HospitalInspections.org

Based on observation and staff interview, the facility failed to comply with AIA 1996-97 Edition. Specific reference is made to the fact that the facility failed to asses the space requirements and appropriate dimensions in the six rooms (Room #s 250, 263, 264, 350, 363 and 364) on the 2nd and 3rd floor Psychiatric units,prior to converting them from single-bedded to a two-bedded room.

Findings include:

During the tour of the Psychiatric inpatient units on the 2nd and 3rd floor of the hospital on 06/06/14 at approximately 11:00 AM, it was noted that the facility had added extra beds to the units without NYSDOH approval. Upon interview of the Medical Director of Psychiatry, it was stated that the facility was given permission by NYSOMH to add an extra medical bed in the single-bedded rooms (Room #s 263, 264, 363, and 364) to accommodate the overflow of psychiatric patients in the hospital.

Upon review of the NYSOMH approval letter, it was noted that the facility was given approval to convert four single-bedded rooms (Room #s 263, 264, 363, and 364) into two-bedded rooms with a recommendation of waiver for room dimensions.

Upon interview of the facility's Director of Construction and Director Of Engineering on 06/06/14, it was revealed that the facility did not notify NYSDOH of such NYSOMH approval and waiver recommendations.

It was noted that these rooms were each of approximately 151.84 sq. feet and did not meet the AIA 7.2 A.2 recommendations of minimum 100 square feet (9.29 square meters) of clear floor area per bed in multiple-bed rooms.

Based on record review, observation and staff interview, the hospital failed to comply with the NYSDOH licensure agreement of limiting the inpatient Psychiatric inpatient bed capacity to 50 as noted on the Hospital's Operating Certificate.

Findings include:

During the tour of the inpatient psychiatric units on 06/11/14 at approximately 11:00 AM, it was noted that the the hospital had a total of 57 inpatient psychiatric beds.

Review of the hospital's Operating Certificate revealed that the hospital was licensed for 50 Psychiatric beds.

On 6/11/14 at approximately 11:30 AM, interview of staff (including the Medical Director of Psychiatry) revealed that the Hospital was granted temporary approval by NYS Office of Mental Health to increase the psychiatric inpatient capacity from 50 to 56. There was no documented evidence that NYSDOH was not notified of this approval.

Based on observations, record review and staff interviews, the facility failed to ensure the correct formulation of acid baths are mixed in accordance with manufacturer's instructions and machine configurations, so that dialysis patients receive the correct acid concentration as ordered by the physicians.

Findings include:

During tour of the dialysis unit on 06/10/14 at approximately 1:00PM, a patient was observed receiving dialysis treatment using a spiked acid bath of 3K 2.5 Ca (3 parts Potassium and 2.5 parts Calcium). Upon interview of the Assistant Head Nurse regarding spiking of the dialysis bath, it was stated that 1 packet containing 9.4 gms of potassium additives was added to the jug containing 2K 2.5Ca acid bath to raise the potassium concentration to 3K 2.5Ca.

Upon review of the packets used in spiking the bath, it was noted that these packets were labeled as 36.83X by the manufacturer and was meant to be used on a dialysis machine configured with dialysate proportioning ratio of 1:35.83. However, during the tour of the unit, it was noted that all dialysis machines available in the facility were labeled with the dialysate proportioning ratio of 1:44 (45X).

Upon interview of this nurse,it was revealed that this staff member was not aware of the different setup configurations of the dialysis machines, dialysate proportioning ratios, and the importance to match the acid concentrate with respect to the proportioning ratio and with setup configuration of the dialysis machines.

Further interview of this employee revealed that the facility ordered 36.83X additives, even though the machines were configured with the dialysate proportioning ratio of 1:44.

Upon review of policy and procedures, it was noted that the facility did not establish written protocols for the quantity of additives to be used to obtain spiked baths and also did not have in place a mechanism for quality control.

Based on record and document review and staff interviews, it was determined that the facility failed to ensure that medical records were promptly completed in 17 of 18 patient records reviewed. (Patient #s 1, 2, 3, 4, 5, 6, 7, 8 , 9, 10, 11, 12, 13, 14, 15, 16 and 17).

Findings includes:

Review of patient #1's medical record on 6/11/14 revealed that there was no dictated operative report for this patient who had surgery on 2/12/12.

Review of patient #3's medical on 6/11/14 revealed that there were no dictated operative report for this patient who had surgery on 4/17/13. Similar findings of no dictated operative reports in the medical record was noted for patients # 2, 3, 5, 8.

