HospitalInspections.org

Based on review of documents and staff interviews, it was determined the hospital did not monitor contractors of services provided in order to comply with all applicable Medicare Conditions of participation and standards for contracted services.


Findings include:

Review of the list of contracted agreements on 9/27/11 determined the hospital maintains a list of agreements totaling approximately 2800 contracts and agreements with vendors for services and goods.

At interview with the Senior Vice President of Patient Care Services and Vice President on 9/27/11 it was stated that the hospital has thousands of agreements which are not considered contracts, and therefore are not subject to evaluation or monitoring by the facility.

There is no evidence the facility evaluated its contracts or agreements for services provided in the hospital to ensure they are provided in accordance with Medicare Conditions of participation, regardless of whether they are provided directly by hospital employees or indirectly by contract or vendor agreements.

Cross refer to findings noted under tag # A267 for lack of adequate monitoring of contracts in the Department of Health Information Management (Medical Records).
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Based on observation, interview and review of emergency department policies it was evident that the facility did not formulate and implement a plan to ensure that patients who come to the hospital with suspected contamination with a toxic material are triaged and assessed in the normal fashion.

Findings include:

Based on observation of the ED ( Emergency Department ) entrance on 9/26/11 at approximately 10:00 AM it was noted that a sign was posted outside the ED beyond the glass exit doors. It was a sign shaped in the manner of a traffic " stop " sign in red and read " Stop " in large capital letters. Under that was written in smaller bold letters : " If you think that you have been contaminated with any material, do not enter facility. Wait for instructions from security and/ or hospital personnel . "

Further observation on that day found that no security guard was on duty or assigned to a post that would visualize a person that was waiting outside for ' permission ' to come in. Interview with the ED Nursing Director on 9/26/11 at 10:30 AM found that it was acknowledged that there was no system in place to ensure that the staff was observing that area so that any patient who waited for further direction was assisted in a timely manner.

Review of ED policies found no reference to that sign.
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1 - Based on observation it was evident that the hospital did not formulate and implement a policy and procedure to assure that patients on ventilators outside the critical care units are placed in rooms in which ventilator alarms are audible from the nursing station.

Findings include:

During the tour of medical - surgical units on 9/27/11 it was noted that patients on mechanical ventilators are not placed in rooms close to the nursing station. Specifically, the patient in MR# 1 had a tracheostomy to ventilator in room 1016A which is the last room by the exit many yards from the nursing station. The patient was moved during the survey to a room closer to the nursing station. Patients in MR#2, 3, and 4 were found to be placed in areas distal to the nursing station.

The facility is not equiped for vent alarms to be noted electronically at the nursing station and no hall light goes off outside the room. The facility relies on the audibile vent alarm only. In that many other alarms ( monitors, IV pumps et. al ) go off at the same time, alarms are the only means to detect that a vent may be malfunctioning , shut off or the patient is extubated or decanulated.

There was no policy found to address the placement of patients on ventilators in suitable rooms.

2 - Based on observation it was evident that the hospital did not ensure that patients who required seclusion were placed in rooms that met minimal standards for occupancy.

Findings include:

During the tour of the inpatient psychiatric unit on 9/27/11 a patient was noted to be in the seclusion room. There was a mattress on the floor occupying a large portion of the floor. Review of the fifth floor plan for Snapper updated 11/22/85 found that the room (522) measured 56 square feet, not conforming to the AIA rule that states that such rooms be 60 square feet without a bed and 80 square feet with a bed.
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Based on interview and review of policies and procedures it was evident that the facility did not formulate and implement a policy and procedure to ensure that persons in forensic restraints are assessed by medical staff on arrival to the ED. There was no policy to ensure that patients in forensic restraints ( handcuffs, shackles ) do not have their restraints attached to hospital property that might be unsafe.

Findings include:

Review of facility forensic policies on 9/26/11 found that there was no policy to address staff responsibility when a patient arrives in a full body restraint applied by Emergency Service Unit (ESU) Officers. ESU officers are part of the New York City Police Department . This type of restraint from head to toe has serious medical implications and requires immediate attention to expedite its removal and replacement with facility approved restraints ( if required. )

At interview with nursing staff in the Psychiatric ED on 7/27/11 it was stated that patients occasionally arrive in such a device without stopping in the Main ED and that staff administer medications through the device.

During the tour of the Psychiatric ED on 9/26/11 survey staff found a patient ( MR#20) alone in a room at the end of the hall handcuffed to the siderail of the stretcher. The officer who had custody of the patient was not present in the room or the hall. The patient was very malodorous. There was no policy and procedure that defines the type of forensic restraints that may be safely attached to hospital devices ( such as bed frames etc. ). There was no evidence that staff examined the siderail to ensure that it was not loose or broken.
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Based on review of documents and staff interview, the hospital did not completely monitor all aspects of performance, specifically including assessment by the Medical Records Department of its two contracted services.

