HospitalInspections.org

16140


Based on review of records, procedures, and staff interviews, it was determined that the hospital did fully implement its plan to ensure compliance with regulations that ensure the protection and promotion of each patient's rights.
Findings include:
Due to the continued findings in the area of patient's rights, the Condition for Participation for Patients' Rights remains out of compliance.
Deficiencies were noted in the following areas:
1. Lack of compliance with distribution of the Important Message for Medicare ( IM) to eligible patients within regulatory time frames. The procedure implemented titled, "Notification of Hospital Discharge and Appeal Rights" did not ensure distribution of the IM to all eligible Medicare beneficiaries. The procedure incorrectly noted ( page #2, item #3) "The notice is not required for patients who have exhausted Medicare part A benefits."
See repeat citation written under tag A117.
2. Lack of updated treatment plans that ensured patient or family participation. This citation is written under tag A129.
3. Lack of adherence to standards of care for documentation of monitoring for Restraints and Seclusion. See repeat citation written under tag A167.

16790


Based on observation, patients/patients' representative and staff interviews, the review of medical record and facility's policy, it was determine that the facility was not consistently informing each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible.
Findings include:
During the tour of the units Telemetry (11th floor) and medical service unit (10th floor), the patients and patients' representative interviewed denied that the facility was distributing, informing and explaining patient rights to them.
The patient in MR # 1(room 1119 # 2) was interviewed on 9/27/12 at approximately 10:15 AM. This 43 year patient reported that he was admitted with seizure disorder. This patient reported that a patient's rights package was not given to him. The patient also stated that this patient rights information was not given to any family member.
Similar findings for the patients in MR # 3, MR # 4 & family members for patient in MR # 2 who were not presented with Patient's Rights package.
It was noted that the electronic records indicated that patient rights packages were given to these patients. However, there was no evidence that the patients signed for such important patient rights documents.
Review of MR # 5, on 9/27/12 at approximately 12:00 PM, noted that this 88 year patient was admitted to the facility on 9/23/12. It was noted that a copy of the IM (Important Message from Medicare) form was not located in the patient's medical record. It was documented that the patient had bouts of confusion. It was noted that this patient's daughter was her health care agent. It was noted that the daughter signed for treatment on 9/23/12. There was no evidence that this important patient rights information was presented to the patient's representative.
The staff interviewed reported that the patient's daughter was very involved in her care.
Review of MR # 6, noted that this 88 year old patient was admitted on 9/22/12. It was noted that two signature section of the form was signed on 9/22/12 & 9/23/12. It was written on the form " unable to sign / unresponsive". The second was crossed out and dated 9/27/12 unable to obtain signature. It was noted that the patient has a spouse. There was no documentation that this patient rights information was given or sent to the patient's representative or the reason why this was not necessary.
Review of MR # 7 on 9/27/12 noted that this 76 year old patient was admitted to the facility on 9/25/12. It was noted that the IM form located in the chart was not completed.

Review of MR # 8 on 9/27/12 noted that this 76 year patient with history of CHF, HTN, and Cancer, was admitted on 9/24/12. The copy of the IM located in the chart was signed but not dated.
According to the regulation, each Medicare beneficiary who is an inpatient (or his/her representative) must be provided the standardized notice, An Important Message from Medicare (IM), within 2 days.
The social worker assigned to the Telemetry unit was interviewed on 9/27/12 at approximately 11:00 am. The staff reported that the Patient Access staff is responsible to provide the patients with the Import Message from Medicare ( IM) and obtain the first signature and Social Worker is responsible for obtain the second signature.
The Notification of Hospital Discharge and Appeal Rights policy was reviewed. According to this policy, if IM remains unsigned due to illness or cognitive impairment, Social work will make an attempt to contact the patient's representatives using efforts such as emailing, faxing or telegrams.
The facility was not implementing this policy.

