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Based on medical record review, the facility does not ensure the medical staff is accountable for the quality of care provided to Patient #11.

Findings include:

Medical record review from 9/27/11 to 9/30/11 revealed that on 8/26/11, Patient #11 presented to the emergency department after falling while intoxicated. CT of the head/C-spine showed a left frontal hemorrhage. Review of the transfer form revealed he refused to be transported to a higher level of care by ambulance and requested use of personal vehicle. Vital signs are listed on the transfer form, but there was no documentation found in the record to indicate his mental status and/or intoxication level prior to being discharged to his personal vehicle.

Based on observation and interview, the facility does not ensure a safe patient care environment as evidenced by lack of emergency training of staff at 1 of 2 sites. (Lockport site)

Findings include:

Observation on 9/26/11 at 10:40 AM during tour of the Lockport site revealed the following:
- No emergency access hardware was on the patient restroom in the radiology department.
- Emergency hardware was available on the patient restroom in the Cardiac Rehab unit; however staff could not verbalize how to use it to access the restroom.

Interview on 9/26/11 with Radiology and Cardiac Unit staff during the tour at the Lockport site revealed the staff were unaware of how to access locked patient restrooms in case of an emergency.

These findings were verified with Staff #7 on 9/26/11.

Based on medical record review, the facility does not ensure a written order and/or evaluation by a physician is obtained prior to the initiation of physical restraints per state regulations, as evidenced for 2 of 2 patients. (Patients #20 and 33)

Findings include:

Review on 9/30/11 of policy "Restraints: Physical" (last reviewed 9/22/10) revealed a physician's written order is required for the use of physical restraints.

Review on 9/30/11 of the restraint order sheets revealed the following:
- Patient #20: On 3/17/11 at 10:00 AM, the order was written as a "read back" verbal order by the nurse.
- Patient #33: On 7/29/11 at 7:00 PM, the order was written as a "read back" telephone order at 7:00 PM by the nurse.
In both examples, the physician signed the order attesting that he examined the patient and restraints are clinically justified. The restraint information on the order form was entered by the nurse and there was no evidence of a date or time for the physician signature/assessment.

Based on document review and medical record review, nursing staff did not implement the use of restraints for Patient #20 per physician order.

Findings include:

Review on 9/30/11 of the following policies revealed the following:
- "Physician orders: Nursing Responsibility" (last reviewed 9/22/10) revealed the nurse shall be responsible for instituting and assuring compliance with a written physician order.
- "Restraints: Physical" (last reviewed 9/22/10) revealed a physician written order is required for the use of restraints.

Medical record review on 9/28/11 for Patient #20 revealed the following:
- On 3/17/11, the restraint order was initially written as a verbal order at 1000 by the nurse. The restraint flowsheet for 3/17/11 revealed restraints were applied at 0600.
- On 3/18/11, the physician order was for a posey/vest. The restraint flowsheet revealed the type of restraints implemented were a vest and mitts. No order was found authorizing use of mitts.
- On 3/19/11, no order was found for restraints. The restraint flowsheet and progress notes indicate a posey/vest restraint was utilized from 2400 to 2300.
- On 3/21/11, the restraint order was signed and dated, but it did not include the type of restraint, reason for restraint or time of order. The restraint flowsheet indicated a posey/vest was utilized for safety, but did not list any behaviors which could result in danger to self or others.
- On 3/26/11, no physician order for restraints was found. The restraint flowsheet and nursing notes indicated a posey/vest restraint was utilized from 1000 to 1800.

Based on document review and medical record review, the facility did not ensure nursing staff assessed and monitored Patient #20 while in restraints as required.

Findings include:

Review on 9/30/11 of policy "Restraints: Physical" (last reviewed 9/22/10) revealed documentation of patient assessment, release of restraint, circulation checks and interventions should minimally be documented every 2 hours. Safety observations are to be documented every 30 minutes and variations are to be described in progress notes. Interventions attempted prior to restraint use are to be documented on the daily patient care flow sheet. The policy does not specify the frequency of assessment for vital signs, respiratory/cardiac status, mental status or skin integrity.