Findings include:

1. Review of Medical Records Department reports and documents on 9/28/11 determined that the medical records department had not completely monitored the provision of medical record requests in accordance with hospital procedures that require the provision of the records within ten days by the patient .

2. There was insufficient assessment and monitoring by the hospital of the performance of its contracted service (IOD) that is responsible for copying, billing, and mailing of medical records, for which billing and mailing is conducted in the contracted agency's out of state corporate location in Wisconsin.

Review of the contract between the facility and a vendor, IOD, on 9/28/11 determined that the contractor is responsible for conducting quality assurance reviews on scanned records that are submitted to the company's central processing corporate center in Green Bay, Wisconsin. Additionally, the company is responsible for monthly management reports and analysis.

At interview with the Director of Health Information Management on 9/28/11 it was stated that monthly reports are received by the hospital from the contracted vendor for outstanding medical record requests, but no formal quality assurance analysis of this contracted service was conducted. A report was provided by the Director on 9/28/11 titled "pending report" dated 9/22/11. There was no evidence of complete resolution noted for 488 outstanding medical record requests listed on this report. Handwritten notes indicating "done" were written for selected entries but this documentation did not reflect if the requests were processed and closed.
It was stated by the Director that the report cannot differentiate between the responsibilities performed by IOD staff from the tasks performed by the hospital medical records employees. Specifically, it was stated the report could not distinguish completed jobs from requests that were not paid. When the surveyors requested whether the time frames for provisions of reports was reviewed, it was stated this document is the only form of quality improvement for medical records requests available.

However, a second report titled , "Turnaround summary report" was provided by the Medical Records Director on 9/28/11 approximately two hours later. This document was sent by the contracted company after the tour of the department. While this report summarized time frames for turnaround of record requests, it was stated there were no meetings or reports that analyzed the meaning of this data by the Medical Records Department.
It was determined these reports did not include the hospital's assessment of the IOD contractor's performance nor monitoring of the overall compliance with release of medical records.

3. There was no evidence the medical records department performed any quality review of the "Silent type" contracted service for, which provides dictation and medical transcription services. It was stated at interview with the medical Records Director on 9/28/11 that there was no quality assurance analysis performed of this service. Review of the contract for Silent Type, Inc. on 9/28/11 determined there are reports required for required turnaround times but there is no evidence these were reviewed or monitored.
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Based on review of documents it was determined that the facility did not ensure the accuracy of reports generated in the course of QAPI activities.

Findings include:

Review PI reports from January to May of 2011 found reference to the laboratory department in which an issue of blood specimen identification errors was discussed. The original form found during the survey alleged that 43 specimen identification errors were reported to the clinical laboratory. There were references that most errors occurred in the Emergency Department and were committed by medical students who were not being properly supervised by the residents. When the survey staff interviewed the ED medical and nursing directors as well as QAPI staff and the author of the report from the lab, it was stated that there were inaccuracies in that report. The ED Nursing Director reported that she was unaware of this allegation. The lab director stated that the report should have included that these were not "errors " per se but were improperly labeled tubes that were " discarded ' by her staff when the Kronos ID number of the staff who " drew " the blood was not noted. None of this information was in the QAPI report. An amended report was submitted that included the " discarding " of questionable blood tubes.
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Based on interview and review of medical record it was determined that nursing staff failed to collaborate with medical staff to assure that all patient care needs are met. The finding was noted in 1 of 6 applicable records reviewed.

Findings include:

Review of MR #16 revealed an 80 year-old admitted on 9/14/11 with a history of hypertension and Parkinson's Disease. A stage III sacral decubitus ulcer was identified on admission measuring 8 cm x 6 cm, gray and green in color without drainage. On 9/17/11 the ulcer is noted to be unstageable; however, the size, color and treatment of the ulcer were not noted. On 9/22/11, nursing documentation indicated that the ulcer measures 13 x 9 cm, moist, yellow and gray without exudate. At interview with the nurse manager on 9/27/11 at about 12:10 pm, he indicated that there was discussion with the physician on 9/26/11 regarding wet to dry dressings with 2% Dakin's solution; however there was no current physician's order for decubitus care/treatment in the record.
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Based on interview and the review of medical record it was determined that the hospital was unable to retrieve a complete medical record of patient undergoing medical treatment at the facility. This finding was noted in 1 of 40 records reviewed.

