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Based on document review and interview the facility did not ensure timely notification to the patient's representative of an occurrence. This was found in one (1) of nineteen (19) medical records reviewed. (Patient #6)


Findings:


Review of medical record revealed patient #6 was admitted on 03/18/16 with history of Alzheimer's disease. On 03/25/2016, at 10:10 PM, the patient sustained a fall. There was no documented evidence that the patient's Health Care Proxy representative was notified by authorized staff.

This finding was acknowledged by and confirmed with staff N (Clinical Informatics), staff V (Risk Manager), and staff W (Assistant Director of Quality Assurance) on 5/12/16 at 11:52 AM.

During interview on 05/13/16 at 12:25 PM, this finding was acknowledged by and confirmed with Staff B1 (Administrative Manager) who stated that there was a "break in the communication."

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Based on document review and interview the facility failed to implement their own policy Guidelines for Incident Reporting/Sentinel Events/NYPORTS. This was found in one (1) of four (4) medical records. (Patient #20)


Findings:


Review of medical record for Patient #20 revealed on 04/29/2016 a CAT scan of the abdomen was conducted and showed that a Percutaneous Endoscopic Gastrostomy tube was incorrectly placed into the patient's colon and not the stomach.

Review of facility Policy titled, " Guidelines for Incident Reporting/Sentinel Events/New York Patient Occurrence and Tracking System (NYPORTS) " dated 2016 documented,
1. " the facility should conduct a huddle followed by debrief immediately after occurrence and/or an adverse event is identified.
2. Occurrences meeting criteria for NYPORTS 900 series codes resulting in an unintended development in a patient ' s condition.
3. These events most often require a Root Cause Analysis."


There was no documented evidence provided from the facility that this patient occurrence for wrong site surgery was reported to the New York Patient Occurrence and Tracking System (NYPORTS).

During interview conducted on 05/16/16 at 10:00 AM, Staff C (Risk Manager) stated, " we intend to notify NYPORTS of the occurrence. " A second interview was conducted with Staff C on 05/17/16, who stated, " a short form has now been filed with NYPORTS and we intend to file a regular form for wrong site placement requiring a Root Cause Analysis later."


There was no documented evidence provided from the facility that an internal Incident Report was completed timely or that a huddle or debrief was performed immediately after this occurrence/adverse event was identified on 04/29/16.

There was no documented evidence provided from the facility that a Root Cause Analysis of this incident was initiated. This was confirmed during interview with Staff J (Chief Medical Officer) on 05/17/16, at 10:00 AM.

Based on document review and interview the facility failed to ensure nursing monitoring and assessments were performed during "One to One" (1:1) Continuous Observation". This finding was evident in one (1) of two (2) medical records reviewed. (Patient#6).


Findings:


Review of the medical record for the patient #6 revealed that on 03/25/2016 at 10:04 AM, the patient was placed on 1:1 observation for patient safety following a fall.

There is no documented evidence that the patient was monitored and no observation flow sheets found in the patient ' s medical record.

Review of facility Policy titled, " Patient Observation: For Safety & Non-Suicidal Patients " dated 10/15 documents, " Patient Observation Flow Sheet/Nursing Assessment must be completed every thirty minutes when the One to One Observation is maintained. "

On May 12, 2016 at about 10:00 AM, staff N (Clinical Informatics), staff V (Risk Manager), and staff W (Assistant Director of Quality Assurance) agreed that the 1:1 flow Sheets were not documented in Patient #6 medical record.

Based on medical record review, document review, and interview the facility did not ensure compliance with the facility's policy for surveillance and monitoring of epidemiologically significant organisms. This was found in one (1) of 28 medical records reviewed. (Patient #8)


Findings include:


A review of the medical record for Patient #8 identified the following: The patient, a 38 year old male was admitted on 3/18/16 for a progression of his diagnosis of urothelial carcinoma.
The past medical history included: HTN, CHF, COPD, asthma, cerebral thrombosis with cerebral infarction, seizure disorder, and polycystic disease of the kidney.

