/30/14 at 11:00AM, an opened multi-dose vial of Humulin R with manufacturer's expiration date of 09/14 lacked the date when the vial was first opened for use.

The Department of Pharmacy Policy and Procedure titled Expiration Date of Multi-Dose Vials last revised in January 2014 notes "the beyond use date after initially entering or opening multi-dose vials is twenty-eight (28) days, unless otherwise specified by the manufacturers in their packaging".

2. At the Children's Health Center on 01/30/14 at 10:30AM, the medication refrigerator contained an opened multi-dose Polio Vaccine that was not dated when it was first opened. The manufacturer's expiration date for the Polio Vaccine was 06/05/15.

A multi-dose Measles, Mumps, and Rubella (MMR) vaccine with manufacturer's expiration date of 11/14 was dated when it was opened for use and had expired on 01/09/14.

At interview with Staff #4 and Staff #5 at 10:45AM, they stated multi-dose vials are good for twenty-eight (28) days and the Polio Vaccine should have been labeled with the date of expiration when it was first open for use. Staff #4 stated the MMR vaccine with expiration date of 01/09/14 should not have been made available for patient use.

However, the review of the Department of Pharmacy Policy and Procedure on expiration date of multi-dose vials revealed that staff lacked knowledge of this policy that excluded multi-dose vials of vaccines, including those supplied for the Vaccines For Children (VFC) Program from the twenty-eight (28) day expiration date after the vial is first open. The policy notes that the multi-dose vaccines are to be used through the manufacturer's expiration date as long as the contents appear free of contamination.
.

.
Based on observation and staff interview, the Food Service Director did not ensure that the daily operation of the Food Service Department was conducted in a sanitary manner.

Findings include:

A tour of the hospital Kitchen was conducted on 01/30/14 at approximately 10:30AM. The surveyor was accompanied by Staff #5. The Food and Nutrition Department is managed by a Dietary Contractor.

Examples of unsanitary environment / food safety issues observed included, but are not limited to, the following:

1. All hand washing sinks were missing a waste basket to discard paper towels.

2. Ceiling tiles were separated above the cook's prep table promoting a habitat for insects.

3. A metal wire was hanging from the tiles. The Food Service Director was unable to tell the surveyor the use for this wire.

4. An ice cream freezer was observed to be located next to the pot washing area.

5. The eye washing sink was dusty. There was no sign posted for the use of this sink.

6. Four (4) upright metal file cabinets were lined against the wall in the kitchen. Each file cabinet had four (4) drawers containing paper documents. These cabinets may be conducive for harboring insects.

7. An upright desk was located in the Kitchen. Beside the desk was another upright metal file cabinet with four (4) drawers containing paper documents.

8. All plastic garbage cans in the Kitchen had no cover. Two (2) garbage cans were observed to have flies.

9. Condiments were not dated as to the date they were open or the date of expiration.

10. Floor tiles below the steamer were observed to be cracked.

11. Skid floor mats were observed to be missing in the dishwashing, pot washing, and cook area. These are hazardous area in the kitchen that often wet and slippery.

12. Hospital menus were not posted in the kitchen.

These findings were aknowledged by the Director of Food and Nutrition during tour of the kitchen on 1/30/14 at 11:30 AM.
.

.
Based on staff interview, review of hospital master menus, and nutrient analysis of menus, it was determined the Food and Nutrition Department failed to ensure that Physician prescribed diets met the therapeutic nutritional needs of patients. This finding was noted in ten (10) of twenty two (22) menus reviewed.

Findings include:

A review of hospital master menus and nutrient analysis of menus was conducted on 01/30/14 at approximately 1:00PM in the presence of Staff #14. The hospital has a one (1) week cycle menu and a diet formulary consisting of approximately forty-four (44) different diets available to the Physician for diet ordering.

Listed below are the findings identified in a sample of twenty two menues and nutrient analysis of prescribed diets reviewed:

1. Review of nutrient analysis showed that menus did not meet the Physician's prescribed diets. For example:

a. The 60gm, Protein Restricted Diet menus were not standardized to ensure that they contain approximately 60gms of protein; instead, the menu was noted to contain different amounts of protein ranging from 68gms to 111gms.

b. The Renal 100gm Protein Diet contained proteins ranging from 44.7gms to 85.1gms and not the 100gms of protein noted on the diet order.

c. The Renal 60gm Protein Diet contained the following amounts of protein on different days of the menus - 85.1gms, 71gms, 33.6gms, 68.4gms, 101gms and 98.3gms.

d. The Renal 80gm Protein Diet contained the following amount of protein on different days of the menus - 85.1gms, 71gms, 33.6gms, 68.4gms, 0gms and 0gms.

e. The 2000mg Potassium Diet contained the following amount of potassium on different days - 2687mgs, 2300mgs, 1980mgs, 2300mgs, 2700mgs and 2800mgs. The potassium in these menus was not equivalent to the amount prescribed in the diet order.