Findings include:
The patient (MR # 17) is a 77 year-old with multiple medical conditions, admitted on 7/18/11. On review of the patient ' s record on 9/27/11, it was observed that the record had been broken down to several volumes because of the extended stay. The ICU flow sheets were requested to track the patient ' s pressure ulcer management. The staff of the unit was unable to promptly retrieve the record on 9/27/11 and during a revisit to the unit on 9/28/11. At interview with Nurse Manager on 9/28/11 at 9:30 AM, he stated that they have not found the missing portion of the medical record.
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Based on observation and interview it was found that the medical record system does not accurately reflect the care given to the patients.

Finding include:

During the tour of the pediatric ED on 9/26/11 it was found that the medical records were inaccurate as to the time of actual assessments and interventions.

Specific reference is made to MR# 18 in that the record reflected the times that the practitioner entered the data, not the time of service. The time of arrival by EMS was 0939 hrs, the patient was triaged at 0956 and yet the exam was noted as 0940 hours.

Further reference is made to MR# 19 where the 12 month old infant who ingested alcohol had no documentation from medical or nursing staff yet it was evident that the patient was in the process of being seen.

At interview with the ED Nurse manager on 9/26/11 it was stated that the electronic medical record system times are not the times of interventions, but rather the times of entry of the date into the system.
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Based upon observations, interviews and review of the facility's policy and procedures and other facility documents, it was determined that the facility failed to be constructed, arranged and maintained to ensure the safety of patients. Therefore the accumulative effect of the Hospital Regulation standard level deficiencies as well as the Life Safety Code deficiencies is that the Condition of Participation for Physical Environment is not met as evidenced by:

1. Failing to maintain the physical plant to assure patient safety and well-being. ( See A 701).

2. Failing to maintain supplies and equipment. ( See A 724).

3. Failing to meet LSC standards. (See K 22, K 25 and K 52)

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Based on observation, document review and staff interview, it was determined that the facility did not maintain the hospital environment in such a manner that the safety and well-being of patients are assured.
Findings include:

Operating Rooms Suite

1- On the morning of 9/26/2011 during a tour of the Operating Room Suite (OR), it was found that nine (9) out of twelve (12) ORs had negative air pressure instead of the required positive air pressure required for ORs.
ORs # 1, 2, 3, 5, 6, 7, 8, 10, and 11 had negative air pressure.

2- The relative humidity (RH) in seven (7) out of twelve (12) ORs was above the range of relative humidity as follow:

OR 2 had a relative humidity of 68, OR 4 had a relative humidity of 72, OR 6 had a relative humidity of 64, OR 7 had a relative humidity of 72, OR 8 had a relative humidity of 70, OR 11 had a relative humidity of 68, OR 12 had a relative humidity of 67.
Per the facility's policy and procedure the RH of the ORs should be 30% to 60%.

It should be noted that per the CDC recommendation and AIA Guidelines for Hospital and Health Care facilities edition 1996-97, the ORs shall have positive air pressure and relative humidity from 30% to 60%.

The above findings imposed potential risk of infection spread for the patients who underwent surgeries in those ORs in the period from 8/16/2011 to the date of correcting the problem on the evening of 9/26/2011.
Interview with the Director of the Operating Suite, revealed that the facility did not test or recorded the air pressure of the ORs.
Interview with the Director of Engineering on the morning of 9/26/2011, revealed that the hospital had defective parts of the HVAC system named pulleys that were found defective on 8/16/2011 and the staff member said the hospital made an order to buy the defective Pulleys and had not received them as of the morning of 9/26/11.

Although, the hospital knew of the issues of the defective pulleys there was no follow up on monitoring of the air pressure of the ORs. This was evidenced by the fact that the facility never tested or recorded the air pressure of the ORs.
The decontamination room of the sterile supply area adjacent to the OR was found to have open window that was open to the clean /sterile part of the sterilization area without a door. The air pressure in both the decontamination and the sterile part of the sterilization area was not maintained negative for the decontamination area and positive at the sterile area as required.

Emergency Department (ED):
During a tour of the ED on the morning of 9/26/2011, the followings were observed:
1- The three isolation rooms of the ED did not have smooth, easy cleanable ceiling tiles that are required for this type of room; instead, the rooms had the regular ceiling tiles.
2- The clean utility room of the ED (room 118) was found to have a negative air pressure instead of the required positive air pressure that is required for this type of room.

