HospitalInspections.org

Based on observation and staff interviews, it was determined that the hospital failed to have a current therapeutic diet manual readily available to the clinical staff.

Specific findings include:

During a visit to medical / surgical unit SLB6 on 12/04/14 at approximately 10:40 AM the nurse manager, a medical resident and the dietitian on the unit was not able to locate the current Diet Manual. The clinical nutrition manager on interview stated that the Nutrition Care Manual is available to clinical staff via the Internet. She also acknowledged that not all clinical staff was trained on how to access the Diet Manual from the Internet.

Based on observation, staff interview and records review, the hospital failed to maintain the condition of the physical plant and the overall hospital environment in such a manner that assured the safety and well-being of patients.

Findings are:

During tours of the hospital over the period of 12/02/2014 through 12/5/2014 the following findings were identified in the presence of the Director of Facilities and Vice President of Operation who were accompanying the state surveyor throughout the time of the survey:

Emergency Department (ED):
On the morning of 12/2/2014 at approximately 10:55 AM during a tour of the Emergency Department, the following issues were identified in the presence of the Director of Facilities and Vice President of Operation who also acknowledged the issues.
1- Two (2) huge (approximately 6 x 6 x 4 feet in dimension) plastic containers containing soiled linen were observed being stored and unattended outside the ED by the patient elevator.
2- The cove base and parts of the wall in the ED area between the clean and the soiled utility rooms were noted to be broken and in disrepair.
3- Three broken ceiling tiles were observed in cubicle #4 and more broken tiles were observed in cubicle #3 and #2 of the main ED.
4- Dried blood drops were observed on the floor by the bed in cubicle #2 of the main ED.
5- Also dried blood drops were observed on the walls by the sharp container next to cubicle #3.
6- Dried blood drops were observed on the floor by the ambulance triage bay of the main ED.
The floor of the ED in general was dirty and sticky. Black dirt and stains were observed on the floor by cubicle #1, in the isolation room, and other locations, including, but not limited to, the floor of the nursing station and various patient cubicles:
a- Syringe covers, alcohol swabs and tissues were observed on the floor by cubicle #1.
b- Empty tetanus vile and used gloves were noted on the floor of the nursing station.
c- Additionally, the electric wirings of computers were observed to be affixed to the floor using scotch tape.
7- The air born isolation room was noted to have the regular ceiling tiles instead of the washable and cleanable type of ceiling tiles that are required for this type of room.
8- The wall of the janitor closet of the ED was noted to be broken by the cove base and some tiles were broken and others were missing. Additionally, the floor was dirty and its ceiling tiles were broken.
9- The facility was noted to store items in the sprinkled storage room on cabinets that were very close to the ceiling tiles, leaving a space between the cabinets and the ceiling tiles of only 2 ½ inches. In a sprinkled room the space between the ceiling and the stored items should be greater than 18 inches to allow the sprinkler system to function appropriately in the event of fire.
10- Dirty floors were observed in the second area of the ED especially the following rooms: room 2- 5G, room 2-7G the OB-GYN room and the eye exam room.

Kitchen:
On the afternoon of 12/2/2014, during a tour of the kitchen area in the presence of the Director of Facilities and Vice President of Operation, the following findings were identified and acknowledged:
1- The paper storage room of the kitchen was found to have an electric outlet that was broken and its cover was missing its screws. Also, the ceiling tiles of that room were found to be aging and there were gaps between the ceiling tiles.
2- The steam pipes of the kettle area were noted to be rusty and had crust of dried food all around them. Also, crusts of dried food were observed on the bottoms of the kettles, which is a potential for food contamination.
3- The metal shield and splash of the column mixer that is used to mix food items like mashed potato and meat loaf was found to be dirty and had dried food particles on it, which is a potential for food contamination.

Inpatient Psychiatric Unit:
On the morning of 12/3/2014, during a tour of the inpatient psychiatric unit, the following findings were identified in the presence of, and acknowledged by, the Director of Facilities.

1- All the patient rooms and bathrooms of the inpatient psychiatric unit had similar findings and issues, which were identified as a potential looping risk. These rooms included, but were not limited to, rooms: 18, 16, 11, 10, and room 8.
The common looping elements are as follow:
a- The bars of the shower curtains of the patient bathrooms were observed not to be secured or fixed to the wall and had gaps between them and the tops of the shower room walls. This poses the risk of use of the bars as weapons and potentially for looping.
b- The metal surface of the soap dispensers above the hand-wash sinks were found to have holes that had sharp edges. This creates a potential for looping and self-injury.
c- The fan coil vents of the rooms had openings on their top surfaces that are a potential looping risk.
d- The window brackets in the rooms had openings that are located at a level of 5 feet from the floor, which are a potential looping risk.
e- The knobs to adjust the blinds of the windows were observed to have protruded metal wire with round ends that are a potential looping risk.