The hospital policy Documentation of Operative and other High -Risk Procedures (Reference # 8045) states that an operative report that has been dictated and transcribed must be authenticated by the surgeon and placed in the medical record promptly and/or within 30 days of the procedure.

Review of patient #7's medical record on 6/11/14 revealed that the patient was admitted on 12/11/13 and discharged on 12/12/13. No discharge summary was found in the medical record. Similar findings of no discharge summary in the medical record was noted for patients #6, 7, 10, 12 and 13.

The hospital policy Delinquent Medical Records (Reference #8117) states that any patient remaining in the hospital more than 24 hours shall require a discharge summary or final progress note that contains relevant elements of a discharge summary.

Review of patient # 14's medical record on 6/11/14 revealed that this patient was discharged on 4/2/12. It was noted that the history and physical done by a physician assistant (PA) was not countersigned by the attending physician as required by the hospital policy. Similar findings of no counter signature were noted for patients #4, 5 and 11 for the discharge summaries not cosigned, and patient #9 for no co-signature for midwife note.

Review of patient #15's medical record on 6/11/4 revealed that this patient was admitted on 10/31/11 and discharge on 11/1/11. It was noted that there was no Emergency Department (ED) provider notes for this visit. Similar findings of no ED provider notes was noted for patient #16.

Findings were confirmed with staff member #2.

An interview was conducted with staff #1 on 6/6/14. Information about delinquent medical records was discussed. Staff #2 stated that if the medical records are incomplete after patient discharge the Health Information Management Department notifies the Clinical staff.

Based on observation, staff interview and review of dietary policy and procedures, the Food Service Director did not ensure that the daily operation of the food service department is maintained in a sanitary manner.

Findings include:

A tour of the hospital kitchen was conducted on 6/4/14 at approximately 10:30 AM. The surveyor was accompanied by the Food Service Director and Director of Operations. The Food and Nutrition Department is managed by a contractor named "Sodexho". Examples of issues observed, included, but are not limited to, the following:
A. Unsanitary Environment/ Food Safety

1- Food cart that delivers meals to the patient floors had yellow tape and glue residue stuck on them.
2- Floor boards were not butting up against wall and a cement column with floor board had deep cracks, both conditions making a potential habitat for insects.
3- All the vents in the kitchen ware full of dust.
4- Intercom box on wall was cracked and dirty.
5- Floor throughout kitchen was dirty with dirt grime.
6- The floor between the refrigerators were dusty and dirty.
7- The ice machine was missing the ice scoop. The seal on the ice machine was detached.
8- All foods store in the refrigerator had only one date or none at all.
9- In a reach-in refrigerator monkey dishes containing a white food content had no label.
The Food Service Director was unable to decipher what was the content in the monkey dishes.
Foods items stored in the refrigerators were not labeled with the name of the food item, date when the food item was opened, or date of expiration. Food items were labeled with only one date.
10- The elevator in the dish room was very dirty. This elevator is used to transport food. The floor was dirty and contained debris and the walls were dirty.
11- A second elevator located in front of the cold prep area was also dirty. This elevator is also used for food transport.
12- The dish room area was extremely flooded and the floor did not have any rubber mats to prevent falls.
13- A hand washing sink located in the dishwashing area contained a stack of dirty plates and a sponge in the sink.
14- In the dish washing area was a room. This room contained two dirty and in poor condition chairs, three (3) milk and a box pulley. The room was dirty and flooded with water from the dish room area. This room was adjacent to an electrical room. Water was seeping underneath the door of the electrical room.
15- There was no garbage receptacle underneath/beside the hand washing sinks throughout the kitchen.
16- The ceiling throughout the kitchen was yellow. There were two spots in the ceiling that had what appeared to be food splash.
17- All plastic garbage cans throughout the kitchen had no cover on them.
18- A roach was seen crawling on the wall in the pot washing area. It hid behind a sign posted on the wall.
19- Two sets of lights in the kitchen were not working.
20- Two reach-in refrigerators next to the dessert preparation area had gaskets that were torn.
21- A walk-in box in the kitchen has very poor lighting- practically dark. Very difficult to visualize foods on the racks.
22- Aluminum doors on the outside of the walk-in box were dirty. Dried yellow stains observed throughout the doors and sides of the doors.
23- A small red bucket siting on the counter in the dessert area had water, a rag and food utensils (scoops) in it.
24- Large plastic condiment containers were not dated when they were opened or when they would expire.
25- Rack containing clean pots and pans felt sticky to the torch.
26- The bottom of the muffin pans were black and brown with accumulated grease grime.
27- The head of a floor and table model Hobart mixer was dusty.
28- The robot (coupe) had water with food debris beneath it.
29- The back of the ovens was heavily soiled and dusty.
30- The front of the oven was greasy and had accumulative dry grease on them.

