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Based on observation during inspection tours, review of records and documents, and staff interviews, it was determined that the facility's Governing Body did not ensure effective accountability for all hospital operations as required.

Findings include:

The facility's Governing Body failed to exercise sufficient oversight of the administrative and clinical activities of the facility as evidenced by pervasive non compliance with the following requirements:

§482.12 Condition of Participation: Governing Body
§482.13 Condition of Participation: Patient's Rights
§482.28 Condition of Participation: Food and Dietetic Services
§482.42 Condition of Participation: Infection Control

1. Condition level non compliance was identified for Patient's Rights. The facility did not provide a safe environment of care in accordance with patients' rights requirements. Specific reference is made to system failures observed of the electronic infant security system and the lack of effective surveillance for access to multiple unlocked pediatric units throughout the facility.

These findings resulted in the declaration of an immediate jeopardy condition on 4/18/13 at 2:20PM and which was eventually abated at 6:20 PM on 4/18/13 when the facility implemented temporary interim measures satisfactory to the Department of Health.
Refer to tag #s A115 and A144.

2. Condition level noncompliance was identified for Food and Dietetics Services due to the failure of the hospital's food and dietetic services to maintain safe and sanitary conditions in the kitchen and due to lack of oversight by the Food Service Director responsible for the daily operation of the dietary services. Refer to tag #s A 618, A 0749 and A0620.

3. Condition level noncompliance was identified for Infection Control due the facility's failure to provide a sanitary environment to minimize the possibility of contamination and transfer of infection. The Infection Control Officer failed to monitor all areas of the hospital including food storage, handling and preparation, housekeeping and maintenance, and maintenance of the facility's ventilation system in providing appropriate air flows in patient care/critical care areas. Refer to findings noted under Tag#s A747, A748 and A749.

Based on observations, staff interviews, and review of procedures it was determined the facility did not comply with requirements for the protection and promotion of patients' rights as required.

The facility failed to meet the Condition of Participation for Patient Rights due to pervasive non-compliance with requirements as follows:

1. The facility failed to implement an effective surveillance system for protection of infants and young children on 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 Columbia division site. An additional instance of malfunctioning of the infant electronic infant protection system was also observed during testing conducted on the postpartum unit located at Weill-Cornell division on 4/23/13.

An immediate jeopardy condition was declared on 4/18/13 at 2:20 PM due to the system failure related to the electronic infant protection devices during testing. In addition, there was noted lack of appropriate monitoring of access to unlocked pediatric units throughout the facility.

The immediate jeopardy was abated at 6:20 PM on 4/18/13 following the submission of temporary security measures which included immediate service inspection by the service provider of the equipment, posting of additional security staff at all times on one pediatric unit, and assurance that remaining pediatric floors had unit assistants posted at unit entrances.

Cross refer to specific citations noted under Patient Rights, 482.13 (c)(2), TAG #A144.

2. The facility did not consistently comply with requirements for the provision and explanation of information to patients or their representatives about Patient's Rights. Refer to Tag # A117.

3. The facility did not establish a system to monitor or ensure the timely resolution of grievance investigation and provision of written responses. The facility did not effectively monitor the grievance process to ensure that cases were correctly categorized as grievances or complaints. Refer to tag #A122.

4. The facility did not consistently provide appropriate or timely notice of the results of the hospital's investigation of grievances. Grievance investigations were incomplete or did not resolve issues in a timely manner. Refer to tag #A123.

5. The facility did not conform to its procedures that require written confirmation of patient involvement in the care planning process. Refer to tag# A130.

6. The facility failed to ensure that patient with application of restraints have appropriate physician orders in accordance with its policy and procedure on restraints.
Refer to tag #A168.







21204

Based on patient interviews, review of records and procedures, and review of the facility's Patient and Visitor Guide booklet titled "Your Rights as a Hospital Patient in New York State" , it was determined the hospital did not effectively notify all patients of patients' rights requirements.

Findings include:

1. The hospital did not comply with requirements for the provision and explanation of information to patients or their representatives about Patient's Rights, including the Bill of Rights or the Important Message from Medicare (IM's). These findings were noted in 12/12 applicable medical records reviewed.

Review of the procedure titled "Notification of In-Patient Medicare Beneficiaries about their Hospital Discharge Appeal Rights" on 4/23/13 finds that Patient Access staff are to attempt delivery of the initial IM notice within 2 calendar dates of admission. The staff may telephone or write to the patient's representative if the patient is unable or is not competent to receive and understand the notice. The follow up copy of the IM is to be distributed by Care Coordination and Social Work Departments no more than 2 calendar days before discharge and no less than 4 hours prior to discharge.

Review of the procedure titled, "Patient Rights and Responsibilities" on 4/23/13 finds that the Patient's Rights information is the responsibility of the registration staff in the Admitting office, Emergency Department, and all Ambulatory Care areas.


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2 . During the tour of the M8HN inpatient unit on 4/15/13 at 3:29 PM, the patient in room 8-131-Bed 01 and his wife were interviewed regarding Patient's Rights. The patient reported that he was transferred from a hospital from New Jersey on 4/12/13 and he was not given a Patient Rights package given to inpatients. The wife also reported that this information was not given to her.
At interview with the Patient Care Manager on 4/15/13 at 3:40 PM, it was reported that the patient was admitted early in the morning of 4/12/13 and he was transferred to an ICU as possible explanation why this information was not given.
A copy of the package given to the patients informing them of their rights was requested for review. A copy of Patient and Visitor Guide Booklet was given to the surveyor. The booklet noted, under Patient Rights and Responsibilities, page 30, that patients were instructed to review " Your Rights as Hospital Patient in New York State". Review of " Your Rights " as a Hospital Patient in New York State " noted written under item # 14 " Participate in all decision about your treatment and discharge from the hospital " . However, this booklet did not include the requirement that the patient has the right to participate in the development and implementation of his or her plan of care.
Item #17 notes: " Complain without fear of reprisals about the care and services you are receiving and to have the hospital respond to you and if you request it, a written response " . It was noted that patients/patients ' representatives were not informed that they are required to receive prompt written responses to their grievances.
It was noted that the booklet " Your Rights as Hospital Patient in New York State" did not include that the patients have a right to the following:
- To have a family member or representative of his or her choice and his or own physician notified promptly of his or her admission to the hospital.
-The right to be free from all forms of abuse or harassment.
These required Patient Rights were not included in the booklet titled "Patient and Visitor Guide during your Stay".

3. The facility did not consistently comply with its policy and procedures for timely distribution of the Important Message for Medicare notices (IM's) to applicable patients or their representatives upon admission or prior to discharge.
Additional samples of inpatient medical records were reviewed on 4/15/13 and 4/23/13. Examples of records lacked documentation of the provision of required IM notices within required time frames and/or confirmation of provision of Patient's Rights information package as follows:
It was noted that medical records for Medicare beneficiaries referenced in MR # 1, 2, 3 did not have copies of IM (An Important Message from Medicare) forms. Therefore, it was determined that the facility was not effectively ensuring that all Medicare beneficiaries were provided with IM within 2 days of admission as required.

MR#4
68 year old patient admitted for treatment of worsening psychoses, depressive symptoms and dementia on 4/9/13. During tour of the unit on 4/15/13 the record lacked evidence of distribution of the Important Message from Medicare.


MR#5
Patient was admitted to inpatient psychiatry on 4/5/13. The IM was not signed until 4/8/13, three days following admission. The requirement mandates notification within two days of admission.


MR#6
This patient was admitted to the facility on 4/10/13 and underwent cardiac catheterization on 4/15/13. During tour of unit 5HN on 4/16/13 at 2:30PM, the patient referenced in MR #6 was interviewed prior to discharge. He stated he received many notices yet review of the record determined no evidence of confirmation of issuance of the Important Message From Medicare (IM).

Also refer to similar findings identified in MR #s: #s 7, 8, 9, 10, 11, and 12.

Based on staff interview and review of grievance procedures and records, it was determined the facility's procedures did not establish a system to monitor or ensure timely resolution for the investigation of complaints and grievances.

Findings include:

1. The facility's process for grievance investigations did not ensure that grievances are investigated and resolved as soon as possible and in a timely manner in accordance with federal regulatory requirements.

The facility's procedure titled, "Patient Complaints/Grievances- No. P110" on 4/19/13 does specify time frames for grievance responses but these time frames are protracted and do not ensure prompt turnaround times for resolution and provision of responses to complainants.

The facility defines grievances as any written complaint, any verbal or written complaint about abuse/neglect/patient harm, or any request made by a patient or representative that complaints be handled formally. A complaint that is resolved by staff at the time of the complaint is not a grievance and it is noted that written complaints attached to patient satisfaction surveys might be considered a grievance following consultation with Patient Service Administration staff.

The procedure notes that grievances should be resolved as soon as practical. Grievances which may endanger patients , such as abuse or neglect, will be immediately reviewed, but that :
" if the grievance is complex and resolution will take longer than a period of seven (7) days, the hospital will advise the patient/representative that the facility is working to resolve the grievance and will follow up with a written response in 2-3 months".

The policy describes that if further review is needed Patient Services staff will initiate timely referrals to departments or committees and that grievances will be reviewed by departments and the Patient Services Administration (PSA) staff. However, this policy describes no documented expected time frame for review and submission of grievance investigation findings by involved departments when feedback is needed.

Review of 7/16 selected grievance files on 4/23/13 determined there was internal documentation that e-mails of departmental investigations were due within ten days.
Refer to Grievance File#s 13G, 14G, 15G, 17G, 20G, 21G, 33G.
This time frame for submission of results of departmental investigations (10 days) exceeds the time frame noted in regulations which require grievance resolution at the earliest practical time, i.e., within seven days from intake date.

This concern about protracted time frames in existing procedures for provision of resolution and response was shared with the facility staff and Director of Patient Services Administration (PSA) on 4/23/13.

It was stated at interview with Director of Patient Services Administration (PSA) on 4/22/13 at approximately 11 am that there are over 7000 grievances and complaints received annually at the facility within the last year and that attempts are made to resolve the complaints and grievances timely where feasible.

2. Patient Services Administration (PSA) staff was asked to provide a log of all complaints and grievances for the period of 2012 to the time of the survey for a total of 12 months (4/15/13).

The log provided on 4/17/13 for the time period requested had contained approximately 7000 entries comprised of complaints, grievances, encounters, patient requests, and reportable incidents that were merged into this spreadsheet log. However this log lacked significant tracking documentation of follow up to identify dates of resolution, departmental reviews, outcomes, corrective actions, provision of responses, or evidence of tracking for closure dates.


3. Review of 14 applicable complaint files on 4/22/13 determined seven instances where grievances were missclassified as complaints. The hospital' s procedure indicates complaints resolved at the time of the complaint by staff are not considered grievances.

It was noted that 7 of 14 applicable complaints reviewed were not resolved immediately and thus were not correctly classified as grievances. Consequently, these concerns were not resolved as grievances in accordance with hospital policy and federal regulatory requirements.
Refer to case file #s 1C, 6C, 7C, 8C, 9C, 11C, 25C.

The facility's process did not review instances identified when complaints were not accurately categorized or resolved as grievances .

The following complaints warranted escalation to grievance status :
Examples include:

File#1C
Complaint file contained multiple issues which were not resolved on the same day. Patient complained of use of thermometer without appropriate hand hygiene and noise on 3/21/12. On 3/23/12 he complained of lab draw technique and treatment for itching. On 3/26/12 he complained of discharge planning and stated he could not return home as well as pain issues. Staff responded verbally to complaints and involved staff. Staff apologized for not using hand sanitizer. Patient was discharged to skilled nursing as requested on 3/27/12 and the file resolution noted "satisfied". Complaints were multiple and no investigation ensued about hand hygiene or pain issue. Patient ' s issues were treated as verbal complaint and no formal resolution was noted.

