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Based on staff interviews, grievance log, grievance files and hospital's policy, it was determined that the facility failed to effectively ensure that the written responses provided to each patient's grievance, meets the Federal guidelines.

Findings include:

Twenty patent's grievances files were selected from the facility's grievance logs for the months of May 2014 to March 2015. It was noted that the each grievance file cover form (Complaints Management Form) indicated that the "reply timescale" for response to grievance was 30 Calendar Days.

Ten Patients' Grievance files were reviewed. It was noted that ten of the ten grievance files reviewed did not meet the federal guidelines; "of on average, a time frame of 7 days for the provision of the response would be considered appropriate".

For example:

Grievance file #1 was reviewed on 4/14/2015. It was documented on the Complaints Management form that the facility received a phone call from the patient's mother on 12/1/2014. The parent alleged that her son was denied care in one of the facility's Outpatient Clinic in Brooklyn. This parent indicated that she requested to file a formal complaint. The written response to the complainant was dated 12/29/2014.

Grievance file #2 was reviewed on 4/14/2015. It was noted that this was a formal complaint from a patient, who alleged that he was "dissatisfied on the way the RN spoke to him, and with the interaction with Security personnel". This complaint was received on 1/6/2015. The file indicated that the complaint was forwarded to the relevant department for an investigation. It was documented in the file that nursing response was dated 1/9/2015 and the medical department investigation was completed on 1/9/2015. In addition, Security Department incident report was dated 1/6/2015. A copy of interim letter to the complainant, dated 1/30/2015, was located in the file. This letter indicated that a final letter would be mailed upon completion of the investigation. This letter did not include a specific date when the investigation would be completed. Although the investigation was completed on 1/9/2015, the final letter to the complainant was dated 2/4/2015.

Grievance file #3 was reviewed on 4/14/2015. It was noted that the facility received the grievance on 1/23/2015. The Complaints Management Form indicated that "the patient expressed concerns regarding the lack of communication and attitude/behavior with the nurses pre and post operatively; lack of communication with the anesthesiologist; violated of rights ('I felt assaulted and sedated against my will')". The file indicated that the final letter was sent to the patient via "snail mail" on 2/20/2015. On 4/2/2015, the facility received an email from the patient that she never received the response.

Grievance file #4 was reviewed on 4/14/2015. It was noted that the facility received the grievance on 1/23/2015 It was documented on the Complaints Manager form that the patient stated "the procedure team seemed disorganized, she was not informed that her lung collapsed , there was a delay in receiving a chest s-ray after exam and inappropriate language was used during her exam". A copy of an apology letter to the complainant, dated 2/2/2015, was located in the file. In addition, there was an interim letter 2/10/2015 that the facility was investigating the allegations. The grievance file indicated that the file was closed on 2/18/2015 and that a written letter was sent to the complainant. A copy of the final letter was not in the grievance file for reviewed.

Grievance file #5 was reviewed on 4/14/2915. The patient filed a complaint with the facility on 1/30/2015 regarding discharge issues. The file indicated that the investigation was completed on 2/11/2015. The final letter to the complainant was dated 2/27/2015 - over two weeks after the investigation was completed.

Similar files responses that were not within the time frame were noted in grievance files: #6, #7, #8, #9 & #10

The Federal Regulation and Guidelines for responding to patient's grievance was discussed with Staff #1 and Staff #2 on 4/14/2015.

Based on staff interview, hospital's policy's, Grievance files , Patient Care and Quality Assurance Operations Committee of the Board of Trustees Minutes, Operations Quality Improvement Committee Minutes, and Patient Experience: Complaints & Grievances Report Grievances Snapshot Weeks of January 16, 2015 to January 29, 215 and January 30, 2015 to February 12, 2015, it was determined that the facility failed to administered its Quality Assurance Program to identify opportunities for improvement in the management of the time frame for responding to grievances.