On 6/11/14 at approximately 1:00 PM a second tour of the kitchen was conducted. The surveyor was accompanied by the Director of Operations and the hospital Chief Executive Officer. A second tour of the kitchen was conducted to validate the Food Service Director statement to the surveyor that the kitchen had been cleaned.
The hospital took appropriate action to correct the unsanitary conditions found in the kitchen during day 1 (6/4/14) of the survey.


B. Review of Food Service document titled "Patient Tray Assessment" was done on 6/10/14 at approximately 11:00 AM. The document notes temperature of foods on a tray when it arrives on the patient floor. This is a sample tray that goes through the tray line and is placed on the food cart.
It is the last tray to be placed on the cart hence it has the hottest foods and coldest food on the tray. The food service worker (Hostess) takes the temperature of the foods and records them on this document.
Forty five (45) "Patient Tray Assessment" forms were reviewed dating from 5/28/13- 4/24/14.
The results were as follows:

Hot food items did not meet the standard temperature noted on the form 87% of the time. This was observed on 39 of 45 tray assessment forms.

Cold food items did not meet the standard temperature noted on the form 71% of the time. This was observed on 32 of 45 tray assessment forms.

Based on the above findings food temperature on patient trays are not met 79% of the time.

In addition, it was observed that the food items that did not meet the standard temperature had no corrective action documented.

The Food Service Director was interviewed on the surveyors findings of foods not meeting standard temperatures on the patient units based on the department document titled "Patient Tray Assessment". The Food Service Director informed the surveyor that this assessment looks at many things not only temperature. The surveyor informed the Food Service Director that food temperature was a problem, not the appearance of the tray.

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 room #s 2, 4 and 7, the following were noted:

(1) The doors of the metal cabinets used for storing supplies in the three Operating rooms were rusted at the bottom.
(2) The wheels of the tray stand and double basin stand in the three Operating Rooms were rusty.
(3) The ledges on the top of the cove base in the three Operating rooms were found to be laden with dust.
(4) The sonogram for vascular surgeries stored in the Operating room #2 was covered with dust.
(5)The perimeter of the wall behind the anesthesia machine was observed to be soiled in all the three Operating rooms inspected.
(6) the floor of Operating Room #2 around the operating table was observed to have numerous dents with chipped off flooring.
(7) It was also noted that the staff stored clean sterile packaged items in an open plastic container attached to the supply cart. These packaged clean supplies were observed to be collecting dust. This practice posed an infection control risk of exposing patients to dust when packets are opened in the sterile field.

Additionally, the facility failed to maintain the two inpatient psychiatric units (2nd and 3rd floor) 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 two units on 06/06/14 at approximately 11:00 AM.

(1) The facility was observed to be using a total of 13 Medical beds with handrails on both units and the beds were not located in direct view of staff, except for one where a patient was placed on one to one observation. The medical beds with handrails are potential looping hazards and poses a higher risk, when not in direct view of staff.
The facility's policy and procedure did not mention any methods or mechanisms used by the facility to mitigate these risks.

On 06/11/14 at approximately 11:30AM, the facility staff removed the handrails from all medical beds and re-located them into the two rooms located opposite to nurses' station on both floors. This re-arrangement of medical beds on both the units allowed visualization of patients in these rooms and thereby mitigated the risks of potential harm.

(2) During the tour of the 2nd and 3rd floor Psychiatric units, it was noted that the captain beds had 3 metallic hooks on each side of each bed. During the exit interview, the Director Of Psychiatry stated that the hooks on the beds were required to apply restraint on violent patients. This employee did not acknowledge the fact that the hooks on the captain beds are potential looping hazards as they can be used to create ligatures.

However, observations and interview of facility staff revealed that the facility is in the process of renovating the psychiatric units and that a renovated patient room and bathroom on 2nd and 3rd floor was noted with approved psych hardware, including captain beds without holes or restraint hooks.

(3) The surface mounted paper towel dispenser, bathroom tissue dispenser, and the hand soap dispenser in the patient bathrooms in both 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.