File #6C
This patient complained on 12/17/12 of " accessibility " issues , advanced directives, and "availability of special care/services". The patient complained he was not satisfied with food selection on 12/24/12 and follow up noted he met with dietary staff. On 12/24/12 he complained of several grievances including: food selection, inability to comprehend dietician, being awakened for medication, medications were not given on time, and feeling " trapped " . Nutrition notes were copied into the electronic case complaint file. Psychiatric follow up consult results were appended into grievance files dated 12/24/12 which noted the patient had some dementia process and that recommended psychiatric follow up and sub-acute rehabilitation placement. The follow up indicated the patient was discharged on 12/27/12. The file lacked recorded investigation of the concerns. There was no recorded final resolution of defined grievances. No response was provided to the patient. Given that complaints continued on different dates and were not immediately resolved, the matter warranted treatment as a grievance accordingly.

File #7C: A complaint referral for quality review was submitted on 12/13/12 involving patient ' s death at another hospital the day following discharge after undergoing a procedure for right hepatic artery chemoembolization. Quality review was requested on 1/10/13. Departmental quality review was performed but not sent back to Patient Services Administration until 4/19/13, which concluded patient was evaluated and procedure had no complications. The standard of care was met and noted future plan to discuss QA findings. While discussion was held with patient ' s son on 12/20/12, no written response was provided. There was no explanation for why this complaint was not re-classified as a grievance.

File #8C : Patient complained about interaction with the physician on 4/9/13, who allegedly did not behave professionally. A meeting was held with a practice manager on 4/11/13 and referral to a new physician was identified. A prospective plan was noted to arrange counseling and psychiatric referral. Patient was noted to understand and expressed appreciation. No follow up was noted with the physician that was alleged to have been insensitive.

File# 9C: Complaint from staff regarding an incident of alleged rough handling during a patient transfer by a staff member on 3/15/13. A referral was made to the supervisor of emergency transporters on 4/10/13. As of 4/18/13, the hospital ' s quality review of this issue had not been completed. There was no documented interview of the patient or examination to evaluate the patient's status. This incident was incorrectly classified as a complaint and this reflects lack of timely resolution in accordance with hospital policy.

File# 11C: Family complained on 4/10/13 about multiple medical issues involving alleged premature discharge, malfunction of PEG tube, readmission, and failure to advise family of PEG change. Follow up was noted on 4/15/13 regarding intern discussion regarding plan of care. On 4/16/13 a departmental quality review was requested and due on 5/13/13. This complaint was not resolved as a grievance, which also requires written notification to the complainant of the date of expected resolution.

File#25C: Incident was classified as complaint on 4/1/12 where husband of patient found a bug in infant bassinet. Date of submission of this complaint was 4/2/12. The bug was taken as a specimen and given to environmental staff. Pest control was contacted and husband reportedly took picture of the insect. Follow up sent on 4/9/12 where an email was sent to Environmental Services requesting feedback on bug identification. Follow up referenced original email on 4/3/12 where the exterminator stated the bug was a silverfish and not harmful. No actions were taken to ensure inspection of the environment for cleanliness and whether further insect infestation was detected. No follow up was noted with complainant. This issue was not resolved on same date yet was incorrectly classified as a complaint.

Based on review of patient grievance records, it was determined that facility did not consistently provide timely notice of the results of the hospital's investigation of grievances.

Findings include:

Review of 9 of 16 grievance records on 4/22/13 found that written grievance files were incomplete with respect to one or more of the following items as follows:
- Grievance investigations were incomplete or did not resolve issues in a timely manner;
- The hospital did not consistently comply with its procedure to issue written responses for grievances. Written responses, when provided, did not address all complaint issues or include pertinent findings of the hospital ' s investigation.

--Seven (7) of 16 grievance files reviewed were missing documentation that acknowledgement letters or written responses were provided to complainants to summarize investigative findings and outcomes. (Refer to file#s 13G, 14G, 15G, 16G, 18G, 19G, 20G)
--Two open grievances filed in April 2013 lacked evidence that acknowledgement letters were issued to complainant to advise of the date of expected completion of the investigation. (File #s G21, G22)

Examples:
14G:
Daughter complained on 10/15/12 that on 10/14/12 that the nurse was disrespectful and allegedly told the family of the patient to be quiet while family members were engaged in prayer. A request for departmental investigation was initiated on 10/17/12 and response was due on 10/26/12 (9 days later), which included interview with staff who stated the patient ' s roommate complained of noise. The staff member was counseled. The daughter requested an outcome response on 10/26/12 and despite this request, the grievance file noted on 10/31/12 that the daughter was informed of staff counseling and allegedly reported no written response was needed. No written response was provided by the facility despite requirement to provide notice in regulation and by hospital policy.

16G:
On 1/26/13 administrator on duty reported patient made allegation of sexual inappropriateness. The patient called 911 from her cell phone. Police arrived and spoke with staff and noted incident was " unfounded " . The file also contained additional data that the patient had fallen, was in a cluster room with a continuously present attendant, and had contained prior excerpts of her request for visitor restriction and name change. Patient was interviewed and complained about a male patient in the same cluster room. She alleged she woke up in bed exposed and that a male patient in the same room was in front of her. Patient also complained staff withheld pain medication. Notes included review of medical provider notes dated 1/26/13 about past history of sexual abuse by father and suggestion to move out of room containing male patient. Follow up medical notes on 1/27/13 indicate patient requests psychological follow up and benefiting from one to one observation and being placed in a female only room. On 1/28/13, file notes described patient was disoriented and called 911 despite staff presence and that Police would not take report because story was "fabricated". The patient was discharged on 1/27/13 and section for resolution noted that no further action was needed based on medical record review and administrator ' s communication. This investigation was incomplete as there was no resolution of patient ' s expressed allegations (male patient behavior and pain issue). No documentation of written response was provided to the complainant.

File 18G:
This grievance involving alleged sexual abuse lacked evidence of timely investigation or provision of response to the complainant.
Patient complained to social worker of sexual abuse by a nurse practitioner provider in an off-site clinic that allegedly occurred on 1/3/12. The facility case file noted this complaint was submitted on 2/27/13. Follow up e-mails between staff were entered into electronic case file which culminated in patient interview on 3/5 /13. Plans were made to interview the employee but no follow up other than that the alleged employee never returned to work after 2/13/13. The file noted, that a physician spoke with the patient on 3/8/13 and that per patient, no further follow up was requested. There was no follow up written response provided to this patient based on file review on 4/19/13. This investigation was incomplete as there was no documented follow up interview of the employee as planned.

File 22G:
This alleged complaint about sexual abuse was not investigated in a timely manner. Patient complained to son that nurse allegedly sexually abused the patient on 4/5/13. The grievance was made in person on 4/10/13. The patient was interviewed on 4/10/13 and stated he was unsure if anything occurred but commented about bruises on the chest and legs. On 4/12/13 the son declined an acknowledgment letter. Arrangements were made to interview staff. No investigative follow up was noted at the time of the review on 4/19/13. The facility is required to provide a response to advise the date the investigation will be completed.

---2/5 applicable grievance files reviewed included written responses provided to complainants but these responses were incomplete. Written responses did not conform to all elements as mandated by regulatory requirements to include the results of the hospital investigation and resolution of each complaint issue raised. Letters also did not include documentation of the option to file a complaint with the regulatory agency in the event of disagreement with the hospital's review. (File #s 17G, 31G)

Example:
File #17G:
Written grievance dated 8/31/12 was not received by Patient Services until 12/12/12. An initial written response acknowledged the survey delay was due to a clerical error. No time frame for follow up was noted with dates as specified in the hospital policy. The patient, who was also an employee, went to the emergency room after bodily fluid exposure in the eye. The complaint alleged staff in the emergency room were rude and failed to don appropriate gloves or adhere to hand hygiene. The patient also complained of a three hour delay. Departmental investigation request requested response in ten days. A final written response was not provided to the patient until 2/15/13, which did not address all of the complaint issues. No explanation was noted for alleged failure to adhere to hand hygiene and no information was included for the option to file a complaint with regulatory authorities.

Similar findings were noted in File#31G, for a patient who complained in writing on 9/6/12 of noisy co-patient/visitors and perceived violation of privacy by a photographer vendor who was in proximity of the patient while a nurse was providing clinical care on 8/16/12. The hospital did not document receipt of the grievance until 10/1/12. The response letter was not sent until 10/5/12 and did not fully address the patient's privacy concern.

Based on review of 4/4 applicable inpatient psychiatric records, the facility did not conform to its procedures that require written confirmation of patient involvement in the care planning process.

Findings include:

Four of four applicable inpatient concurrent psychiatric records reviewed during tour of inpatient psychiatry unit M9GN on 4/15/13 lacked documented evidence that patients participated in their plan of care.
Written treatment plans were not signed by patients in accordance with behavioral health procedures which require patient signature on care plans. Review of the behavioral health policy titled, "Comprehensive Treatment Plan-C10" on 4/19/13 found that patients and family are encouraged to participate in treatment plans, which is supported by patient signature or recorded in progress notes. Where this participation is refused, this condition shall be documented with an explanation.
It was confirmed at interview with the Nurse Manager on unit M9GN on 4/15/13 at approximately 1PM that care plans are not routinely signed, but that attempts are made to involve patients and family members in care plans.

Example:
MR #5:
72 year old female admitted on 4/5/13 due to suicidal plan for ingesting 300 alprolazam pills with alcohol. Review of Psychiatry comprehensive treatment plans dated 4/5/13 and 4/15/13 determined that there was no evidence of patient signature to validate involvement with care plans. There was no supporting documentation to explain patient participation in plans or rationale why this requirement was not met.

Similar findings were identified in MR #s : 4, 7,13.

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:

The hospital did not provide sufficient safety monitoring of the environment of care for infants and children to minimize risk of harm or potential for abduction. The electronic infant protection system did not properly operate in three of four instances during system testing conducted at the Columbia division site. In addition, it was also noted that the hospital did not implement appropriate security mechanisms on pediatric units not under electronic infant tag surveillance. For example, the perimeters of pediatric units without electronic infant tag surveillance were not maintained in a manner to mitigate safety risks, in that it was observed these pediatric units were unlocked and freely accessible to visitors. The only hospital employee posted at these unit entrances is a unit assistant, who has multiple job duties other than visitor screening.

Reference is made to the repeat observations of the failure of the electronic infant security alarm system to activate in a timely manner. The electronic infant monitoring protection system malfunctioned during three of four test inspections performed at the Columbia Hospital division site on 4/18/13. In addition, the electronic protection system did not properly operate during an inspection test performed at the Weill Cornell Hospital division on 4/23/13.

Details include:
1. During tour of the newborn and post partum units at the Columbia Division on 4/18/13, it was stated by staff representing Security and Nursing Administration that an electronic tag system manufactured by " Accutech " is used to augment safety and tracking of newborn infants on units 6 Central and 5 Central. These units are accessed via employee card access only but the exit doors are unlocked for anyone who tries to depart using the exit doors of the unit.
It was reported at interview with hospital administrators on 4/18/13 that 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 when the infant wearing the device approaches the proximity of the exit doors to the unit ; this feature includes a ten second lapse when the infant wearing the tag loiters around the exit doors;
-the visual and audible alarms are to immediately activate when the band is cut.

2. The electronic infant monitoring system failed to consistently operate during 3 of 4 test inspection sessions performed on 4/18/13 at the Columbia Division and hence did not ensure the provision of a safe environment of care for hospitalized infants and children. Four inspection trials were conducted at the Columbia Division on 4/18/13 between 11AM and 11:54 AM which determined that the electronic audible alarm did not consistently operate in a manner that ensured the safety and security of infants and pediatric inpatients.

Inspection of the hospital ' s electronic infant security was conducted on units 6 Central (Postpartum and newborn nursery) and 5 Central (antepartum, post partum and newborn rooming in) on 4/18/13 between 11 AM and 11:54 AM. Two surveyors and approximately eight hospital staff were present during these testing sessions, which included but were not limited to the following staff: Director of Environmental Health and Safety,
Director of Facilities,
Senior Director of Nursing/Quality & Compliance,
Director of Nursing, and
Patient Care Director.