Adult CPEP:
On the morning of 9/26/2011, the followings were observed in the Adult CPEP:
1- The shower temperature knob of the patient bathroom in the Adult CPEP unit was of the regular type and not of the safety type that is required for this type of unit and imposes risk of looping hazard.
2- The water faucet of the hand-washing sink of the patient bathroom in the Adult CPEP unit was observed to be of the regular type and not of the safety type that is required for this type of unit and imposes risk of looping hazard.
3- The stall and its water fixture of the patient bathroom in the Adult CPEP unit, was of the regular type and not of the safety type that is required for this type of unit, and imposes risk of looping hazard.
4- The door knobs of the patient bed rooms of the Adult CPEP was of the regular type and not of the safety type that is required for this type of unit, and imposes risk of looping hazard.
5- The cord of the pay phone of the CPEP unit was >36 inches long and imposes risk of looping hazard.
AIA 11.1.F.environment

The Labor and Delivery Suite (L&D):
On the afternoon of 9/26/2011, the followings were observed in the labor and delivery Suite:
1- The soiled utility room (room #148) of the labor and delivery suite had a positive air pressure, instead of the negative air pressure that is required for this type of room.
2- There was no meter to check for the Relative Humidity (RH) of one of the two ORs of the L&D. and therefore no RH was recorded at this room and its RH could not be verified.
3- The RH, of the second OR of the L&D suite was 80%, exceeding the requirement set by CDC guidelines (RH of 30%-60%). During the tour, the Director of engineering said that the meter of the second room was not working properly and needed calibration.
4- The nursing call bell of the patient bathroom in front of the dressing area did not have a sound annunciation as required. The state surveyor activated this nursing call, and no staff member responded to the call for more than 5 minutes.

Endoscopy Suite:
During a tour of the Endoscopy Suite on the afternoon of 9/26/2011, the followings were identified:
1- The scope processing room was observed to have broken walls on the back of the room without repairing the walls, and the broken sheetrock was exposed. When asked, the staff said that they cut the wall to pass equipment through this opening few weeks ago. However this was not fixed or repaired as of the time of this observation. This is an infection control concern.
2- The nursing call bell of the patient bathroom of the recovery area had a button that was mounted 4 feet above the floor. This configuration makes the nursing call bell not accessible for patients who might fall on the floor and need assistance.

Psychiatric Unit- CHC Building 13th Floor:
On the morning of 9/27/2011, during a tour of the Psychiatric unit on the thirteenth floor the following findings were observed:
1- The seclusion room 1345 was observed not to be padded and the door of the bathroom that served the seclusion room had regular hinges, instead of the piano hinges. Also, the faucet of the hand-wash sink and the stall of the bathroom were of the regular type. All the above mentioned features imposed risk of self-harm and/or looping of the suicidal patients.
2- The beds in many of the patient bed rooms have metal frames with sharp edges that can be used for self-harm especially from suicidal patients. Also, those beds were not bolted to the floor that renders them a looping hazard.
3- 3- The door handles of the patient bed rooms were observed to be a metal projection that imposed looping hazard. This observation is true for all of the patient rooms in this unit.
4- The shower temperature knob of the patient bathroom this unit was of the regular type and not of the safety type that is required for this type of unit and imposes risk of looping hazard.
5- The stalls of all the patient bathrooms in this unit, had gaps of minimum one inch between the stalls and the walls, and their covers been fixed to the stalls with metal bars. This imposes risk of looping hazard.
6- The light fixtures of most of the patient rooms were mounted on the walls seven feet (7ft) above the floor and had chains that could be used for looping. Examples included but were not limited to rooms 1339 and 1340.
7- The electric outlets in many locations of the corridors were observed to be of the regular type and not the tamper resistant that is required for this type of units.
8- The cord of the pay phones in multiple locations of the unit were observed to have long cord that were approximately 36 inches long and imposed looping hazards. Examples included pay phone next to the water fountain and next to room 1318.
9- The cord of the regular phone in the activity room was > 5 feet long and could be used for looping.
10- The floor of the entire unit was observed to be dirty especially in its perimeters.
AIA 11.1.F.environment

Pediatric unit:
1- It was observed and confirmed with the facility staff that the pediatric unit that has 32 beds, did not have an airborne isolation room as required by AIA Guidelines.
2- The soiled utility / soiled linen room in the pediatric unit did not have one hour separation, did not have the proper door that capable to maintain the negative air pressure needed for this room. Also, its door did not have a self-closing device.
3- Penetrations were noted around four (4) conduits in the electric equipment room 834 that had one hour fire separation.

Critical Care Areas
Coronary Care Unit 9th floor of CHC Building:
1- The six beds coronary care unit did not have an airborne isolation room as per AIA guidelines, 96/97 edition. AIA 7.2.C1.

Surgical ICU - 6th Floor of Snapper Building:
1- The surgical ICU unit had 8 beds, did not have an airborne isolation room as per AIA Guidelines; AIA 7.2.C1.
2- There were two rooms in the ends of the unit that could be used as isolation rooms, were observed to be used for storage of clean supplies and equipment, which is a potential for the spread of infection and fire safety hazard.
3- The bathrooms within the rooms in the two ends of the unit were converted to storage area.

