HospitalInspections.org

Based on review and interviews it was evident that the governing body failed to ensure that a contract for essential services was implemented and signed. Specific reference is made to the contract for laboratory services which is to be provided by another facility.

Findings include:

On April 25, 2012, the facility submitted a Plan of Correction (POC) for the survey conducted on 12/16/11 to address the deficiencies cited by the Wadsworth Labs as well as the State Department of Health. An integral part of that plan was the contracting for laboratory services with another hospital laboratory. The date provided for such action was 2/21/12.

Review of a draft of a contract / agreement submitted to the survey team was tentatively dated 2/16/12 but not signed by either party.

At interview with the CEO ( Chief Executive Officer ) on 4/25/12 it was stated that this draft was under review by attorneys for both parties.

Based on review of records, procedures, and staff interviews, it was determined the hospital did not ensure compliance with regulations that ensure the protection and promotion of each patient's rights.
Findings include:
Due to the pervasiveness and scope of findings in the area of patient's rights, the Condition for Participation for Patients' Rights is not met.
Deficiencies were noted in the following areas:
1. Lack of compliance with distribution of the Important Message for Medicare ( IM) within regulatory time frames. See citation written under tag A117.
2. Lack of complete investigations and written responses for Patient Grievances. See citation written under tag # A 123.
3. Lack of adherence to safe patient care for psychiatric patients in the ED, who had long delays in transfer to the inpatient psychiatric units. See citation written under tag A144.
4. Lack of adherence to standards of care for Restraints and Seclusion. See citations written under tag A159, A 167, and A 183.

Based on review of eight medical records, procedures, and staff interview, it was determined that the hospital did not consistently comply with regulations which require the provision of the written notices for hospital discharge rights to be delivered to Medicare beneficiaries (IM's, "Important Message from Medicare About Your Rights").

Findings include:

1. The hospital failed to ensure compliance with regulatory requirements that mandate issuance of required initial and follow-up notices to applicable Medicare recipients about hospital discharge appeal rights. The regulations require a first notice be distributed within two days of admission which advises patients of the right to file a discharge appeal and also requires a follow up notice to be administered to applicable inpatients within 48 hours in advance of discharge.

7 of 8 applicable inpatient medical and psychiatric records reviewed on 4/25/12 and on 4/30/12 found that the hospital did not consistently adhere to federal regulations and hospital procedures for the provision of the initial Important Message for Medicare notice notice within 2 days of admission. Three retrospective records lacked inclusion of both initial and follow-up notices. Refer to MR #s 1,2,3, 4, 5, 6, 7.

2. In addition, the hospital did not ensure that consistent use of standardized forms "CMS-R-193" were distributed to Medicare patients. Specifically, it was determined that records for Medicare patients contained both the CMS R-193 form and another discharge notice intended for non-Medicare patients. This second discharge notice did not conform to the format as required by CMS and these records instead required inclusion of a second CMS- standardized discharge notice.

3. Hospital procedures for the delivery of the IM notice specified that if the patient or representative is unable to sign the notice, efforts can be made to contact the next of kin or representative by fax, e-mail, or telegram, and that if attempts are not successful for two days, the social worker would be responsible for follow-up. At interview with the Director of Social Work on 4/30/12, it was stated that staff were advised by Risk Management staff not to mail or telegram the notice to the patient's representative for undetermined reasons.

Based on review of patient grievance records, procedures, and staff interviews, it was determined that the grievance files and written grievance responses were incomplete and did not conform to requirements in CMS Federal regulations specified at CFR ? 482.13 (a)(2)(iii).
Findings include:
1. a. Review of grievance records on 4/30/12 and 5/1/12 found that written grievance response letters provided to complainants were either missing or incomplete.
b. Grievance response letters provided to complainants or their representatives did not consistently include results of investigation of multiple allegations made in instances where there were more than one complaint issue raised.
c. Grievance investigations did not include written reports of departmental investigations, including reports of interviews with all staff or record reviews along with conclusions or corrective actions taken, as indicated.
2. Four (4) of fourteen (14) computerized grievance / complaint files reviewed on 5/1/2012 contained no evidence that written responses were provided to complainants. These findings did not conform to requirements in hospital procedures for "Patient Grievance Mechanism", which requires a final written response of investigation outcomes will be sent to the complainant within 30 days of receipt.
Examples:
MR # 8: Complaint was received on 11/17/11 from a patient stated that her fiance was "roughed up" and was involved in a physical altercation with Security after being told he must leave while visiting his newborn. There was no internal departmental investigation documented within the patient grievance file. The complaint summary indicated that a tape was reviewed , that the fiance initiated the scuffle and that the fiance had stated he had a gun. The complaint was referred to Risk Management but no ultimate outcome was noted. There was no letter or response documented to the complainant.
MR# 9: Complaint was received on 3/4/12 from the daughter of a patient who complained she was not allowed to stay overnight with her mother. The patient was terminal and subsequently passed away. The file contained notation of interview with a staff member, who reported the unit was busy and information about patient's terminal condition was not disclosed. The request was denied. A referral was made to nursing on 4/10/12. No departmental response was included. The file did not contain any written response to the complainant. The hospital's risk manager stated on interview on 5/1/12 that the complaint was unresolved but this status was not reflected in the computerized grievance file.
Similar findings were noted in MR #s 10,11.
3. Letters issued to complainants for the results of the investigation were missing information about whom to contact if the complainant was dissatisfied with the response. All letters were incomplete where they did not specify any option for contacting regulatory authorities, including the State Agency, for complaint reviews, regardless of whether or not the patient has chosen to have the hospital investigate the complaint.


4. Grievance notification letters issued did not consistently address findings for each specific allegation in instances where the complainant had alleged multiple complaints.

Refer to MR #s 12, 13, 14, 15, 16, 17, 18, 19.

5. Grievance investigation files were incomplete where the hospital did not include findings resulting from departmental reviews in order to justify effective grievance resolution.

Written grievance investigation files were incomplete for inclusion of findings resulting from departmental investigations. The hospital did not implement its grievance procedures, which require that relevant grievances be forwarded to relevant department(s) and/or medical staff for investigation.

Review of 10 of 14 grievance and complaint files on 4/30/12 for the period after July 2011 through March 2012 found that the facts and results of internal department-specific investigations were not consistently included in grievance records in order to support the hospital's decisions and actions taken. Complaint records did not routinely contain the reports of record reviews and results of staff interviews. As a result, notification letters issued to complainants also did not always address each specific grievance in instances where the complainant had alleged multiple concerns.

Examples:

MR # 12
Complaint received on 3/20/12 from a patient who complained of multiple issues surrounding an alleged burn on the breast sustained during a gynecological surgical procedure performed on 8/18/11. The internal report listed 9 complaints including incorrect information received by the patient from the nurse regarding the extent of the procedure and including inconsistencies about what had caused the burn. The investigation attached did not address lack of follow up after the burn was reported, and did not include corrective action taken for all of the issues raised. The grievance response letter provided to the complainant noted the burn and the physician's delay in communication, as well as action taken for re-inservicing of staff on communication protocols. However, the results of the investigation for each of the issues raised, including the lack of follow up of the residual skin problem was not included in this correspondence.
See also corresponding citation noted under tag # A951.

MR # 15
Patient complained she was discharged from the ED and complained that she was in too much pain. The nurse reportedly struggled with the patient and forcibly removed the heplock resulting in the need for physician intervention. The manager was unable to identify the employee. There was no evidence of departmental review, chart review, or staff interviews with other staff to determine if the clinical care provided was acceptable and if the pain was addressed. The letter to the complainant consisted of a general apology and did not include the result of the investigation findings or lack thereof.