* It was noted that this is a repeat citation

Based on staff interview and review of medical records, it was determined that the facility did not consistently ensure that patient's rights, comprehensive treatment plans and initial treatment plans were updated. Additionally, the facility did not ensure that each patient participated in the discharge plan.
This deficient was noted in one of two appropriate medical records reviewed (MR #9)
Findings include:
During the tour of the unit (Geriatric psychiatric unit) on 09/28/12 at approximately 12:50 PM, the staff reported that the patient in MR # 9 was scheduled for discharged. The record was reviewed. It was noted that this 82 year old female with diagnosis of schizoaffective disorder was an Involuntary Admission on 8/28/12 at 16:50. It was documented that the patient was a nursing home resident who was admitted because she was spitting out her medication and spitting at people.

The Discharge Summary indicated that treatment goals and objectives were fully achieved. The Multidisciplinary treatment plan was reviewed. It was noted that on 8/31/12, Social Worker goals/objective "The patient will not be verbally abusive and compliant with treatment ". The interventions/ method "to provide 1:1 individual therapy with the patient for three times a week ". This provider's interaction and interventions with the patient, and the patient's responses to this intervention during the treatment was not documented.
The social work staff was interviewed on 9/28/12. The staff reported that the goal above was not appropriate for the patient as the patient was in a wheelchair. There was no documentation in the record that the treatment goal was updated to meet this patient's needs.
It was noted that the Multidisciplinary treatment plan form had documentation dated 8/31/12 & 9/25/12. It was noted that the patient was admitted on 8/28/12. Although, there was a section for the patient to sign this document it was noted that the day for patient or family involvement in the plan was not signed or the reason why this was not necessary.

16401




16790


Based on review of record, it was determined that the facility did not consistently ensure that all patients placed on restraints were properly monitored.
Findings include:
During the tour of the unit on 9/27/12 at approximately 3:05 PM, MR # 6 was reviewed. It was noted that this 87 year old nursing home resident was admitted for high fever on 9/22/12. It was noted that the patient was placed on wrist restraints: 2 point. It was noted that there was a restraint order dated 9/23/12 at 10:30 PM.
The physician signed the order on 9/23/12 at 11:00 PM. The restraint assessment monitoring tool and nursing assessment/reassessment for this date could not be located in the record. There was no electronic nor paper documentation.
It was noted that the staff in the unit was given the opportunity to locate this document without success.

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

Findings include:

Review of MR #17 noted that this patient was admitted on 9/9/12 with intact skin. The patient was identified as being at risk for pressure ulcers using the Braden scale. A stage 2 decubitus ulcer was identified on 9/18/12 measuring 6X3 cm, pink/red and no drainage. The physician's order on 9/18/12 at 6:00am for decubitus care noted: hydrocolloid dressing Q 3 days and PRN, irrigate with normal saline.

The electronic pressure ulcer flow sheet failed to indicate that the patient received decubitus care to the sacral ulcer on 9/21, 24, 27 or PRN. The nurse's note for 9/21/12 at 12:37 noted dressing clean and dry at this time. The nurse's note for 9/26 noted left buttock area cleaned, dressing applied.
Both notes failed to indicate that decubiti care was performed as per physician's orders.


Review of MR #18 on 9/28/12 noted that this patient was admitted on 9/21/12 with skin intact. On 9/26/12 an unstageable pressure ulcer was observed on the upper back. The physician's orders on 9/26/12 at 5:47pm noted PU- unstageable upper back enzymatic debriding agent Collagenase Q 12 H.

The electronic pressure ulcer flow sheet dated 9/26/12 at 18:38 indicated 2X1 necrotic unstageable with transparent dressing.
Nursing documentation indicated that the staff failed to treat the pressure ulcer with collagenase as per physician ' s orders.

THIS IS A REPEAT CITATION.

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 9/26/2012, to 9/28/2012, the following were identified:

Surgical Operative Suite (OR):

During a tour of the Operating Suite on the afternoon of 9/26/2012, with the
facility's Director of Engineering and the Director of the Housekeeping the following were identified:
1. There were small holes on one wall of OR 1 and four (4) other holes in another wall which present an infection control concern.