It was stated at interview with nursing administration, safety, and security staff that the hospital utilizes an electronic system for newborn infants on 2 units (6 Central and 5 Central). This system is composed of an electronic device which is attached to a special bracelet placed around the ankle of the newborn following birth. There are two components of the system: the first involves the activation of locking the exit doors from the unit when a tagged infant is located close in proximity to the exit doors within 10 seconds. The second feature involves the immediate activation of an alarm (both auditory and visual alarms) when the bracelet is cut. Of note the visual alarm component posts the last known location of the device on the unit displayed on an electrical display panel board on the wall across from each unit ' s nursing station. Each of the four tests determined the door locking function operated upon approach to the exit door. However, three of four tests performed found the second component of the system failed to activate the alarms immediately as required when the band was cut.

The first test inspection was conducted on postpartum/newborn unit 6 Central at 11am. The Senior Director of Nursing for Quality & Compliance wore the bracelet and the transponder during which it was observed that the auditory alarm failed to activate immediately when the band was cut.

A second simulation test was performed on a newborn inpatient on 6 Central. The exit door was propped open in an attempt to simulate an abduction where the entrance door would be manipulated to remain ajar. When the band was cut, at 11:14 AM and 30 seconds, it was observed by all hospital attendees and two surveyors who witnessed that the surveyor and nurse were able to remove the infant from the unit before the alarm activated, within an approximate time lapse of 60 to 75 seconds.
It was stated by the Director of Security that the alarm was supposed to activate in ten seconds or less.

A third simulation test was conducted on the infant at 11:24 AM where it was determined that the visual and auditory alarms activated within 1 second after the band was cut.

Simulation test #4 was performed on unit 5 Central in which the exit door to the unit was held open. During inspection performed on Unit 5 Central at 11:54 AM it was determined that the alarms did not activate for 11.47 seconds following the cutting of the sensor band on an infant. The surveyor and nurse escort were able to remove the infant from the door held open on the unit within this time frame.

It was also confirmed with staff at interview that the electronic device system is not linked to the elevator system so that if an abductor bypasses the door lock feature, the elevators would not be deactivated. In addition, while the alarm activation occurs in the main security office, it is not audible at the first floor security greeting desk located at the entry point to the Children ' s hospital.

Interview with the Director of Security and nursing executive staff on 4/18/13 determined that any one who arrives to the unit must be buzzed in by staff and have visitors passes. These visitors would have been screened by security staff proximal to the first floor of the Children ' s Hospital and are granted visitor passes prior the visit.

3. Review of the written policy OB-151 titled " Security Monitoring System " on 4/18/13 detail instructions for application of the transmitter, assignment of patients in the Accutech computer system, and for determination of the location of the alarm. However, this procedure 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. A procedure for " Identification of protection of Infants/Children " at risk is cross-referenced in this policy, but this document was not provided to surveyors despite query for any associated infant protection procedures.

4. The facility did not ensure the implementation of a comprehensive security system to ensure the safety and monitoring of pediatric patients on six units (other than newborn units) where electronic surveillance devices are not utilized.
These pediatric units are located in the Children ' s Hospital in the Tower and Central Buildings, which include 8 Central, and units on Tower wing (Pediatric units located on floors 4, 5, 6, 9, and 10).

During tour of pediatric unit 8 Central on 4/18/13 at 12:15 PM, it was noted by surveyors and confirmed by staff interview that the entry doors to this unit are unlocked and fully accessible to employees or visitors. The floor plan of the unit is constructed in a manner that does not permit accessible viewing of all persons entering or exiting the unit. There are multiple patient rooms located proximal to the points of egress which are not readily visible by nurses or other staff. It was stated by the Director of Security that there are cameras posed at the corridor side of the exit doors by the elevator banks which are visible at the security command center.
Interview with nursing staff on the unit on 4/18/13 at 12:15 PM determined it is the nurse or unit assistant ' s responsibility to verify the identity of visitors and that the RN will perform hourly checks. If a child is high risk for abduction, a security one to one monitor would be placed with the patient. It was also confirmed pediatric patients on this unit may include infants after three days of age through 18 years.
It was further confirmed by interview of nursing and administrative staff on 4/18/13 that newborns older than three days of age and young children would be admitted to other unlocked pediatric units in the Children's hospital where there is no electronic surveillance tagging system in effect and where only a unit clerk is responsible for screening visitors who arrive to these unlocked units. These units include 8 Central, and units on Tower wing (pediatric units located on floors 4, 5, 6, 9, and 10).

Due to the system failure of electronic infant security protection monitors and the insufficient measures present on six general unlocked pediatric units to ensure a safe environment of care, an immediate jeopardy situation was declared at approximately 2:20 PM on 4/18/13. The hospital submitted a written plan to provide temporary security measures, which included an immediate service request to ECOM technologies (the company charged with maintenance and inspection of the infant monitoring system) for assessment and repair of the infant protection system to restore functioning. In addition the hospital proposed the placement of a Security officer for monitoring round the clock on unit 8 Central and assurance that unit assistants are posted at the entrance to each remaining pediatric unit located in the Tower and Central Buildings. The hospital submitted a written statement on 4/18/13 at 6:20 PM, which noted, " An assessment of all inpatient pediatric units will be completed to identify additional proactive measures. "

The immediate jeopardy was abated at 6:20 PM at the Columbia Division, following the submission of an accepted interim plan of correction.

5. Another instance of malfunctioning infant electronic infant protection system was observed during additional testing conducted on the postpartum unit located at Weill-Cornell division on 4/23/13. During test inspection of the electronic infant security system on unit 7 Central at 11:04 AM, the audible and visual alarms were not distinctly noticeable following the cutting of the band. The visual flashing is not readily visible unless staff is present in close proximity to the computer display. In addition, the audible alarm was weak and barely detectable.

6. The hospital did not consistently implement effective procedures for the prevention of infant and child abduction.
At interview with the Senior Vice President of Children's Services, Vice President of Safety/Security/Emergency Services, Director of Security, Vice President of Operations, Vice Presidents of Nursing and Operations for Children's Hospital, and Senior Manager of Children's Hospital (CHONY) on 4/18/13 at 4PM, it was stated that the hospital implements a multi-level program to ensure child and infant security. Training programs and testing drills are conducted for "Code Pink" which involves the alert and search system when a child goes missing from any inpatient unit. Access control measures are implemented in the lobby by Security to issue passes to visitors. Electronic monitoring is employed in high risk areas (newborn -postpartum unit) based on risk assessment by units.
A 24 hour command center monitors activity through hundreds of cameras. Electronic notification includes Code Pink response which is reinforced through video training of staff. Drills are conducted once every 6 months on antepartum and post partum units and a hospital wide annual drill including lockdown is performed. Officers from Security round on units and on unlocked pediatric units, unit assistants are stationed at the greeting desk at all hours. At the patient level, nurses screen for high risk situations and Security performs visitor restrictions as needed.

During review on 4/18/13 of monthly infant and child protection security system inspection documents for dates ranging between October 10, 2012 and March 14, 2013, it was determined these reports did not document testing for all possible elopement or abduction methods that would warrant activation of electronic infant alarms. For example, while staff reported company testing includes drills for conditions where unit exit doors leading from the units are left unlocked, the documented monthly inspection reports did not reflect documented testing for this possible contingency where portals remain open. In fact, the provider noted on 2/7/13 report that the Allen division facility staff was taught how to disconnect when doors need to be held open for extended periods.

Furthermore, the hospital's procedures did not sufficiently describe detailed actions taken by staff for screening of visitors to infant and pediatric units, in order to safeguard access to vulnerable patients. Review of procedure titled, "Patient Visitation Rights" on 4/18/13 at 330 PM found these procedures describe criteria that govern patient access and visitor restriction, but did not explain how security and unit based staff screen to verify that persons who request access to pediatric units are authorized to visit.

7. Review of complaint and grievance logs on 4/19/13 found that there were two instances during 2012 of patient elopement or code pink incidents from the Children's Hospital. In these instances the facility did not ensure a secure environment of care for pediatric patients.

Incident #24I -The first event involved the removal of a 1 year old child from the Tower 4 pediatric unit on 3/20/12. The patient had to be moved to a different room in order to accommodate a different patient. After discussion at 6:30 PM efforts were made to repair the television and prepare the new room; at that time the parents expressed dissatisfaction with the room change. Staff noticed the patient and her parents were missing at 7:10PM. Security was contacted and code pink emergency activated. The complaint/incident file contained contradictory information. One note referenced the parents were stopped by Security and taken back to the room whereas another notation indicated the patient and her parents could not be found after code Pink was initiated. The family returned call from the hospital staff and returned with the patient to the hospital.

The second event involved a 17 year old pediatric patient who eloped on 7/30/12 from unit Tower 4 (4T) after admission for vomiting and abdominal pain at 6 AM. The patient had disconnected the IV tubing three times prior to the initiation of code pink alert at 11:10 AM. The patient was last seen by staff at 0930AM. And review of video camera found the patient was seen leaving via the main entrance of the Children's hospital. The Police were contacted and found the patient returned to the mother ' s home . Follow up contact with the patient's mother was conducted to advise the patient to return if symptoms continued. (Incident #29I )



16140




21204

Based on interview, the review of medical record and other documents, it was determined that the facility failed to ensure that patients on restraint have appropriate physician orders in accordance with its policy and procedure on restraints. This finding was noted in 1 of 3 applicable medical records reviewed.


Findings include:

The patient referenced in MR# 14 is 46 year-old male with multiple medical conditions and a history of schizophrenia and poly substance abuse. The patient was evaluated in the Emergency Department on 4/9/13 and was intubation for worsening pulmonary edema.

The review of the patient ' s Restraint Flow Sheet indicated the patient was in 2-point restraint from 4/10/13 to 4/17/13 to prevent physical harm to self due to documented behavior that includes agitation, restlessness and confusion. The review of the physician order summary shows that the patient was sometimes in restraint without current physician orders.

The 2-point wrist restraint was initiated on 4/10/13 at 1000 for 30 minutes only. The physician order summary notes an order for 2 point wrist restraint on 4/9/13 at 2328 that was discontinued before the application of the 2 point restraint on 4/10/13 at 1000.

The patient was on 2-point restraint for 24 hours on 4/12 and 4/13; however, the physician order for the 2-point restraint was written on 4/12 at 0041 and immediately discontinued on 4/12 at 0042. There was no physician order for restraint on 4/13 and on 4/14 when the patient remained on restraint till 0300.

The Hospital Policy and procedure titled Restraint notes the use of restraints must be in accordance with a written MD/NP/PA order and modification to the patient ' s plan of care.

At interview with the Charge Nurse on the Medical Intensive Care Unit (MICU-A) on 4/18/13 at 1130 AM regarding physician orders for restraint, she stated nurses are aware that physician order for 2-point restraint is valid for 24 hours and must obtain a new order for continuing use of the restraint.

Based on review of records and staff interviews, it was determined the hospital's Quality Improvement process did not ensure sufficient monitoring or analysis of the effectiveness of processes for the management of complaints/grievances and discharge planning program.

Findings include:

1. The facility did not demonstrate adequate analysis of complaints and grievances. Specifically, there was no evidence of tracking of time frames and closure of complaints/grievances.
Patient Services Administration (PSA) staff was asked on 4/15/13 to provide a log of all complaints and grievances for the period of 2012 to the time of the survey for a total of 12 months. The log reviewed on 4/17/13 for the time period requested had contained approximately 7000 entries comprised of multiple categories for complaints, grievances, encounters, and reportable incidents labeled as complaints, which were merged into this spreadsheet log. This log contained dates corresponding to submission dates and assigned broad complaint classification categories and subcategories, such as quality of care, communication, patient rights and responsibilities, or informed consents for minors. However this log lacked significant tracking documentation of follow up to identify dates of resolution, departmental reviews, outcomes, corrective actions, provision of responses, or evidence of tracking for closure dates of complaints and grievances.

2. The Patient Services Administration (PSA) did not monitor compliance with its own performance to assess the timeliness of resolution of complaints and grievances.
On 4/23/13 the surveyors reviewed Patient Services 2012-2013 grievance/complaint/event logs, 2012 PSA Quality and Performance Improvement (QAPI) Annual summary, and QAPI Committee meeting minutes of the Board of Trustees dated 9/25/12. These logs and reports contained no evidence of review or tracking for the timeliness of the resolution of complaints and grievances.