Medical record review from 9/27/11 to 9/30/11 for Patient #20 revealed the following:
- On 3/20/11, the restraint flowsheet assessment section was blank from 0800 to 1400.
- On 3/23/11, the restraint flowsheet assessment section was blank from 0700 to 1400.
- On 3/29/11 at 1300 and 1600, nursing notes indicated a posey vest was utilized. The restraint flowsheet assessment section was blank from 0700 to 2300.
- On 3/30/11, the restraint flowsheet assessment section was blank for 2300.

No evidence was found to indicate whether restraints were continued, applied or removed during these time frames. No evidence was found to indicate (if applicable) required restraint assessments and safety checks of Patient #20 were performed by nursing staff during these time frames. Vital signs, respiratory/cardiac status, mental status and/or skin integrity were not documented as part of the patient assessment/monitoring while in restraints. Review of the entire medical record for Patient #20 revealed vague and/or lack of documentation related to least restrictive techniques attempted by staff prior to the utilization of any restraint application.

Based on document review and interview, the facility does not ensure staff are trained and demonstrate competency in the application of restraints, monitoring, assessment and providing care for a patient in restraints for all staff who have direct patient care responsibilities. (Staff #17-29)

Findings include:

Review from 9/27/11 to 9/30/11 of credentials and personnel files for Staff #17-29 revealed no evidence of restraint training.

Review on 9/28/11 of policy "Restraints: Physical" (last reviewed 9/22/10) and policy "Inservice Education Policy" (last reviewed 4/27/11) revealed no reference to staff training requirements for restraint and seclusion.

During interview on 9/28/11, Staff #2 verified these findings.

Based on medical record review, document review and interview, the facility does not ensure that deaths associated with the use of restraints or seclusion are reported to CMS within the required timeframe.

Findings include:

Medical record review on 9/28/11 for Patient #20 revealed use of physical restraints within 24 hours of his death.

Review on 9/28/11 of the Internal Medicine Department meeting minutes dated 8/2/11 revealed the medical record of Patient #20 was reviewed for mortaility, but the use of restraints is not mentioned. The care and treatment was determined to be appropriate.

Interview on 9/30/11 at 11:50 AM with Staff #3 revealed the facility does not have a policy for reporting deaths associated with the use of restraint or seclusion to CMS. Staff #3 stated the facility was unaware of the requirement, and so did not report Patient #20's death to CMS.

Based on document review and interview, the facility QAPI program does not track or monitor patient restraints despite the high risk of injury and/or adverse patient events.

Findings include:

Cross-refer to Tag #A214.

Review on 9/30/11 of governing body minutes, committee minutes (medical executive, medical records/UR, internal medicine, emergency and surgical) and quality assurance data for 2011 revealed no evidence of tracking or monitoring of restraint use.

Interview on 9/30/11 at 11:50 AM with Staff #3 revealed the facility the facility does not have many patients in restraints. Staff #3 indicated there is no quality assurance documentation related to patient restraints.

Based on document review, the facility does not ensure actions are implemented in response to identified issues to improve care, as evidenced in the lack of physician completion of medical records at 2 of 2 sites. (Lockport and Newfane sites)

Findings include:

Review on 9/30/11 of medical bylaws 7.3 "Automatic Suspension" (adopted 3/30/10) revealed when a practitioner fails to complete medical records on a timely basis, his or her clinical privileges shall automatically and immediately be suspended until the completeness of his or her medical records is in compliance with medical staff rules and regulations.

Review on 9/30/11 of the medical records/UR committee minutes dated 10/14/10 revealed the following:
- Lockport - incomplete charts: 829, physician deficiencies on incomplete charts: 895, delinquent physician deficiencies on incomplete charts over 30 days: 584, H&P reports: 33, operative reports: 5, and discharge summaries: 100. The topic status is "noted" and does not include followup and/or actions to be implemented for improvement.
- Newfane - incomplete charts: 736, physician deficiencies on incomplete charts: 893, delinquent physician deficiencies on incomplete charts over 30 days: 724, H&P reports: 10, operative reports: 0, and discharge summaries: 79. The topic status is "noted" and does not include followup and/or actions to be implemented for improvement.