Similar findings for lack of inclusion in response letters for findings corresponding to each allegation, lack of inclusion of documented departmental investigations, and /or incomplete investigations that did not reflect investigations of all issues, were noted in MR #s :

MR # 13
MR # 14
MR # 15
MR # 16
MR # 17
MR # 18
MR # 19
MR # 20
MR # 21

Based on review of records and staff interviews, it was determined that the hospital did not ensure a safe environment for patients in the psychiatric emergency department in that patients are kept in the psychiatric emergency department for protracted periods of time waiting for available inpatient psychiatric beds.

Findings include:

Delays in transfer from the psychiatric emergency department to the inpatient psychiatric units were evident for patients who required acute emergency inpatient psychiatric admission. This deficiency was noted in 6 of 6 records reviewed.

Six inpatient psychiatric records reviewed on 4/25/12 and 5/1/12 found a pattern of delay in waiting times between arrival in the psychiatric emergency department and actual transfer to inpatient psychiatric units. While medical and psychiatric emergency assessments were provided timely that resulted in decisions made for inpatient admission, delays were observed in waiting time for available beds and transport to the inpatient unit for those patients for whom inpatient admission was deemed necessary.

Examples include:
MR # 23: 52 year old male patient was brought by NYPD and ambulance to the ED on 1/31/12 at 12:26 AM and restrained for agitated and violent behavior as well as medication non-compliance at the assisted living facility. Psychiatric assessment on 2/1/12 at 2 PM found a need for inpatient acute treatment for stabilization, but no psychiatric bed was available at that time. The patient did not arrive to the inpatient unit until 2/3/12 at 7:50 PM. This represented a delay of approximately three days and 19 hours from the time of ED arrival until he was transported to an available inpatient psychiatric bed. While in the ED the patient was agitated and required emergency IM medication administration three times for agitation and threatening behavior.
The delay of inpatient admissions was attributed to high census and lack of available beds.
During interview of inpatient psychiatry staff on 4/25/12, it was stated that there is a shortage of inpatient beds and that frequently patients who are seen in the ED on Fridays who require admission to inpatient psychiatry cannot be admitted until an available bed becomes available. This sometimes delayed admission and transport to inpatient psychiatry up to two or three days.
Similar findings were noted in the following medical records:
MR # 24: 88 year old patient with dementia and delusions was triaged at 5:24 AM on 4/3/12. Patient was assessed medically at 5:56 AM and by Psychiatry at 2:30 PM on 4/3/12. A brief psychiatric admission note was documented at 10:35 AM; yet the patient arrived to the inpatient unit at 3:10 PM on 4/4/12, almost 34 hours following arrival.
MR # 25: 72 year old nursing home patient with schizophrenia and dementia was arrived in the ED secondary to assessment of confusion and agitation. Patient was triaged at 11:19 AM on 4/12/12. A bed was available at 1652 on 4/13/12. Patient spent more than 28 hours in the ED.
MR # 26: Patient with schizoaffective disorder admitted for treatment of agitated and aggressive behavior. Patient in the ED from 3:14 PM on 4/2/12 and was received on the inpatient unit at 8 pm on 4/3/12, almost 29 hours after arrival.
MR # 27: 86 year old male admitted for agitated and aggressive behavior in setting of Alzheimer's dementia arrived to the ED on 7:19 pm on 4/7/12 and taken to the inpatient unit on 4/9/12 at 6:30 PM, 47 hours later.
MR # 28: Patient was seen in the ED on 4/21/12 at 1855 hours and was not transferred to the inpatient psychiatric service until 4/24/12 at 8:30 PM, approximately three days after arrival.

Based on review of procedures, inspection of devices, and staff interviews, it was determined that the facility did not have manufacturer guidelines available or did not implement manufacturer recommendations for two different types of physical restraints available for use in inpatient Psychiatry.

Findings include:


During tour of inpatient psychiatry unit CP4 on 4/26/12 it was noted that the facility had a calming blanket and waist restraint in stock.
It was stated at interview with the nursing staff that while these restraints are rarely used, the waist restraint, which had two handles attached for placement on the arms, is used for external transport of unstable patients to CT scan or radiology in rare instances.
The manufacturer guidelines were provided for review prior to the end of the survey. Review of these written recommendations for the Posey "connected non-locking cuffs" found that this type of restraint is to be used only for attachment to a movable part of the bed frame.

The facility had a separate policy for wrist to belt restraint policy which describes use for transport, but it was not integrated with the hospital-wide restraint and seclusion policy and was not updated since 10/03.
The facility's restraint and seclusion policy refers to written orders for wrist to belt restraint type but did not specifically describe its use for transport as stated by staff or elsewhere in the procedure.

The second device, a calming blanket, had no available manufacturer recommendations to guide safe application or usage. The facility's calming blanket policy, was not updated since 10/03, and was also not integrated with the hospital-wide restraint and seclusion procedures.
See citation noted under tag # A167.

Based on review of the facility's written procedures for restraint and seclusion and staff interviews, it was determined that the facility did not implement effective policies and procedures for restraint and seclusion.

Findings include:

1. The facility procedure for restraints and seclusion does not accurately describe the facility's implemented practice for continuous monitoring of behavioral health seclusion and physical restraints.

During tours conducted of inpatient psychiatric units on 4/25/12 and 4/26/12 it was stated during staff interviews that when seclusion, physical restraints, or chemical restraints are implemented, the patient is continuously monitored and never left alone. Staff must document the patient's condition every 15 minutes on a monitoring form and flow sheet as directed by hospital policy. However, review of the Restraints and Seclusion policy, revised on 5/10, does not describe the practice implemented for continuous monitoring in Behavioral Health for restraints, or seclusion as stated by staff during interviews.
The policy only references that patients are continuously monitored for behavioral restraint initiation until seen by a physician or RN within 30 minutes of application, and from that point observation/assessment occurs every 15 minutes. The policy specifies continuous observation for medical immobilization only in the Quick reference section.

It was found during tours on 4/25 and 4/26/12 that the seclusion room in the psychiatric units are equipped with a camera that is wired for viewing by staff at the nursing station. It was stated by staff and physicians that an attendant is also stationed outside of the locked door in order to monitor and listen for any auditory signs of patient distress. The policy for restraints and seclusion does not describe the facility practice as stated during interviews which includes continuous monitoring of restraints or seclusion in behavioral health. Instead, the policy only notes observation is required for Q 15 minutes (every 15 minutes).

The facility did provide procedures for the use of the calming blanket and wrist to belt restraint, and these procedures had not been updated since 10/03. A reference for use of 1:1 monitoring was only noted for calming blanket use alone. This is contrary to the policy for behavioral restraints in the main hospital-wide Restraint and Seclusion policy as noted above, which describes frequency of monitoring required every 15 minutes for behavioral restraints.

2. The policy and procedure for Restraints and Seclusion permits nursing assistants, patient transporters, and physical therapists to apply and remove restraints, which is contrary to accepted standards of practice. Furthermore training records did not reference training of transporters and physical therapists for this function to assess their competency and skill.

3. The facility did not effectively implement its written restraint and seclusion procedures in the following records, which require physician orders and use of the "Restraint/Seclusion assessment and monitoring form."

MR # 25:
72 year old male was a patient who was transferred from a nursing home for combative behavior on 4/12/12. There was no evidence of a written physician order for restraint or the use of the proper monitoring form in the ED. The nursing ED notes for 4/13/12 at 7:07 am, documents that the patient was started on restraint. The vest Posey was ordered by the physician (name documented). The patient was maintained on close observation and was still waiting for a psychiatric evaluation. Staff did not utilize the correct form for restraint monitoring and only used the regular 15 minute check sheet. Staff did not utilize the restraint/seclusion assessment monitoring form per policy.
Furthermore, a psychiatric consult on 4/12/12 at 23:45 hours in the ED notes the patient was trying to take off his restraints that were placed for safety and recommended that the patient be maintained on 1:1 watch. Nursing notes corresponding for that time period do not reference the use of a restraint. Notes at 6:07 am on 4/13/12 document that the patient is disoriented, trying to get out of bed, and continued on close observation.