2. Diets listed on the Physician Diet Formulary lacked the amount of nutrients provided on diets; therefore, the Physician and patient are unaware of the amount of nutrients in the diet. The accuracy of the nutrient analysis was unknown. Examples of these findings are:

a. High Calorie High Protein Diet menus did not specify the amount of calories or protein in the Physician Diet Formulary and in the nutrient analysis.

b. High Fiber Diet did not specify the amount of fiber on the Physician Diet Formulary, patient's menu, and in the nutrient analysis,

c. Low Cholesterol / Low Cholesterol-Low Fat Diet lacked the amount of fat listed on the Physician Diet Formulary, patient's menu, and in the nutrient analysis for the diet.

d. No Added Salt Diet lacked the amount of fat listed on the Physician Diet Formulary, patient's menu, and in the nutrient analysis for the diet.

3. There were no age specific menus for Pediatric patients. The Dietary Department had only one (1) menu titled "Pediatric" which addressed the adolescent population in food items and food portions. Infant, toddler, and school age children require different food or food portions than that of an adolescent. There was no evidence that the infant, toddler, or school age child was provided the food and food portion required by the age group. In addition, there was no nutrient analysis available to substantiate that the nutritional needs required for these age groups are being met.

These findings were verified by Staff #14 during joint review of the hospital master menus and nutrient analysis of menus on 01/30/14 and 01/31/14.
.

.
Based on observation, staff interview, and review of diet formulary, it was determined that the facility failed to ensure that the American Academy of Nutrition Pediatric Diet Manual is used as a guidance for ordering and educating patients on their prescribed diets.

Findings are:

1. The Pediatric Diet Manual was not utilized as reference in the establishment of age specific menus. There was no evidence that age specific needs were met with the hospital generic menu meant to address the adolescent population.

2. In reviewing the nutrient analysis of the hospital master menu and hospital Physician Diet Formulary, it is evident that the Nutrition Care Manual for Adults was not used as a reference since diets such as BRAT and Bland included in the diet formulary had been deleted from the Diet Manual. Special approval for these diets from the hospital Nutrition Committee was not available.

3. Diet reference from the Diet Manual was not evident in the Physician Diet Formulary since the amount of the diet restriction was absent in the diet formulary was well as the patient menu.

During review of the Physician Diet Formulary and the hospital master menu on 1/30/14 at 2:30 PM, the Clinical Nutrition Manager informed the surveyor that she was in the process of updating the diet formulary and changing the menu.
.

Based on observations, and staff interview, the facility failed to be in compliance with the Condition of Participation of Physical Environment. This was evident by the facility's noncompliance with the maintenance of a safe, sanitary, and comfortable environment and the Life Safety Code.


Findings are:

The facility failed to maintain a safe, sanitary, and comfortable environment to ensure that the safety and well-being of patients are not compromised. (See A 701)

The facility failed to meet the Life Safety Code Standards. (See A 710)
.

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

Findings include:

1. Damaged / Stained Ceiling Tiles:

a. On 01/27/14 observation revealed stained / damaged / missing ceiling tiles were observed in multiple areas in the facility.

- At 11:15AM observation revealed that there were stained / damaged ceiling tiles located throughout the Kitchen.

- At 11:50AM observation in Ultrasound Room #3 revealed two (2) stained ceiling tiles.

- At 11:55AM observation in the CT Control Room revealed one (1) stained ceiling tile.

- At 12:00PM observation in the MRI Machine Room revealed five (5) stained ceiling tiles.

- At 12:25PM observation revealed that there was an open ceiling tile found in Radiology Patient Room #4.

- At 1:42PM observation in the Emergency Department Urgent Care Area revealed that there was one (1) stained ceiling tile found.

- At 2:15PM observation in the Respiratory Suite Clean Utility Room revealed one (1) stained ceiling light cover.

b. On 01/28/14 observation revealed stained / damaged ceiling tiles.

- At 9:52AM observation in the Pathology Lab revealed one (1) stained ceiling tile.

- At 10:30AM observation in the Chemistry Lab revealed one (1) stained ceiling tile.

- At 10:45AM observation in the Hematology Area revealed that there were four (4) broken ceiling tiles in the Hematology Back Room, and one (1) stained ceiling tile in the Hematology Storage Room.

- On the afternoon of 01/28/14 observation in Bariatric Exam Room #1 revealed two (2) stained ceiling tiles.

- At 12:25PM observation in the Rehabilitation Medicine Equipment Room revealed two (2) stained ceiling tiles.

- At 3:00PM observation in the Operating Room Sterile Supply Area revealed one (1) stained light cover.

c. On 1/29/14 observation revealed stained / damaged ceiling tiles.

- At 12:18PM observation in Dental Clinic Treatment Room #2 revealed two (2) damaged ceiling tiles.

- At 12:30PM observation in the vicinity of the Dental Suite Clinic revealed one (1) stained ceiling tile.

d. On 01/30/14 observation revealed stained / missing ceiling tiles.

- At 10:22AM observation in the Post-Anesthesia Care Unit revealed one (1) stained ceiling tile.

- At 11:30AM observation in Medical Intensive Care Unit revealed that two (2) stained ceiling tiles were found in both Room #3 and Room #4.

- At 11:39AM observation in the Medical Intensive Care Unit revealed three (3) stained ceiling tiles and one (1) missing ceiling tile.

- At 2:00PM observation in the vicinity of the Medical/Surgical Suite Storage Room revealed one (1) stained ceiling tile.