Medical ICU - 6th Floor of Snapper Building:
1- This unit houses 10 beds, and was observed to have no airborne isolation room as per AIA Guidelines; AIA 7.2.C1.
2 It was noted that the unit did not have a readily accessible hand wash-sinks for the staff to wash hands as required per AIA guidelines and CDC recommendation; AIA 7.3.A8. An observation was made for a staff member who went inside the soiled utility room to wash her hands during our tour of the unit.
3 Many small flies were observed in the unit.

Neurological ICU- 6th Floor of Snapper Building:
This unit houses 6 (six) beds, and was observed to have no airborne isolation room as per AIA Guidelines; AIA 7.2.C1.

Same day surgery:
1- There were what appeared to be dried blood drops noted on the wall next to the sharps container in room 624.
2- There was no nurse call bell at the patient bathroom on the 6th floor at the same day surgery unit.
3- Also, there was no nursing call bells in four out of four (4/4) patient waiting rooms.

Central Sterile Supply:
On the afternoon of 9/29/2011, during a tour of Central Sterile Supply:
1- The ceiling tiles of the central sterile tiles area were noted to be of the regular type, not the smooth, washable or easy cleanable type that is required for this type of room.
2- The decontamination room of the central sterile supply had a positive air pressure in relation to the clean/ sterile area, instead of the required negative air pressure that is required for this type of room as per AIA guidelines and CDC recommendation.

Rehabilitation Suite:
On the afternoon of 9/29/2011, the followings were observed during a tour of the Rehabilitation Suite on the 3rd floor of CHC Building:
1- No nursing call bell in patient bathroom of the rehab area.
2- No exit signs were provided in the rehab area, waiting area of the rehab and occupational therapy and the occupational therapy areas. In the event of fire or smoking, staff could not find their way out of those areas.
3- No fire strobes were provided in the patient bathrooms, the waiting area, or the occupational therapy areas.
4- No nursing call bell was provided in the bathroom of the occupational therapy area.

Dental Clinic:
On the afternoon of 9/29/2011, during a tour of the dental clinic, the followings were identified:
1- No hand-washing sink was provided for the sterilization room of the clinic. The staff used the instrument sink to wash their hands. This is a potential of cross contamination.
2- No nurse call bell was provided in the bathroom of the dental oral surgery suite.

Radiology Suite:
1- On the morning of 9/30/2011, during a tour of the Nuclear Medicine Area, it was noted that the nuclear medicine procedure room 331 did not have a hand-washing sink.
2- Six (6) large sharp containers were observed in the intervention radiology room 418, in the front and obstructing the way to the hand-washing sink. This is an infection control concern.
3- The pipes underneath the hand-wash sink of the ADA bathroom of the mammography suite was observed not to be insulated and or configured to prevent the contact abrasion or burn as required by the ADA requirement.

During the tour of 9CHC on the afternoon of 9/28/2011, found the following: The storage of dirty intravenous (IV) poles and medication pumps in the clean utility room. Also noted were four medication carts that need stripping and cleaning. On top of one of the medication carts was a pill crusher that was laden with grime. In room 932, an IV pole in use was observed dirty; the IV pole stand had white stains and was dusty

In rooms 933B and 934A, reusable IV tubes were left open air; the tips of the tubes were not capped to prevent cross contamination.

Upon entering room 936, the patient in bed 36A was observed to be on contact isolation evidenced by a contact precaution sign posted at the head of the bed. There was no stop sign posted at the door in accordance with the hospital policy titled "Isolation and Precaution " . Stop signs are to inform staff and visitors to report to the nurse before entering the room. At interview with the unit nurse manager, he stated that the nurse in charge is responsible for ensuring that isolation is initiated and maintained according to hospital policy.
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Based on staff interview and document review, the facility did not maintain its systems and equipment to ensure an acceptable level of safety and quality.

Findings include:

Review of the Medical Gas Test report for 2011:
1- Medical Gas Alarm Panels:
Review of the medical gas Test report for 2011 that was conducted in December 2010, revealed the following findings:
1- The medical gas alarm on the 2nd floor Snapper Building- Nursery did not have audible indicator or visual indicator and the alarm was inoperative, but was not corrected as of the day of reviewing the report on 9/29/2011.

2- The medical gas alarm on the Basement Aaron Building- Biomedical Engineering did not have audible indicator or visual indicator and the alarm was inoperative, but was not corrected as of the day of reviewing the report on 9/29/2011.

3- The medical gas alarm on 5th floor Aaron building- nursing station, rooms 588-598 did not have audible indicator or visual indicator and the alarm was inoperative, but was not corrected as of the day of reviewing the report on 9/29/2011.

4- The medical gas alarm on the 2nd floor of Katz Building rooms 226- Right side did not have audible or visual indicator, but was not corrected as of the day of reviewing the report on 9/29/2011.