2. The floor of OR 4 was observed to be chipped in multiple locations, therefore, it is not easy to be cleaned properly and it has a potential of spreading infection.

3. Piles of towels, gowns and blankets were observed being stored on a cart inside OR 4.

4. The covers of the thermostat in OR 4 and on the wall next to the scrub sink by room T251 were missing.

5. The water temperature of all the scrub sinks in the OR suite were found to have cold water. Per CDC recommendation the scrub sink should have a water temperature of 110 F to 120 F.

6. A linen cart with clean linens was stored in the decontamination room.


Geriatric Psychiatric Unit:

During a tour of the Adult Psychiatric Unit on the afternoon of 9/27/2012, the following were identified:

1. The cabinet that was used to store items for arts and craft in the lounge room was found to have handles and metal pad locks that were more than 30 inches above the floor and presented a looping hazard.

2. Small flies were observed in the bathrooms of rooms T401 and T 416, and other areas of the psych unit.

3. The bathroom #431 in the patient lounge room had the following looping hazards :
a. The door closing device and the door knob were not safe fixtures as required for the psychiatric unit.

b. The hand washing sink was affixed at more than two inches from the wall and presented a looping hazard.

c. The water faucet of this room and the exposed draining pipes presented looping hazards.

4. The patient beds had restraining holes at the sides of the beds that presented looping hazards.
Examples included but were not limited to beds in rooms 416, 418, 420 and 421.

This is a repeat deficiency from the survey of 5/1/2012 that was not corrected in all beds.

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

All of the above deficiencies are repeat deficiencies from the previous survey of 5/1/2012

6. 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.

7. 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.

The above deficiencies are repeated deficiencies from the previous survey of 5/1/2012.

Adult Psychiatric Unit:

1. Room #422 was found to have exposed pipe of the heating system which imposed a looping hazard.
2. The piping of the heat unit of patient room 422 was exposed and presents looping hazard.

The above deficiencies are repeated deficiencies from the previous survey of 5/1/2012.

Emergency Department (ED):

During a tour of the Emergency Department on the afternoon of 9/27/2012, the following deficiencies were identified:

1. Dried blood was observed on the floor by bay#6.

2. Unused disposable cannula was found to have dried blood on its surface and was kept on the storage cabinet in the pediatric ED.

3. Dried blood was also found on the base of a soiled hamper in the pediatric ED.

4. No Nursing call bell was provided in the pediatric ED's bathroom.

5. Part of the floor (approximately 2 feet x 6 " in size) at the exit way between the exit door T125 and the waiting area was broken and presented tripping hazard.

6. Also, the floor of the waiting area of the ED was observed to be broken at multiple locations.


Psychiatric Treatment Area of the ED:

1. The sprinkler heads of the psychiatric ED were not of the safety type and present looping hazard.

2. The temperature thermostat that was mounted to the wall next to room #T138 was loose and broken and presents looping hazard.

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 odor.

6. The fire extinguisher cabinet was left open and presented looping hazard and the small fire extinguisher inside the cabinet could be used for patient harm.

7. The self-closing devise on the door next to room T138 presents looping hazard.

8. The handles of the metal cabinet used for storing gowns linens and other supplies present looping hazard and the cabinet was kept open.

9. 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 water control handles, the toilet flusher and the drain pipes of the hand washing sink were not of the safety type required for the psychiatric units.

e. The door knobs imposed a looping hazard.

All of the above deficiencies are repeated citations from the previous survey of 5/1/2012.


CCU and ICU Units:

During a tour of the ICU and the CCU units on the morning of 9/28/2012, the following were identified:

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

2. 6 out of 8 rooms of the ICU units were found not to have hand-washing sink.

The above findings are repeat citations from the previous survey of 5/1/2012.