- At 2:05PM observation outside of Medical / Surgical Suite, Room #882, revealed one (1) stained ceiling tile.

e. On 01/30/14 observation revealed stained / missing ceiling tiles.

- At 3:47PM observation in Nursery #3 revealed one (1) stained ceiling tile.

- At 3:51PM observation in the Nursery Janitor Closet revealed a homemade "cardboard" ceiling tile.

2. Delaminated Wallboards / Damaged Walls:

a. On 01/27/14 at 1:54PM observation at the Emergency Department Food Pantry revealed that the caulking around the sink was damaged.

b. On 01/27/14 at 2:28PM observation revealed that the handrail was ripped loose from the wall exposing a hole in a wall of the Pediatric Outpatient Clinic Waiting Room.

- On 01/30/14 at 10:41AM observation revealed that there was a hole in a wall of the Cardio Pulmonary Care Room #616

- On 01/30/14 at 2:15PM observation revealed that there were four (4) unsealed holes in a wall of the Medical / Surgical Suite Wash-Tub Room

- On 01/30/14 at 12:50PM observation revealed that there were approximately twelve (12) holes in a wall of Labor and Delivery Room #5.

- On 01/30/14 at 2:50PM observation revealed that there were four (4) holes in a wall of Labor and Delivery Room #3.

c. On 01/27/14 at 2:35PM observation revealed that there was a loose outlet in a wall of Pediatric Room #4.

- On 01/2/8/14 at 11:33AM observation revealed that there was a missing wall plate for an electrical outlet in Nuclear Medicine Injection Room.

On 01/30/14 at 1:58PM observation revealed that a missing plate cover in the Geriatric Shower Room was covered with a piece of duct tape.

On 01/30/14 at 2:40PM observation revealed that there was a broken outlet cover in Labor and Delivery Room #9.

- On 01/30/14 at 12:50PM observation revealed that there was a missing outlet cover in Labor and Delivery Room #3.

d. On 01/27/14 at 2:35PM observation revealed that there was a damaged section of wall in the Pediatric Medication Room.

- On the afternoon of 01/28/14 observation of the Vascular Lab revealed that there was a damaged wall and hole within the Waiting Room.

- On 01/28/14 at 2:25PM observation revealed that the bottom of a wall in the Rear Equipment Storage Room was damaged.

- On the morning of 01/30/14 during a survey of the Cardio Pulmonary Care Unit, observation revealed that the walls of Rooms #608, #616, #618, #627 and #631 were damaged. Specifically, the corner bead was exposed within the wall.

- On the morning of 01/30/14 observation in Geriatrics Suite Room #806 revealed that the corner bead was exposed within one (1) of its walls.

e. On 01/29/14 at 12:18PM observation revealed that there were delaminated / damaged cabinets in all four (4) Treatments Rooms in the Dental Clinic.

On 01/30/14 at 11:25AM observation revealed that in Medical Intensive Care Unit Room #5 the wallboard behind the sink was delaminated from the wall.

- On 01/30/14 at 11:30AM observation in Medical Intensive Care Unit Room #11 revealed that there was a delaminated wall board on the side of the sink.

3. Storage Issues:

- On 01/27/14 at 1:40PM observation revealed that there were two (2) mountain bikes, a walker, a cone, etc. stored in Emergency Department Decontamination Room.

- On 01/28/14 at 11:30AM observation revealed that there was a floor cleaning machine being stored in the Nuclear Medicine Storage Room.

- On 01/28/14 at 12:20PM observation revealed that medical records were being stored with new and used equipment, and miscellaneous boxes in the Rehabilitation Medicine Equipment Room.

- On 01/30/14 at 2:46PM observation revealed that a Soiled Linen Cart, two (2) balloons, an umbrella, crutches, etc. were being stored in the Labor and Delivery On Call Room Bathroom.

4. Ceiling Vents:

a. On 01/27/14 at 12:14PM observation revealed that a ceiling vent in the Radiology Janitor Closet was dust laden.

- On 01/27/14 at 2:20PM observation revealed that a ceiling vent in the Respiratory Staff Room was dust laden.

- On 01/30/14 at 2:12PM observation revealed that a ceiling vent in the Medical / Surgical Suite Wash-Tub Room was dust laden

- On 01/30/14 at 3:51PM observation revealed that a ceiling vent in the Nursery Janitor Closet was dust laden.

b. On 01/28/14 at 9:52AM observation revealed that there were two (2) ceiling vents in the Pathology Lab that had paper towels shoved in them so the airflow could be blocked.

- On 01/30/14 at 2:00PM observation in the Medical / Surgical Suite Storage Room revealed a ceiling vent covered with duct tape.

- On 01/30/14 at 3:45PM observation in the Operating Room Clean Utility Room revealed that a piece of cardboard was installed within the ceiling vent.

5. Items on Floors/Dirty Floors:

a. On 01/28/14 at 10:20AM observation revealed empty plastic containers on the floor behind the Chemistry Lab Biohazard Refrigerator.

- On 01/30/14 at 10:30AM observation revealed a diaper and a dressing were on the floor of Room #608.

- On 01/30/14 at 10:50AM observation revealed that a saline flush and a plastic lid were found on the floor of Cardio Pulmonary Care Room #618.