5- The medical gas alarm on the 1st floor of Strausberg Building - ED Fast Track, did not have audible or visual indicator and was documented to be inoperative, but was not corrected as of 9/29/2011.

6- The medical gas alarm on the 4th floor of Strausberg Building - Cardiac Cath Recovery, did not have audible or visual indicator and as documented to be inoperative but was not corrected as of 9/29/2011.

7- The medical gas alarm on the 1st floor of Strausberg Building - Pediatric ED, did not have audible or visual indicator and was documented to be inoperative, but was not corrected as of 9/29/2011.

2-Medical Gas Shutoff Valves:

Also, the report included numerous areas where the gauges of the Medical Gas Shutoff Valve were not present. Examples of the missing gauges of the shutoff valve included but were not limited to the followings:

1- NE Side of CHC Building, Rooms 614,617,618, 624,625,628,631,633,634,635, CHC Building 6th Floor OR.
2- Mislabeled SW Side of CHC Building, Rooms 612,613,640, 6th Floor OR and Recovery.
3- SW Side of CHC Building 6th Floor old and new Recovery Area, 1st Floor, 5th Floor, 7th Floor 8th Floor, 10th Floor, 11th Floor and 13th floor.
4- Dental Suite - Medical Air in Room 110 is not controlled by a ZVB.
5- Rooms 318, 318 C, 330-1, 336 mislabeled.
6- MRI Suite.
7- LDR Rooms 1-9, Delivery Room 142.
8- Rooms 606 and 629 of SICU, Rooms 612 MICU and Room 618 Bariatric Unit.
9- 4Th Floor Snapper Building- Patient rooms 414-423 Mislabeled, Rooms 477-488, 460-466.
10- 2nd Floor Snapper Building- Rooms 274,275, 276. Mislabeled Room 281, Rooms 268, 269 and Nursery C.
During an interview with the director of Engineering on the afternoon of 9/29/2011, he stated that the facility corrected some of the deficiencies identified in the medical gas report, however, other deficiencies including the the above named findings were not corrected.

Fire Alarm and smoke Detectors:
Review of the fire alarm testing records on the afternoon of 9/28/2011 revealed that many smoke detectors were not tested during two consecutive tests performed in 2011, specifically, on 1/18/2011 and 6/20/2011. Examples of non tested smoke detectors included smoke detectors # 2103055, 2103056, 2103057, 210305859, 2103060, 2103061, 2103062, 210306364, 2103065, 2103066, 2103067, 2103068, 2103069, 2103070, 2103071, 2103072, 2103073, 2103074.

Another set of smoke detectors were not tested during the two semiannual tests of 2011, included Smoke detectors # 0602053, 0602054, 0602055, 0602056, 0602057, 0602058, 0602059, 0602060, 0602061, 0602062, 0602063, 0602064, 0602065, 060266, 0602067.

Interview with the Director of Safety, revealed that the facility had a fire in the energy center on December 22, 2010, and that this area is under construction. When asked, the safety director said the large number of the damaged smoke detectors was because the electric wires of many detectors were damaged by the fire, and that the affected locations do not have smoke detector coverage now.
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1 - Based on observation and interview it was evident that the infection control program did not ensure that patient rooms are not used for storage of sterile and clean supplies for use for other patients.
Findings include:

Observation during tour of the MICU and SICU found that the rooms at the end of each these units had glass doors and room for 2 patients and a separate exit into the halls. In these rooms, patient on contact isolation were also found. It was stated by nursing staff that these rooms can be converted to respiratory isolation by the use of a HEPA filter. In each of these rooms was found a closet with the door removed containing sterile and clean equipment for the unit. In one room behind the patient bed was found 5 IV pumps ready for use on other patients.

The facilty acknowledged that placing supplies for general patient use in a patient room was not standard practice and would be corrected.

2 - Based on observation, it was evident that the infection control department did not implement procedures to identify patients with certain types of isolation.

Findings incudes:

During the tour of the facility on 9/27/11 it was noted that a sign on the door of the patient in room 1005 which was printed by hand stated " neutropenic " isolation. There was no directive on that door for visitors or non-professional staff to see the nurse prior to entering. There is no definition for visitors and others to understand the meaning of " neutropenic ".


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3 - Based on interview and the review of documents, it was determined that the hospital infection program did not include a mechanism to ensure that patients returning to the facility that are known to be colonized with Multiple-Drug Resistant Organisms (MDROs) are promptly identified upon admission to determine the need for appropriate prevention of infection transmission.

Findings include:

At interview with the Infection Control Coordinator on 7/18/11, she stated that the hospital presently does not have a system to flag all returning patients who are colonized with Multi-drug Resistant Organism. Returning patients are considered for isolation based on their presenting symptoms and subsequent cultures. She stated that sometimes, name recognition helps the staff to identify patients that have been treated in the past for MDROs. The patients are then isolated upon confirmation. The Infection Control Coordinator stated that the new computer program due to be installed would flag returning patients with MDROs for prompt identification and assessment upon admission to the hospital.