3. Trend analysis of complaints and grievances was incomplete. The 2012 PSA summary reported counts for problems, complaints, and grievances for the time period from January 2011 to June 2012. This report calculated the total number of complaints and grievance issues, which were combined together into one calculation. There was a separate count for another category titled "problems". This report calculated combined frequencies for complaints and grievances that were counted by month and separated by department for adult and pediatric services.
It was determined that the report is not accurate since it was reported that the counts for problems actually represented complaints. At interview with the PSA Director on 4/23/13, it was stated that the label in the report is incorrect because the department count for "problems" actually represented the total number of complaint issues. It was also stated the report of combined grievances/complaints really represents counts for grievances only.
This is at variance with reference in the Board of Trustees QAPI report dated 9/25/12 that noted the issues/event category may represent problems that are promptly resolved.
Furthermore, there was no documented trend analysis by unit, location, shift or provider for complaints and grievances. There was no analysis of data received after June 2012 for evidence of analysis of time frames for resolution of complaints and grievances.
The methodology of counting complaints and grievances also did not include a calculation of the prevalence of patients reporting complaints or grievances. It was stated by the PSA Director that the count reflects the total number of complaints and grievances by issue. Therefore the calculation does not consider the total number of patients who complain divided by a denominator over time to determine the scope and rate of patients who file complaints and grievances.

4. The hospital's Board of Trustees quality assurance process did not ensure timely review of complaints and grievances.
Reports of complaint and grievance data is only reported on an annual basis to the Board of Trustees Quality and Performance Improvement Committee (QAPI). Review of Board of Trustees Quality and Performance Improvement Committee (QAPI) meeting minutes dated 9/25/12 reviewed January 2011 to June 2012 grievance, complaint, and problem data. No reports were provided for complaint and grievance data after June 2012.

5. Review of Department of Social Work Quality Assurance meeting minutes were reviewed on 4/22/13 for meetings conducted 1/4/12, 6/21/12, 10/2/12, 12/11/12 and 4/18/13 . These reports were mainly limited to discussion of patient satisfaction survey scores and complaint review. Meetings from 10/2/12 to 4/18/13 repetitively discussed need for revision of components of orientation manuals. There was no indication that orientation manual chapter revision had been completed. At interview with the Director of Social Service on 4/22/13, it was reported that the orientation manual had been completed. This was at variance with the report dated 4/18/13 that still referenced the orientation manual chapters needed revision.

Social Work QAPI meetings did not consistently document quarterly discussion of outcome measures related to chart reviews contained in Provision of Performance reports (PPR). These reports comprise compliance with documentation of discharge planning services provided by staff. These compliance measures were only discussed in the 1/4/12 report and briefly mentioned as an action follow up plan in relation to a complaint discussed during the 4/18/13 meeting report. There was no evidence of discussion of these results at any other time nor evaluation as to whether indicators needed revision if sustained compliance remained high.

6. Review of the Board of Trustees Quality and Performance Improvement Committee (QAPI) meeting on 4/24/12 accepted the report and briefly updated that goals , performance improvement, scope of services were reviewed. The report did not discuss details of the annual 2012 Social Work Quality and Performance Improvement data reports submitted. It was stated that the Department only reports annually to the Board of Trustees Quality and Performance Improvement Committee (QAPI) .

Based on record review and staff interview, it was determined that the hospital failed to ensure that each patient's care plan was kept current in regards to pain management. This is evident in 1 of 5 records reviewed.

Findings include:

Based on review of MR #15 on 4/15/13 it was noted that Hydromorphone 4MG PO Q6H PRN for pain was ordered. The medication administration record indicated that Hydromorphone was administered on 4/13/13 at 12:00 and 19:00 with no documented assessment or reassessment. Hydromorphone was also administered on 4/14/13 at 12:00 and no assessment was documented. Nursing failed to indicate the need for the medication administered on all three occasions and reassess the response to the interventions. Interview of nursing staff on 4/18/13 about 10:30 am stated that the patient should be assessed as to facial expression and vital signs for pain and that medication administered via intravenously; the patient should be reassessed 15-30 minutes and oral medication 30 minutes to an hour.

Based on record review and staff interview, the hospital did not effectively ensure that all clinical staff assigned to patient care were able to easily access the patients ' information.

Findings include:

The unit 9HN was toured on 4/15/2013 at 11:00 AM. While on the unit MR # 16 was reviewed. It was noted that the patient was a 42 year old male with paraplegia to spine who was admitted to the facility with diagnosis of UTI.
The RN assigned to the patient was interview on 4/15/2013 at 11:20 AM. This RN reported that the patient was transferred from another unit and he was assigned to her on 4/13/2013. It was noted that the patient was admitted to the facility on 4/4/2013. The surveyor requested information from the initial nursing assessment. However, this staff was unable to retrieve this information. After approximately 15 minutes, the administrator assigned to escort the surveyor retrieved the required information

Based on observation, staff interviews, review of records and quality assurance and infection control documents, it was determined that the hospital's food and dietetic services was not organized and directed in such a manner so as to ensure that the environment of the kitchen is maintained in a safe and sanitary condition, in order to prevent the possibility of contamination and transfer of infection.

Findings include:

The Condition of Participation for Food and Dietetic Services is not met due to failure of the hospital's food and dietetic services to maintain safe and sanitary conditions in the kitchen (refer to Tag # A0749). Moreover, the Food Service Director responsible did not implement effective oversight of the daily operation of the dietary services. (Refer to Tag # A0620)

Based on observations, staff interviews and review of documents, it was determined that the director of the food and dietetic services was not responsible for the daily management of the dietary services. The food service director failed to monitor all areas of the kitchen including, sanitation, safety practices for food handling and preparation.

Findings include:

The Food Service Director (FSD) failed to monitor all areas of dietary services to ensure that food safety and sanitary conditions were maintained in the kitchen.
(Cross -refer to tag #s A0749 and A0618).

Based on observations made during inspection tours of various patient units, it was determined the facility did not maintain a clean environment for each patient as required.

Findings include:
Tours of the following units were conducted on 4/15, 4/16, 4/18, and 4/19/13. The facility failed to maintain a clean environment for each patient as follows:
Unit 8HN - room # 121- The tile under the bathroom sink was dirty and bathroom wall was in disrepair.
Unit 6 Garden South - room # 350 - Surveyor noted gloves, paper and gauze on the floor.
Unit 6 Garden South Room # 352 - Surveyor noted a dirty bathroom floor.
Unit 6 Garden North, Room # 444 - Surveyor noted shower stall with black hole.
Unit 6 Garden North, Room #431- Surveyor noted gauze with red substance and wash cloths on floor; the floor observed to have dirty black spots.
Unit 6 Garden North, Room #452 - Surveyor noted bathroom with stool collection biohazard container in wash basin present on the floor; this was a 2 bedded room occupied with 2 patients.
Unit Vanderbilt C4 - Surveyor observed exam room #414 had no running hot water.



19043


Based on observations and staff interview, the facility failed to maintain the environment of the physical therapy area on the 5th Floor of the Children's Hospital in a manner to ensure safety and well being of patients.

Findings include:

The electrical receptacles in the corridor, reception area, and the two treatment areas were not classified as a Tamper Resistant type. Therefore, the facility did not attempt to reduce the risk of electric shocks, if and when an attempt to tamper the receptacle would be made. This finding was confirmed by the facility staff.


26934

Based on observation and staff interview, the hospital environment was not maintained in such a manner that the safety and well-being of patients are assured.

During the tour of the facility from 04/15/13 to 04/23/13 between 11:00 AM to 4:00 PM, the following issues were noted, which were verified with the staff accompanying the surveyor.

4TH & 3RD FLOOR-MILSTEIN ~ Operating Rooms

1. On 04/15/13 at 11:45 AM, during the survey of the Surgical suite (ORs) in the Milstein building-4th floor, it was noted that the sub-sterile corridors (the corridor or area behind ORs through which staff transverses equipment and traffic flow) were dusty and dirty in corners, under cabinets, and behind sterilizers. These conditions thus may contribute to risk for environmental/cross-contamination. Furthermore, the floors were noted to be stained with dirt and dirt streaks.

2. The electrical panels were observed to be blocked by carts and various equipment in almost all sub-sterile areas of the OR suite, including but not limited to, the corridor of the ORs 13-14-15 and 17-18-19-20.

3. The Angiography room OR #24 was noted to have a copious amount of supplies stored in the room. Supplies were placed in cabinets/carts with doors of the rolling type, and at the time of observation, a procedure was being performed in this room and these cabinet doors were noted to be rolled up. This situation of abundant combustible supplies may lead to fire hazard and storing large amounts in the OR may also lead to infection control risks.

4. There was no hot water in the hand washing sink of the isolation room and the automatic paper towel dispenser did not operate or dispense paper towels.

5. The exhaust return was noted to be blocked by equipment in OR #5.


CENTRAL STERILIZATION AREA- VANDERBILT CLINIC 'B' FLOOR.

On 04/16/13 at 10:30 AM, during the survey of the Central Sterilization area, following issues were noted:

1. The electrical closets in the area were not closed from unauthorized access.

2. A portion in the corner of the wall in the Central Sterile Workroom was noted in disrepair revealing the underneath structure.

MICU-4TH FLOOR-MILSTEIN BUILDING

1. On 04/16/13 at 12:30 PM, during the tour of MICU-B side, it was noted that the wall of room #275 was in disrepair.

2. Room #222 had an abundant amount of storage of equipment (such as IV pumps, IV poles and others), to the degree that equipment was coming out of the room and merging into the path of egress.

3. The isolation room did not have a self-closure installed at the exit door thus did not comply with the requirements of AIA Section 7.2.C4 for isolation rooms.
This requirement states that "air borne infection isolation room shall have self-closing devices on all room exit doors".

4. Room #224 and 226 were noted to be dirty and dusty.

ENDOSCOPY SUITE-13TH FLR-HERBERT IRVING BUILDING

1. During the survey of the suite on 04/16/13 at 2:30 PM, it was noted that the electrical closets in the suite/unit were blocked by cabinets/racks.

2. Clean supplies were noted to be stored in the Janitorial Closet.

3. The electrical closet was noted to be dusty and dirty.

4. A housekeeping cart was noted to be stored in the Soiled Utility Room.

INFUSION CENTER-14TH FLR-HERBERT IRVING BUILDING

1. During the tour of the unit on 04/16/13 at 3:15 PM, it was noted that a chair in bay#2 was dirty with streaks of dark fluid going down the hand rest.

2. The electrical closet was blocked by equipment/furniture.

3. An ice-machine in Pod C was noted to have a thick layer of pink material around the nozzle.

On 04/17/13 at 11:00 AM, the Director of Environmental and Health Safety acknowledged that that foreign material appeared similar to glue/residue and was not supposed to be there.

MILSTEIN BUILDING 6th FLOOR

1. During the tour of the General Medicine unit on 04/17/13 at 10:45 AM, it was noted that the handrails by the nurse's station were very dusty and dirty.

2. There were stained ceiling tiles by the Staff lounge (room #324) and in the clean utility room.

3. The electrical closets were noted dusty and dirty.

4. The nutrition fridge was noted with broken and dirty gasket. The refrigerator gasket was also noted dirty in the Bone Marrow Transplant unit.

5. The stretcher used for transport was noted to have large amounts of tape stuck to it.

MILSTEIN BUILDING 8th FLOOR

1. During the tour of the Rehab unit on 04/17/13 at 12:45 PM, it was noted that a chair in the Physical Therapy gym (on the exercise staircase landing) had torn upholstery.

2. Refrigerator gasket was dirty.

3. The cabinets in the ADL kitchen was noted dirty with stain and residue of food particles.

4. The floor of the Physical Therapy was observed to be stained.

LABOR & DELIVERY & NICU-CHONY TOWER 10TH & 7TH FLR

1. On 04/17/13 at 2:15 PM, during the tour of the Labor and Delivery unit it was noted that the Placenta/specimen refrigerator was indicating a temperature of 48*F. As per the log maintained for the temperature of this refrigerator, the temperature recorded earlier in the day was 43* F. The Patient Care Director could not explain the reason of the high temperature.