Review on 9/30/11 of the medical records/UR committee minutes dated 2/10/11 revealed the following:
- Lockport - incomplete charts: 644, physician deficiencies on incomplete charts: 707, delinquent physician deficiencies on incomplete charts over 30 days: 395, H&P reports: 17, operative reports: 2, and discharge summaries: 57. The topic status is "noted" and does not include followup and/or actions to be implemented for improvement.
- Newfane - incomplete charts: 481, physician deficiencies on incomplete charts: 564, delinquent physician deficiencies on incomplete charts over 30 days: 428, H&P reports: 5, operative reports: 4, and discharge summaries: 46. The topic status is "noted" and does not include followup and/or actions to be implemented for improvement.

Review on 9/30/11 of the medical records/UR committee minutes dated 6/9/11 revealed the following:
- Lockport - incomplete charts: 947, physician deficiencies on incomplete charts: 1034, delinquent physician deficiencies on incomplete charts over 30 days: 553, H&P reports: 14, operative reports: 3, and discharge summaries: 75. The topic status is "noted" and does not include followup and/or actions to be implemented for improvement.
- Newfane - incomplete charts: 460, physician deficiencies on incomplete charts: 519, delinquent physician deficiencies on incomplete charts over 30 days: 328, H&P reports: 11, operative reports: 1, and discharge summaries: 42. The topic status indicates the medical records department staff are to contact physicians for completion of medical record documentation.

No evidence was found to indicate a corrective action plan was implemented and evaluated/revised to ensure and maintain compliance with facility policies and state/federal regulations related to the completion of medical records.


Based on document review, the facility does not ensure actions are implemented in response to identified issues to improve care, as evidenced in the area of staff ACLS education at 2 of 2 sites. (Lockport and Newfane sites)

Findings include:

Cross-refer to Tag #A394.

Review on 9/30/11 of the ICU committee minutes revealed the following:
- Minutes dated 2/15/11 revealed the committe members discussed the importance of ACLS. It was determined a proposal would be developed to provide training in house.
- Minutes dated 4/19/11 and 6/21/11 revealed no evidence to indicate the status of this issue or of any followup required by the committee related to staff ACLS training.

Based on document review, the facility does not ensure CPR/ACLS training is maintained by the nursing staff per policy and state regulations for 11 of 12 staff. (Staff #17 and 19-28)

Findings include:

Review on 9/30/11 of policy "CPR Certification" (last revised 5/26/10) revealed all RNs, LPNs, OR technicians, ER aides and dialysis technicians will maintain BLS (CPR/AED) certification. The education department will schedule BLS classes and advise staff members who have certification that is expiring. All personnel required to have CPR certification must meet this requirement every two years to maintain satisfactory employment status. The education department is responsible for maintaining records and tracking compliance of staff.

Review on 9/30/11 of policy "Inservice Education Policy" (last reviewed 4/27/11) revealed all nursing staff employees, dealing in patient care, will provide proof of competency in CPR. Attendance is recorded and placed in the employee's educational record.

Review on 9/30/11 of the job description for a registered nurse for cardiac services at the Lockport site (last reviewed/revised 4/09) revealed the position qualifications require current CPR and ACLS certification.

Review on 9/27/11 of personnel files for Staff #17 and 19-28 revealed no evidence of current CPR and/or ACLS certification.

Review on 9/28/11 of the Lockport nursing department inservices for 2011 revealed the following:
- Staff #17 was an RN (Cardio) - no CPR or ACLS training was listed.
- Staff #19 was an LPN (OB) - no CPR or ACLS training was listed.
- Staff #20 was an RN (ASU/PACU) - no CPR or ACLS training was listed.
- Staff #26 was an RN (2C) - no CPR or ACLS training was listed.
- Staff #27 was an LPN (2N) - no CPR or ACLS training was listed.
- Staff #28 was an RN (OB) - no CPR or ACLS training was listed.