Findings include

Patient Experience: Complaints & Grievances Report Grievances Snapshot Weeks of January 16, 2015 to January 29, 215 and January 30, 2015 to February 12, 2015 were reviewed on 4/14/2015. It was noted, in the weeks of January 16, 2015 to January 29, 2015, the facility closed 37 grievances cases and of the 37 cases closed only 3 were closed were within 7 days. During the weeks January 2015 to February 12, 2015 the facility closed 42 grievance cases and of the 42 cases closed only 2 cases were closed within the 7 days.

Operations Quality Improvement Committee Minutes, February 23, 2015 was reviewed on 4/14/2015. This report indicated that the Patient Experience Department presented its goal and ongoing initiatives. This reported indicated that the Patient Experience Department achieved a 93% closure rate of grievance within 30 days. This report did not include a plan on how it plans to meet the federal guidelines of responding to grievances within 7 days.

Twenty patent's grievances files were selected from the facility's grievance logs for the months of May 2014 to March 2015, on 4/14/2015. It was noted that the each grievance file cover form (Complaints Management Form) indicated that the "reply timescale" for response to grievance was 30 Calendar Days.

Patient Complaint and Grievance Policy reviewed date: 11/2014 was reviewed on 4/14/2015. This policy indicated that an Acknowledgement will be sent by Patient Relations to the patient or their representative within seven days of receipt. The Acknowledgment will inform the patient or their representative of the referral to Department/Point of Contact and that they will receive a written response within 30 days. As per CMS guideline, an acknowledgement is not consider a response to a patient's grievance. This policy also indicated within seven days of receipt of a grievance, the hospital will attempt to review, investigate and reconcile the issue raised. This policy did not specify how it will reconcile the issue.

Staff #1 and Staff #2 were interviewed on 4/14/2015. This staff stated that they were in compliance with the facility's Grievance policy.

Cross refer to tag # 0122

Based on review of hospital policies and procedures and interviews it was determined that the medical records department failed to implement a policy that was found in its policy and procedures.

Findings include:

Review of medical records policy and procedure on 4/20/15 titled: "Record Retention" which was issued by "Administration" with the effective date of 8/2009, revised 11/2012 with appendix revision date of 5/2014 found in section (4) - Responsibilities Part A - Department Records Managers reference to an organization structure that did not exist.

The policy referred to a group of Department Records Managers composed of individuals designated by Department Heads to serve as Record Managers for each departmental area. These are not employees of the Medical Records Department. Each manager was responsible for such vital decisions as determining appropriate retention times for departmental records where no specific time frame was mandated by law. Additional duties included entering active records into the Medical Center's contract management data base and inactive records in the On-Base program, assessing the disposition of records no longer required for current operations, with authority to convert to other media or sending records to an offsite facility, supervising the conversion of records into substitute images and disposing of records that have been successfully converted. Further duties of the Department Records Managers included arranging for or supervising removal or destruction of duplicate records.

At interview with the Director and Assistant Director of Medical Records on 4/21/15 at 2 PM it was stated that they were unaware of the program referenced above. Furthermore, they stated that there were no records sent to any offsite storage facilities.

Based on staff interview and review of hospital policies and other hospital documents, it was determined that although the institution has policies on Discharge Requirements and Utilization Review, it failed to have a written Utilization Review Plan in place that meets the regulatory requirements

Findings include:

The facility's Utilization Review Plan was requested from Staff # 3 on 4/17/2015. This staff submitted the document titled "Process of Care Committee (PCC) and Utilization Management Plan," reissued 10/19/2012. This staff stated that the facility does not have an annual Utilization Review Plan.

"Process of Care Committee (PCC) and Utilization Management Plan," reissue date 10/19/2012, was reviewed on 4/17/2015. It was noted that the Utilization Review (UR) Plan document submitted for review described the Patient Care Committee structure and the committee's organization / accountability / responsibility. However, this plan did not describe how the institution plans to review the services furnished by the institution.

Patient Care and Quality Assurance Operations Committee of the Board of Trustees Meeting Minutes, dated March 18, 2015 was reviewed on 4/17/2015. It was noted that the facility's Utilization Review Plan was not included in the report to the Board of Trustees. It was unclear if the Board of Trustees accepted the Utilization Review plan for the current or coming year.

