HospitalInspections.org

Based on document review and interview, the hospital's Governing Body did not ensure; (1) patient grievances are reviewed for resolutions and, (2) the responsibility for grievance resolution was formally delegated to a Grievance Committee in writing.

Findings include:

During interview on 9/15/16, at approximately 10:30 AM, Staff A, Assistant Vice President of Quality and Improvement, stated that the Board of Trustees delegated the responsibility of reviewing and resolving grievances to a Grievance Committee, and that the Grievance Committee was recently established in May 2016. Review of the Grievance Committee Minutes noted that the first meeting to review, investigate and resolve patient complaints was held on 5/20/16.

The hospital was unable to provide written proof that the Board of Trustees delegated the responsibility of reviewing and resolving grievances to a "Grievance Committee."


During interview with the Assistant Vice President of Quality and Improvement, on 9/15/16,
there was no indication that the Board of Trustees reviewed and monitored complaints and grievances for resolutions, prior to May 20, 2016.


The facility policy and procedure titled "Patient Complaint /Grievance Resolution," last revised May 2016, stated; "It is the policy of Vassar Brothers Medical Center to provide a formal process reviewing the patient complaints and to help resolve concerns and conflicts. The governing body at Vassar Brothers Medical Center has delegated the responsibility to review and resolve all patient complaints to the Grievance Committee, a subcommittee of the Quality Performance Improvement Committee of the Board of Trustee."

The hospital was unable to provide evidence that the formal process for reviewing patient complaints was fully implemented.

Based on observation, document review and staff interview, the hospital did not ensure that the condition of the physical plant and the overall hospital environment is maintained in such a manner that the safety and well-being of patients are assured.

Findings include:

On 9/12/2016, during a tour of the facility, the following were identified:

Operating Rooms:
1. There were 4 electrical outlets that were observed being covered by surgical adhesive tape and a written warning stating do not use those 4 outlets, and advised the use of other outlets on the same electrical beam.
2. The ceiling tiles of the isolation room in the Post-Operative unit was found to be from the regular type instead of the washable ceiling tiles that is required for this type of room.


Intensive Care Units (ICU):
1. The cove base (a type of trim that is installed along the base of an interior wall) on some of the walls of the ICU rooms were broken, and there were many cracked floor tiles in the ICU rooms.
2. There were broken parts of the walls of the nurse station and broken Formica of the countertop of the hand wash sinks.
The broken areas of the floor tiles, cove base and countertops, prevent the proper cleaning of these surfaces and is a potential for transmission of infection.

3. The Anteroom of the Isolation Room #6 was found to have a positive air flow to the corridor, instead of the negative air flow that is required for this type of room.


Vassar Ambulatory Surgical Center (VASC):
During a tour of the same day surgery on the morning of 9/13/2016, in the presence of the Vice President of Operation, the following were identified:

1. The floor at the entrance of the corridor to the operating room, was found to be bulging at
least in three different areas, which present a tripping hazard.
2. Two J- boxes (Electrical Boxes) on the ceiling right above the table where the clean instruments are assembled, were observed lacking their covers.
3. There was no hand-wash sink provided at the decontamination room of the central sterile
area for the staff to wash their hands.
4. The decontamination room was found to have a positive air-flow to the corridor, instead of the required negative air-flow for this type of room. This presents an infection control concern.


Outpatient Physical Therapy and Occupation Therapy- (VASC): PT/OT:
Two hydro collators in the PT area were found to be rusted at their inside surfaces.


MRI Suite:
1. Items containing metal material were observed in the zone (the area immediately outside the MRI room) and in the Control Room, which is a potential for causing injury to patients if one of those items are accidentally taken inside the MRI Room. Items included but were not limited to:
a. Metallic Pediatric Cart for pediatric anesthesia,
b. Stationary items in the Control Room; paper clips, paper holder clips, pens, etc.

The above findings were identified in the presence of the Vice President Operation, who acknowledged the findings.

Based on observation and interview, the facility failed to maintain facilities, supplies and equipment in such a way to ensure acceptable levels of safety and quality.

The finding is:

1) During a tour of the facility on 9/12 and 9/13/16, multiple rooms throughout the hospital were observed to be lacking identifying signage. Examples include but are not limited to several supply storage closets in the Neonatal Intensive Care Unit, the staff lounge in the Orthopedics Unit and an electrical closet in the South Circle 7 wing.

Failure to ensure that rooms throughout the hospital can be readily identified may result in injury to patients.
This finding was verified by the Director of Engineering and Facilities Manager, who were present during the tour.



35161

2) On 09/12/16, at 12:45 PM, during the tour of Four South Unit, two (2) emergency intubation boxes were inspected. It was noted that one of the box was missing Magill forceps (used when advanced life support measures are being undertaken).
On 09/12/2016, at 12:50 PM, during the interview with Staff K, Director of Patient Care Services, she stated that only one Magill forceps is required to be on the unit.
Review of the "Code Cart Inventory" revealed that Magill forceps are required to be in the intubation boxes.

Based on observation and interview, the facility failed to identify infection control hazards, to reduce the potential for transmission of infection.


Findings:

During a tour of the facility on 9/12, 9/13 and 9/14/16, the following were identified:

1. The isolation room in the Core Emergency Department was lacking a patient toilet.

2. The Neonatal Intensive Care Unit #1 lacked the required one hundred square feet per
space around each patient bed.

3. The soiled utility room in the Pediatrics Unit was lacking the required hand washing sink.

See additional findings:
Tag A 701.

Failure to identify infection control hazards may result in the spread of illness among patients.


These findings were identified in the presence of the hospital Vice President Operation, Director of Engineering and the Facilities Manager, who acknowledged the findings.