MR #29:
22 year old male was transferred from another hospital for assessment of aggressive behavior and suicidal ideation. The patient was seen by the MD at 1732 on 2/8/12 who ordered haldol 5 mg IM, diphenhydramine 50 mg IM, and lorazepam 2 mg IM at 1746. These medications were given 30 minutes later at 6:15 pm.
Orders at 6:15 PM on 2/8/12 note were for seclusion X 3 hours for agitation, and medication used as a restraint (the restraint/seclusion order form did not specify the drugs and instructs MD to write separate medication order.)
The patient was placed in seclusion for safety protocol, per nursing notes at 1817 on 2/8/12 in the ED. There was no evidence of use of the special restraint/seclusion assessment monitoring form, as per policy.

Another episode that required the need for simultaneous chemical restraint and seclusion occurred on 2/16/12 following physical aggression to staff that was noted at 1:10- 1:15 PM. A telephone order for ativan 2 MG IM and seclusion for agitated /aggressive behavior as well as the completion of a MD restraint/seclusion order form at 1:15 PM noted the order for both seclusion and ativan used as a restraint.
However, the specific monitoring of both the simultaneous use of ativan as a chemical restraint and seclusion was not recorded on the special restraint/seclusion assessment monitoring form used. The form only documented the use of seclusion for the time period between 1:15 pm and 3:30 pm, at which time the seclusion was discontinued. A nursing progress note at 3 PM noted that the patient was asleep in seclusion but this was not recorded on the flow sheet. Specialized monitoring for chemical restraint use in addition to seclusion was not formalized.







16401

Based upon record review and interview, the facility failed to evaluate the needs of the patient and follow its ' policy for restraints.

Findings include:
Review of (MR# 30) on 4/30/12, the patient a 78 year old was admitted on 4/15/12 with shortness of breath, hypotension, CHF exacerbation and severe sepsis. Left wrist restraint was ordered on 4/17/12 for confusion and pulling at tubes and dressings. The restraint/seclusion assessment monitoring form indicated that staff failed to release the patient Q2H for the periods 4/17- 4/18/12 from 3:00am to 6:00am and 7:00am to 10:00am. Interview of facility staff indicated that the restraints should be alternating between continued restraints/seclusion and release and return to restraints/seclusion. Restraints are not released Q2H as per facility ' s policy.

Based on review of records and procedures for restraint and seclusion, it was determined that the form used for monitoring of restraints did not adequately accommodate recording and monitoring methods for simultaneous use of chemical restraints with either physical seclusion or physical restraints.

Findings include:

1.The facility's restraint and seclusion monitoring form does not include how physical and chemical restraints implemented simultaneously are monitored.
Review of restraint record and forms on 4/27/12 found that the document used for monitoring of physical and chemical restraints did not include a format to describe monitoring implemented when more than one type of restraint is simultaneously used.
The form did not document and describe the specific type of monitoring implemented for the simultaneous use of physical or chemical restraints. The form includes a check box for use of pharmacological interventions as an alternative prior to restraint/seclusion, but does not differentiate method of monitoring when medications used as a restraint and seclusion are used together or within close temporal proximity.

The restraint /seclusion assessment monitoring form did not list or describe differences for how each separate type of chemical and physical restraints were monitored in instances when used at the same time.

This is contrary to the facility policy which notes that restraint and seclusion are not to be used simultaneously; the policy did not reference simultaneous use of chemical restraint medications and seclusion or permit the specific monitoring for its simultaneous use in monitoring flow sheets.

2. Specific example include:

MR # 29:
The episode that called for the need for simultaneous chemical restraint and seclusion occurred on 2/16/12 following physical aggression to staff noted at 1:10- 1:15 PM. However, the specific monitoring of both the simultaneous use of ativan as a chemical restraint and seclusion was not recorded on the special restraint/seclusion assessment monitoring form used.

MR # 22:
Patient with psychotic disorder NOS was provided with orders on 1/13/12 at 12:30 AM for medication used as a restraint plus seclusion. Pharmacological interventions were checked as alternative measure prior to restraint but were ordered as chemical restraint as well. The monitoring form for restraint and seclusion did not differentiate interventions to monitor effects of medication used as a restraint and seclusion.

Based on review of hospital -wide performance improvement reports, it was determined that reports were not submitted from the Department of Social Work to evaluate the quality of clinical and discharge planning services provided.

Findings include:

Review of Performance improvement reports for 2011 and 2012 determined that the Department of Social Work did not submit any reports to assess the clinical services or discharge planning services provided.

At interview with the Social Work Director on 4/30/12 and Care Management Director on 5/1/12 it was stated that there is a mutual project performed regarding length of alternate level of care stays.

These reports were submitted to the hospital-wide performance improvement committee as required . However these reports did not include assessment of clinical discharge planning for all service areas. Social work did not develop department indicators to measure the timeliness or quality of discharge plans for all affected service areas, including but not limited to: ED, OB, inpatient medical surgical, and pediatrics services.

There was no evidence of reports that analyzed clinical services provided by the Department of Social Work . Refer also to citations noted under tag # A843.

Based on interview and medical record review, it was determined that a medical history and physical examination was not conducted prior to a procedure requiring anesthesia services. This finding was noted in 1 of 4 applicable medical records.

Findings include:

MR # 31, a 53-year-old nursing home resident, was admitted for a peripherally inserted central catheter (PICC line) placement on 4/30/12. The patient's medical history included subdural hematoma, status post hemi craniotomy. The medical record did not contain a complete medical history and physical examination prior to the procedure that required anesthesia services. The " Pre Operative Anesthesia Record " documented laboratory report, EKG and imaging studies. However, the portion of the record for "System Review and Physical Examination" was left blank.

At interview with the Nurse Manager on the 10th Floor, she stated that the patient was admitted for a 23-hour stay and no History and Physical examination is required. Patients are admitted under this status only for procedures and they are discharged within a 23 hour period.

Based upon record review the facility failed to evaluate the needs of the patient and ensure that care was provided as per physician's orders.

Findings include:
Review of MR #30 on 4/30/12, revealed that the patient, a 78 year old, was admitted on 4/15/12 with stage 4 pressure ulcer of the sacrum measuring10 x 9 x 4cms noted to be pink and with slough. The Physician's orders on 4/16/12 for decubitus care stated: cleanse with NS and apply wet to dry dressing BID. The pressure ulcer flow sheet (Pink Sheet) failed to indicate that decubitus care was being performed consistently as ordered. No entries were noted for 4/21, 22, 23, 24 and 25 on the decubitus flow sheet, and nurse's notes failed to indicate that the pressure ulcer dressing was changed BID as ordered. Decubitus care is not being consistently performed as per physician's orders.

Based on review of medical records and other documents, it was determined that the Nursing Department failed to implement an interdepartmental policy concerning nutrition referral for the management of patients with pressure ulcer.

Findings include:

1. During review of medical record of patients with pressure ulcer on the unit ICU, CCU, and Tower 8, the surveyor asked for the process of nutrition referral to the Dietitians when a patient has acquired a pressure ulcer. Surveyor was informed by CNMs that referrals were done verbally not formally. There was no evidence by the Nursing Department or Nutrition Department of a written interdepartmental policy concerning nutrition referral and the management of patients with pressure ulcer.

2. Review of MR# 33 on 4/30/12 noted that an adult patient was admitted to the hospital on 4/24/12. Adult Multidisciplinary History and Physical on 4/24/12 noted on skin assessment that patient had a Braden Score of 19 and multiple pressure ulcers. The nutrition screen by the nurse noted a total score of 2 denoting No Nutrition Intervention Required at this Time. The nutrition screen did not reflect that the patient had multiple pressure ulcers and required nutritional intervention. The nutrition screen was incomplete.
Similar findings are MR# 35, MR #37.