Food Service Area:

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

2. The exhaust duct of the dishwasher was observed to be leaking water from multiple locations, and was rusty at parts of that duct.

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

The above findings are repeat citations from the previous survey of 5/1/2012.


The above findings were identified in the presence of the hospital's Director of Facilities who accompanied the state surveyor during the days of the of the survey and acknowledged them.

Also,the above findings were brought to the attention of the hospital leaders at the exit conference on the afternoon of 9/28/2012.

Due to the continued scope of findings in the area of discharge planning, the Condition for Participation of Discharge planning remains out of compliance.
Deficiencies were noted in the following areas:
1. Lack of integration of discharge planning processes across disciplines.
This is a repeat citation.

The hospital failed to implement procedures for nursing screening to identify discharge risk using consistent criteria as noted in discharge procedures. The hospital did not implement structure in the electronic medical record (EMR) to note referrals for patients meeting high risk criteria for discharge. Refer to tag # A800.

2. Lack of appropiate needs assessment or psychosocial assessment to accurately identify patient needs.
Refer to tag A806.

3. Continued findings for incomplete discharge planning evaluations or discharge plans that did not address identified needs.
Refer to tag A808.

4. Lack of adherence to discharge planning requirements for the lack of patient participation in discharge planning, lack of ressessment of disharge plans, missing discharge planning assessments, and identically worded social work notes that did not incorporate individualized assessment of patient needs.
Refer to tag A817.

16790


Based on review of discharge planning procedures and patient records, it was determined that the facility did not implement effective risk assessment screening and referral processes upon admission for the early identification of patients' discharge-related needs.

Findings include:

The hospital did not implement procedures for discharge screening risk assessment for admitted inpatients. Procedures did not specify a mechanism in the electronic record system to identify consistent risk criteria as specified in discharge procedures. In addition, procedures did not establish a system for nursing staff to generate referrals for discharge planning where necessary.

Review of the hospital's procedure 100.4 , "Discharge Review Program", on 9/27/12 found that the hospital's initial discharge planning screening practice for inpatients is performed by nursing. Screening of risk factors for anticipated discharge needs on patient care units or from the emergency room is conducted upon admission by nursing staff.

Referrals are then initiated to necessary personnel , including Care Management and Social Work personnel.

According to the procedure, "Patients identified as requiring additional information or referrals to community resources will be referred to social services for follow up." In addition, this policy indicates that psychiatry patients in the ER are screened by a social worker and that coordination for discharge planning may need to include a Care manager.
The coordination of this discharge screening process is not clearly explained.

The procedure continues to identify the risk criteria that would warrant discharge planning referral but did not explain how a referral is made from the nurse screener to staff whose assigned responsibility includes discharge planning. The policy indicates that from the emergency room, "assistance is available to the ED staff through contact information for Care Management and/or Social Services".

Review of the electronic medical record finds that the facility utilizes an electronic medical record (EMR) system to document patient care and admission in the emergency room. This electronic record has no structure or process to assess consistent risk factors that match all the high-risk criteria as listed in the Discharge Review policy.

Review of the emergency EMR and admission assessment section finds no mechanism in this template to document or generate a referral for case management or social work for purposes of discharge planning.

Consequently, the hospital did not describe in its policy nor create an electronic mechanism system in place to allow nursing to:

Identify risk in the EMR using consistent screening criteria as outlined in the Discharge review policy.

Assign risk status.

Generate and document referrals by nursing for discharge planning in the ER electronic record upon admission.

The hospital did not implement this procedure in the example of MR # 10.

Review of this record on 9/27/12 found that this 33 year old male was registered in the ED on 9/25/12 with a chief complaint of suicidal ideation who required psychiatric assessment. The patient was receiving 1:1 watch. The patient was also on contact isolation for c-diff.

The admission assessment section of the ED electronic medical record (EMR) found that the patient arrived on the unit at 2300 on 9/25/12 where it was noted that he needed an isolation room and was admitted to TELE.