- On 01/30/14 at 11:30AM observation revealed that there were two (2) soiled gauze pads on the floor of Medical Intensive Care Unit Room #4.

- On 01/30/14 at 1:35PM observation revealed that there was one (1) gauze pad on the floor of Geriatric Suite Room #806.

- On 01/30/14 at 2:20PM an open box of gloves was on the floor of the Medical / Surgical Suite Janitor Closet

b. On 01/30/14 at 10:27AM observation revealed a stained floor in the Cardio Pulmonary Care Storage Room.

- On 01/30/14 at 10:50AM observation revealed that the Cardio Pulmonary Care Janitor Closet floor was stained.

- On 01/30/14 at 10:55AM observation revealed that the Cardio Pulmonary Care Room #629 floor was stained.

- On 01/30/14 at 2:25PM observation revealed that the Medical / Surgical Suite Room #851 floor was stained.

6. ADA Requirements:

a. Nurse Pull Cords:

- On 01/27/14 at 1:45PM observation in the Emergency Department Decontamination Room revealed that the Nurse call audible and verbal alarm did not activate.

- On 01/27/14 at 2:00PM observation revealed that the Nurse call bell, audible and visual alarms did not activate throughout the Pediatric Emergency Department.

- On 01/30/14 at 10:53AM observation revealed that the Nurse pull cord was wrapped around a pole in the bathroom of Cardio Pulmonary Care Room #627.

- On 01/30/14 at 10:58AM observation in Cardio Pulmonary Care Room #631 revealed that the Nurse pull cord was too long, and part of it was on the floor.

- On 01/30/14 at 11:15AM observation in Cardio Pulmonary Care Room #651 revealed that the Nurse pull cord was too long.

- On 01/30/14 at 1:50PM observation in the Geriatrics Suite Room #820 Bathroom revealed that the Nurse pull cord was wrapped around a pole.

- On 01/30/14 at 2:22PM observation in the Medical / Surgical Suite Room #853 Bathroom revealed that the Nurse pull cord wrapped around a pole.

b. Signage

- On 01/27/14 at 11:46AM observation in Radiology revealed that there was missing signage for the equipment processing room, etc.

c. Sink Sleeve

- On 01/27/14 at 1:30PM observation in the Children's Waiting Room ADA Bathroom revealed that the sleeve for water pipes located under the sink was missing.

7. Other Issues:

- On 01/28/14 at 11:25AM observation in Nuclear Medicine Image Room #4 revealed that there was a towel shoved under the air conditioning unit.

- On 01/28/14 at 3:30PM observation in the Post-Anesthesia Care Unit revealed that access to Bay #12 was partially blocked by an oxygen rack with ten (10) oxygen tanks in it, and a Bair Hugger Heater.

- On 01/30/14 at 11:17AM observation in the Cardiac Special Care Unit Pantry revealed that the sink was half filled with stagnant water, and the drain was blocked up.

- On 01/30/14 at 1:45PM observation in Room #810 revealed that there was water dripping into a garbage can. Towels were also found on the floor.

- On 01/30/14 at 3:15PM observation in Operating Room #3 revealed that there was a frayed extension cord. The cord for the infant warmer is also damaged.

- On 01/30/14 at 3:20PM observation in Operating Room #2 revealed that there were two (2) non-hospital grade extension cords plugged into explosion proof twist plugs.

All of the above findings were concurrently verified by Staff #16.
.

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

Findings include:

During the survey of the facility from 01/27/14 - 01/31/14, Life Safety Code deficiencies were noted in multiple areas of the Code requirements and were cited under the following Fire / Life Safety Code K-Tags:

K 17 (Corridors are separated from use areas by wall constructed with at least one-half {½} hour resistance rating).

K 18 (Doors protecting corridor openings constructed of one and three quarters {1¾} inch solid-bonded core wood or capable of resisting fire for at least twenty {20} minutes).

K 20 (Vertical openings between floors are enclosed with construction having a fire resistance rating of at least one {1} hour).

K 22 (Access to exits is marked by approved, readily visible signs in all cases).

K 29 (One {1} hour fire rated construction [with three-quarter {¾} hour fire-rated doors] for hazardous areas).

K 72 (Means of egress are continuously maintained free of all obstructions or impediment).

K 76 (Medical gas storage and administration areas are protected in accordance with NFPA 99, Standards for Health Care Facilities).

K 145 (The Type I EES is divided into the Critical Branch, Life Safety Branch and the Emergency System in accordance with NFPA 99. 3.4.2.2.2).

K 147 (Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2).
.

Based on observations, staff interviews, and review of policy and procedure, the facility failed to be in compliance with the Condition of Participation for Infection Control as evidenced by the failure of the Infection Control Officer to ensure there is ongoing monitoring and tracking of the surveillance activities to ensure the maintenance of a sanitary environment.

Findings include:

The facility failed to ensure that Infection Control Officer implemented of systematic tracking to monitor compliance with daily rounds to all units and there is follow-up to any issue that is identified.

The facility failed to ensure tracking, trending and analysis of the daily rounds to determine systemic issues regarding the quality of the environmental services.

Cross reference specific citations noted under Tag A 0748.