2- The mirrors on the wall of the corridor by room 16 and room 5 were found to be mounted to the wall using a mounting bracket that had about 5 inches of space between the mirror and the wall that could be used for looping.
3- The shelf next to the hand-wash sink of the bathroom in room 10 was found to have chipped and broken Formica.
4- The metal cover box of the flush-meter in the patient bathroom in room 11 and 8 were observed to be loose and not secured, which poses a safety risk.
5- The nozzle of the soap dispenser of bathrooms of rooms 8 and the one that serves patients of room 6 and 7 had an elongated metal rounded end, which is both a safety and looping risk.
6- The TV in the lounge room was found to be mounted to the wall in a way that allows for looping around it. Additionally, its cables and electric wiring were exposed and pose the risk of looping.
7- The door of the lounge room to the courtyard had a metal push bar that had a gap of about 4 inches between it and the door, which poses the risk of looping.
8- There was a curtain that was observed to be mounted above the door of the lounge. The curtain bracket is a potential looping hazard.
9- The electric outlets in the lounge room were not the tamper resistant type that is required for the psychiatric units.
10- Room 7 was noted to have a patient closet whose piano hinges were not extended to the top or the bottom of the closet, which poses a looping risk.
11- In room #7, which is being used for patient restraint, there was a chair with wheels. That chair in that room is a potential safety risk.
12- Room 6 and the space between room 7 and room 6 were found to have two square cuts in the sheetrock of the ceiling that were about 64 inches each. The location of the ceiling cut on room 6 was directly above the patient bed. These openings pose the risk of looping. During the observation of this finding the Director of Facilities asked one of the nurses "when these openings were made?" She responded that they had been there for two weeks.
13- The covering box of the flush-meter of the bathroom between room 6 and 7 was found to have two openings that are a potential looping hazard.
14- The door to the area between room 6 and 7 was found to have a regular handle that is a potential looping hazard. Additionally, that door had a door closer on it which also is a potential looping hazard.
15- In room 5 holes and openings were observed next to the mirror and at multiple other places in the sheetrock wall.

Dining room:
a- The hoses and wiring of the coffee machine and its filter were exposed and posed a looping risk.
b- The water fountain in the dining room and its faucet are a potential looping hazard.
c- There are at least four doors from the lounge room and all of them had regular door handles and door closers, which all are potential looping hazards.

Activity Room:
The activity room was found to have a regular door handle that is a potential looping hazard.
The exit door to Bard Avenue was found to have metal push bars that had gaps between the bars and the door, which poses a looping hazard.

Maternity and newborn Unit:
On 12/4/2014 at about 10:00 AM, during a tour of the maternity and the newborn unit in the presence of the Director of Facilities, the following were identified:
1- Dried blood drops were observed on the wall next to the sharp container in the newborn admission room.
2- The cover of the temperature thermostat of the admission room was noted to be missing.
3- The soiled utility room of the maternity unit was found to have positive air flow instead of the required negative air flow for this type of room.

Adolescent Psychiatric Unit:
On the morning of 12/4/2014, during a tour of the Adolescent Unit, the following findings were identified in the presence of and acknowledged by the Director of Facilities:

1- The fire extinguisher box was left unlocked or secured and the fire extinguisher was accessible to anyone, including the patients. This is a safety risk as the fire extinguisher can be used by patients to harm others.
2- There was a wooden cupboard in the dinning room that was used for storing Wii Games and video games that had many features that posed a potential looping hazard.
3- The TV and a wheeled cart that had a DVD player and a VCR player had exposed wiring and cables, which posed a potential looping hazard.
4- Additionally, the cables and wiring of the ice machines and the refrigerator were exposed and not secured and also posed a potential looping hazard.
5- The core of the lock of the main door next to the nursing station of the Child and Adolescent unit was observed to be missing.

Comprehensive Psychiatric Evaluation Program: (CPEP Unit):
On the morning of 12/4/2014, during a tour of the CPEP Unit, the following findings were identified in the presence of and acknowledged by the Director of Facilities:
1- Interview/ Examination room #4 was found to be open and had no staff present. Room #4 had (5) small oxygen tanks that were unsecured and accessible to anyone in the unit, including patients. That is a safety risk since these tanks can be used by patients to harm others.
2- Three (3) sprinkler heads in the corridors of the CPEP Unit were observed as missing their escutcheons, which poses a potential looping risk.