Review of systems did not include a dedicated section for all psychosocial risk criteria as mandated by the discharge review program policy.

Admission criteria in this EMR included information about living environment, alcohol use, substance use, and a risk assessment for limited criteria for domestic violence, abuse/neglect, and crime victim status. In this case, the patient reported no risk but in different queries had reported smoking a small amount of marijuana and ingesting 1 bottle of wine every other day.

A reference was made to obtain a copy of advance directive from a shelter. Psychosocial factors were limited to issues related that would affect the learning process, whereby it was noted psychosocial factors: " yes, with history of mental problems".

The discharge assessment section noted the date and time the record was created (9/25/12 )9:34) and did not record any content. Status was noted as "active".
The intervention section noted "yes" to formatted text that queried about : "patient/family participating in plan of care, demonstrates capacity for coping, communicates clearly and appropriately".

This record did not demonstrate any mechanism or system to assign risk and generate a timely referral for discharge planning staff. There was no referral initiated to address this patient's evident mental health crisis, suicidal ideation, substance use, and evident homelessness. Furthermore, the limited psychosocial criteria as listed on the admission assessment section of the EMR form did not exactly correspond to the high risk criteria as noted in Discharge review policy that would warrant the need for referral.

There was no structure in place in the EMR for nursing to initiate a referral to Social work or case management as is required by policy.

This failure to implement and coordinate procedures across disciplines to ensure timely screening and assessments for discharge planning is a repeat deficiency from a prior survey ending on 5/1/12.

Based on observation, patient interview, and review of medical records it was determined that the facility did not ensure that all patients needing discharge evaluation have complete and appropriate needs assessment that include an assessment of factors that impacts on the patients' needs after discharge. This deficiency was noted in three of seven applicable medical records reviewed ( MR # 10, MR # 4 & MR # 16)
Findings include:
During the tour of the unit (Telemetry) on 9/27/12 at appropriate 10:00 AM, the unit s census list was reviewed. It was noted that writing next to the patient in MR # 10
" Homeless wants adult home kicked out - D/C to shelter " .
Review of MR # 10 on 9/27/12 , noted that this 33 year old male was admitted to the psych unit for his depression and suicidal ideation. The patient was admitted to medical unit on 9/25/12 after stool was positive for C-diff. The psych evaluation dated 9/24/12 at 14: 14 indicated that the patient was diagnosed with schizoaffective who was homeless since 2009. It was noted that the patient informed the psychiatrist "I am tired of living in the shelter. I want to shoot myself with a gun and end it ".
The discharge planning assessment was reviewed noted that on 9/26/12 the case manager noted that the patient may need placement upon discharge, or ongoing community service. The case manager noted social work to follow up.
On 9/27/12 at 1240, SW noted patient medically cleared for discharge home. The SW noted " patient agrees to be discharged to a shelter patient was provided with a metro card and a list of intake shelter ". This patient did not have a psychosocial assessment or a complete discharge planning evaluation.
It was noted that the patient's statement not wanting to continue to live in a shelter was not explored with the patient prior to discharge. It was noted that the patient was non-compliant with prescribed outpatient program. However, the patient's non-compliant to treatment was not addressed with the patient before discharge.
Review of the Discharge / Transfer form noted that the disposition was to a skilled/sub-acute nursing facility. This patient was discharged with a token and list of shelter. The patient was not provided with an outpatient appointment for continuing of care. The medical follow up for the patient was to follow up with a private MD. This discharge plan was inadequate. There was no documentation that the patient had a private MD or the private MD was contacted while the patient was an inpatient.
During tour of unit (Telemetry 11th floor) on 9/27/12 at approximately 10: 15 AM, it was observed that the patient in room 1124- ( MR # 4) was dressed in street clothes sitting on the bed and she had her belongings packed. The patient was interviewed. The patient reported that she was scheduled for discharged. The patient reported that she resided alone but she was waiting for her son to pick her up. When queried about the discharge papers, the patient reported that the staff will give the discharge papers to her son.
The Nurse Manager interviewed reported that the patient was not medically cleared. This staff also stated that "every day the patient was ready to go".
This staff reported that the patient had bouts of confusion.