2. The upholstery of the sofa in room #1013 was noted to be torn.

3. The isolation room in the NICU area did not have a self-closure at the exit door.

4. The waiting room chairs of the NICU were noted to be soiled with dirt stains all over these chairs.

5. The electrical closets in the NICU floor were noted to be dusty and dirty.

DENTAL OUTPATIENT CLINIC- FORT WASHINGTON AVE

During the tour of the clinic on 04/19/13 at 1:45 PM, it was noted that the staff placed sterilized items in drawers of the patient examination areas. The Director of Facilities was asked about the monitoring of humidity. The Director of Facilities acknowledged that no monitoring of humidity was performed for this clinic and the storage of sterilized items.

ADULT EMERGENCY DEPARTMENT

1. During the tour of the Adult Emergency Department on 04/19/13 at 2:00 PM, it was noted that there was no hot water in the hand wash sinks. Three sinks were tested in the eye room, area C, and trauma room. The temperature ranged from 80*F to 82.6*F.

2. Stained ceiling tiles were noted by Area B.

3. No preventive maintenance records were provided for the Decontamination body showers installed outside the Emergency Department by the Ambulance entrance.

4. Electrical Closet was blocked by carts and equipments.


EYE INSTITUTE- OPERATING ROOMS & Recovery 7 & 4 FLR

1. During the tour of the floor on 04/22/13 at 11:00 AM, it was noted that the alcove/sub-sterile corridor housing the sterilizer was very dirty and dusty in its perimeter.

2. The isolation electrical panels were blocked in OR #A & B.

3. The floor at the entrance of OR #C was noted to be in disrepair with broken/chipped part.

4. The soiled utility room was noted housing the electrical gear/equipment. This arrangement may lead to a fire hazard situation since no combustibles and other similar things are permitted to be to stored in a room housing the electrical equipment/gear. Furthermore, this room type requires to be rated or spinklered.

5. The family waiting room/day room in the eye recovery floor was noted to have a very dusty and soiled carpet. Furthermore, the chairs were also noted to be dusty.

EYE INSTITUTE-PSYCH OUTPATIENT 6TH FLR

1. During the tour of the unit on 04/22/13 at 11:45 AM, it was noted that in room 647 there were cobwebs by the vent. In room #647A the chair had torn upholstery.

2. The exhaust vent of the patient bathroom was noted to have a thick layer of dust and dirt.

3. A stack of chairs with metal legs were noted to be stored in the corner of the patient waiting room. This may lead to a potential patient safety issue in the Psychiatric setting, since these chairs may be used as weapons or method of harm to others.

CORE LABORATORY

During the tour of the Core Laboratory on 04/23/13 at 11:30 AM, it was noted that the Lab was very dusty and dirty . Thick layers of dust and dirt were observed under cabinets, around receptacles/wires, and all around the perimeter.

All of the findings noted above were verified with Director of Environmental Safety, Director of Facilities, Field Director Regulatory Compliance/Fire safety , and other supervisory staff escorting the surveyor at the time and date of observations.





21204


During a tour of the Psychiatric unit on the 9th floor of the Milstein Building on the morning of 4/16/2013, the following deficiencies were identified and brought to the attention of the hospital staff members who accompanied the state surveyor during the tour and during which staff acknowledged the findings:
1- The water faucet of the hand-washing sink in the snack room was noted to be a goose neck type, which presents a looping hazard.
2- The door to the snack room has two (2) metals " HASP " used for pad lock which presents looping hazard.
3- The exit signs in the unit were observed to be mounted to the ceiling tiles and walls with gaps between them and the ceiling of about 1-2 inches that could be used for looping.
4- The electric closet 9GN-420 was found to have multiple penetrations that were not sealed by the proper fire stops and part of the wall sheet rock was missing.
5- The bathroom of room 421 was observed to have flies.
6- The laundry vent for the dryer was found to have a gap between it and the wall and affixed to the wall by a metal strips, therefore the gap and the metal strips and water hoses in the laundry room presented looping hazard.
7- The fire extinguishers were mounted to the wall at 4 feet above the floor and the handle of the door of the fire extinguishers presented looping hazard.
8- The window latches of all the rooms of the Psychiatric unit protruded metals that could be utilized for looping.
9- The piano hinge of the closet of room 448 was not extended to the top of the closet and there was a gap of > 1 inch at the top of the hinges that presented looping hazard.
10- The smoke wall (partition) of telephone closet room# 9GN-447A was not extended to the slab above, leaving a gap of penetration that was not sealed by the proper fire stop.
11- The cables and wires of the commuters of the day room were observed to be exposed and not secured which present safety and looping hazard.
12- There were two protruding screws (>1/2 of inch) on the wall outside the door of the bathroom 9GN-438A that presented safety hazard.
13- The two doors of the day room had regular door handles that present looping hazard.
14- Three surface sanitizers were observed to be mounted to metal holders on the walls at different areas of the psychiatric unit and presented looping hazard.
15- The cabinet pull handles, the water control handles and the TV mount in the activity room present looping hazard.

Food and Nutrition Room - Garden South 9th floor:
During a tour of the Garden South 9th floor and the area between the Psychiatric unit and the 9 garden South of Milstein Building on the afternoon of 4/16/2013, the following deficiencies were identified and brought to the attention of the hospital staff members who accompanied the state surveyor during the tour and acknowledged the findings:
1- The dispensing hoses of coffee and hot water of the coffee machine were noted to be dirty and had black and brown discoloration.
2- The ceiling tiles were on top of the freezer and refrigerator at the nutritional room.
3- The floor and the base of the cabinets were noted to be very dirty.
4- The floor of the 9 Garden South was noted to be dirty and tissues and caps of ampules were observed on the floor near room 9GS-331.
5- The medication room of 9 Garden South did not have hot water, which is an infection control concern.

7 Hudson South and North:
During a tour of the 7 Hudson South and North on the 7th floor of Milstein Building on the afternoon of 4/16/2013, the following deficiencies were identified and brought to the attention of the hospital staff members who accompanied the state surveyor during the tour and acknowledged the findings:

1- The floor of room #248 was noted to be dirty and the over-bed table was kept on the restroom. It should be noted that this room was empty and ready to receive a patient.
2- Brown stains were present on the floor of room # 7HS-258 and the floor was dirty.
3- The 30 minutes fire and smoke rated walls of the telecommunication room were observed to have penetrations that were not sealed by the proper fire stops.
4- A clean linen cart was stored on the corridor next to room 7HS-233, which partly blocked the exit way and presented a fire hazard.
5- Room 7HN-127 was noted to have an empty saline bag in the hand-washing sink which presents a cross contamination.
6- The floor of room (electric room) 7-129 was noted to be very dirty and dusty. In addition, there were multiple penetrations of the fire rated wall between that room and the corridor at the area where the wall meets with the ceiling.
Children Hospital (CHONY):
During a tour of the Children hospital (CHONY) on the morning of 4/18/2013, the following deficiencies were identified and brought to the attention of the hospital staff members who accompanied the state surveyor during the tour and acknowledged the findings:
1- The temperature of the refrigerator of pantry room CHC #515 was found to have a temperature of 50 F and it had many small milk and yogurt containers. The temperature of the refrigerator on daily log of that was recorded as 38F.
It should be noted that per CDC guidelines the stored food temperature should not exceed 40F.
2- The soiled utility room CHC 818 did not have a negative air pressure as required for this type of room.
3- The clean utility room CHC on the 8th floor did not have a positive air pressure as required for this type of room.
4- The tub room and bathroom # CHC 827 was noted to be very dirty and had a band aid, tooth brush, gauzes and debris on the floor.
5- The storage room of the medical supply was observed to have dextrose, connected tubes and saline gags on the floor. Also, the floor was observed to have red-colored stains under the storage shelves.

Radiology Department:

1- The male and female dressing rooms of 3rd floor of Milstein Building were observed to have soiled hampers and piles of clean gowns on the chair of those rooms.
When interviewed, the Radiology Manager of that department said that they did not have another place to store the clean gowns.
2- The CT scan room was found to have adhesive tapes, bandages caps and debris on the floor and the floor was not clean.

MRI Suite:
1- Many floor tiles at the entrance of the MRI Suite on the basement of Milstein building were broken and presented a tripping hazard.
2- The wall outside the MRI by the reception area and near the TV mount was broken and had an opening about 8 x 8 inches in diameter. This opening contained a roach trapping sheet called "Roach Pheromone".
3- The cord of the nurse call bell of the patient bathroom of the MRI suite (room B-35 was found to be wrapped around the handrail several times which impede its function.

5th floor of Milstein- Garden and South:
During a tour of the Garden and South units on the 5th floor of Milstein building on the afternoon of 4/29/2013, the followings were identified and brought to the attention of the hospital staff members who accompanied the state surveyor during the tour and acknowledged the findings:

1- No hand -wash sink was provided for 7 patient beds (M5-M12) of the Cath Lab unit.
2- The floor of the electrical closet MHB-204A was very dusty and is located across the corridor of the critical care patient rooms.
3- The floor of the sprinkler closet across the corridor from Cath Lab H in the Cath Lab unit was observed to be very dusty and contained significant amount of dirt. A dirty cloth was observed on the floor and in addition it was noted this room had vertical penetrations.
4- The corridor outside the D (EP Lab) and Cath Lab EP S - (MHB2-101) was blocked by stretcher, OR supplies, Case Cart and Laser Equipment.

Based on observation, the facility failed to maintain equipment to ensure an acceptable level of safety and quality.
Findings include:
During a tour of 7 Garden North on 4/16/13 at about 3:00 pm, the nursing staff after breaking the plastic lock to the emergency crash cart, was unable to gain access.

Based on observations, staff interviews, the review of policies and procedures, and infection control and quality assurance documentation, it was determined that the facility failed to provide a sanitary environment to minimize the possibility of contamination and transfer of infection.

Findings include:

Pervasive Infection Control violations were noted in the hospital.
Specific reference is made to the failure of the Infection Control Officer to monitor all areas of the hospital including food storage, handling and preparation, housekeeping and maintenance, and maintenance of the facility's ventilation system in providing appropriate air flows in patient care/critical care areas.
Cross-refer to findings noted under Tag#s A748 and A749.

Based on observation and review of records and procedures, it was determined the hospital did not implement effective policies to ensure the maintenance of a sanitary physical environment, in order to reduce risk of infection and cross-contamination.

Findings include:

1. The facility did not implement effective monitoring and surveillance of water and ice machine systems to ensure these dispensing machines were maintained in a sanitary manner. Specifically, the facility did not ensure the timely change of water replacement cartridges to ensure the water and ice dispensed from these machines were free of infectious agents.
The Sensor safe ice and water dispensing machines were observed in clean utility rooms or pantries on inpatient units.
a. During tour of unit 7GS on 4/16/13 at 10:45 AM, an ice and water dispensing machine, " Sensor safe " was observed in the clean utility room. A form was posted on the side of this device that listed a schedule for replacement of the water filter. This form was labeled as " Aqua-Pure Cartridge Replacement chart " . The column labeled " time to change " : contained three dates: 11/21/11, 3/31/12, and 12/6/12. The column list for " Date of change " was left blank.

b. Tour of the alcove pantry on unit 5 Central in room CHC 515 on 4/18/13 at noon determined the presence of the water and ice machine dispenser. The chart for Aqua Pure water filter cartridge change listed three dates in a column noting " Time to change " as 5/21/11, 7/14/12, and 12/7/12. The words " Time to " had been crossed out. The column representing date of change had been left blank.

c. Tour of Unit 5HN on 4/16/13 at 2:30 PM found that the sensor safe ice -water machine in the clean utility room posted a log to represent the water cartridge change schedule. This form titled " Aqua- Pure Cartridge Replacement chart " noted the " date of change " of the cartridge as 11/30/11. The column labeled " time to change " contained three dates: PM 5/21/12, 10/15/12, and PM 12/6/12. The words " time to " had been crossed out by pen.