Review on 9/28/11 of the Newfane nursing department inservices for 2011 revealed the following:
- Staff #21 was an RN (ASU/PACU) - CPR expired 4/11, no ACLS training was listed.
- Staff #22 was an RN (ER) - CPR expired 1/11, no ACLS training was listed.
- Staff #23 was an LPN (Med/Surg) - no CPR or ACLS training was listed.
- Staff #24 was an RN (ICU) - CPR expired 2/11, no ACLS training was listed.
- Staff #25 was an LPN (Med/Surg) - CPR expired 9/30/09.

Review on 9/30/11 of the CPR/ACLS list revealed 1 of 11 staff in the ICU and 6 of 18 staff in the ER were not currently certified for CPR and/or ACLS.

These findings were verified on 9/28/11 with Staff #2 and 37.

Based on medical record review, nursing services does not supervise and evaluate the care for each patient, as evidenced for 2 of 6 patients. (Patients #11 and 13)

Findings include:

Medical record review from 9/27/11 to 9/30/11 revealed the following:
- Patient #11 presented to the emergency department on 8/26/11 after falling while intoxicated. There was no evidence of a triage assessment and/or nursing assessment for this episode of care.
- Patient #13 presented to the emergency department on 7/9/11 and was diagnosed with a left clavicle shaft fracture. Initially he was to be transferred to a higher level of care, but was discharged home to his mother. There is no evidence of a nursing note to indicate why the discharge plan changed and no evidence that discharge instructions were provided.

Based on medical record review, the facility does not ensure that nursing staff develop a complete nursing care plan for each patient, as evidenced for 9 of 24 patients. (Patients #1-6, 13, 31 and 32)

Findings include:

Medical record review on 9/26/11 through 9/29/11 revealed the nursing care plans did not include patient comorbidities in addition to the active admission diagnosis in the following medical records:
- Patient #1 - depression, bipolar disorder
- Patient #2 - diabetes, hypertension
- Patient #3 - decubiti, liver and renal disease, 4+ lower extremity edema
- Patient #4 - hypertension, tobacco abuse
- Patient #5 - hypertension, diabetes, wound care
- Patient #6 - cardiac, diabetes, and psychiatric history
- Patient #13 - thyroid disease
- Patient #31 - hypertension, coronary artery disease, cardiac stents
- Patient #32 - thyroid disease, supermorbid obesity, type II diabetes, GERD, depression

These findings were verified with Staff #2 on 9/29/11.

Based on medical record review, the practitioner did not write orders with all required elements in accordance with standard practice to ensure safe preparation and administration for 1 of 1 orthopedic patient. (Patient #5)

Findings include:

Medical record review on 9/28/11 for Patient #5 revealed a physician order for "enema of choice prn constipation." The order lacks clarity as to what type of enema was to be administered to the patient.

This finding was verified by Staff #2 on 9/28/11.

Based on document review and interview, the facility does not ensure competency in intravenous medication administration as required by state and federal regulations for 8 of 8 nursing staff. (Staff #17 and 19-25)

Findings include:

Review on 9/30/11 of policy "Intravenous Therapy: Insertion and Monitoring of" (last revised 6/14/11) revealed aseptic technique for insertion and care of the intravenous catheter will be done by competent/credentialed RNs and LPNs.

Review on 9/30/11 of policy "Inservice Education Policy" (last reviewed 4/27/11) revealed no evidence that IV therapy education/competence evaluation is provided to the nursing staff.

Review from 9/27/11 to 9/28/11 of personnel files for nursing Staff #17, 19, 20, 21, 22, 23, 24 and 25 revealed no evidence of current competency, training and/or periodic education related to intravenous therapy.

These findings were verified on 9/28/11 with Staff #2 and 37.