Based on observation, it was determined that the facility did not maintain a safe, sanitary and comfortable environment to ensure that the safety and well-being of patients are not compromised.

Findings include:

1.(a) During the survey of the 9th floor-Rehab HJD building on 0414/15 at 12:30 PM, it was noted that the facility did not ensure safe environment to prevent safety hazards for patients. The metal parallel bars in the gym of PT/OT had protruding rivets. During exercise the protruding rivets may pose harm or injury to the patient's palm.

(b) Similarly on 04/17/15 at 1:00 PM it was noted that in the PT/OT gym of HJD, there is a metal parallel bar missing rivets/screws in approximately 10 holes. The holes did not have any covering therefore were sharp on contact.

(c) The shatter-proof status of the tall exercise mirrors situated in PT/OT gym area of the HCC and HJD buildings could not be verified at the time of survey.

2.(a) During the survey of 8th floor Peds in HJD building on 04/17/15 at 1:15 PM, it was noted that when a nurse call was elicited from a patient room, it did not register in the clean utility room, as per American Institute of Architects (AIA) 7.32.G1

(b) Furthermore, it was noted that this multi-corridor 8th floor-Peds unit in HJD did not have any intersectional corridor lights, as required by the same code mentioned above.

It is to be noted that the unit is arranged such that there is only one nurses's station from which some of the patient rooms and the emergency dome lights in the unit may be viewed. There is a corridor behind the station that has patient rooms that cannot be seen from this nurse's station from any angle. The presence of a nursing call bell console at the nurse's station, emergency dome lights at the patient room door, secondary signals in the ancillary rooms, and multi-corridor lights, are all essential parts of the way which the facility can ensure that prompt help to the patient is available when requested.

Similar finding of missing multi-corridor lights was observed on 9th floor -Rehab HJD building which has the same configuration.

All above findings were verified with the Director of Facilities, Director of Engineering , Assistant Project Manager and other staff members accompanying the surveyor.

Based on observation, staff interview, and record review, the hospital failed to insure that infection control officer or officers develop, implement, and evaluate measures governing the identification, investigation, reporting, prevention and control of infections and communicable diseases within the hospital.

Specifically, the Hospital failed to insure the following:
(a) Maintenance of a sanitary hospital environment;
(b) Development and implementation of infection control measures related to hospital personnel; hospital staff, for infection control purposes, includes all hospital staff, contract workers (e.g., agency nurses, housekeeping staff, etc.), and volunteers;
(c) Monitoring compliance with all policies, procedures, protocols and other infection control program requirements;
(d) Educating staff, as appropriate, about infections and methods to reduce transmission in the hospital; and
(e) Provisions to monitor compliance with all policies, procedures, protocols and other infection control program requirements;

Findings are:

1. During a tour of the Operating Rooms on the 6th floor of Tisch Building on 4/13/2015 from approximately 11:30 AM to 12:45 PM, the following was identified:

(a) Trash bin that was about 4x3x5 feet was observed being stored in the clean corridor across from the hand washing sink. During an interview with the Nurse Manager, she indicated that they stored the trash bin in this location because they did not have another place to store it and because they don't have a linen shute since the Sandy's storm.

(b) A house keeper was observed cleaning the OR #1 after a surgical procedure, there was blood on the floor around the operating table, in at least at four (4) spots, and that each spot measured around one (1) square foot. The housekeeper was observed stepping on the blood and he did not have shoe cover. He also, was observed taking a bag of garbage and leaving the Operating Room #1 and walking in the corridor to the trash room with the blood stains from his shoes on the floor of the clean corridor. This observation was made in the presence of the nurse manager who said that this is a breach of the infection control standards.