.
Based on observations, record review, and staff interview, it was determined the Infection Control Officer was not effective in her role in identifying conditions that would potentially cause contamination and the spread of infection and failed to ensure that services were provided in a clean and safe environment.

Findings:

1. On 01/27/14 at 12:25PM observation in the Radiology Department revealed a one-half (½) full container of soup in the Radiology Housekeeping Closet.

2. On 01/28/14 at 3:27PM observation in the Post-Anesthesia Care Unit (PACU) revealed clean supplies (i.e. paper towels, toilet paper) were being stored in the Soiled Utility Room.

3. On 01/27/14 at 1:50PM observation in the Emergency Department revealed that the Soiled Utility Room had neutral air pressure.

- On 01/30/14 at 11:39AM observation in the Medical Intensive Care Unit (MICU) revealed that the Soiled Utility Room had neutral air pressure instead of the required negative air pressure needed for this type of room as per AIA Guidelines.

4. On 01/30/14 at 9:45PM observation in the Pediatric Intensive Care Unit (PICU) revealed that a pillow was found under the sink cabinet of the Family Lounge.

5. On 01/30/14 at approximately 11:45AM, observation and interview with Staff #16 revealed that all of the hospital Airborne Isolation Rooms had non-scrubbable ceiling tiles. This included, but is not limited to the following:

- The morning of 01/30/14 observation in Room #441 and Room #443, both Airborne Isolation Rooms did not have scrubbable ceiling tiles which are required for this type of room as per AIA Guidelines.

- At 10:15AM observation revealed that the Cardiac Cauterization Lab had non-scrubbable ceiling tiles.

- At 11:15AM observation at the Cardiac Special Care Unit (CSCU) revealed that Isolation Room #641 had non-scrubbable ceiling tiles.

- At 11:35AM observation revealed that all of the MICU rooms had non-scrubbable ceiling tiles.

6. On 01/30/14 at 1:50PM observation revealed that the Geriatric Suite Airborne Isolation Room #820 did not have a self closure device that is required to keep the negative air pressure of this room.

7. On 01/30/14 observation revealed that patient beds, chairs, etc. were not maintained in a clean and safe environment.

- At 10:17AM observation in the PACU revealed that the patient beds located in Bays #3, #4, and # were damaged / broken. Additionally, tape was found on patient beds in PACU Bays #4 and #5.

- At 10:30 M observation revealed that a chair was stored in the Cardio Pulmonary Suite Room #608 Bathroom.

- At 10:41AM observation revealed that one (1) chair in the Cardio Pulmonary Suite Room #616 was torn. Additionally, the other chair located in this room had blood drops on it.

- At 10:50AM observation revealed that both of the chairs located in the Cardio Pulmonary Suite Room #23 were torn.

- At 1:35 M observation revealed that the mattress covers for both of the beds in Geriatric Suite Room #808 were torn.

- At 1:54PM observation revealed that the mattress covers for both of the beds in Geriatric Suite Room #827 were torn.

- At 1:58PM observation revealed that a mattress cover for one (1) of the beds in Medical / Surgical Suite Room #888 was torn.

- At 2:30PM observation revealed that the mattress cover in Labor and Delivery Room #9 was torn.

- At 2:55PM observation revealed that the mattress cover in Labor and Delivery Room #3 was torn.

6. On 01/30/14 observation and staff interview revealed that that the floors were not maintained in a clean and safe environment. Specifically:

- At 10:58AM observation in Cardio Pulmonary Suite Room #631 revealed a blood drop on the floor.

- At 11:22AM observation in CSCU Room #657 revealed two (2) blood drops on the floor.

7. On 01/30/14 observation and staff interview revealed that medical tape was improperly used in various areas of the hospital. Specifically:

- At 11:13AM observation revealed that the cameras located over the patient beds in CSCU Rooms #647 and #651 had a thick layer of medical tape over them.

- At 11:30AM observation revealed that an IV pole in CSCU Room #4 had layers of medical tape on it.

- At 2:45PM observation outside Labor and Delivery Room #8 revealed that four (4) CALF carts had mouse pads that were made with medical tape, paper, and plastic on them.

8. On 01/30/14 at 11:22AM observation in CSCU Room #655 revealed that a sharps container on the floor was in contact with a patient's jacket and a chair.

All of the above findings were concurrently verified by Staff #16.

9. During a tour of the 6 Floor CPCU on 01/27/14 at 11:00AM, the following issues were noted:

a. A syringe plunger was found on the floor in Room #612 and another on the patient's ventilator unit in Room #620.

b. The window shade in Room #620 was dirty and soiled with dried solutions.

c. The intravenous pumps in Room #620 and Room #623 were soiled with dried solutions.

d. Dirt was on the base of the patients' ventilators in Room #612 and Room #620.

e. Dirty floors and cabinets in patient Bathrooms #620 and #B623. Two (2) pedals under the sink in Room #620 had a buildup of dirt and grime.

f. Patient Shower Room #B617 had dirty walls, bar soap was on the floor.

g. Patient Shower Room #B615; the floor was dirty and a covered, clean commode was stored in the bathtub. The Head Nurse was present and stated this room had not been used in about two (2) years and is used to store equipment.

h. Clean equipment is stored at the end of the corridors in a "designated clean area". The clean area that is close to Room #B623 had clean equipment and a Recycle Bin was observed mixed in with the clean equipment. The bin was soiled and dirty and was filled with garbage.

i. A standing lamp in Room #623 had dirt on its base. "Vein Finder" equipment was also in the room and this equipment had hair particles on the cuff.

j. The floor in the Soiled Utility Room was soiled and dirty. The room was filled with utility equipment which blocked access to the sink and access to areas within the room.