Based on medical record review, the hospital does not ensure that medical records are promptly completed, as evidenced for 3 of 9 discharge records. (Patients #28-30)

Findings include:

Medical record review on 9/28/11 for Patient #28 revealed the following:
- Admit date was 6/27/11; discharge date was 6/29/11.
- No evidence of an MD discharge note.
- No MD signature on an admission note, or on admission orders.

Medical record review on 9/29/11 for Patient #29 revealed the following:
- Admit date was 8/30/11.
- The physician order sheet contained an order for STAT type and cross match/transfusion, but it contained no date or physician signature.

Medical record review on 9/29/11 for Patient #30 revealed the following:
- Admit date was 7/21/11.
- The history and physical form was blank, and there was no other documented history and physical in the record.
- Physician telephone orders were not signed.

Based on medical record review, the facility does not ensure all orders, including verbal orders, are dated, timed, and authenticated promptly by the prescribing practitioner. (Patients #5, 6, 9-11, 17, 21, 34 and 35)

Findings include:

Medical record review from 9/27/11 through 9/30/11 revealed the following:
- Patient #5 - The admission orders lacked a signature by Staff #10.
- Patient #6 - The physician consult report lacked a signature by Staff #36.
- Patient #9 - The preliminary x-ray report from 9/13/11 lacked the time and signature of the interpreting practitioner.
- Patient #10 - The preliminary x-ray report from 9/4/11 lacked the date and time of signature by the interpreting practitioner.
- Patient #11 - The preliminary x-ray report from 8/26/11 lacked the date and time of signature by the interpreting practitioner.
- Patient #17 - The wound/skin assessment was dated 1/22/11 and signed off by the nurse. On 9/26/11, the physician signed off: "I agree with the above abnormal wound/skin assessment".
- Patient #21 - Physician orders were not signed or dated by Staff #8.
- Patient #34 - The preliminary x-ray report from 9/13/11 lacked the time and signature of the interpreting practitioner.
- Patient #35 - The preliminary x-ray report from 7/19/11 lacked the date and time of signature by the interpreting practitioner.


Based on medical record review and document review, the facility does not ensure physician restraint orders are complete for Patient #20.

Findings include:

Review on 9/28/11 of the restraint order sheets for restraint use for Patient #20 revealed the following:
- On 3/18/11, the physician did not date and time his signature.
- On 3/20/11, the restraint order did not include a time.
- On 3/22/11, the physician did not date or time the order.
- On 3/23/11, the physician did not time the order. The nurse "took the order off " on 3/22/11 at 1450. This date was one day prior to the date of the restraint order.
- On 3/24/11 and 3/28/11, the physician did not time the orders.
- On 3/29/11, the physician did not time the order, but the nurse signed off on the order at 2400.
- On 3/30/11, the physician did not time the order. The nurse signed the order 3/30/11 at 2400. Another nurse "took off the order" on 3/30/11 at 1500. This time was prior to the co-signature of the nurse.
- On 3/31/11, the physician did not time the order.


Based on medical record review, the facility does not ensure all medical record entries are legible. (Patients #3-5, 13, 21, 25 and 27)

Findings include:

Medical record review revealed:
- Patient #3 - Review on 9/26/11 revealed illegible note and orders written on 9/26/11 and 9/27/11 by Staff #8.
- Patient #4 - Review on 9/26/11 revealed an illegible xray report by Staff #9, and illegible progress notes by Staff #8 written on 9/25/11, 9/26/11 and 9/27/11.
- Patient #5 - Review on 9/27/11 revealed illegible progress notes written by Staff #10 from 9/19/11 through 9/23/11, and by Staff #8 on 9/25/11.
- Patient #13 - Emergency department physician notes were illegible.
- Patient #21 - Review on 9/27/11 revealed the physician progress notes written by Staff #8 were illegible.
- Patient #25 - Review on 9/28/11 revealed illegible physician orders and progress notes written by Staff #8 on 5/29/11 and 5/30/11.
- Patient #27 - Review on 9/28/11 revealed illegible physician orders and progress notes written by Staff #8 on 8/26/10. Additionally, the discharge summary was illegible.

These findings were verified by Staff #2 on 9/28/11.