Surgical and Medical Intensive Care Units (ICU):
On the afternoon of 12/4/2014, during a tour of the ICU, the following findings were identified in the presence of and acknowledged by the Director of Facilities:

1- The supporting metal frames of the ceiling tiles of many ICU rooms were observed to be rusted and had brownish discoloration and stains.
2- There were holes on the wall behind the head side of the patient beds in some of the Surgical ICU rooms. These rooms included, but were not limited to, room #33 and #35. This poses a potential for germ retention as it would be difficult to wash / disinfect these walls.
3- One drawer of the night stand in room #33 was found to be missing and the other drawers were not working properly.
4- The windows of some rooms of the surgical ICU unit were found to have adhesive tape around their peripheries and linen stuffed on to some of the sills. These rooms included, but were not limited to, room #37, #41 and #49.
When interviewed, the nurse manager of this unit stated that the tape around those windows is to stop a draft of cold air that comes in around the windows. The nurse manager stated that the windows are old and need replacement. She, also added that this is an ongoing problem. The Director of Facilities agreed that these windows had problems that would require repair or replacement.

Radiology Department:
On the morning of 12/5/2014, during a tour of the Radiology Department, the following findings were identified in the presence of and by the Director of Facilities:
1- The nurse call bell in the bathroom of the Nuclear Medicine Camera Room was not working.
2- There was no call bell in two of the change rooms, #1-94B and #1-94-C.

Bayley Seton Site:
On 12/5/2014, during a tour of the inpatient Psychiatric Unit of Bayley Seton Campus, at approximately 1:30 PM, the following findings were identified in the presence of and acknowledged by the Director of Facilities and the Vice President of Operations:
1- The handrails in the corridors of the psychiatric inpatient unit were found to have gaps between them and the walls of about 4 inches, which is a potential looping hazard.
2- All the doors of the units, including the patient rooms, were found to have the regular type of the door handle, which is a potential looping hazard.
3- The exit doors of the unit were found to have a metal push bar that have a gap between them and the doors, which poses a potential looping risk.
4- The electric closets on the corridors were found to have handles and padlocks, which pose a potential risk for looping.
5- The covers of the exhaust coil vents in various locations of the unit were found to have openings of about ¼ of inch, which poses a potential looping hazard.
6- The heads of the sprinkler system in the corridors of the unit were noted to be of the regular type and posed a potential looping hazard.
7- The manual pull stations of the fire alarm system were square like boxes that were mounted to the wall at approximately 5 feet from the floor, which poses a potential looping risk.
8- Some patient beds (at least 5 beds) that included, but was not limited to, those in room #378 and #380, were found to have restraint holes on the sides of the beds which could be used for looping, especially those in rooms that are not in close proximity and or in a direct line of observation from the nursing station.
9- The fan coil units in all the patient rooms were found to have grills on their top surface of a type that poses a potential looping hazard. Additionally, those fan coil units were secured to the walls by an L shaped metal bracket that leaves a space between the units and the wall which poses a potential looping hazard.
10- The screws that were used on the fan coil units were not of the safety type and pose a safety risk.
11- The nurse call bell in the patient bathrooms can be used for looping. Additionally, the toilet tissue dispensers posed a potential looping risk.
12- Moreover, the tissue dispensers in some patient bathrooms were found to have spaces between them and the walls, which poses a potential looping risk.
13- The metal strike plates on the frames of the doors of patient rooms and patient bathrooms were found to protruded beyond the doors and pose a safety risk for the patients and others.
14- The faucets and the water control knobs of the hand-wash sinks of the patient bathrooms were of the regular type and pose a potential looping risk.
15- The door handle of the bathroom of room 378 was found to be in disrepair.
16- Room 377 was found to have a broken part of the wall where the wall meets the door handle.
17- The mirrors and shelves of many of the patient bathrooms were noted to be loose and not secured properly to the extent that they can easily come off the walls. This posed both a potential looping and safety risk.






32144

Based on this onsite validation survey it was observed that the facility failed to maintain plumbing fixture piping in good repair.

Findings :

During a tour of the kitchen facilities conducted on December 1, 2014 at 10 AM, the surveyor discovered a twenty-five foot water feed pipe extending above the kitchen floor, which was covered with disintegrated insulation along its entire length. The frayed fibers of this insulation pose an infection control risk in that they have the potential to become airborne and could then contaminate food which, at the time, is open to the air.