Interview with Administrative staff on 4/16/13 at 3:05 PM determined the water filter cartridge must be changed every 6 months. It was stated the water filter was changed on 12/12/12 and hence was not late. It was confirmed that the documentation on the form was inaccurate because the due date for cartridge change was noted in the incorrect column labeled " time to change " . Consequently there was no documented evidence to validate the water filter cartridges had been changed at timely intervals.
The manufacturer guidelines for the water/ice and cartridge machines were requested. Two guidelines were provided on 4/23/13. These documents included instructions for icemaker cleaning and sanitizing procedures for "Follett Ice and water dispenser cleaning " . These instructions did not describe guidelines for maintenance of the water filter cartridge as required, which is produced by a different manufacturer, CUNO consumer products.

2. During tour of inpatient psychiatric unit 9GN at 12 noon on 4/15/13 the following deficiencies were noted:

--Soiled utility room contained 24 patient lockers used for storage of patient contraband and personal belongings. It was stated by the nursing manager that this property must be sequestered for safety and may include personal items like toiletries and other personal items. These belongings are stored in paper bags in lockers and dispensed by staff to patients under supervision. It was stated the location of this storage area was approved. It was stated the lockers are then disinfected with towel wipes at discharge.
In this room was also a specimen storage refrigerator used for temporary storage of urine specimens. The storage of personal items in this location represents a risk for cross contamination.

--The seclusion room, #9GN 445, was not maintained in a sanitary manner: soiled dirt was observed on floor, 2 lights did not operate, and the mattress was torn with 3 large cracks. The plexiglass panel on the door window was stained or soiled. It was stated at interview with the Nurse manager that a new mattress was on order and an invoice approved on 3/22/13 was presented to surveyors. No follow up was evident at the time of the tour on 4/15/13.

--Three faucets in patient bathrooms lacked warm/hot water in the following locations:
--Single Room bathroom with captain bed across from dining room & nursing station;
--ADA- compliant bathroom adjacent to the Day room;
--bathroom adjacent to the seclusion room.
Interview with the Nurse Manager determined that the faucet mixes hot and cold water and that frequently 3 to 4 manual push attempts of the faucet button are required to obtain warm water.



19043


Based on tour of the facility and staff interview, the facility failed to implement policies and procedures governing infection control precautions to prevent transmission of infections among patients treated in the facility.
Specific reference is made to the temperature of water of scrub sinks located outside the Operating Rooms, the condition of floor in OR#5, and the isolation rooms in Intensive Care Unit of the Childrens' Hospital.

Findings include:

During the tour of the Operating Rooms in the Children's hospital on 04/22/13 at approximately 11:00 AM, it was noted that the facility failed to maintain the temperature of the hot water in the scrub sinks at 110 degrees, as recommended by CDC. The temperature of the hot water in the following sinks were below the recommended range and were as follows:
(1) The temperature of the hot water of scrub sink located on the left side of OR #5 was at 69.9 degrees Fahrenheit.
(2) The temperature of the hot water of both scrub sinks located outside of OR #6 was at 69.9 degrees Fahrenheit.
(3) The temperature of the hot water of both scrub sinks located outside of OR #7 was at 75.3 degrees Fahrenheit.
(4) The temperature of the hot water of both scrub sinks located outside of OR #8 was at 73.5 degrees Fahrenheit.

Upon interview of the nurse in charge of the operating rooms, it was revealed that the staff did not monitor the temperature of the hot water in the scrub sinks and that their daily checks conducted every morning did not include the temperature of water in the scrub sinks.

Moreover, during the inspection of OR #5, it was noted that the epoxy coating of the floor in the middle of the room was chipped off in multiple locations, creating crevices on the floor.
These crevices were capable of harboring dirt and moisture, causing the growth microbial organisms.
The surveyor was not able to inspect the other 7 operating rooms at that time as they were occupied. The facility staff upon interview were not able to verbalize whether the floor of the other rooms were in similar condition.

In addition, the air pressure in the two isolation rooms ( Room #s 906 and 907) available on 9 Central were found to be with positive pressure, contrary to AIA recommendations of having negative pressure. This arrangement is potential of causing cross-contamination and transmission of air-borne diseases. Interview of the ICU revealed that these rooms were then occupied by patients who did not require air-borne isolation and that the facility would take immediate actions to correct the airflow.

26934




A. Based on observation and staff interview, it was determined that the facility did not ensure that its HVAC system/airflow, humidity, and temperatures are maintained for prevention of cross contamination and are within the recommendations of American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE) and American Institute of Architects (AIA).

Findings include:

1.(a) On 04/16/13 at 10:30 AM, during the tour of the Central Sterile Supply & Work Area (Vanderbilt Clinic -floor B), it was noted that the clean sterile workroom was negative to the outside corridor (by the main entrance/alcove and also to the corridor by the sterile storage area.

(b) It was noted that the temperature of the sterile workroom/preparation was 88*F and the sterilizer equipment room/area had the temperature of 90* .The Director of Central Sterile acknowledged the fact that "today the area was very very hot". In reviewing the log it was noted that on 04/16/13 at 12 AM, the temperature was noted as 77*F. As per AIA 1996 Table 2, the sterile work area cannot exceed temperature of 75*F. The facility's policy (written on the log) also conforms with the requirement.

As per Director of Central Sterile, the issue of the department being too hot was reported to Engineering in the evening. The Director provided a work order # 130393 indicating that on 04/15/13 at 5:01 PM, the complaint about the hot department was made to Engineering. The work order indicated that the status is 'completed' and substatus is 'work is done'.

The Director of Facilities indicated that he was told of the issue in the morning of 04/16/13 and was not aware before that time.


On 04/17/13 at 11:00 AM, the surveyor was notified that the work was completed in fixing the airflow and temperature, and the problem identified was a faulty damper.

On 04/18/13 at 1:30 PM, the last preventive maintenance on the air handler supplying the Central Sterile was provided, which was done on 07/02/12.

(c) In the sterilizer work area no audible and visual alarm was noted for exhaust system which is intended to alert the staff for the loss of air-flow as required by AIA 1996 7.31.D19.

2. On 04/17/13 at 2:00 PM, during the tour of the Medical Oncology Unit (6th Floor -Milstein), there were 4 rooms noted that were labeled as 'Isolation room'. The Patient Care Director/Nurse Manager for the unit stated that these 4 rooms are the positive air pressure/protective environment used for Bone Marrow Transplant patients. Staff was interviewed regarding the placement of a bone marrow transplant patient that may also have air borne disease. The Patient Care Director stated that these rooms can also be used as negative air-pressure rooms. As per the engineering staff, the rooms in the facility are not interchangeable and if they are negative they stay negative and if they are positive they stay positive.

Therefore, as per the Patient Care Director's interview and acknowledgement of Director of Nursing, the patients requiring negative air-pressure are being placed in positive air-pressure room which may lead to cross-contamination and represents an infection control issue.

3. On 04/16/13 at 2;45 PM, during the tour of the Endoscopy/Bronchoscopy floor ( Herbert Irving -15th floor) it was noted that the procedure room #3 that is used for Bronchoscopy exhibited positive air-pressure instead of negative air-pressure.

The Patient Care Director stated that procedure room #3 is a room used as backup to Bronchoscopy room. The room, if not used for Bronchoscopy, was used for Endoscopy. The requirement for Endoscopy room is positive air pressure and Bronchoscopy is negative air pressure.

As per the engineering staff, the rooms in the facility are not interchangeable and if they are negative they stay negative and if they are positive they stay positive.

4. On 04/18/13 at 1:45 PM during the document review of the air handlers and negative/positive airflow checks, it was noted that facility did not document implementation of prompt action to fix issues in areas that do not demonstrate the required air flow.

Some of the examples include:

i. MHB 8th flr- From 03/04/13 to 03/22/13, ICU room #s 344 and Pharmacy indicated that it did not pass the air flow/smoke test. No documentation or follow up was provided regarding the facility's actions during the course of this 18 day period to fix this issue. Subsequent follow up actions taken were not documented.( Note the log's column for work order was left blank).

ii. MHB-3&4 flr- From 03/04/13 to 03/08/13, Soiled Utility room #s 4-245, 4-299 and 4-423 indicated that it did not pass the air flow/smoke test. No documentation or follow up was provided regarding the facility's actions during the course of this 5 day period to fix this issue. Subsequent follow up actions taken were not documented (the work order column indicates 'Failed' and no number or follow up provided).

iii. Heart CTR-From 03/11/13 to 03/22/13, Soiled Utility room #s 3-617, LL1647 and 4670 indicated that it did not pass the air flow/smoke test. At the end of the logs, the staff indicated that these rooms should be negative but are measuring positive.
No documentation or follow up was provided regarding the facility's actions during the course of this eleven day period to fix this issue. Subsequent follow up actions taken to fix this issue were not documented (the work order column was left blank with no number or follow up provided).

iv. MHB 4th flr- From 01/07/13 to 01/11/13, room # 4-238,
indicated that it did not pass the air flow/smoke test. At the end of the log the staff indicated that "room #238 has not been working properly for sometime. A work order was put in but no results as yes".
No documentation or follow up was provided regarding the facility's actions during the course of this four day period to fix this issue. Subsequent follow up actions taken to fix this issue were not documented (the work order column was blank).

v. CHONY -9 & 10 (Tower & Central)-From 03/04/13 to 04/16/13, room #s 1028, 1039, 1032, 1034, 1035 & 1036 indicated that it did not pass the air flow/smoke test for positive pressure. There were work order numbers written in the log of 03/04/13 to 03/08/13 but then there were no work order numbers and this issue was consistent and persistent. No other documentation or follow up was provided regarding actions taken by the facility in all of these instances to fix the issue. As per Director of Facilities and review of work order #130364, the rooms were fixed on 04/15/13 (this constituted more than a month later to fix this issue).

5. On 04/23/13 at 11:00 AM, during the tour of the Core, Microbiology and Serology Laboratories, Director of Facilities was asked regarding how the different kinds of labs were maintained for their specific ventilation/air flow (such as Biochemistry and Serology requires positive air pressure and the rest require negative air pressure). The Director of Facilities was not aware of the provision for specific ventilations as required by AIA 1996 Table 2.

During the tour following was noted:

i. In the Core Lab, the space housing the Chemistry test equipment could not be verified for positive air pressure.
ii. In Microbiology, the room/area was neutral to the corridor instead of being negative.
iii. In the corridor/area housing the lab for Serological testing, the area itself was not positive to the outside corridor. Within the area only one Serology lab (out of two or three) had a door and when it was closed, the airflow was negative in the room instead of positive.

6. During the tour from 04/15/13 to 04/23/13 between 10:30 AM to 4:00 PM, packed sterilized instruments were noted being stored in the corridors/sub-sterile corridors of the various OR. As per the Director of Facilities, these corridors do not have a dedicated monitoring for humidity. There were areas such as the sub-sterile corridor/alcove in the Eye Institute OR that has a window facing the outside and the humidity/temperatures may vary depending on the sun exposure and weather.

All sterilized equipment should be stored in an area where humidity can be monitored as per AIA 1996-97 Table 2.

7. During the survey of the facility from 04/15/13 to 04/23/13 from 10:45 AM to 4:00 PM, various soiled utility rooms, janitor closets and clean utility closets throughout the facility in different areas exhibited the wrong flow of air pressure.

i. 4th floor Milstein-OR Soiled Utility- Room was positive instead of negative.
ii. 6th floor Milstein- General Medicine-Clean Utility room was negative instead of positive.
iii. 8th floor Milstein- Rehab- Soiled Utility Room was positive instead of negative.
iv. Dental Clinic- Soiled Utility room was not negative.
v. 3rd floor Heart Ctr- Soiled Utility was positive instead of negative.
vi. 3rd floor Heart Ctr- Janitor ' s closet was neutral instead of negative.
All findings were observed and verified with Director of Environmental and Health Safety, Director of Facilities, and Field Director Regulatory Compliance/Fire Safety.