Staff #7 who was present during the tour acknowledged the need for cleaning the infusion pumps and stated the RNs are responsible for cleaning the pumps and equipment after patient use and as needed.

Review of the facility's Policy 4-7: Nursing, Infection Prevention and Control stated "All pumps (PCA, Infusion, etc.) shall be cleaned with a germicidal disposable cloth (sani-wipe) before and after use". It was noted that the policy does not include cleaning the pumps while in use. This finding was acknowledged by Staff #8 during an interview on 01/28/14.

Staff #9 was present during the tour, and stated a Respiratory Therapist is assigned to each patient and will clean the ventilators as needed. Staff #9 acknowledged that there is no policy for staff to clean the ventilators while they are in use and the ventilators are cleaned after patient use by Environmental Services downstairs.

This statement was confirmed during an interview with Staff #8 on 01/28/14. Staff #8 stated the Environmental staff does not clean the equipment "when it is attached to the patient" and there is no policy for cleaning the ventilator while it is in use.

During an interview with Staff #10 on 01/31/14 at 10:35AM, it was stated that the Supervisors in Environmental Services makes daily rounds to the Medical Units and annually to the Non-Clinical Areas. Daily logs were presented to the surveyor but it was noted that there was no systematic tracking to ensure compliance with daily rounds to all units and follow-up to any issue that is identified. There is also no, tracking, trending and analysis of the daily rounds to determine systemic issues regarding the quality of environmental services. The lack of compliance check and of data analysis was acknowledged by Staff #10.

10. The following observations were made during a tour of the Women's Health Center on 01/30/14 between 11:15PM and 11:45PM.

A kidney dish with a used toe nail clipper was placed on the counter top in the Medication Room.

There was commingling of clean and dirty items in the Soiled Utility Room; clean supplies including bandages and boxes of Blood Glucose Monitoring System were stored in a cabinet in the Dirty Utility Room. An open box of Vacutainers, urine collection device was stored in close proximity to three (3) patients' specimen bags.
.



32522

.
Based on staff and patient interviews, and review of medical records, it was determined that the hospital failed to consistently ensure that all patients identified as needing discharge planning evaluation have: (1) complete and adequate discharge planning evaluations, 2) that the Discharge Planner discusses the discharge evaluations and plans with these patients. This deficiency was noted in four (4) of twelve (12) applicable medical records reviewed (MRs #25, #26, #27, #28).

Findings include:

1. During the Unit tour on 01/27/14 at 2:16PM, the patient in Room #729-B was interviewed. The patient stated that he was to be discharged and he was annoyed because he was still not discharged. According to the patient, he did not understand the reason for the delay.

Staff #17 was interviewed on 01/27/14 at approximately 2:30PM. The staff stated that the patient #25 was to be discharged home with home care services, but his previous home care agency did not want to take the patient back, so she was working on getting another agency to accept the patient.

2. Review of the record for Patient #25 noted a 54-year-old with history of Human Immunodeficiency Virus, Hepatitis C, Diabetes Mellitus 2, Hypertension and Chronic Foot Ulcers, presented to the facility's Emergency Department (ED) on 01/15/14 with complaint of pain to his left foot. Physician evaluation showed infected ulcer and leg cellulitis. The patient was admitted to Medicine and Infectious Disease Services.

The patient had a debridement of the infected ulcer on 01/17/14 and bone biopsy showed acute osteomyelitis. On 01/21/14, the Physician noted that the discharge plan to home with NPWT (Negative Pressure Wound Therapy) for four (4) weeks and IV (intravenous therapy) antibiotics for six (6) weeks to end 02/27/14.

On 01/21/14 the Case Manager noted patient for PICC (Peripherally Inserted Central Catheter) line placement. The Case Manager noted that the patient said he is with a home care agency before and would like to use the same infusion company but that agency did not accept the patient. The patient was informed of the status of the home care agency. The Case Manager noted referrals were made to two (2) other home care agencies and the patient will be discharged home, possibly 01/23/14. There was no documentation that there was a discussion with the patient on this arrangement, the referrals that were made, and the patient's response to the Plan of Care.

On 01/22/14 the Physician noted that the patient was medically stable for discharge to a skilled nursing facility but the patient did not want to pay the deductible.

The patient was discharged on 01/27/14 home with home care services. It was noted that the Discharge Planning Evaluation did not include the discharge issues identified including the issue with payment of deductible for the skilled nursing facility. These issues were not mentioned in the Social Work / Case Manager Assessment. This patient remained in the hospital to 01/27/14 although the patient was medically stable on 01/22/14.