Review of MR # 4 on 9/27/12, noted that this 79 year old female with history of DVT, HTN, Hypercholesteremia, and PE, walked into the facility's Emergency Department ( ED) on 9/22/12 with chief complaint of chest pain.
It was documented that the patient had not taken her Coumadin x 3 days. After evaluation, it was discovered that the patient was on Coumadin but the Coumadin was not therapeutic. It was documented that the patient was alert, and oriented x 3. There was no documentation in the record that this patient was confused or disoriented while in the hospital.
It was noted that on 9/24/ 12, the MD noted chest pain resolved; discharge after therapeutic INR. It was noted on 09/26/12, that the MD noted the patient's son was contacted x 2 voice mail left in mailbox. There was no documentation in the record that the discharge plan was discussed with the patient or the reason why this was not necessary.
The discharge planning assessment for this patient was not located in the record.

Similar findings of lack of psychosocial assessments for patient in MR #16, 56 year old with medical history of CVA admitted on 9/24/12 and discharged on 9/27/12 .
It was noted that the only SW assessment, dated on 9/27/12 at 0100 documented "Pt medically cleared for D/C to NH".

Based on observation and review of medical record, it was determined that the facility did not effectively ensure that all patients needing discharge plan have a complete discharge evaluation. This deficiency was noted in two of ten applicable medical records reviewed
( MR # 11 & MR # 12)
Findings include:
Review of MR #11, on 9/27/12 at approximately 11:50 AM, noted that this 87 year old male history of MI, CHF, HTN, and Alzheimer Disease presented in the ED with chest pain on 9/17/12 and was admitted from home . On 9/19/12, the Case manager noted management assessment done. The Case manager noted "patient admitted from home may need SNF placement " . On 9/27/12 at 12:40 PM, the Medicine Attending noted discharge to chronic care facility. On 9/27/12, Case manager noted informed by MD that patient is cleared for discharge. PRI done SW to follow up.
On 9/27/12 at 0100, SW noted -spoke to patient's daughter "daughter states that homecare referral is not necessary at this time and that patient does not need NH placement. Patient's family to continue to care for patient at home. Patient has out of state insurance and is in the process of enrollment with Elder care plan. Daughter to F/U with community homecare referral if need.
Plan is for patient to discharge home with family daughter will pick up patient at about 11 PM. No other social work f/u need " .
The discharge planning evaluation was incomplete as it did not include if the patient's caregiver understood the patient's discharge needs. The patient's continuing care needs after discharge was not listed. The SW noted that the daughter will follow up in the community home care referral if need. A list of such community resources and the resources appropriate for this patient's needs was not provided.
It was noted that patient's MD ordered long care placement after discharge. The SW documented that the patient's daughter indicated that nursing home placement was not necessary. The discharge evaluation did not include if this was a safe and appropriate discharge for this patient.
During the unit tour of on 9/27/12 at approximately 10:45 AM, MR #12 was reviewed. It noted that the patient, 95 year old Russian speaking with history of HTN, CHF, Afib, DM, was admitted with syncope. The patient was admitted on 9/25/12.
On 9/27/12, the MD ordered DC home with home care today. Discharge/Transfer form dated 9/27/12 was located in the record. This document indicated the patient was to be discharged to home with HHA.
The discharge planning evaluation for this patient was reviewed. It was noted on 09/26/12, that the case manager noted "Comments: Pt., 95 year old from home lives with care taker, admitted to Tele s/p syncope episode. Initial case management review completed, will follow to ensure a safe care. Plan at this time is for patient to return home with home care services, SW to follow that Pt. /family are in agreement with the above plan and to provide options of home care services available ".
There was no documentation if the home care services were reinstated prior to discharge.
The social work assessment was not located in the record.