Based on record review it was determined that the hospital failed to formulate and implement a policy and procedure to govern the safe administration of drugs ordered PRN
( as needed ).

Findings include:

Review of MR# 51 on 4/26/12 found that the physician ordered Ativan 2mg. IV PRN for seizure lasting more than 3 minutes. The order was transcribed by the Nurse as Ativan 2mg IV " if with seizure". The order was entered on the MAR ( Medication Administration Record ) under PRN medications.

The form (MAR) does not note the frequency of this PRN order. Without such limitation this order as transcribed makes it a contingency order with no limit on the number of doses that may be given PRN if the patient has multiple seizures.

The order specifies that the Ativan 2mg is to be given if there is a seizure more than 3 minutes. The nurse transcribed the order as to be given for seizures of any duration.

Based on record review and staff interview, it was determined that a medication was administered by nursing staff that did not conform to requirements for proper documentation of medication administration.
Findings include:

MR # 34: During review of concurrent inpatient psychiatry record on 4/26/12, it was determined this patient received a STAT PO medication that was not documented in the medication administration record as required. Nursing progress notes dated 4/25/12 at 4:45 PM recorded the "patient was given STAT PO Meds as ordered" following hostile statements and verbal threats made against staff. The name of the medication was not recorded.
Review of the medication administration record in the presence of the hospital staff found that the order for Ativan 2 mg PO Q6H PRN for anxiety was renewed on 4/25/12, along with other PRN medications. However, the medication administration record corresponding to that date lacked documentation that the Ativan was administered.
Interview with unit nursing staff on 4/26/12 determined that Ativan was given as ordered on 4/25 at 4:45 pm, but it was not documented in the medication administration record.

Based on review of contracts, staff roster and interview it was evident that the facility failed to ensure that the laboratory was operating in a manner that met the needs of patients.

The facility is still unable to independently operate a laboratory under Part 493 of this chapter.

Findings include:

The hospital failed to have a fully executed contract with another hospital based laboratory. A a POC ( Plan of Correction ) stipulated that such a contract would be in effect in 2/21/12.

Review of the document on 4/25/12 entitled " Service Agreement between North Shore - Long Island Jewish Health System Laboratories, Inc. and Episcopal Health Services, Inc. " dated 2/16/12 found that the document submitted for review as a contract was an unsigned draft with many portions in shaded type. The last page of the draft was dated 2/1/12 with no signatures. The facility was operating with no contract for lab services from 2/1/12 to 5/4/12.

Review of the staff roster of the North Shore - LIJ Health System Laboratories found that there were 30 names of employees of the LIJ lab assigned to the hospital under the agreement. . This roster included two ( 2) Administrative Directors, a blood bank supervisor, a QA/PI consultant and (2) two pathology consultant.

At interview with the CEO( Chief Operating Officer ) on 4/25/12 it was stated that this draft was not finalized in that is was being reviewed by legal staff representing both parties.

Based on Hospital Wide Performance Improvement Committee Manual , it was determined that the Food Service Director did not ensure that the Nutrition Division of the Food and Nutrition Department provide clinical nutrition findings to integrate in the department 's quality improvement program.

Findings include:

1. Review of Hospital Wide Performance Improvement Committee Manual from 2011 thru April 2012 was done on April 30, 2012. The Food Service division of the Food Service and Nutrition Department reported quarterly their findings of food service issues such as patient satisfaction, food temperature and food quality. Review showed no evidence that the Nutrition Division of the department performed quality improvement review on dietetic indicators. Interview with Clinical Nutrition Manager confirm that there is no clinical nutrition program in place. As a result the integration of the Food and Nutrition Department's quality improvement program is incomplete.

2. Review of the policy and procedure manual noted no evidence of formal interdepartmental policy regarding nutrition referral by nursing to the nutrition department concerning patients with hospital acquire pressure ulcer. Information on patients with acquired pressure ulcer is done verbally to Dietitians by Nursing or when Dietitian nutritionally re-assesses patient.

3. Review of the Food and Nutrition policy and procedure manual noted no evidence of protocol for nutrition reassessment. Policy titiled Nutrition Assessment, Intervention, Monitoring and Evaluation stated, "The Dietitian monitors and evaluates the patient's response to care, the frequency of this is based on the "type of intervention implemented".
Policy is vague and does not define type of intervention provided with the frequency the patient would be seen or evaluated.

Based on medical record review and staff interview, it was determined that the hospital did not ensure that a written policy for the nutritional care of patients with pressure ulcer exists.

Findings include:

Review of MR# 33 on 4/30/12 noted an adult patient was admitted on 4/24/12 with diagnosis 2nd and 3rd toe gangrene. Nutrition screen on 4/24/12 noted no nutrition intervention warranted- Total Score 2. Patient is on special diet-Diabetic. Nurse skin assessment noted patient had multiple pressure ulcer- stage II and Unstageable.
No evidence of nutrition referral. Patient did not receive a nutrition assessment.
Nutrition Note on 4/26/12 noted "No Nutrition Intervention indicated at present time as per nurse. Will re-screen within 5 days". As of 4/30/12 patient continued to have a stage II pressure ulcer at the heel which increased in size (3x 1.8 to 2x 6.2).

In reviewing medical records of patients with pressure ulcers on the critical care unit on
April 30, 2012 the surveyor asked the Clinical Nurse Manager what was the procedure for referring patients with pressure ulcers to the Dietitian? Surveyor was informed that the process was informal, that it was by word of mouth. Staff Dietitian (Staff # 5) was asked the same questions- her answer was the same.

The Food and Nutrition Department Policy and Procedure Manual did not have a policy on Nutrition Intervention of the Patient with Pressure Ulcer which would have included nursing nutrition referral for a patient with pressure ulcer. As a result, patients with pressure ulcers were assessed at moderate nutritional risk which extended the time for Dietitians to nutritionally reassess the patient in 5-7days.

There is no policy for Nutrition Reassessment (follow-up). Guideline for patients assessed at high nutrition risk is available however there are no clinical guidelines for patient reassessed at moderate or low risk other than a time frame.

Review of MR#36 on 4/30/12 noted that an adult patient was admitted to the hospital on 4/6/12. There was a nutrition screen done on 4/6/12 which noted that nutrition intervention was warranted. Nutrition assessment done on 4/9/12 revealed a nutritional status of being severely compromised. No evidence of nutrition reassessment. On 4/24/12 at 2:30PM a Nutrition Note by the Dietitian stated " Patient on TPN being followed up by Nutrition Support Team. Once patient is weaned to NGT/PEG feeds and or PO diet please order diet consult ". The patient was not seen by the Dietitian from 4/9-4/24/12

There is no policy on the role of the Dietitian when TPN/PPN is prescribed. Dietitian (staff # 5) informed Surveyor that staff dietitians do not monitor patients on TPN. TPN is followed up by the Nutrition Support Physician- (Staff # 7). There is no support team only a physician. Surveyor reviewed Food and Nutrition Policy and Procedure Manual for TPN policy. There was no documentation regarding that the nutrition support physician following up patients on TPN. A page titled "Parental Nutrition Daily Orders Sheet" was present. There was no policy referring to this order sheet. The daily order sheet does state "Nutrition Consult required for all new orders" yet Dietitian Notes states "Nutrition Support Team " will follow up patient. Policy is required for Nutrition Support to correct discrepancies on the role of the dietitian.
Similar finding on MR#37 (Nutrition Note 4/30/12- 9:45AM)

Based on menu review and staff interview, it was determined that the hospital did not ensure that the hospital menus have an updated nutrient analysis when foods items are changed on the menus.