Based on medical record review, verbal orders are not authenticated within the 48 hour time frame, as evidenced for 3 of 25 patients. (Patients #5, 6 and 41)

Findings include:

Medical record review on 9/27/11 for Patient #5 revealed that verbal/phone orders taken on 9/18/11, 9/19/11, 9/22/11 and 9/23/11 were not authenticated.

Medical record review on 9/27/11 for Patient #6 revealed that verbal/phone orders taken on 9/22/11 and 9/23/11 were not authenticated.

Medical record review on 9/29/11 for Patient #41 revealed that verbal/phone orders taken on 9/22/11 and 9/23/11 were not authenticated.

These findings were verified by Staff #2 on 9/29/11.

Based on medical record review, the facililty does not ensure that medical records are completed within 30 days of discharge, as evidenced for 4 of 9 discharge charts. (Patients #27-30)

Finding include:

Medical record review on 9/29/11 at 1:00 PM revealed the following:
- Patient #27 - The copy of the death certificate in the medical record was entirely blank, with the exception of the physician's portion of the document.
- Patient #28 - The record lacked a physician's (Staff #35) discharge note, and lacked signatures on admission and discharge notes.
- Patient #29 - The record lacked a physician's (Staff #35) signature or date for a STAT cross match and transfusion.
- Patient #30 - The record lacked evidence that an admission history and physical was performed.

Based on observation, nursing staff do not ensure that medication carts are locked and secured when unattended and not in use at 1 of 2 sites. (Lockport site)

Findings include:

Observation on 9/26/11 at 10:20 AM of 2 Center at the Lockport site revealed the medication carts located outside of rooms #2119 and 2125 were left unattended in the hallway and not locked.

This finding was verified with Staff #5 on 9/26/11.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 5/25/07.

Based on interview and document review, the facility does not protect the public water supply at 1 of 2 sites. (Lockport site)

Findings include:

Interview on 9/30/11 at 11:00 AM with Staff #4 revealed the check valve on the Lockport site's sprinkler system is not tested annually as required by Part 5 Section 5-1.31(c) of the New York State Sanitary Code. Review on 9/30/11 of the Davis Ulmer Fire Protection and Security Systems report revealed the device is not equipped with test ports and unable to be tested for proper operation.

Based on observation, the facility does not maintain supplies to ensure an acceptable level of safety and quality at 2 of 2 sites. (Lockport and Newfane sites)

Findings include:

Observation on 9/26/11 at 10:00 AM of the Lockport 2 Center medication room revealed the following:
- 1 spinal needle, 18 gauge located in the drawer expired 4/11
- 2 culture swabs located in the cabinet under the omni refrigerator expired 7/11
These findings were verified with Staff #3 and 5 on 9/26/11.

Observation on 9/26/11 at 10:35 AM of the Lockport ICU nursing station revealed the following:
- 5 dark green blood tubes located in the bins containing phlebotomy supplies expired 7/11
- 5 culture swabs located on the counter to the left of the nursing station expired 7/11
- 1 bacti swab located on the counter to the left of the nursing station expired 5/26/11
- 1 Cetacaine Topical Anesthesia Spray expired 4/11
- 1 can of Hurricaine Spray expired 5/11
- 2- 10 ml vials of NaCL 0.9% expired 2//11 and 4/11
- Multiple Betadine swabs expired 6/08.
- 2 Scrublane Surgical Scrub Brush expired 3/11
- 2 bottles of triadine located on the counter to the left of the nursing station not dated and/or initialed when opened
These findings were verified with Staff #3 and 5 on 9/26/11.

Observation on 9/26/11 at 10:45 AM of the Lockport ICU nursing station thoracentesis kit located on the counter to the left of the nurse's station revealed the following:
- 2 needles, 22 gauge expired 12/10
- 2 needles, 21 gauge expired 10/09
- 1 10 ml syringe with a 22 gauge needle expired 11/10
- 1 protect IV, 14 gauge expired 5/10
- 1 silk 3.0 suture expired 1/11
- 1 bottle of triadine not dated and/or initialed when opened
These findings were verified with Staff #3 and 5 on 9/26/11.

