HospitalInspections.org

Based on observations and staff interviews, it was determined that the facility failed to designate or construct an area for the sole purpose of achieving a less restrictive intervention for its patients on the Mental Health Unit.

Findings include:

The facility failed to create a quiet/comfort room as required and as stated in its Plan of Correction dated March 2, 2011. During an inspection of the Mental Health Unit on 4/19/11 at approximately 2:00 PM, it was observed that the facility had designated a quiet area for its patients in a meeting room. Approximately 1/3 area of the room had been designated as a quiet area while the remaining 2/3 of the room was furnished as a conference room. The area of the room designated to be used as a quiet room had items such as a mini-water fountain, a radio, a bean bag, an exercise ball, VHS tapes in a massive wall unit, 2 regular hospital blankets and a bottle of incense. In the conference area was a rectangular table surrounded by at least 10 chairs. In the area designated as the quiet area there were 2 straight backed chairs. Staff #1 stated at that time that the social worker sometimes uses the room for group sessions. Staff #1 also stated that staff meetings are held in the room if the patients are not using the room. However the staff noted that the social workers' offices could be used for staff meetings if a patient is using the quiet area.

It was noted that the facility's Plan of Correction to create a sensory room on the unit has not been fully implemented. An area has been created within the meeting room and the room remains essentially a multi-purpose conference room instead of a designated quiet room to be solely used by patients.

In addition, the POC was not implemented by the implementation date as submitted. The lights could not be dimmed; the chairs could not be reclined; there were no large piece puzzles; and there were no comfort mats. Staff #1 stated that he was in the process of purchasing a rocker, weighted blankets, "S" shaped chairs, light diffusers, and getting the light switch changed to a dimmer switch in the near future.

Currently, furniture items such as the conference table and hard materials type chairs located in the room can be used by the patient to harm self or staff who may be assigned to watch the patient while deescalating.

Based on observation and staff interview, it was determined that the facility failed to ensure that the Hydrocollators in the Physical Therapy Department were kept in clean and sanitary condition.

Findings include:

On 04/18/11 at 12:15 PM during the tour of the Physical and Occupational Department, it was noted that one Hydrocollator was extremely dirty with rust and black streaks on the bottom of the Hydrocollator. The Director of PT/OT stated that these black streaks are in fact scratches/rust that cannot be removed. When a piece of paper and a metal piece were also noted in the Hydrocollator, surveyor asked for a prong to see if the piece of metal was a part of the machine or a broken piece. On putting the prong inside the equipment/water to reach for the broken piece, the black streaks started moving from their location and in fact were noted to be dirt dissolving in water.

Findings were shared with Staff #2 and Staff #3.

THIS IS A REPEAT DEFICIENCY. Facility had stated in Plan of Correction that the 'Hydrocollator will be cleaned' and X5 date was 4/4/11. Facility needs to ensure that the plan of correction is implemented system-wide and not restricted to case-by-case citations only.

Based on observation, it was noted that the carts/obstruction stored in front of the electrical panels in the Emergency Department had not been removed to allow easy access in case of emergency.

Findings include:

On 04/18/11 at 11:45 AM, during the tour of the Emergency Department, it was noted that a clean linen cart was stored in front of the electrical panels in Exam Bay #8. This prevents/limits access to the panels by the engineering staff in case of emergency.

THIS IS A REPEAT DEFICIENCY. Facility had not responded to this issue in the plan of correction. Facility had only responded to the issue of securing the panels which were open at the time of first visit but did not respond to the issue of removing stored carts/obstruction from in front of the panels.

Findings were verified with Staff #2 and Staff #3 at the time of observation.

Based on observation and staff interview it was determined that the facility did not ensure that ORs and Central Sterile Supply area had the required air pressures as required. Furthermore, facility did not ensure that ALL non-patients areas of the facility had the required air-pressure as per code.

Findings include:

1 (a) On 04/18/11 at 2:15 PM, during the tour of the Surgical suite, it was noted that surgical procedures were taking place in OR #3 and OR #1. When a thin tissue paper was used to verify the directional flow/air pressure, it was noted that the air-pressure was negative (air coming in) instead of positive (air going out). OR #4 had neutral air pressure. Only OR #5 was tested to be positive.

Staff #2 was interviewed regarding the facility's procedure to ensure that the ORs are maintained with their positive air-pressure at all times. Staff #2 stated that he was unsure and probably there was no procedure. In the meantime Staff #2 directed the engineering staff to check why the ORs were negative.

(b) At 4:00 PM, Staff #2 stated the ORs were working with positive air pressures. He stated that one of the dampers was stuck and needed to be repaired. Staff #2 was asked when was the last time the dampers and air balancing was checked. He stated that he will look for the records.
On 04/19/11 at 1:15 PM, surveyor was provided with a report from 'Northeast Medical Consulting' dated 12/17/10 indicating that the ORs were checked for air flow and air-pressure. Staff #2 stated that no other report or work record was available indicating ORs were checked in the past 4 months, specifically for positive air pressure.

2. On 04/18/11 at 11:30 AM, during the tour of the Central Sterile Supply area, it was noted that the Decontamination room had positive air pressure and the Central Sterile Supply work room exhibited neutral to negative air pressure.

THIS IS A REPEAT CITATION. Facility had responded that 'Facility will re-check air balancing and adjust dampers to ensure negative pressure for this area'. It is to be noted that this response was incorrect as for Central Sterile Supply area 'POSITIVE' air pressure was required and for Decontamination room only negative is required. In this case both rooms did not have the required air-pressures.