Findings include:

On April 30, 2012 current menus were reviewed and nutrient analysis compared to diets on menu. Review of menus was done with Clinical Nutrition Manager ( Staff # 6) present. It was found that food items on the menu did not match the nutrient analysis of the menu provided to surveyor.
Menu: Week 1 Day 3 Tuesday - Regular diet- Bread selection states Bagel or Roll is available-Waffle is noted on nutrient analysis not bagel or roll. Entree states herb eggs or breakfast potatoes- nutrient analysis states turkey bacon for entree. Clinical Nutrition Manager confirms that nutrient analysis of menus have not been updated with menu food items. The nutrient analysis confirms that the physician prescribed diet is being provided. Current menu's nutrient analysis does not confirm that the diet prescribed is being provided.

Diabetic diet titled "Carbohydrate Control" listed on menu slip provided on patient's tray is abbreviated (non-legible) and does specify the amount of carbohydrate (grams/day) prescribed. Example of this is a patient's menu read, Cardiac Carb CTRL. The menu does not read accurate nor is it a complete diet without the grams of carbohydrate prescribed and specified on the menu.

Based on medical record review and staff interview it was determined that the facility failed to ensure that nutritional objective data is obtained for the evaluation of the patient nutritional status.

Findings include:

Review of MR #38 on 4/30/12 noted that an elderly patient was admitted to the hospital
on 4/5/12 with a diagnosis of S/P Syncope. The patient was nutritionally screen at low risk- patient on special diet of 2 gram sodium. A nutrition assessment was not done due to nutrition screen. Dietitian note on 4/6/12 stated, "Patient currently at moderate nutritional risk. There was no nutrition objective data or interview of the patient to conclude the patient was at moderate nutritional risk.

Review of MR #39 on 4/30/12 noted that an elderly patient was admitted on 4/23/12 with multiple pressure ulcers. A nutrition assessment was done on 4/26/12 with patient being assessed at moderate risk which indicates that patient would be reevaluated in 5-7 days. Nutrition assessment stated that the amount and type of patient tube feeding did not meet patient's nutritional needs. Nutrition document titled "Identification of Need for Assessment" states patient with pressure ulcer stage II-IV is at high nutritional risk and should be evaluated within 3-4 days. Nutritional status was incorrect resulting in patient not being seen for 5-7days.

Review of MR #40 on 4/30/12 noted that an elderly patient was admitted to the hospital on 4/3/12 with a diagnosis of dysphasia and failure to thrive. Nutrition data was:
Diet NPO, history of COPD, HTN and Parkinson Disease, Height 5 ' 10 Weight 126 lbs,
%IBW 85, Alb. 2.7 and patient have multiple pressure ulcers. Patient's nutrition assessment on 4/5/12 classifies the patient's nutritional status as moderately compromised when the nutrition parameter notes patient is at high nutritional risk. Nutritional classification of patient at moderate nutritional risk denotes patient will be followed up in 5-7 days.
Similar findings were noted in MR#37, MR # 41 .

Review of medical record on 4/30/12 noted that patient's nutrition assessments and reassessment were untimely.

Review of MR #42 on 4/30/12 noted that an elderly patient was admitted on 3/8/12.
Nutrition screen noted patient required nutrition intervention. The Nutrition Assessment was done on 3/19/12 at mild nutritional risk. Nutrition reassessment was done on 3/29.
Similar findings were noted in MR# 43, MR# 35 , and MR# 44.

Based upon observations, interviews and review of the facility's policy and procedures and other facility documents, it was determined that the facility failed to be constructed, arranged and maintained to ensure the safety of patients. Therefore the accumulative effect of the Hospital Regulation standard level deficiencies as well as the Life Safety Code deficiencies reflects that the Condition of Participation for Physical Environment is not met as evidenced by:

1. Failing to maintain the physical plant to assure patient safety and well-being. ( See A 701).
2. Failing to meet LSC standards. (See K21, K22, K25, K29, K39 and K74 )

Based on observations made during tour of the facility, it was determined that the facility did not maintain a sanitary physical environment to ensure the safety of patients.

Findings include:

During tour of the inpatient geriatric psychiatry unit on 4/25/12 at 12:10 PM, it was determined that the locked seclusion room was not maintained in a sanitary manner for patient safety. Specifically, this room, T421, on Tower 4 exhibited a strong smell of urine which emanated from this room and into the patient corridor. The room had no lavatory and no ventilation. Hospital staff confirmed the presence of a strong urine odor during interview with the surveyor. The surveyor questioned the inspection and cleaning maintenance and was advised that it is difficult to remove odor from carpet.

The walls of this seclusion room were covered in carpeting intended for use on the floor and therefore presented a fire safety hazard due to the use of floor carpeting for a purpose other than intended.

Interview of the Risk manager (staff # 3) and administrative staff at that time found that the carpet was used to cover a plexiglass panel that had permitted viewing from the nursing station. Staff stated that patients had broken the window in the past and this carpet was used in order to prevent patients from breaking the window.
In addition, there was a sliding lock located on the external corridor side of the seclusion door which did not function. Staff stated that the sliding lock was never used and that the only method of entry was via use of a key by staff only. However, this external sliding lock device was never removed and could present a potential risk for persons or patients to be locked in the room from the outside by other patients.

It was later determined with the life safety surveyor that the facility was unable to provide information about the flame spread rating of the carpeting and thus the use of this covering represents a fire safety hazard.



21204


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

During a tour of the hospital on period from 4/25/2012, to 5/1/2012, the followings were identified:

Surgical Operative Suite (OR):


1. The corridor outside OR #3, #2 and #8 was partly obstructed by stretchers, suction machines, 12 screens of fluoroscopy equipment and three video towers for endoscopy.

2. The corridor between the surgical suite (OR) and the central sterile supply had alcove that was used for storage of anesthesia machine, many empty cases of endoscopies stored in a rack which extends from the floor to the ceiling, Carbon Dioxide cylinders, Nitrous Oxide cylinders and Oxygen cylinders. Storing of all these supplies in the alcove presents a fire hazard.

3. The corridor which is the second means of egress of the surgical suite separating it from the central sterile supply was noted to be used (converted to) a storage room that housed boxes full of supplies. Additionally, the fire and smoke door on the surgical suite corridor which is 8 feet wide that was converted to a storage room was replaced by 3 feet door which is not wide enough to permit a timely evacuation of the surgical suite in the event of fire.

4. There was an exit sign in the above referenced part of the corridor that direct the staff towards the surgical suite, which contradicts sound infection control practice. There was also an exit sign on the other side of the door in the surgical suite to direct the staff towards the closed storage room.

5. On the afternoon of 4/25/2012, it was noted that the Decontamination room of the Central Sterile Supply had positive air flow in relation to the corridor, instead of the required negative air pressure required for this type of room.

6. There was no hand washing sink available for the staff to use in the decontamination area.

7. The clean preparation room of the Central Sterile Supply was found to have negative airflow in relation to the corridor instead of the required positive air flow required for this type of room.

8. There was no hand washing sink available for the staff in the clean preparation room.


Geriatric Psychiatric Unit:

During a tour of the Geriatric Psychiatric Unit on 4/26/2012 at approximately 10:45 AM, the following looping and suicidal hazards were observed:

1. The bathroom #431 in the patient lounge room has the following looping hazard:
a. The door closing device and the door knob were not safe fixtures as required for the psychiatric unit and could be a looping hazard.
b. The hand washing sink was affixed at > two inches from the wall and presented a looping hazard.
c. The water faucet of this room and the draining pipes presented looping hazards.

2. All of the electric outlets on the corridors and the patient rooms were not the safety type that are required for the psychiatric units.

3. All the closets of the patient rooms had regular hinges which presents looping hazards, not the piano hinges that are required for the psychiatric units.