B. Based on observation and staff interview, it was determined that the facility did not ensure a safe environment consistent with recognized infection control practices and prevention of cross contamination.

Findings include:

1. (a) On 4/16/13 at 10:30 AM during a survey of the Central Sterile Supply & Work Area, it was observed that the ceiling tiles in the room were porous and had holes that may retain dirt (they were not monolithic). Thus, these did not comply with AIA 7.28.B8. Such porous ceiling tiles compromise thorough cleaning, which is required to keep the environment of Central Sterile as clean/sterile as possible.

(b) The vinyl coved by the sterilizers, washer #s 2 &3, and around the perimeter of the clean workroom and sterile storage room exhibited dirt and dust.

(c). The washers #2 and #3 had dust and dirt all around the perimeters and in its corners.

(d). Dust and dirt was also noted under the storage racks of the sterile packs in the sterile storage area.

(e) Large amounts of garbage and dirt/dust was noted around and behind the Ultrasound Washer. There were strips, papers, gloves and similar items noted accumulated in the gaps.

2. (a) On 04/15/13 at 11:45 AM, during the survey of the Surgical suite (ORs) in Milstein building-4th floor, it was noted that the sub-sterile corridors (the corridor or area behind ORs through which staff transverses equipment and traffic flow) were dusty and dirty in corners, under cabinets, and behind sterilizers. These conditions may contribute to risk for environmental/cross-contamination. Furthermore, the floors were noted to be stained with dirt and dirt streaks.

(b) The ceiling tiles of the isolation room in 3rd floor post recovery were not cleanable/monolithic. Thus these tiles were porous and had holes that may retain dirt (they were not monolithic) and thus were not in compliance with AIA 7.28.B8.

(c) The ice-machine in the sub-sterile corridor opposite OR #21 was noted to have a dirty black layer of dirt inside the machine.

(d) A dirty endoscope cabinet was noted stored in the utility room of the 3rd floor. This cabinet had clean endoscopes stored and was noted having open shutter/door with dirty and dusty base.

(e) A chair in bay #2 of the recovery area of 3rd floor was noted dirty.

(f) The negative air-borne isolation room (3rd floor recovery) was noted to be very dusty and dirty all across its perimeters. There were orange-colored stains on the floor. The receptacles were dusty.

(g) The refrigerator gasket was noted dirty (3rd floor recovery).

3. During the survey of the Endoscopy Suite on 04/16/13 at 2:45 PM, it was observed that the ceiling tiles in the Endoscopy processing room were not of monolithic type, and cleanable.

Furthermore, the processing room of the Endoscopy suite was not arranged in a manner where there is a separate dirty and clean room with negative and positive air pressures respectively, as required by AIA 9.5.E.
The flow of work for instruments in this one room used for endoscopes processing was also not arranged from dirty to clean, and to prevent clean items from not entering the dirty area once cleaned.
4. The main clean linen storage room in Service building (4th floor) was noted to be dusty and dirty around its perimeters. Some of the carts were noted parked directly below structural beams and HVAC ducts where there was potential for dust fallout that may result in cross-contamination. This room did not have any drop ceiling to prevent contamination of the clean linen.

As per AIA 1996-97 section 7.28.B8 it is stated that "In dietary areas and in other areas where dust fallout may present a problem, provide a suspended ceiling".


All findings were observed and verified with Director of Environmental and Health Safety, Director of Facilities and Field Director Regulatory Compliance/Fire Safety.


C. Based on observation, staff interviews, review of records and quality assurance and infection control documents, it was determined that the infection control officer failed to monitor all areas of the hospital including proper food storage, handling and preparation of food and sanitary environment is maintained to prevent the possibility of cross contamination and transfer of infection. There was no evidence that the food and dietetic service was integrated into the hospital infection control program.

Findings include:

During tour of the Presbyterian campus kitchen on 4/15/12 between 10:55 AM 1:15 PM and on 4/16/13 between 10:10 AM - 12:00 PM the following issues were noted.

1. Temperatures:

On 4/15/13 at approximately 11:00 AM the following observation was made. One tray of milk, a tray with individual cups of apple sauce, a tray with individual gelatin cups, and a tray of Dannon individual cups yogurt was observed on the tray line held on a surface that was warm to touch. Food temperature was checked by the Food Service Supervisor and found to be in the "danger zone". Temperature of milk was 57 F, apple sauce 49 F, gelatin cup
64 F and Dannon yogurt 48F. All food items were discarded.

On 4/16/12 during a joint survey of the kitchen with the Principal Sanitarian/Field Coordinator of Environmental Health, the following findings were identified in the presence of the Hospital's Food Services Director (FSD). It was noted that potentially hazardous foods were not being maintained at or below 41 F.

In the basement re-thermalization room reach-in refrigerator there were approximately 40 single containers of macaroni and cheese, penne pasta, rice, soup, and other items that had temperature between 62-68 F. The food items were brought over from the main kitchen to the rethermalization room sometime that morning. All food was discarded at 11:30 AM.

The reach-in refrigerator by the grill had several food items being held over 45 F. Garlic butter and shredded cheese had an internal temperature of 52 F. Interview with staff revealed that these items were in reach-in earlier in the day. These items being hazardous were discarded.


2. Unsanitary Environment

During tour of the Food Service Department it was observed that the kitchen and storage rooms were not being maintained clean and in good sanitary condition.

Tray line area was observed with packages of apple slices on the ground, along with garbage and food debris.

The floor throughout the kitchen was found to be filthy with dirt and grime and appeared like they were not routinely cleaned.

The ceiling tiles throughout the kitchen were observed to have debris, blackened, and noted with thick yellow greasy stain. The ceiling vents had black build-up of soot forming a circular pattern around the vent.

The walls throughout the kitchen was observed to be dirty and filled with grime.

All walk-in refrigerator units in the kitchen had fan shields that were coated with grime and debris, but all were at adequate temperatures.

Floor and wall mounted fans in the kitchen were heavily laden with dirt and grime.

The door of the ice machine that provides ice to cool food and keep the tray line cold was found coated with dust and grime and the ice shoot had black and brown residue present.

Two motorized steam kettles in the kitchen had motors that were encrusted with dirt and debris and laden with dust. These motors are above the kettles and therefore dirt and debris can fall from the motors during operation into the food been prepared.

Bins used for storing flour, sugar, bread crumbs, and cornstarch was observed coated with food debris. Three of the bins were observed on 4/15/13 and were not labeled. The bin that contained flour was incorrectly labeled "bread crumbs". No scoop was provided for the breadcrumbs bin.

Stainless steel table in the kitchen were observed on 4/15/13 wrapped with plastic wrap and therefore could not be sanitized. Surveyor informed the FSD that this practice is prohibited. Revisit to the kitchen the next morning on 4/16/13 a stainless steel table in the warm preparation area was observed wrapped with plastic wrap.

A ceiling light was observed to be held with blue tape.

The emergency eye wash sink in the kitchen was found to be filthy and the maintenance tag attached was dirty and greasy.

Towel dispensers throughout the kitchen was grimy, encrusted with food, and did not work. The Food Service Director (FSD) informed surveyor that these did not work because they are lacking batteries.

Majority of the Burlodge food trucks that transport food trays to the re-thermalization room and to patient bedside delivery was observed to be dirty, encrusted with food debris, and enormous amount of amount of tape residue (glue) and broken gasket. These trucks are not refrigerated and transport cook chill food from the kitchen located in the Harkness Building to the re-thermalization room across the street in the basement of the Herbert Irving building.

Walk- in -in # 3 by the grill area floor was observed to be dirty and coated with food debris; the grout was discolored and in some places missing.

The outside surface of four cook's carts used for storing utensils was found very filthy, encrusted with food and grime. Inside the cart, utensils were found unwrapped lying on trays that was dirty, encrusted with food, and personal items were also stored in the cart.

Wall by the warm preparation area had a gap present between table and wall allowing food to fall in.

Storage - Ceiling, walls, and floor in the storage rooms were observed to be dirty, build up of dust was found on shelves, and wall paint was chipped.

Cross Contamination
Clean pots and pans were inappropriately stored on the lower shelves of the preparation table located near the grill area, which exposed these items to debris and collection of dirt.

The hand washing sink near the cooking area was lacking hand washing signs, paper, and waste baskets.

The majority of cutting boards in use were observed with food debris, grooves, and rough spots making it hard to clean sanitize.

A spray hose for cleaning is kept mounted on the wall above a food preparation table. The hose was observed hanging down on the table on 4/15/13. This represents a high risk for cross-contamination.

Based on staff interview, review of medical record and hospital policy, it was determined that the facility did not effectively ensure that all patients identified as needing discharge planning received complete assessments.
This deficiency was noted in six of sixteen applicable medical records reviewed.

Findings include:

1. 2/7 applicable concurrent inpatient records determined that discharge planning evaluations were incomplete with respect to assessment of the patient's capacity to be cared for safely in the proposed discharge setting.
Examples include:
MR#17:
89 year old Spanish-speaking male admitted on 4/5/13 for chest pain and COPD exacerbation. Past history significant for CHF, pacemaker , depression, dementia, prostate cancer, diabetes mellitus type II, c-diff colitis. Medical hospitalist assessment dated 4/12/13 noted the patient had been in and out of skilled nursing facilities (SNF's) in recent months and was taken out against medical advice to spend "remaining days with wife at home". Initially the patient lacked sufficient home care but the patient's son reported the patient had current home health aide for 12 hours X 7 day per week. The patient was bedbound and completely dependent in activities of daily living (ADL's).
During tour of the inpatient medical unit 7GS on 4/16/13, the patient was observed to be under close observation in a cohorted room with 3 other patients under the supervision of a nursing attendant on 4/16/13 at 11AM. The patient stated through a staff translator he was waiting for his family to take him home.
Review of the medical record found orders for close observation and cohorting with other patients due to agitation/restlessness/confusion for the purpose of prevention of injury or device removal. During his stay the patient required medication with ativan IM 0.5 mg IV push X1 on 4/12/13 at 1332 (1:32PM). Nursing notes dated 4/12/13 at 1332 indicated the patient was loud, agitated and combative. Patient noted to be confused, and with dementia with behavioral disturbances.
Social work initial assessment was not provided until 4/15/13 which indicated the patient had advanced dementia; the assessment indicated the 12 hour x 7 day HHA was reinstated and the patient would be discharged home the next day with the HHA to reside with his wife. This assessment was incomplete as it did not ensure complete assessment of safety and behavioral needs and the extent to which the patient could be cared for safely at home with his wife in the community. The discharge planning assessment did not address who would assume responsibility for care and behavioral needs during hours when the home health aide is not on duty.

MR #18:
86 year old Turkish -speaking female transferred from another facility for evaluation of CAD and NSTEMI on 4/13/13. It was noted in the record the patient speaks limited English but is able to understand instructions and respond to questions. Patient underwent cardiac catheterization and stent placement. Initial social work assessment dated 4/15/13 determined that patient lived with her daughter prior to arrival. It was noted the patient would be discharged the following day. The daughter requested the patient be placed in subacute rehabilitation prior to return home. The daughter stated the patient had not been out of bed for one week and thus would need rehabilitation. The patient was offered translation services but declined this and deferred to daughter for provision of information. The worker noted the patient is agreeable with subacute rehabilitation but did not explain how agreement was elicited for this plan given the patient's limited English. Physical therapy assessment dated 4/16/13 noted patient ambulated 25 feet x 2 with contact guard utilizing a rolling walker. Recommendation was made for subacute rehabilitation. The assessment did not record explanation of discharge options offered directly to the patient, specifically related to lack of advisement for home care options.