Based on observation, record review and staff review, the facility failed to implement safe humidity levels to prevent surgical fires in the operating rooms.

Findings include:

During the testing of humidity level in Operating Room #5 it was noted that the humidity was at 25% and not between 30% and 60% as required. Review of the October-November daily monitoring logs for humidity and temperature in the Operating rooms, it was noted that the humidity level in all the 11 Operating Rooms were below 20% , contrary to ASHRAE requirements. Low humidity levels were observed to be noted on the logs for 10/19/14,10/20/14, 10/27/14, 10/28/14, 11/02/14,11/03/14, 11/04/14, 11/08/14,11/09/14,11/10/14,11/15/14, 11/16/14, 11/17/14, 11/18/14, 11/19/14, 11/20/14,11/21/14, 11/22/14, 11/23/14, 11/26/14, 11/27/14,11/29/14 and 11/30/14.

Low Humidity in the Operating Rooms poses a risk for surgical fires. Upon interview, the Vice President of Facilities stated that the building infrastructure is old and therefore it was becoming difficult to maintain optimum humidity levels, especially in winter.
However, the facility has not conducted an Interim Risk Assessment to prevent surgical fires.

16399




19043

Based on observation, staff interviews and documents, the facility failed to: 1) maintain a safe and sanitary environment to minimize the transmission of infections; 2) comply with its infection control practices to avoid potential sources of cross contamination which increase risk for spread of infection;and 3) maintain proper airflow in rooms which require negative pressure to mitigate risk of infection;

Findings include :

(1) During the tour of the Operating Room suite on 12/02/14 at approximately 10:30 AM, the surveyors observed the operating room had tiled walls with grout filling in between. It was also observed that the tiled wall was dirty and stained, as noted in Operating Room #6. The tiled walls are not washable and cleanable, as the grout in between the tiles absorb moisture and promote microbial growth. Therefore, the tiled walls in all the 11 operating rooms pose an infection control risk for microbial contamination.

(2) In addition, chipped tile was noted on the wall behind the anesthesia cart in Operating Room #2. The floor of the three Operating rooms (OR #s 2, 5 and 6 in the Spellman building) inspected were observed to be strewn with debris, after being cleaned and prepared to accept a patient. The base of the wall (molding between the wall and floor) of Operating room #6 was cracked on all four sides of the room.

The base of the Anesthesia machines in all the 3 Operating Rooms inspected for cleanliness, was observed to be laden with dust and dirt.
The base of the metallic poles used to hang Intravenous solutions were observed to be rusty in all the Operating Rooms inspected. The base of the stand used to store Cautery Equipment in Operating Room #6 was also observed to have rust.
The base of the stand with three rinse basins in Operating Room #2 was also observed to be rusty.

(3) During the testing of the airflow in Operating Room #s 7, 8, 9, 11 and 12 on 12/02/14 at approximately 11:30 AM, it was noted that the airflow in all these operating rooms were negative in relation to the corridor. Upon interview of the Director Of Engineering, it was stated that the Fire Alarm was tested by a vendor in the morning and the dampers were turned off. The airflow was returned to positive pressure in all these operating rooms at 11:40 AM. Upon request for logs indicating daily monitoring of airflow in the Operating rooms, it was stated by the Director Of Engineering and the nursing staff, that the facility did not monitor the airflow in the operating rooms on a daily basis.

In addition all the 7 sub-sterile rooms with flash sterilizers were observed to have positive airflow in relation to the corridor, instead of negative pressure as required by AIA Table 2 1996-97 Edition.

(4) During tour of the kitchen on 12/1/14 at approximately 10:50 AM eleven (11) plastic bags with white kitchen towels was observed stored in the janitors closet.

This citation was confirmed with the Director of Food Services

(5) Tour of the Psych Inpatient Unit on 12/03/14 at approximately 11:30 AM revealed:
(a) There were no paper towels in the patient's bathrooms in Rooms # 5, 6, 7, 8, 10, 12 and 13. Staff #1 stated paper towels are not left in the bathrooms because the patient(s) will clog the toilet with the paper towels. Patient(s) are instructed to ask for paper towels
(b) The Daily Room Temperature Log for the Accu-Chek Test Control Strips (the Blood Glucose Monitor test strips) in the Medication Room, showed out of range readings on approximately 80% of the dates from August to November 2014. No corrective action was recorded and Staff #1 was unable to verbalize the corrective action for the out of range readings.
(c) Staff #2 performed blood glucose monitoring for Patient #1 and proceeded to Patient #2, but did not clean the meter after use for Patient #1. Staff #2 acknowledged that the meter should be cleansed between each patient and then proceeded to clean the monitor as required.. The facility's Addendum to the Policy: Accu-Check Inform II Blood Glucose Testing, requires cleaning the device between each patient.
At interview 12/03/14 at approximately 3:00 PM, Staff #3 stated the Accu-Chek strips should be moved to another location until the problem is corrected. This requirement is specified in the document, "Point of Care Reminders."