Findings were verified with Staff #2 and Staff #3

3. During the tour of the facility from 04/18/11 to 04/20/11 between 10:30 AM to 4:00 PM, it was noted that non-patient areas/ancillary areas of the facility did not have the required air-pressures as per AIA Table 2. Facility was cited for this issue during the previous survey of 01/2011. In the plan of correction facility had indicated that it will 'Monitor non-patient areas that may contribute to infection control/contamination to ensure that they have the required air pressure'.
During the current survey, it was noted that the facility did correct 'some' of the previously cited areas but did not ensure a system-wide correction.
Examples, including but not limited to, are:
i. The soiled utility room in PT/OT did not exhibit negative air pressure.
ii. Housekeeping closet in the ORs did not have negative air pressure.

Findings were verified with Staff #2 and Staff #3.

4. During the tour of the CCU/ICU on 04/19/11 at 11:15 AM, it was noted that the isolation room did not have negative air pressure and instead exhibited positive air pressure.

Facility was cited for a similar issue for other isolation rooms on 5th floor to which the facility had stated that it will 'Re-check air balancing in the isolation rooms that do not have negative pressure and adjust dampers to ensure negative pressures in these rooms'. X5 date was 04/04/11. Facility did not ensure that it corrected the issue system-wide.

Findings were verified with Staff #2 and Staff #4.

Based on observation, documentation and staff interview, it was determined that the facility did not ensure that the environment is maintained to prevent the spread of infection.

Findings include:

1. On 04/19/11 at 11:15 AM, during the tour of the CCU/ICU, it was noted that the isolation room did not have the required non-porous ceiling tiles and self-closure on exit doors as required by AIA 7.2/7.28.B8.

Facility was cited for a similar issue for its isolation rooms in Med/Surg units. In the plan of correction the response was 'Replacement of ceiling tiles in the isolation rooms with non-porous ceiling tiles'. X5 date was 4/4/11. Facility did not ensure that the correction was made to all isolation rooms in the facility.

Findings were shared with Staff #2 and Staff #4.

2. On 04/19/11 at 11:45 AM, Nurse Manager of Med/Surg unit 5th floor was interviewed regarding the provision of protective environment for immunocompromised patients (This includes a room with 'positive air pressure', cleanable/non-porous ceiling tiles and self-closure on the exit doors). The Nurse Manager stated that the infection control committee is still working on the issue to provide a protective environment room/modality for the patients.

THIS IS A REPEAT DEFICIENCY since at the time of survey of 01/11 there was no provision for such room and facility still has not corrected the issue. In its plan of correction, facility had stated that 'Infection Control Community Risk Assessment to address 'reverse isolation' and room designation for immune-compromised patients that fall into this category', would be done. The X5 date was 4/4/2011.

Staff #5 was requested at 12:00 PM to provide information regarding what steps have been taken as part of the plan of correction to ensure such arrangement for these patients. Staff #5 provided a grid as a part of the Infection Control meeting minutes plan of correction. It indicated that "reverse isolation will be provided disease specific". No further 'specific information' was provided regarding what actual steps, including provision of protective environment room, will be in place once such a patient is identified in the facility.

3. (a) On 04/18/11 at 11:30 AM, during tour of the Central Sterile Supply workroom, it was noted that dust and dirt were present around the perimeters of the sterilizers. Some construction debris such as small stones and dust were also noted around the perimeters of the room. Findings were verified with Staff #2.

THIS IS A REPEAT DEFICIENCY. Facility stated in the plan of correction that 'Thorough environmental cleaning of the perimeters/corners of the steam sterilizer in the Clean Sterile room', would be done.

(b) The door from the decontamination side to the clean side was not latched positively to close it shut, and also exhibited a gap allowing environmental contamination. THIS IS REPEAT DEFICIENCY. Facility had stated 'Closure of the door' would be done, and X5
date was 4/4/11.

Findings were verified with Staff #2 and Staff #3.

4. On 04/18/11 at 11:30 AM, during the tour of the Central Linen room/Laundry, it was noted that the room had dust and dirt along its perimeters. THIS IS A REPEAT DEFICIENCY. Facility had stated in its plan of correction, 'Through environmental cleaning of the main clean linen room/Laundry room' would be done; X5 date was 4/4/11.

Findings were verified with Staff #2 and Staff #3.

5. On 04/20/11 at 11:30 AM, during the tour of the Ambulatory Surgical unit it was noted that a chair was stored in the patient toilet. Such arrangement may contribute to cross contamination.

Nursing staff was interviewed regarding the purpose of the chair. The staff stated that it is there so that patients can change their clothes and keep their clothes and belongings on the chair. She also stated that the toilet is used as changing room. It was noted that two changing bays were present in the unit which were being used as storage for clean supplies and were not being used for changing.

AIA 1996-97 section 9.5.F5.j states 'A separate area shall be provided for outpatients to change from street clothing into hospital gowns and to prepare for surgery.'

6. (a) On 04/19/11 at 2:15 PM, it was noted that a chair was stored in the waiting room toilet of the Jefferson outpatient women's clinic. Facility was cited for a similar kind of issue of storing a wheel chair in one of the extension clinics. In its plan of correction the facility had responded that it would complete 'Removal of wheelchair found in a multi-patient bathroom at the Wurtsboro Extension clinic'. Facility needs to ensure that not only one bathroom or one isolated case is corrected, but that the correction is made system-wide based on its understanding of the intention of the citation, which is prevention of cross-contamination.

Findings were verified with Staff #2 and Staff #3.

(b) At the same Women's extension clinic, dirty (janitorial) and clean items (open tissue rolls for patients) were noted stored in one room that was labelled as dirty room. Facility does not have two separate rooms to store clean and dirty items separately.

Findings were verified with Staff #2 and Staff #3.