On 3/18/16 the patient had a Cystoprostatectomy, a Penectomy, and an Ileal Conduit procedure(s) performed. The patient's post operative course was complicated by episodes of episodes of emesis, constipation and diarrhea, from 3/19/16 to 3/27/16. On 3/27/16, the patient's white blood cell count was elevated and reported as 13.7. (Normal range expressed in international units as 4.3 - 10.8 x 109 cells per liter).

On 3/28/16, a culture of the surgical wounds was sent for culture and sensitivity. This culture and sensitivity of the patient's wounds, was reported on 3/31/16, as positive for MRSA and E. coli.
The Physicians' Progress notes documented that the surgical wound was opened to allow for drainage on 3/31/16.
Upon the recommendation of an Infectious Disease specialist, the patient was treated with unasyn/vancomycin. The Consultant's Impression: was wound infection and a pelvic abscess.
The record indicated that the patient returned to the Operating Room on 4/1/16 and 4/7/16 for wash outs of the wound infection.


A review of the facility Policy and Procedure titled "Protocol For Surveillance Of Epidemiological Significant and Resistant Organisms and Outbreak Investigation," revised 2/13, stated that it is the facility's policy "to conduct surveillance of epidemiologically significant organisms and resistant organisms on a daily basis to determine: (a) clustering of organisms with similar antibiogram patterns (b) placement of patients on appropriate isolation/precautions. A list of routinely monitored epidemiologically significant organisms (including Methicillin-resistant Staphylococcus aureus (MRSA) is to be provided to Infection Prevention and Control. This listing is maintained on a daily basis for all patients units.

The facility did not provide the surveyor with a listing of routinely monitored epidemiologically significant organisms as specified by the policy, and there was no documented evidence that this patient's MRSA infection was monitored.

A telephone interview was conducted with the Assistant Director of Quality on 5/18/16. The Assistant Director stated that the Infection Control Nurse tracks only clusters of MRSA, not individual cases of MRSA.



A review of the facility's "Infection Prevention and Control Plan," revised 2/15, documented the indicators for the Infection Prevention and Control. These indicators includes "Surgical Wound Surveillance - An assessment of the likelihood and degree of contamination of a surgical wound site at the time of operation." The source of this assessment is prospective chart and microbiology review.

There was no evidence the individual case of MRSA in Patient #8 was reported to or tracked by the Infection Prevention/Control Staff at the Hospital. In addition, there was no evidence that a chart review or microbiology review was conducted for this case as required by the facility's policy.

Therefore it was unclear if the facility appropriately monitored this individual case of MRSA and collected data for the Indicator titled "Surgical Wound Surveillance" in its Infection Prevention and Control Program.

Based on document review and interviews the facility failed to develop and implement a written policy for confirmation of a Percutaneous Endoscopic Gastrostomy (PEG) tube placement.


Findings:

Review of medical record revealed Patient #20 was admitted on 03/25/2016 with medical history of Cerebral Palsy. On 04/12/2016 a Percutaneous Endoscopic Gastrostomy tube was placed in an Operating Room.

On 04/13/2016, the patient was discharged home.

On 04/23/2016 the patient was re-admitted to the facility eleven days post discharge with gastrointestinal symptoms including abdominal distension, diarrhea, and the feeding formula backing up into the tube.

On 04/29/2016 a CAT scan confirmed that a Percutaneous Endoscopic Gastrostomy tube had been incorrectly placed into the Patient #20 colon. The patient's tube feedings and medications were administered through the colon instead of the patient' s stomach.

The medical record did not have documented radiographic evidence that fluoroscopic imaging was performed to confirm placement prior to discharge on 4/13/16.

Review of hospital Policy titled, " Gastrostomy Feeding Catheter (PEG-Tube) " dated 08/13 documents, " For Bolus Feedings first verify the physicians medical order. Check that tube placement was initially confirmed by x-ray radiography."

On 05/18/16 at 8:00 AM, Staff S (Gastroenterologist), was presented with a copy of this policy and staff S stated, " I have never seen it before. "

During interview on 05/18/16 at 8:00 AM staff S, stated, "confirmation of placement is done visually (during the insertion)."

On 05/18/16, at about 14:00, staff J (Chief Medical Officer) stated, " This is not a good policy. Staff E (Vice President for Nursing) stated, "we will revise the policy."