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4 - Based on observation, staff interview, and document review, the hospital failed to provide a sanitary physical environment to prevent spread the transmission of infection. Specifically, the facility did not provide handwash sinks where required.

Findings include:

Medical ICU - 6th Floor of Snapper Building:
1- It was noted that the unit did not have a readily accessible hand wash-sinks for the staff to wash hands as required per AIA guidelines and CDC recommendation; AIA 7.3.A8. An observation was made for a staff member who went inside the soiled utility room to wash her hands during our tour of the unit.

Dental Clinic:
On the afternoon of 9/29/2011, during a tour of the dental clinic, the followings were identified:
1- No hand-washing sink was provided for the sterilization room of the clinic. The staff used the instrument sink to wash their hands. This is a potential source of cross contamination.

Radiology Suite:
1- On the morning of 9/30/2011, during a tour of the Nuclear Medicine Area, it was noted that the nuclear medicine procedure room 331 did not have a handwash sink.
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Based on interviews, tours of inpatient units, review of medical record, it was determined that the facility did not consistently ensure that all patients identified as needing discharge planning evaluations have complete need assessments. This deficiency was noted in nine (9) of twenty three (23) applicable medical records reviewed (MRs # 7, # 8, # 9, # 10, # 11, # 12, # 13, # 14 & # 15)

Findings include:
Mother & Baby unit was toured on 9/26/11 at 11:24 AM. While in the unit, the nurse assigned to the patient in MR # 7 reported that that patient was to be discharged today pending the laboratory results; she was cleared by social work for discharge.

Review of MR # 7 noted that this 16 year-old female went to the facility by ambulance on 9/24/11. The chief complaint was contractions and bleeding since 23:30. Reasons for hospitalization: labor, contractions, anemia and intrapartum pain. The patient gave birth to a baby boy.
- --Department of Case Management Maternal- Child Psychosocial form dated 9/26/11 was reviewed. It was documented that the baby ' s father was not involved. The reason why the baby ' s father was not involved was not documented. - The social worker noted on the form that homecare referral to Healthy Families Brookdale was rejected. The need assessment did not include the homecare services that the patient and baby required or services to be provided by the agency.
-It was noted prior to admission the patient, mother and four siblings (ages 15, 12, 10 & 9) resided in a shelter. It was noted that the patient was placed in the current shelter on 9/17/11.-The reason why the family was placed in a shelter was not documented. It was noted that the psychosocial assessment did not include if there was a discussion with the teen mother on the impact of the newborn on her life or why this was not necessary.

-The social worker (SW) documented in the progress notes that homecare was offered but declined by the patient ' s mother. The patient ' s opinion was not included in this assessment. The reason why the patient ' s mother refused the homecare referral was not documented. It was noted that the list of resources available in the community for teenage mothers were not offered to the patient and patient ' s mother or the rationale why this was not necessary.

The social worker assigned to the unit was interviewed on 9/26/11 at 12:15 PM. The social worker reported that the patient is a minor therefore the patient ' s mother is responsible for both mother and baby; the mother refused the home care agency.

The patient and baby were discharged on 9/26/11. The chart was requested and re-reviewed on 9/27/11 at 11:00 AM. It was noted that on 9/26/2011 at 13:20 the SW documented in the chart that " patient has been living with her mother and siblings in a shelter for the past two months. They were recently transferred to the current shelter (on 9/17/11) because another sibling from Dominica Republic to New York " . This assessment is still incomplete as it did not include the reason for the initial shelter placement and what impact if any will this new born has on the house hold.

The Director of Case Management and Assistant of Director Social Worker were interviewed on 9/28/11 at approximately 3:19 PM. The assessments in various medical records were discussed. They acknowledged that the assessments were incomplete and the assessment tool (form) for the Mother & Baby unit was limited. The surveyors were given new Social Work Psychosocial Assessment- Pediatric form. The facility plans to implement this form immediately.
Similar findings for adolescent teen mothers and babies records with incomplete discharge assessments and evaluations ( MRs: # 12,# 13, # 8,# 10,
#9, # 14 & # 11)

Review of (MR # 9) Neonatal Intensive Care Unit progress form noted that this term baby was admitted to the unit on 7/10/11 due to respiratory distress and clinical sepsis. It was noted that the patient ' s mother, a 15 year old mother, tested positive for cannabinoids. The mother was discharged to a foster care agency and the baby was discharged to her father and paternal grand mother.
It was noted that on 7/15/11 at 3:01 PM the SW noted newborn can be discharged to her father and paternal grandmother. The SW noted "father has a car seat; patient is socially cleared as VNS will follow up in the community". This assessment was incomplete. For example, there was no paternal parent information documented in the record except his name.
A signed copy of the discharge plan by the patient ' s father/grandmother that they were in agreement with the plan was not included in the record reviewed.