(c) A surgical Technician and a Nurse were observed after a surgical procedure in OR #18 stepping on blood on the floor around the operating table without shoe covers. The area of the floor that had blood was about 3 feet x 4 feet. The two staff members left the room, walked to the right hand side about 150 - 200 feet on the clean corridor outside the room to the trash room. This observation was made in the presence of the Nurse Manager and other staff members from the hospital. The Nurse Manager did not comment or interfere to correct this issue during the observation. The state surveyor, asked the Nurse Manager about this repeated practice, and asked the nurse Manager and the other staff members who were there during the observation to implement corrective measures to stop additional contamination of the corridors and other Operating Rooms. The Nurse Manager stated that the Hospital's policy on wearing a shoe cover is optional, and that the staff are to wear them when their shoes are visibility soiled. However, there is no mechanism in place to determine when staff member's shoes are soiled. Review of the hospital policy's regarding shoes and shoe covers (in the Operating Rooms) indicated that the staff are to wear a shoe cover if their shoes are visibly soiled, and when it is expected that their shoes will be soiled from the procedure/ task. The hospital's policy did not have a provision to address what should be done when the staff step on a floor that is soiled with blood, body fluids and other contaminants. Also, the hospital policy did not address the frequency of changing the shoe covers especially when soiled during a procedure. Additionally, the facility's policy did not address the precautions to prevent the occurrence of similar situations.

(d) The floor outside OR #1 and OR #2 was noted to be dirty.

(e) The floor of the electrical closet (Electrical Equipment room) near OR #1 was found to be dirty and dust laden.




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2. During the tour of the facility from 04/10/15 to 04/20/15 between 10:30 AM and 4:00 PM, the following areas were observed exhibiting wrong air flow/pressure:

(a) The Housekeeping closet, room # 1750 in 17 West of Tisch building, exhibited positive air pressure instead of the required negative air pressure.

(b) The equipment room housing clean items on 16 West floor of Tish building was noted exhibiting negative air pressure instead of a positive air pressure. Since this room is housing clean equipment and is serving the purpose of a clean holding room it requires positive air pressure.

(c) The medication room on 16 West floor of Tish building (1673) exhibited negative air pressure instead of the required positive air pressure.

(d) The Janitor's Closet on 8th floor-HJD building exhibited neutral air pressure instead of the required negative air pressure.

(e) The Clean Utility room #HJ 962 in the HJD building 9th floor, exhibited neutral air pressure instead of the required positive air pressure.

(f) The Medication room #HJ 870 B in the HJD building 8th floor, did not exhibit the required positive air pressure.

3.(a) As per American Institute of Architects (AIA) 7.9.D22, on the nursing unit there should be at least one airborne infection isolation room which complies with the requirements of Section 7.2. Section 7.2.C4 states that "air borne infection isolation room shall have self-closing devices on all room exit doors." During the survey of the 13th Floor Tisch Building at 2:30 PM, it was noted that the isolation room #1315 did not comply with all of the requirements of Section 7.2. The isolation room did not have self-closure or self-closure mechanisms installed at the exit door. Similar finding was observed for the isolation room #HJ 814 on the 8th floor-HJD building.

(b) The isolation rooms in the 17 floor Tisch Building including, but not limited to, isolation room #1712 and #1713 did not comply with the requirements of AIA 1996-97 section 7.28.B8. The ceiling tiles were porous and were of such material that they would not minimize the retention of dirt as required and would not be thoroughly cleanable.

4.(a) During the survey of the Pharmacy of Cobble Hill Emergency Department (CHED) on 04/14/15 at 3:15 PM, it was observed that the hood for compounding the antibiotics was very dirty.

(b) During the tour of the Pharmacy CHED it was also observed and verified with the Pharmacy staff that there was no provision of monitoring the temperature in the pharmacy. It is to be noted that there are many drugs present in the pharmacy that require room temperature storage and which may be sensitive to a higher temperature. This room is designed so that its window, when the sun is shinning, receives direct sunlight. This feature results in a solar gain increase of the room temperature - particularly during the summer months.

5. On 04/20/15 at 2:00 PM, during the tour of the Operating room suite at SC1 in HJD building , it was observed that the Sterile Supplies room did not have any mechanism for humidity monitoring.


All above findings were verified with the Director of Facilities, Director of Engineering , Assistant Project Manager and other staff members accompanying the surveyor.