Moreover, the facility failed to implement and maintain a program to ensure that all equipment are installed and operated in a safe manner to ensure patient safety and well-being.
Specific reference is made to the following:

(1) During the tour of Operating rooms on 06/04/14 at approximately 10:30 AM, it was noted that anesthesia equipment in all the ORs were connected using a power strip. These power strips are potential of causing fire when electrical circuit is overloaded.
This practice of using power strips to connect medical equipment was also observed in other patient care areas throughout the hospital.

(2) During the tour of the recovery area on 06/04/14 at approximately 11:30 AM, it was noted that the electrical receptacles served by the Emergency Electrical System was not marked in 3 out of 6 patient bays. Upon Interview the nursing staff was not able to identify the unmarked receptacles that were connected to the emergency power. Therefore it was determined that the hospital did not have receptacles on emergency power at every patient bed in this recovery unit.

(3) Tour of the labor and delivery operating rooms on 06/04/14 at approximately 1:30 PM revealed that there was only one shut off valve for oxygen gas outside OR#1 and OR #2.
According to NFPA99 1999 Edition recommendations, Shutoff valves must be located outside each anesthetizing location and arranged so that shutting off one room or location does not affect the others.

Based on observations, staff interview and document review, the facility failed to maintain all equipment in good repair to ensure an acceptable level of safety and functional working condition. The facility also lacked an established plan for preventive maintenance and safety checks for all equipment in accordance with the equipment manufacturer's instructions.

Findings include:

During the tour of the dishwashing machine room on 06/04/14 at approximately 1:30 PM, it was noted that the dishwasher was leaking and standing water was observed on the floor around the machine. Further inspection of the performance of this equipment revealed that the temperature gauges for the wash, rinse and final rinse were not functioning. The surveyor observed a dietary aide unloading the chinaware dishes and plastic cups with bare hands as they came out of the dishwasher. It was also observed that these utensils were wet and covered with water droplets.

Review of the "Dishwashing/Ware Washing machine Temperature Log" revealed that the facility staff, at 6:45 AM, documented wash, rinse, and final temperature respectively as 156 degree Fahrenheit, 162 degree Fahrenheit and 189 degree Fahrenheit.

During interview of the Director of Dietary Service at approximately 2:00 PM, it was stated that the staff checked the final rinse temperature of the machine every morning using a temperature strip.
Review of the manufacturer guidelines for the testing strip revealed that a black stripe on the end of the strip was expected to turn bright orange upon being exposed to 180 degrees of temperature and the strips did not provide quantitative temperature readings.

Upon request of the surveyor, the Director Of Dietary Service conducted two tests for temperature using the two strips tied around plastic cups. It was noted that during the first test, the black stripe on the end of the strip did not turn bright orange and the cup and the china ware on that load were noted to be wet with water droplets. During the second test, the black stripe on the temperature strip turned into bright orange, but the plastic cup was still observed to be wet.

Therefore, it was determined that the dishwasher was not functioning properly or consistently at the appropriate temperature. The facility implemented their back-up plan to use paper plates and wash plastic trays manually, while the dishwasher was under repair for leaks, non-functioning gauges, inconsistent temperature and drying system.

The dishwasher was repaired on 06/09/14 and the facility was back into normal operation.
Upon review of the maintenance records, the facility did not have an established Annual Preventive Maintenance program according to manufacturer's recommendations and therefore did not conduct any Preventive Maintenance on the equipment. However, it was noted that there were numerous repairs conducted on the equipment in 2013- June 2014.

In addition, an onsite-inspection of an offsite Women's Health extension clinic on 06/10/14 at approximately 1:30 PM revealed:
(a)the facility failed to conduct electrical safety checks on a centrifuge stored in the soiled utility room
(b) the annual electrical safety check on the fetal heart rate monitor in the fetal heart rate monitoring room was conducted 02/11. The facility failed to conduct electrical safety check after 2011.

Based on observations during tours of the facility and staff interview, it was determined: facility failed to monitor and implement Infection Control practices related to the environmental design of the facility, in order to prevent the potential for cross contamination and spread of infections.

Findings include:

During the tour of the endoscopy unit on 06/05/14 at approximately 11:30 AM, the surveyor observed a technician pre-cleaning an endoscope in the handwashing sink of the procedure room. Upon interview of the technician, it was revealed that the decontamination room located outside the endoscopy suite did not have a decontamination sink. Therefore the staff practice was to soak and pre-clean the scopes in the procedure room, prior to placing them in the steris machine for disinfection located in the decontamination room.

This practice is potentially a source for cross contamination and spread of infection.