4. The closet locks presented a looping hazard.

5. All of the patient beds had restraining hooks that presented looping hazards.

6. The strike plate of the door of room # T 433 had sharp edges that could potentially cause patient harm.

7. Room T 410 was observed to have flies in the room and dirty toilet paper in the shower of that room.

8. The sprinkler heads in the psychiatric units are not of the safety type and could present looping hazard.

9. The dining room B was observed to have a very dirty and sticky floor and many small flies were observed in the room.

10. The seclusion room of the geriatric psychiatric unit was found to have a carpet lining its four walls. The flame spread rating of that carpet could not be provided. Covering the seclusion room with carpets of unknown flame spread rating is a fire safety hazard. Also, there was a metal sliding lock on the outside of the door, which imposed a risk of patient harm.

11. The toilet of the treatment room had multiple looping hazards, examples included but were not limited to: a gap of two inches between the wall and the hand washing sink, the flush of the toilet is of the regular type that imposed looping hazard.

12. The patient bathroom # 447 in front of the seclusion room of the geriatric Psych unit had many looping hazards that included: a gap between the hand washing sink and the wall; the water faucet is not the safety type; the draining pipes are not covered; there was a gap between the grab bars and the walls, and the shower head and the door handle imposed looping hazards.

Adult Psychiatric Unit:

During a tour of the Adult Psychiatric Unit on the afternoon of 4/26/2012, the following were identified:

1. All the electric outlets in all the patient rooms and on the corridors were not of the safety type that is required in the psychiatric units.

2. In the dining room #415, the cord of the refrigerator (> 3 feet long) was exposed and imposed a looping hazard and safety hazard.

3. A coffee maker machine was observed on a table on the dining room that was not fixed, and has a cord of approximately 3 feet long. This imposed a looping hazard and other safety hazard in the psych unit.

4. Room #422 was found to have exposed pipe of the heating system which imposed a looping hazard.

5. The patient lounge room was found to have unfixed speakers on the top of the Television. These speakers can be used as a weapon and imposed a safety hazard. Also, there was an opening on the side of the Television and video set that leads to the electrical wiring and was accessible to the patients.

6. The lock of the quiet room was not operable from the inside of the room.

7. The floor of dining room B was observed to be dirty.

Emergency Department (ED):

During a tour of the Emergency Department, the following issues were identified:

1. The floor of the patient bathroom in the waiting area of the ED was found to be in disrepair and was rusty around its perimeter and did not have a nursing call bell.

2. The Nursing call bell of the bathroom of the OB&GYN in the ED was not functioning.

3. The wall and the floor of the OB & GYN bathroom in the ED were broken and in disrepair and imposed a risk of infection.

4. The pediatric bathroom of the ED did not have a functioning nursing call bell.

5. The clean utility room of the pediatric ED had negative air flow instead of the required positive air flow for this type of room. Also, this room was found to have no air diffuser and had only an exhaust.

6. The soiled utility room of the ED had a positive air flow, instead of the required negative air flow for this type of room.

Psychiatric Treatment Area of the ED:

1. The temperature thermostat that was mounted to the wall next to room #T138 was loose and broken.

2. The floor of the Adult Psychiatric Unit was dirty and dried blood was observed on an area covering more than one inch of the floor.

3. The seclusion room of the ED had a very dirty floor and the room was observed to be very cold.

4. The door of the seclusion room had a sliding metal bolt that protruded more than one inch on the outside surface of the door and imposed safety hazard.

5. The patient bathrooms of the psychiatric area of the ED had an unpleasant dor.

6. The patient toilets of the psychiatric ED had many looping hazards as follow:

a. There is a gap of two inches between the hand washing sink and the wall.
b. The water faucet was not the safety type that is required for the psychiatric units.
c. The shower head and the shower knob were not the safety type required for the psychiatric units.
d. The door knobs imposed a looping hazard.
e. The floor of the toilet was very dirty.

Pulmonary unit:

The nursing call bell of room #10002 did not have an audible signal.

Lab:

During a tour of the Lab on the morning of 4/30/2012, there were dried blood drops observed on the floor of the blood gas analyzer area.

CCU and ICU Units:

During a tour of the ICU and the CCU units at approximately 12:00 noon of 4/30/2012, the followings were identified:

1. The CCU unit did not have an airborne isolation room as required by the AIA and the CDC guidelines.

2. The floor of the CCU unit was found to be dirty and had many alcohol swabs and plaster bandages on the floor.

3. The floors of the ICU's corridor and rooms were observed to be dirty and had open gloves and catheter coverings.

Food Service Area:

1. The walls of the kitchen and the dishwasher area were broken and in disrepair, especially the perimeters of the kitchen at the ceramic tiles of the base of the walls.

2. The exhaust duct of the dishwasher was observed to be leaking water from a rusty area of that duct.

3. The GFI covering behind the dishwasher machine was noted to be broken.

4. The temperature of the walk-in freezer was 9- 10 F at 2:15 PM of 4/30/2012. According the facility's policy and procedure, the range of temperature of the food freezer is from zero to -10 F. The freezer's temperature was retaken one hour later, and was still 9 F.

The Radiology Suite:

1. The floor of the CT scan room was observed to be very dirty, especially behind the CT table where it had stains and had contrast material that looked like waxy spots, and dried blood drops on the floor. Also, there was blood and stains on the floor under the CT bed.

2. The wall of the hallway of the CT scan area was in disrepair and its sheetrock was broken.

3. The patient bathroom of radiology room #TB 066 did not have a working nursing call bell. The soap dispenser of that room was broken.

4. The nursing call bell in the patient bathroom of radiology (room # TB 056) was not working. According to the Director of facilities, the nursing call system in the entire radiology department is not working and the facility is planning to have it repaired.

The Labor and Delivery Suite (L&D Suite):

1. The soiled utility room of the labor and delivery suite on the second floor had positive airflow instead of the required negative airflow for this type of rooms.

2. The clean supply room of the L&D suite had a negative airflow, instead ofthe positive airflow that is required for this type of room.

All the above findings were identified in the presence of the hospital's Director of Facilities who acknowledged them. The above findings were brought to the attention of the hospital leaders at the exit conference on the afternoon of 5/1/2012.

Based on review of records, procedures, and staff interviews, it was determined the hospital did not effectively oversee the provision of discharge planning processes and services within the hospital to ensure that patients' post hospital care needs are met.
Findings include:

Due to the pervasiveness and scope of findings in the area of discharge planning, the Condition for Participation of Discharge planning is not met.
The cited deficiencies limited the ability for effective organization and direction within the social work /discharge planning department and did not reflect integration of procedures and processes with other departments, including Care management.
Deficiencies were noted in the following areas:
1. Lack of updated, approved policy and procedure manual for Social Work/Discharge Planning manuals and lack of integration with associated manuals for Care Resource management and Care Resource Management Plan dated 9/14/10. See citations written under tag A800.
2. Lack of oversight and supervision of unlicensed Social Work interns. See citation written under tag A807.
3. Lack of oversight regarding use of alternate computer software system for assessments which resulted in lack of inclusion of discharge planning assessments into hard copy medical records. See citation written under tag A807.
4. Lack of timely or complete social work /discharge planning assessments, which did not address post discharge needs. See citation written under tag A811.
5. Evidence that psychiatric discharge summaries were documented in advance of discharge, without any evidence that affected patients were stabilized or ready for discharge. See citation written under tag A817.
6. Lack of evidence of implemented procedures for the distribution of written listings of qualified home care agencies or facilities to patients or their representatives as required. See citation written under tag A830.
7. Lack of quality improvement reviews and reassessment of the clinical aspects of social work /discharge planning in critical service areas, such as Emergency Services, child abuse, obstetrics, pediatrics, ambulatory care, and inpatient services. See citation written under tag A843.