16790

MR # 19: Review of MR # 19 on 4/15/13 at approximately 3:40 PM noted that this 39 year old patient with medical history of esthesioneuroblastoma was admitted to the hospital on 4/2/13 with diagnosis of brain mass. According to the facility ' s Screening/High Risk Screening, Assessment and Reassessment of Patients Policy, this patient ' s impaired mental status met the facility ' s high risk criteria. This policy indicated that patients who meet the high risk criteria will receive a psychosocial-assessment. The patient ' s medical record was received in the unit on 4/15/13 and printed copy obtained on 4/18/13. It was noted this record lacked a complete psychosocial assessment as critical information such as the patient ' s living arrangement; living environment and family support were not included in the assessment.
On 4/5/13 at 16:15, the social worker (SW) noted " discussed with the patient ' s daughter the possibility of Calvary Hospital as a good option " . The SW noted " patient ' s functional status has acutely declined which would make caring for her at home a challenge for her family. The patient ' s daughter will discuss with the rest of her family " . It was noted that the patient ' s opinion was not included in the decision making process. It was noted that the patient ' s daughter was not fully educated on hospice care program and what services are offered in a hospice program. Additionally, patient ' s daughter feelings/concerns regarding hospice care was not documented.
It was noted that the Nursing Plan of Care dated 4/9/2013 at 10:00 AM indicated that the discharge plan was hospice care. It was noted that the Palliative Care Consultant met with the patient ' s daughter on 4/9/13 at 13:14. The Palliative Consultant noted " Daughter said they want to send my mother to Calvary, but I promised her that I would never dump her somewhere like that. Explored with her understanding of what Calvary Hospital is about and educated her regarding the special crew that her mother would receive there " . " The daughter requested information on Social Security Benefits. I directed her to the internet " . It was noted that this patient ' s representative was not provided with information on Medicare Hospice benefits.
On 4/10/13 at 16:00, the SW noted " met with patient and daughter and MD. Family agreeable to Calvary Hospital placement. Application was made. Transfer pending medical clearance and bed "
" The SSA, section 1861(ee) requires a hospital ' s discharge plan to include an evaluation of the patient ' s likely need for hospice care and post-hospital extended care services and to provide a list of the available Medicare certified hospice and SNFs that serve the geographic area requested by the patient. In addition, the discharge plan shall not specify or limit qualified hospice " . It was noted that the facility did not follow this guidelines. It was also noted that the patient ' s family was not in agreement, as on 4/11/2013 at 17:43, the SW noted that transport was canceled because other family members arrived in the hospital who refused patient ' s discharge to Calvary.
On 4/12/13 at 19:45, the SW noted that Family meeting ended at 6:30 PM and so patient will remain in hospital this evening. The SW noted weekend worker will be asked to call Calvary and reserve bed and transfer tomorrow afternoon. On 4/13/13 at 10:23, the social work assistant noted phoned to Calvary and the patient was not scheduled for admission this weekend. On 4/13/13 at 15: 53, the weekend SW noted that Calvary was contacted and no beds were available at this time. The SW noted "patient is not being discharged " . According to the Discharge Summary, the patient was ready to be transferred to Calvary hospice on program at 4/11/ 13 at 15:38 but the patient was not discharged until 4/15/13 due to inadequate discharge planning.

MR #20: During tour of the unit on 6N on 4/16/13 at 10:11 the patient (MR #20) in RM #452-2 and her daughter were interviewed. The patient was interviewed using an interpreter. The patient reported that she was to be discharged and she was waiting for the doctor.
Review of MR #20 on 4/16/13 at approximately 10:42 noted the 89 year old patient with past history of diverticulitis, HTN, HLD, GERD was admitted on 4/12/2013 with diagnosis of GI bleed.
It was noted that the patient' s bio- psychosocial needs were not assessed as a psychosocial assessment was not located in record. A printed copy of the patient ' s discharge plan assessment was requested. The SW discharge note was received on 4/16/13 at approximately 4:55 PM. The SW discharge note dated 4/16/2013 at 12:48 was reviewed. The SW noted that the patient was to be discharged home today. The SW noted spoke with patient who requesting transportation. Patient ' s daughter desired to take her home today and she was requesting transportation as soon as possible. SW noted arranged for ambulance to transport patient home; Home Health Aide is at bedside. The SW noted that the patient received Home Health Services and HHA (Home Health Aide) 5 hours/5 days. It was noted that the Health Care Services mentioned in the discharge note were not listed. It was documented in the record that the patient was able to walk with assistance. However, it could not be determined if physical therapy was included in the home care services as it was not documented. It was noted that the Home Health Care agency was not documented. It was noted that it was not documented if the patient/patient ' s representative were satisfy with current Home Care Agency or if the patient was receiving adequate home care services.
MR #21: Review of MR #21 on 4/23/13 at 10: 00 AM noted that this 86 year old woman with history of HTN, HLP, and CAD s/p CABG, mechanical MVR, atrial fibrillation, HTN and stroke was admitted to the facility on 3/3/13 with chief complaint of ptosis. It was noted that this was a readmission as the patient was admitted on 2/24-2/27. It was noted that the discharge plan was home with home care service. It was noted that on 3/4/13 at 12:23 the patient was referred to VNS of NY for home care. On 3/6/2013, the SW noted patient to be discharged home today services reinstated through VNS. There was no documentation that the patient had a discharge planning evaluation. There was no documentation that the discharge planner discussed with the patient/patient ' s daughter if there were any issue with the home care agency or if the home care services in place were still appropriate.
The staff interviewed on 4/23/13 reported that the social work reassessment was necessary because the patient was discharged and readmitted within the 72 hours and as per social work policy an assessment is required within 72 hours of admission. This response is inaccurate as each admission require a reassessment in order to ensure that services in place were still appropriate for the patient.
MR #22: Review of MR #22 on 4/23/13 at approximately 11:30 AM, patient is 39 year old with medical history of Congenital Hydrocephalus was brought to the facility ' s Emergency Department with chief complaint of seizure disorder and she was admitted. Review of the SW Initial Assessment dated 2/28/13 at 12:57 noted that the patient receive home care services prior to admission and the discharge plan was home with resumption of homecare services. The assessment did not include if there was a discussion with the patient/patient ' s representative regarding the home care services or if there were any issues with the home care agency or if the current services still meet current needs. On 3/1/13 The SW discharge note indicated patient was going to have home care services from MJHC/RN, PT, and OT. The date and time of the services was not included in the assessment.

Based on review of medical record it was determine that the facility did not effectively ensure that patients are provided list of HHAs as required. This deficiency was noted in two of five applicable medical records reviewed
Review of MR #23 on 4/23/13 at approximately 11:00 AM noted that this patient was a 79 year old with history including HTN and DM was admitted 3/12/13 for hydrocephalus. The discharge planning assessment was reviewed. It was noted that on 3/13/13 the SW noted that the patient was recommended for sub-acute rehab facility but the patient defers to going home with his family. On 3/14/13, the SW noted that the patient was medically ready for discharge. The SW noted that the patient was discharged with home care services from Good Samaritan. There was no documentation that the patient was given a choice of agencies or the reason why this was not done. The date and time the services initiated was not documented.
Review of MR # 24 on 4/23/13 at approximately 11:30 AM noted that the patient this 58 year old with past history ( PH) of diabetes, depression , and s/p traumatic brain injury was admitted on 3/3/13 with diagnosis of hydrocephalus. Review of the discharge plan noted that the discharge plan was home with home care services. The SW noted that the patient ' s anticipated to be discharged home with home care services once medically stable. On 3/11/13 the SW discharge indicated that the patient was medically ready for discharge. The SW noted that the patient will receive home care services from Bergen Home Care services as patient will be staying at his family in NJ. The assessment did not include if the patient was given a choice of home care agency or the reason why this was not necessary.

Based on review of records it was determined that discharge plans were not fully implemented for identified patient needs. This finding is noted in 2/4 pediatric records reviewed.

Findings include:

Two of four concurrent pediatric records revealed discharge plans were not fully implemented to reflect appropriate arrangements made for identified post discharge needs.

MR# 25:
During tour of Pediatric 6 Tower unit on 4/17/13 at approximately 3pm, this 17 year old male was discharged home with parents. The record noted the patient sustained right tibial shaft fracture while playing baseball. Physical and occupational therapy consults were provided on 4/17/13. Patient was non weight bearing and ambulated with crutches and contact guard. The patient was taught to negotiate stairs for 1 flight. Manual wheelchair and commode were recommended. In addition, outpatient occupational therapy (OT) and physical therapy (PT) were recommended upon clearance by physician, Equipment needs were discussed with staff and social worker. Social work assessment dated 4/17/13 noted patient lives with mother in a 4 story walk up and mother works. While OT noted parents were educated and can assist upon discharge, the discharge plan did not address the practical assistance given residence in a fourth floor walkup when both parents were working. In addition, follow up regarding wheelchair and commode equipment was not documented. The specific type of wheelchair was noted with justification, but validation of this order was not documented.
Patient was discharged in long leg case and was not weight bearing. Discharge instructions required non weight bearing for 2 weeks. Arrangements for provision and receipt of recommended equipment were not documented.

2. MR #26:
16 year old patient with history of biliary atresia, liver transplant , and Post-transplant lymphoproliferative disorder (PTLD) was admitted with lymphadenopathy and IV contrast reaction on 4/10/13. Social work assessment on 4/15/13 noted the patient lives at home and both parents are involved with care. The patient was assessed by PT and OT due to severe low back pain. Patient was able to ambulate with supervision and no assistive devices with one stand break on 4/16/13. OT assessment dated 4/17/13 recommended OT to increase functional independence and reported having difficulty with showering due to inability to stand for long periods. Recommendation was made for shower chair and social worker was paged for notification.
Follow up social work notes dated 4/17/13 indicated the patient would be discharged the following day (4/18/13) with no outstanding home care needs. It was also noted that worker will arrange for home physical and occupational therapy based on family's preference. Prospective plan was noted to order home care equipment as per family/team. Social work discharge note on 4/18/13 at 1235 PM recorded that no additional discharge needs were evident and that vouchers/school/parking letters were provided. Plans noted to follow up to be provided as an outpatient. The form noted "Home discharge without services". The section for home care/equipment was left blank . Review of patient discharge instructions at 0620 AM noted the patient was discharged home on 4/18/13 without evidence that confirmed arrangements were made for recommended shower chair equipment.

Based on review of policy and interview it was evident that the hospital formulated and implemented an operating room policy and procedure that does not require that a record of items placed inside a patient and then removed from the patient's body be maintained as part of the operative report or in any other permanent record .

Findings include:

Review of hospital policy number # 1260 titled " Count Policy and Procedure of Retained Surgical Items " on 4/20/13 specified under the section for " documentation " that the " count worksheet " is maintained only for the duration of the case as an inventory of items used during the surgical procedure.

There was no further reference in any Surgical or O.R.( Operating Room ) policies as to what defines the " duration of the case " , who is accountable for the holding of the " inventory " list during the procedure and how disposed and what staff is authorized to discard the forms.

Review of the the hospital policy # 1260 on 4/20/13 defined above found that surgical counts are performed once before the procedure ( initial count ), when new items are added to the field, before closure of a cavity within a cavity, ( excluding instruments ), when wound closure begins, and a " final count " at skin closure at the end of procedure or when counted items are no longer in use. Also, a count is done at time of the permanent relief of either the scrub person or RN circulator, although direct visualization of all items may not be possible. Section (3) (a) of the above referenced policy states that all counts are recorded on a " campus specific " count sheet. Section (3)(f) describes the circulating nurse maintains an ongoing record of those objects added to or deleted from the sterile field.

Section (6) refers to what steps need to be taken when a count discrepancy is suspected or confirmed. It does not include retaining the " count sheet " for Quality Assurance activity to review points during the surgical procedure where other counts occurred which might identify where the miscount occurred. .

Review of the documents titled " Operating Room Count Worksheet " found that this is a form that contains a section on the upper right space that is titled " if no plate, print name. sex and medical record number. It contains 12 columns for " counts " with 50 types of items sectioned as " sponges " and " sharps ".The other sheet is titled " Operating Room Count Worksheet " and " SBAR ( Situation, Background , Assessment, and Recommendation) " form. It has sections for noting " counts " and both of these forms are maintained only for the duration of the procedure.

At interview with facility administrative and regulatory staff on 4/23/13 it was stated that the count worksheet is not retained in any fashion after the conclusion of the case.