3. Patient #26, a 16-year-old patient at forty-one (41) weeks gestation status was sent from the Clinic to induce labor secondary post-delivery date. The patient was admitted to the Labor and Delivery Department on 10/01/13. The patient had a normal spontaneous vaginal delivery on 10/02/13. The patient was discharged on 10/04/13. It was noted that the Discharge Evaluation was conducted on the 10/04/13, the day of discharge.

Clinical Resource Management (CM) Assessment by the Social Worker (SW) dated 10/04/13 noted "patient medically cleared to be discharged. Patient resides with her mother and three (3) sisters in an apartment. Mother very supportive and the infant's father, age 16-year-old is involved in the patient's life. There is adequate support and patient's mother will be assisting in the child care. Patient socially cleared to be discharged". There was no documentation that the Discharge Planner had a discussion with the patient's mother regarding assisting the patient with child care.

In addition, the "Prenatal Psychosocial Screen Form" dated 06/13 was reviewed. This form indicated that the patient and the patient's boyfriend were no longer together. There was no evidence that the Discharge Planner had a discussion with the baby's father in order to make the decision that the infant's father was involved. It was noted that the patient resides in a household with seven (7) others and she was now bringing a baby into this household. It was noted that neither the housing sleeping arrangement nor the grandmother's financial status was included in the Discharge Assessment.

In addition, the "Prenatal Psychosocial Screen Form" dated 06/13 was reviewed. This form indicated that the patient and the patient's boyfriend were no longer together. There was no evidence that the Discharge Planner had a discussion with the baby's father in order to make the decision that the infant's father was involved. It was noted that the patient resides in a household with seven (7) others and she was now bringing a baby into this household. It was noted that neither the housing sleeping arrangement nor the grandmother's financial status was included in the Discharge Assessment.

4. Patient #27, a 17-year-old female, was admitted to facility's Labor and Delivery Unit on 11/08/13. She delivered a healthy baby on 11/08/13. The OB (Obstetric) patient profile dated 11/08/13 at 6:51PM noted that the patient was single, first child and she received OBS services at another hospital. The CM Assessment Notes indicated that the patient was medically discharged today, 11/10/13. The patient was referred to a home care agency for parental skills and assessment. The name of the home care agency was not listed. There was no documentation that there was a discussion with the patient regarding this referral.

In addition, it documented in the record that the patient received prenatal at another hospital. It was noted that this information was not verified prior to discharge. It was noted that this patient's address indicated that the patient's residence was in close proximity to the other hospital, yet the patient did not delivered the baby in that hospital. This information was not explored with the patient. The relationship between the baby's father and the patient was not included in the assessment. There was no documentation of a follow-up appointment at discharge or the reason why it was not necessary.

5. Patient #28, a 70-year-old female with past medical history of Hypertension, CHF (Congestive Heart Failure) (diastolic), Diabetes Mellitus, A-Fib, and Coronary Artery Disease was admitted to the hospital on 12/05/13 for evaluation of syncope. On 12/10/13 at 11:05, the Social Worker (SW) noted a telephone conversation with the patient's daughter who stated the patient lives alone in an apartment with three (3) flights of stairs. The daughter stated that prior to admission the patient was having difficulties ambulating and had fallen at home. Prior to admission, the patient received six (6) days, four (4) hours of HA (Home Aide) service from a home care agency.

The SW noted the patient was seen by PT (Physical Therapy) and recommended for sub-acute rehab. The patient's daughter was in agreement with discharge to sub-acute facility and she provided a first and second choice sub-acute facility. On 12/11/13 at 3:15PM, SW noted patient was accepted to one of the sub-acute facilities. As per the patient's daughter, she and the family would like to accept placement.

It was noted that although this patient was evaluated to be alert and oriented to place, person and time, there was no documentation that the patient delegated a representative to make decision for her. However, this Discharge Planner did not discuss the discharge plan with the patient. It was also noted that the patient was admitted from her private residence. Other than PT recommended for rehabilitation, the Assessment did not include reasons why the patient could not receive care in her own home. In addition, there was no documentation that the Discharge Planner educated and/or assisted the patient in preparing her to reside in a skilled nursing facility.
.

.
Based on interview, and review of medical records, it was determined that the Post-Anesthesia Assessment was not comprehensive and did not conform to current standards of Anesthesia care. This finding was noted in four (4) of four (4) applicable records reviewed (Patients #1, #16, #17 and #18).

Findings include:

1. Patient #16 is a 70-year-old male with past medical history of Multi-Level Degenerative Disk Disease and Spondylosis with Radiculopathy who underwent "Anterior Decompression Stabilization and Fusion" of Lumber (L) 1/2, L2/3, L3/4 and L4/5 on 01/22/14.

The Post-Anesthesia Assessment documented by the Anesthesiologist on 01/22/14 did not describe all the elements evaluated. The medical record was stamped with a Post-Anesthesia Assessment Tool for the evaluation of six (6) elements that include patient's alertness and orientation; vital signs; respiratory distress; nausea / vomiting / dizziness; swelling / cough / gag reflex and pain.

The Anesthesiologist circled "Yes" for alertness and orientation but failed to describe the level of alertness and orientation. For vital signs, the Physician circled "Stable" with no documentation of the patient's vital signs. All the other elements were either circled "Present or Absent" with no supporting documentation. The post-operative hydration status of the patient was not evaluated and documented as part of the Post-Anesthesia Assessment.