Based on review of procedures and staff interview, it was determined that the Social Work Department did not have an updated or complete written discharge procedure manual that was integrated with that of other departments and which clearly described early identification of all high-risk patients across service areas.
This action limited the effective organization and direction of the Social work /Discharge planning department.
Findings include:
1. The Social Service and Discharge planning policy manual was not updated and did not conform to actual practices being implemented at the hospital. In addition, the manual was not integrated with that of other departments, including the Care Management manual and the Care /Resource manual plan approval document dated 9/14/10, in order to have a consistent approach to discharge planning. It was reported that both Social Work Department and Care management were in process of updating their manuals.
2. At interview with the Director of Social Work on 4/30/12, it was reported that the social work/discharge planning policy and procedure manual was in the process of being updated. Review of updated policies found that these did not contain the name of the hospital, nor include approvals or effective dates. At the lower right corner of each procedure contained the copyright logo for "Medical Consultants Network, Inc. (800)538-6264". It was reported that this was a company that provides standardized templates for policy manuals that was purchased some years ago. It was stated that the Director reads each procedure to determine if it is appropriate.
Procedures were not applicable to the unique practices and characteristics of the hospital. For example, the Policy for "Social service guidelines" did not describe time frames for screening and assessment. These did not reflect what was stated on interview, that cases are referred within 72 hours of admission and also that the social workers see all inpatients.
For example, review of the template procedure for "Child Abuse and Neglect" determined it did not contain all processes to be followed in the case of child sexual abuse, i.e., for offense evidence collection. It did not reflect actions to be taken when coordinating a Joint Response with Agency for Childrens' Services ( ACS) and Police, and did not contain contact numbers other than the general hotline.
In addition, the procedure did not describe any criteria to guide clinicians regarding discharge planning in the ED, and instructs the physician to sign a form provided by ACS if it is felt that the child should not be released into parental custody. This statement assumes Child protective agency staff will arrive in the hospital, which is not always accurate. There is no criteria to guide the decision to release children, and no requirement for mandatory consult and clearance by ACS and Social Work staff in the hospital to obtain social clearance prior to release.
The policy does not describe limited social work coverage in the emergency department. It was stated on 4/30/12 by the Director of Social Work on interview that social work coverage is less than optimal in the ED and available Monday-Sunday 8-4:30 PM.
ER staff must call ACS and there is no child abuse log. It was stated on interview that there is no child abuse coordinator for the hospital and the social worker would be informed only if the child was admitted. Therefore, the social worker would not know about those who were treated and released unless the physician referred the case or the reporting form for follow up. The policy is incomplete in that it described that the social worker will be notified if the report was made for inpatients and if the child is admitted from the ER for protective custody.
Tthere was no process for follow-up referral to social services if the child is treated and released. The child abuse procedures contain no stated provision for obtaining on-call consults by qualified social work staff prior to the discharge of suspected victims treated during non- business hours.

Based on record review and staff interview it was determined that qualified and licensed staff did not ensure consistent and appropriate review of work provided by graduate school interns.

Findings include:

Review of MR #45 found that the social work intern had documented a computerized assessment on 3/5/12 in the "Meditech system", which was not appropriately countersigned by a licensed social worker to ensure proper review and supervision. This computerized note was not included in the hard copy of the record.
Interview with Social Work director and Administration staff determined that the hospital's practice includes supervision and countersignature of all students' notes by the director. It was also stated that staff had been advised to record assessments in a different computer system, MIDAS, because the Meditech computer record assessments do not properly conform to record requirements, including proof of electronic signatures. It was reported that some staff continued to document assessments from the old MEDITECH computer software system despite being advised to change to the MIDAS recording system.

Based on review of records it was determined the hospital did not provide timely discharge planning evaluations or formulate appropriate discharge plans that met patients' discharge needs.
Findings include:
Patients did not receive timely or complete discharge planning assessments from social work.
3 of 3 applicable records reviewed found discharge plans did not consistently address patient post discharge medical , functional, or social needs.
Examples:
MR #45: 74 year old male with history significant for CAD, DM, HTN, asthma, COPD, recent NSTEMI, seizure disorder, and noted unsteady gait was admitted on 3/4/12 for assessment of chest pain. Patient was noted to be a poor historian and was unable to sign his initial Important message for Medicare (IM) form on 3/5/12, secondary to documented altered mental status. The patient was noted to reside alone and had history significant for past heavy alcohol abuse.
The patient was assessed by a social work intern on 3/5/12. The social work intern noted the patient lives alone, and that based on discussion with external agency JASA social worker, he might not be able to care for himself due to frequency of emergency room visits. Follow up plan included need to contact home care agency that provided services before admission, VNS CHOICE. Patient was noted to alert but at times confused. Follow up on 3/9/12 by the licensed social worker found that the VNS choice on site worker informed the worker that the patient is safe to return home and services would resume the next day.
The assessment was incomplete in that there was no justification recorded to explain how the patient would be safe and how his needs would be met. The previous issues noted for inability to provide self care were not followed up upon to ensure post discharge safety needs were met. Capacity assessment was not evident nor justification written to explain why it was not required. In addition, Physical therapy assessment determined that patient had weakness and needed ambulation training. Recommendations were made for outpatient PT. However discharge instructions or plans did not provide referrals for PT or justify why these recommendations were not followed. Patient was advised to come back to medical clinic in 2-3 days.

MR # 46: 72 year old male nursing home resident transferred on 3/14/12 acute assessment of uropathy, metabolic acidosis, and pneumonia. Patient also with noted chronic renal failure. Social work/discharge assessment was delayed until 3/20/12 and written in the Meditech computer software system, which was not incorporated into hard copy records. The assessment did not reflect an interview of patient and noted "patient is confused per nursing home records".
A family practice student noted on 3/27/12 that the patient is alert and oriented. Follow up social work progress note on 4/2/12 arranged for patient transfer back to the nursing home and noted the patient was advised of discharge. No further assessment of patient needs or patient agreement with plan to return to the same facility was evident.

MR #47: 56 year old male with past history of CAD, DM, and hypertension, was hospitalized on 3/7/12 from clinic for uncontrolled DM where the blood sugar level was noted of 599. Patient had reported he does not take his Metformin medication when drinking alcohol once per week.
Timeliness and date accuracy of initial social work/discharge planning was not evident. The computerized Meditech assessment was dated 5/31/11 from the social worker despite reference to the 3/7 to 3/12/12 hospitalization. It was noted that the patient would be discharged to a shelter. After he lost his job in April he became homeless and lived in his car. He applied for Medicaid and his daughter was noted to be available for emergency. The plan was to discharge him to a shelter. Nursing assessment in the record dated 3/7/12 notes that the patient lives alone and does not reference homelessness. The patient was discharged to home on 3/12/12 with a visiting nurse referral scheduled the next day.
Patient was referred for visiting nurse, who instructed him about insulin administration. The patient's housing needs were not mentioned. Inconsistencies about the housing issue were not addressed.

Based on review of medical records it was determined that 3of 5 concurrent inpatient psychiatric records contained documentation of discharge summaries that were charted in advance for acute patients who were not discharged. These summaries inaccurately described patients' condition at discharge for an event that had not yet occurred.

Findings include:

Review of 3 of 5 inpatient concurrent acute psychiatric records on unit Tower 4 Geriatric psychiatry on 4/25/12 at approximately 1 PM found that discharge summaries for these patients had been charted in advance. None of these patients had evidence of physician orders for discharge.

It was stated by Administrative staff that the fields that do not change, i.e., the reason for admission could be filled out in advance because the mode of arrival and condition on admission would not change. However, further review of these summaries found that staff actually described the patients' condition on discharge, which would not have been possible to describe in advance for currently unstable and hospitalized patients.

Follow-up on 4/26/12 determined all three patients were still in need of acute psychiatric care and were not yet ready for discharge.
Refer to MR #s 25, 26, and 27.