(6) During tour of the Rehabilitation Outpatient Clinic on 12/4/14 at approximately 1:40 PM accompanied by Staff #6, it was observed that the vinyl upholstery on the seat of a bicycle located in the gymnasium was torn; this condition prevents adequate cleaning and disinfection of the seat, which poses an infection control risk for microbial contamination.








32522

Based on interview, the review of medical record and other documents, it was determined the facility failed to implement its policy to assure patients' safety. Specifically, the facility failed to ensure that, (1) patients treated in the Emergency Department receive adequate discharge instruction for continued care and, (2) patients departing the Emergency Department before completion of treatment signs an informed consent that includes the consequences of leaving against medical advice. These findings were noted in 2 of 14 patient records reviewed (Patient #3 and Patient #4).

Findings Include:

Patient #3 is an 81-year-old male with a history of Benign prostatic Hypertrophy (benign enlargement of the prostate) who presented to the Emergency Department on 12/2/14 at 1:29 AM with complaint of being unable to urinate.

Physical examination by the ED physician on 12/2/14 at 1:42 AM revealed palpable distended bladder. An indwelling catheter placed at 1:50 AM had a return of 500 centiliters of urine. Following diagnostic tests and evaluation, the physician impression was urinary retention and hyponatremia.

The nurse noted on 12/2/14 at 4:54 PM that the patient was discharged after review of follow up appointments and discharge instruction. The physician note, digitally signed on 12/2/14 at 5:50 PM indicated the patient has follow up appointment with a urologist; however, the written discharge instruction provided to the patient was generic and lacked specific information regarding the referral and appointment. In addition, there was no evidence the patient was educated regarding maintenance of the indwelling catheter other than a written discharge information on urinary retention and management.

At interview with Staff #4 on 12/4/14 at 2:15 PM, he stated the patient received "After Care Instruction" which contained the location and phone number of the facility's outpatient clinic. He stated that in addition to the generic information, the name of the urologist and contact information should have been provided on the discharge instruction.

At interview with Staff #5 on 12/4/14 at 2:35 PM, she stated the "Aftercare Instruction" was reviewed with patient that included care of indwelling catheter and urinary bag. Staff #5 stated that nursing teaching and patient's response were not documented.


Patient #4 is a 23-year-old male who was brought in by ambulance on 4/12/14 at 1:18 PM. The patient was status-post head trauma with a brief period of unresponsiveness. Triage evaluation at 1:18 PM indicated the patient was conscious, lethargic, and disoriented.

CT scan of the head and cervical spine were negative, but urine drug screen was positive for Methadone, benzodiazepines, cocaine and Marijuana. The clinical impression was head injury and poly-substance abuse.

On 4/13/14 at 00:37 PM, physician noted the patient was admitted to Telemetry Unit for continuous monitoring. The physician noted, "Patient may have potentially taken something that could cause respiratory arrest, fatal arrhythmia, and cardiac arrest". Admission history and physical was completed on 4/13/14 at 5:14 AM. Nursing disposition note on 4/13/14 at 11:36 AM indicated the patient left the Emergency Department against medical advice.

The patient's record did not contain a written discharge instruction for follow up care, and in accordance with the facility's policy, the record lacked a signed AMA (Against Medical Advice) document that includes the consequences of leaving the facility before the completion of treatment.

The review of facility's policy titled "Consent to medical treatment" last revised June 1, 2010, notes in section 12, "The appropriate house staff physician has the responsibility to present to the patient for signature the Discharge Against Advice and Release form . . . The name, date and time should be completed at the time the form is executed by the patient.

At interview with Staff #4 on 12/4/14 at 2:20 PM, he acknowledged that the patient did not receive a written discharge instruction and the signature of the patient was not obtained on the "Discharge Against Advice and Release form". Staff #4 stated Patient #4 had been admitted, and it was the house staff physician's responsibility to discuss the consequences of leaving against medical advice with the patient and obtain patient's signature on the "Discharge Against Advice and Release form".