Review of MR # 15 noted that the patient 71 year-old with past medical history including HTN, CAD, Dyslipidemia, asthma and ETOH abuse was found unresponsive on the street; he was brought to the facility ' s Emergency Department (ED) by ambulance . The patient was admitted on 7/9/11 for syncope and alcohol intoxication. Patient had a psychosocial assessment on 7/12/11 at 12:30 PM. The social worker (SW) noted that the patient reported " having completed ETOH treatment programs in the past but they don't work " . The documentation did not include the reasons the patient gave why the treatments programs do not work. SW noted offered patient substance abuse treatment options; patient stated he will consider it. SW noted provided list of programs to patient to outpatient follow up. The discharge Summary dated 7/22/11 was reviewed. It was noted that the outpatient substance abuse treatment referral made on the patients behalf was not listed on the discharge plan.
-On 7/19/11 at 15:05 SW noted patient requested a staff member to accompany to Social Security to change his pin number and access his money. There was no documentation that the reason why this elderly patient requested assistance with gaining access to his money was explored/ discussed with the patient. Instead, the SW noted " the patient was informed that the hospital does not provide day pass and he can do this when he is discharge " . This patient was not discharged until three days later.
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Based on record review and staff interview, it was determined that the facility did not document complete discharge planning evaluations that included necessary communication or follow-up with authorized child protection agency personnel in 2 out of 2 applicable records.

Findings include:


Review of two medical records found the discharge planning assessments were incomplete for at risk infant twins admitted for suspected child neglect; the records did not contain sufficient rationale to ensure implementation of a safe discharge plan nor did these reflect required follow-up communication with child welfare authorities to validate placement.

Review of MR #s 5 and #6 on 9/28/11 revealed these 3 month old twins had been transported by ambulance to the hospital on 8/1/11 by Emergency medical technician staff and Police who found the babies crying in an unhygienic apartment with no baby food. The mother was reportedly a 17 year old adolescent. The children were found to be malnourished and underweight for age. The emergency staff discovered the children while making an unrelated call for another patient . A cardiology note dated 8/2/11 in MR #6 referenced that the childrens' mother was arrested. Both twins were admitted for dehydration, failure to thrive, and child neglect.

Review of discharge planning assessments found these were incomplete. Progress notes dated 8/3/11 in MR # 5 indicated that the Agency for Children's Services worker had advised the hospital staff that the case was brought to court and that the worker would communicate the final outcome of the court's decision. A follow up note indicated the case was referred to VNS for home care and that VNS staff would follow up with ACS worker to determine where the infants would be placed. The hospital social worker noted the patients' mother would visit with them prior to pick up by child welfare agency social worker. The children were discharged in the custody of the ACS social worker on 8/3/11 but no final disposition regarding destination to either placement or home was noted.

Both records lacked a complete psychosocial assessment and did not validate any information about the childrens' mother or family situation with Agency for Children's Services staff (ACS). The final destination for placement of the infants was not noted or followed up in the record with ACS staff. A prospective plan noted by the hospital was that the Visiting Nurse Service would follow up with the Agency for Children's Services to inquire about the placement of the children.

The hospital failed to establish the final disposition of the children with Child Welfare staff and referred the patients for visiting nurse services without a final disposition.

Interview with the facility's Administrative staff (Senior Vice President of Patient Care Services) on 9/28/11 determined that the grandmother of the children had been attended to by ambulance staff when the condition of the children was noticed. The record did not reflect any attempt to interview the grandmother in order to obtain supporting information about the circumstances of the alleged neglect of the infants.
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Based on review of documents, records of staff meetings, and interviews with staff, it was determined the facility did not conduct a complete assessment or reassessment of the quality and appropriateness of discharge planning processes in accordance with regulatory requirements.

Findings include:

Review of Case Management medical record quality assessment documents on 9/28/11 revealed that quality review activities were not conducted for all service areas to ensure that discharge plans were clinically appropriate and met patients' needs. The quality chart review audit documents reviewed found that chart audits were performed but there was no indication of the total number of charts reviewed nor include the percentages of records that either complied with or did not meet requirements for each specific indicator.

Interview with the Director of Case Management and Assistant Director of Social Work on 9/28/11 at 4 PM found that data was collected for inpatient medical surgical units but no quantitative data was collected for the emergency room, maternal child, and other clinical areas that require discharge plans in order to assess quality. Samples of e-mail reminders were provided to staff to advise of the chart deficiencies identified but the data for total number of charts reviewed for each worker and for all clinical areas was not available.