2. Patient #17 underwent laparoscopic gastrectomy and hiatal hernia repair on 01/27/14. The Post-Anesthesia Assessment was not dated and timed. The Assessment documented that the patient was noted to be asleep and had no pain; her mental status was assessed as awake and oriented.

3. There was no comprehensive Post-Anesthesia evaluation for MR #18 who underwent a Right Total Hip Replacement on 1/27/14.

4. Similar findings regarding the lack of an adequate Post-Operative Assessment were noted in Patient #1 who was admitted for a closed fracture of the femur and underwent a Left Hip Open Reduction on 01/09/14.


During interview with Staff #6 on 01/28/14 at 2:15PM, he stated there was a recent revision in the Post-Anesthesia Assessment Tool which meets Regulatory Guidelines but has not been implemented.
.

.
Based on interview, review of medical records, and other documents, it was determined the facility failed to implement an Emergency Services Policy and Procedure to assure that discharged patients are provided with written Discharge Instructions before leaving the Emergency Department. Specifically, patients that requested to depart the ED prior to the completion of treatment were not provided Written Discharge Instructions for follow-up care. This finding was noted in seven (7) of sixteen (16) Emergency Department records reviewed (Patients #8, #9, #10, #11, #12, #14 and #15).

Findings include:

1. Patient #8 is a 41-year-old male that was brought to the Emergency Department by ambulance on 11/01/13 after being found unconscious on the street. The Triage Assessment on 11/01/13 at 2:35PM revealed the patient was hypotensive (79/55mm/Hg) on arrival with capillary blood glucose of 581mm/dl. The patient was diagnosed with acute drug intoxication and hyperglycemia for which he received treatment. The Physician documentation on 11/01/13 at 9:03PM indicated the patient signed out against medical advice after risks of leaving before the completion of treatment was discussed with him.

The patient's record lacked documentation of verbal and written Discharge Instructions.

2. Patient #9 is a 27-year-old female who was referred to the ED by her Gynecologist to rule out ectopic pregnancy. The patient was triaged on 01/15/14 at 2:35PM with a chief complaint of Abdominal Pain. Past medical history included Seizure Disorder, Asthma / Chronic Obstructive Pulmonary Disease and one (1) Ectopic Pregnancy.

An ultrasound pelvic and transvaginal sonogram report on 01/15/14 at 4:48PM noted that an intrauterine pregnancy was not visualized; there was a heterogeneous mass in the left ovary and a dense tissue in the cervix. The report recommended a close follow up of the patient.

The ED Physician's Note on 01/15/14 at 10:33PM indicated the patient refused to wait for an evaluation by the Obstetric / Gynecology Consultant and has signed out against medical advice after being informed of potential risks. The Physician notes the patient was instructed to follow up at the outpatient clinic, and to return to the ED for worsening symptoms.

The patient's ED record lacked written Discharge Instructions and instruction for referral for the close follow up care recommended by the Radiologist.

3. Patient #10 is a 4-year-old male that was evaluated in the ED on 01/04/14 for right shoulder pain. The Triage Assessment at 8:05PM noted the patient's mother reported that the patient fell out of bed last night and has limited range of motion of the right shoulder.

The patient was diagnosed with an acute non-displaced fracture of the middle third of the right clavicle. The Physician noted on 01/04/14 at 8:30PM that a sling was placed on the patient's arm and his pain improved with Motrin. The Physician added that she would discharge the patient with follow up care with his private Medical Doctor.

The written Discharge Instructions provided to the patient include the diagnosis and home care instruction but lacked follow up care instructions.

4. There was no discharge instruction for MR #11 who left against medical advice on 11/14/13 after presenting on the same day for a chief complaint of chest pain.

5. MR #12 had no discharge instruction before departing the ED on 11/1/13 following treatment of difficulty breathing secondary to Asthma.

6. There was no documentation of a written discharge instruction for MR #14 who presented on 11/5/13 with a chief complaint of chest pain after drug use.

7. MR #15 was not given a written discharge instruction prior to the patient ' s departure from the ED against medical advice on 1/9/14. The patient was evaluated for a chief complaint of seizures.


At interview with Staff #2 on 01/28/14 at 10:30AM, she stated patients discharged from the ED are given a written Instruction Summary that includes their diagnosis, home care instructions and follow up referral and appointment. A signed copy of the Discharge Instructions is placed in the patient's chart.

ED Policy #660.1, last revised January 2011, notes that "All patients must be provided with printed and verbal instructions on their diagnosis and follow up care before they leave the ED. Instructions will include diagnosis; special needs; restrictions, if any; follow-up appointment; medication information and instruction on what the patient should do if symptoms persist or worsens."

During interview with an ED Physician, Staff #3, on 01/30/14 at 9:59AM, he demonstrated the discharge process in the EMR and stated that the written ED Discharge Instructions are generic and are based on the patient's diagnosis; however, the instruction can be individualized by documenting instructions in the field allocated for additional notes and instructions. It was noted that this field was not completed in eight (8) of sixteen (16) ED records reviewed and hence the Discharge Instructions to patients lacked information for follow up care.