Example MR #25:

Patient was admitted 4/13/12 from nursing home for agitated and combative behavior. During tour of the unit on 4/25/12, the patient was still under acute psychiatric care and on 1:1 supervision for fall safety. The discharge summary had been written in advance but did not include physician signatures or appointments. During re-visit to the unit on 4/26/12, staff reported patient is still acute and no discharge order was apparent. The discharge summary had been completed in advance and it was noted under section for condition at discharge, "not agitated, not suicidal/homicidal."

Similar findings were also evident in MR #s 26 and #27.

Based on medical record reviews, draft procedures, and interviews with staff, it was determined that the facility did not provide listings to patients or their representatives to ensure choice of home care services or nursing home selection as required.

Findings include:

The facility has not implemented a policy to provide to patients and their representatives complete listings of qualified providers for home care agencies and nursing facilities.

At interview with Social Work and Care Canagement Directors (staff #s 2 and 4) on 4/30/12, it was determined that the facility has not yet implemented a finalized procedure to distribute listings to patients and/or their representatives for options in the selection of home care agencies and nursing homes. The agency has representatives from three on-site certified home care agencies and there was no process in effect to ensure unbiased selection of referrals. It was stated that the referrals are given generally to the first agency representative who answers the case.

Social work staff indicated that the policies were in revision with Care Management department and that staff distribute a complete listing of options if needed. A subsequent draft of a policy was provided from Care Management for choice in skilled nursing or home care options. It was stated that the facility is still in the process of trying to implement this plan.

This deficiency for the failure to provide listings of home care agency options were noted in two applicable medical records reviewed.

Refer to MR #s: 47, 48, and 49.

Based on review of hospital-wide quality improvement data and social work documents, it was determined the facility did not conduct review of all high risk clinical service areas to ensure discharge planning processes appropriately met patient discharge needs.

Findings include:
At interview with the Director of Social Work on 4/30/12, it was determined that despite having clinical responsibility for the implementation of discharge plans, there was no quality assurance activity to ensure clinical review of social work assessments or discharge plans in the emergency room, obstetrics, pediatrics, or medical surgical areas.
While collaboration is conducted with Care/Resource Management staff for review of alternate level of care inpatients, readmissions, and length of stay, there was no evidence that current and retrospective inpatients were reviewed to assess the quality and clinical appropriateness of patient discharge plans.
Deficiencies include:
1.There was no evidence of monitoring of the timeliness and quality of inpatient social work/discharge plan assessments. There was no social work monitoring performed for the requirement to perform social work assessments within 72 hours of admission since 2009. Only an inservice memorandum advising staff of the need for timely documentation was evident, dated 2/15/11.
2. While the social workers provide the discharge notice Important Message for Medicare (IM notices), there was no evidence of quality monitoring since 2009.
3. There was no evidence of monitoring of notification of patients about the right to options in the selection of home care agency or nursing home facilities.
4. Care Management first quarter report of 2012 was limited to quantitative length of stay statistics by service, readmissions, and insurance denials.
There was no evidence of review of child abuse cases or the adequacy of discharge plans conducted by the clinical social work department. At interview with the Social Work Director on 4/30/12, it was stated there is no child abuse log and referrals of 2221 report forms from hospital providers are forwarded to the Child protective agency. No clinical review of safety and discharge plans for child abuse cases or domestic violence patients was evident.

Based on review of documents, it was determined that the facility failed to implement effective surgical care procedures to ensure a safe environment of care for a patient following an intraoperative incident during which a patient sustained a burn.

Findings include:


The facility failed to enact proper safety procedures to minimize the risk of harm for a patient who sustained a burn intraoperatively. Specifically the facility failed to document an intraoperative burn complication, failed to note that the patient was informed about the burn, failed to file a timely incident report, and failed to document that effective corrective actions were taken, including inspection of equipment/devices, staff training, and environmental audits to reduce the risk of surgical burns in the operating room.

The patient filed a complaint that was received by the facility on 3/20/12 in which multiple complaints focused on the reported after effects of a burn under the left breast which was sustained during surgery performed on 8/18/11 in the hospital.

The patient complained of several issues including receipt of incorrect discharge education and lack of timely communication with the physician.

Review of MR # 12 found that this patient underwent a dilitation and curettage, hysteroscopy, and laparoscopy with tubal perfusion on 8/18/11. Review of the operative report, nursing, and anesthesia records found no documentation of any intraoperative event involving a burn.
A computerized plan of care notes dressing for dry/steristrips/tegaderm but does not denote the location. A post operative anesthesia note records absence of complications. Operative notes make no mention of the event.
Nursing notes at 1:50 pm on 8/18/11 noted "left breast base tegaderm dressing intact".
Discharge instructions noted silvadene ointment to apply to skin daily X 4 days, see MD in 1 week, and recommendation to take motrin over the counter for pain.

A post operative telephone call form dated 8/23/11 noted the patient's comments, " I have a burn on my breast". The response noted was "call MD if skin changes are noted." No other follow up was evident in the record to investigate this issue.

Review of memorandum on 5/3/12 found the patient sustained a "burn caused by a penlight left on the drape vs. penlight caught fire and burned the skin." An occurrence report was not completed until March 2012, seven months following the event. The alleged fire was not reported in accordance with policy. The chart did not include mention of this intraoperative burn event. There is no location noted on computerized OR nursing notes for the site of the tegaderm dressing. Discharge instructions also lacked the site of silvadene application. There was no evidence in the record of follow up actions taken after the post-op call determined that the patient stated she had a burn on the breast, other than general instructions noted to call the MD if skin changes were noticed.

A letter dated 4/19/12 to the patient described that an event took place involving the scope light which might have focused on the skin and the hospital apologized for a superficial burn resulting in a keloid. Staff was re-inserviced about communication and management of instruments during procedures. The report did note that the MD called the patient at home after surgery to apologize and that he could not do so after the procedure because the patient was not awake. Nursing staff was also counseled about communications to reduce potential for receipt of conflicting information.

While the letter references a root cause committee review and document includes mention of the need to prevent recurrence, there was no investigation of practice activities, staffing errors, or equipment that contributed to this event, nor evidence that corrective actions were taken to prevent recurrence.

Review of the record did reveal a lack of correspondence between the consent and actual procedure performed, as well as no documented discussion with the patient after the surgery to disclose the event and actual surgery performed.

Based on interview and medical record review, it was determined that nursing staff failed to consult with social services when appropriate to assure a safe discharge of patients from the Emergency Department.

Findings include:

MR # 50 is a 21 month-old male who was brought to the Emergency Department by his mother on 3/21/12 with complaint that he ingested one ounce of perfume. The history and physical examination conducted by the ED physician at 1318 was unremarkable. The patient was discharged home with his mother. The discharge instruction was for follow up care with the patient's Private Medical Doctor.

The "Abuse/Neglect Screen" completed by the nurse indicated there was no evidence of Abuse/Neglect. The nurse did not utilize available resources to assure a safe discharge. There was no risk assessment conducted by the social worker to determine the child's living condition and the level of risk that endangered the child's welfare.

At interview with the Director of Social Work on 4/27/12, she stated that a social worker is assigned to the ED daily from 0800 to 1630.

Based on record review and staff interview it was determined that qualified and licensed staff did not ensure consistent and appropriate review of work provided by graduate school interns.

Findings include:

Review of MR #45 found that the social work intern had documented a computerized assessment on 3/5/12 in the "Meditech system", which was not appropriately countersigned by a licensed social worker to ensure proper review and supervision. This computerized note was not included in the hard copy of the record.
Interview with Social Work director and Administration staff determined that the hospital's practice includes supervision and countersignature of all students' notes by the director. It was also stated that staff had been advised to record assessments in a different computer system, MIDAS, because the Meditech computer record assessments do not properly conform to record requirements, including proof of electronic signatures. It was reported that some staff continued to document assessments from the old MEDITECH computer software system despite being advised to change to the MIDAS recording system.