Observation on 9/26/11 at 10:45 AM of the Lockport emergency department code room revealed the following:
- 18 BD Bactec bottles expired 8/31/11.
These findings were verified with Staff #3 and 5 on 9/26/11.

Inspection on 9/26/11 at 11:00 AM at the Lockport site of the ICU crash cart revealed the following:
- 2 suture sets expired 10/10 and 1/10
- 7 Vacutainer tubes expired 2/11, 5/11, 6/11 and 7/11
These findings were verified by Staff #2 on 9/26/11.

Inspection on 9/26/11 at 11:15 AM at the Lockport site of the clean utility room in the ICU revealed:
- 1 bottle of Stomahesive expired 2/11
This findings was verified by Staff #2 on 9/26/11.

Inspection on 9/26/11 at 11:30 AM at the Lockport site of the ED revealed:
- 1 Dexon S 6-0 sutures expired 5/11
- 1 cotton umbilical tape expired 7/11
- 1 TriCon 4-0 sutures expired 12/02
- 2 Chromic Gut 2-0 sutures expired 7/11
- 1 BD spinal needle expired 3/11
- 2 Endopath expired 1/11
These findings were verified by Staff #2 on 9/26/11.

Inspection on 9/28/11 at 9:00 AM at the Lockport site in the OR suite #2 revealed:
- 1 Adult NU-TRAKE set expired 2/05

Inspection on 9/29/11 at 10:00 AM at the Lockport site of the OB medication room revealed:
- 10 culture tubes expired 8/11

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 4/25/07.



23054


Based on observation, the facility does not maintain a clean and sanitary environment for linen storage at 1 of 2 sites. (Lockport site)

Findings include:

Observation on 9/26/11 at 2:10 PM during tour of the Reflections Center at the Lockport site revealed the following:
- The Clean Linen Storage room had dust and debris accumulations. Dust was covering the ceiling, walls, and HVAC exhaust diffuser. Debris was built up behind the patient washer and dryer. The linen rack was uncovered and dust had accumulated on the linens.
- Housekeeping equipment and supplies were stored on the floor of the soiled linen closet.

These findings were verified with Staff #4 on 9/26/11.

Based on interview and document review, the facility does not ensure infection control standards are implemented per manufacturer's instructions for surgical sterilization and per a hospital-wide infection prevention and control program at 2 of 2 sites. (Lockport and Newfane sites)

Findings include:

Interview on 9/27/11 at 2:10 PM with Staff #14 revealed Eye Kits (surgical eye instrument packages) at the Lockport site are run through the AMSCO Steam Sterilizer "unwrapped" on the Pre Vacuum setting, providing 4 minutes of sterilizing temperature of 270 degrees Farenheit with no dry time. Review of the AMSCO Operation Manual Techniques of Sterilization revealed in an "Express Cycle" (Flash), a wrapper must be on the instrument tray. Review of the Phaco Hand piece care and cleaning manual revealed the products are required to be wrapped. Furthermore, the manual states the Express or Flash Sterilization cycle is to be used only in emergency situations. Review of the facility's "Policy for Packaging Materials Used in CSR/OR" revealed all sterilized packages must be wrapped.
THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 4/25/07.

Observation on 9/27/11 at 2:45 PM during tour of the Lockport site revealed carpet glued on the bottom of endoscope storage cabinets. Carpet is not easily cleanable material. This finding was verified with Staff #14 on 9/28/11.

Observation on 9/27/11 at 2:45 PM during tour of the Lockport site revealed dead insects on the floor and dust accumulations on the exhaust diffuser and sterilizer table in the Gas Sterilization room. This finding was verified with Staff #15 on 9/27/11.

Observation on 9/29/11 at 3:15 PM during tour of the Newfane site revealed countertops in the soiled processing room and clean processing room of the operating room suite were missing laminated surfaces on the sides of the counters. This finding was verified with Staff #14 on 9/29/11.