HospitalInspections.org

Based on review of contracted services, the facility failed to renew expired contracts in a timely manner.

Findings include:

Two contracts with outside agencies expired.

1. The Radiation Therapy Service Agreement (Yonkers Radiation Medical Practice) was executed and signed on 10/1/04 and according to the contract, was in effect for 2 years with an automatic renewal for an additional 1 year. Therefore, the contract expired on 10/1/07.

2. The St. John's Radiological Associates, LLP contract was executed and signed on 9/1/04 and according to the contract, was in effect for 5 years. Therefore, the contract expired on 9/1/09.

3. Interview with Staff #1, on 3/25/11, revealed that there are ongoing negotiations with all parties involved in the expired contracts and there were no other current executed contracts or memoranda of understanding in effect.

Based on document reviews and staff interviews, the facility did not show measurable improvement in indicators for which there is evidence that it will improve health outcomes.

Findings include:

On 3/23/11 at 4:20 PM, Staff #1 stated that not all the departments at the facility were submitting data to QAPI and a list of indicators being reviewed by the Quality Assurance and Performance Improvement Program (QAPI) at the facility was not available for review. Staff #1 also stated that the Medical /Surgical Departments are undergoing corporate culture revamping that will ensure that the departments are represented in QAPI.

A review of the documents reveal that the following departments having direct relationship with improving the health outcomes of patient care did not submit data to QAPI: Medical, Surgical, Housekeeping, Dialysis, Engineering, and Central supplies. The Environment of Care Committee also did not submit data or report to QAPI for review. The following studies were also not submitted to QAPI as indicators for improving patient care: Mortality reviews, and Grievances/Complaints.

A review of the facility's QAPI program description "Plan for Improving Organization Performance" revised 01/09, revealed that it stated on page 1 in #3 under Goal Statement: "To this end, the Governing Body has established a hospital-wide Performance Improvement Program.".

During the pre-exit summation with Staff #1 and Staff #4 on 3/28/11 at 3:07 PM, Staff #4 stated: "Is it required that I have all departments involved in QA?"
The facility failed to ensure that all the departments and programs were involved in QAPI by having them select indicators to collect data that will lead to improved health outcomes for the patients.

Based on document reviews and staff interviews, the hospital did not ensure that all hospital services, programs, and operations collect and measure data, analyze and track quality indicators and other aspects of performance that assess processes of care.

Findings include:

SEE CITATIONS AT A0265

Based on facility document reviews and staff interviews, the facility did not ensure that quality indicator data, including patient care data and other relevant data, for example, information submitted to or received from the hospital's Quality Improvement Organization, were incorporated into the program.

Findings include:

On 3/23/11 to 3/24/11, the facility QAPI documents were reviewed for the period January 2010 to March 2011. During the review, it was revealed that the infection control officer submitted data to QAPI regularly as scheduled. However, there was no data related to surgical operations or infections in the documents submitted to QAPI. On 3/24/11, Staff #1 was asked if such a document was available for review. Staff #1 submitted the document for review on 3/25/11.

A review of the document showed that data was collected by relevant categories from the 1st quarter of 2010 to the last quarter, but there was no analysis of the data and no trending, and no corrective plans were identified for organisms that were repeatedly identified.

Based on facility document reviews and staff interviews, the facility did not ensure that data collected was used to monitor the effectiveness of service and quality of care.

Findings include:

SEE CITATIONS AT A0274

Based on facility document reviews and staff interviews, the hospital governing body did not ensure that the frequency of reporting was specified for all departments, programs and services.

Findings include:

On 3/23/11 during the review of the facility QAPI documents, the reporting calendar was requested from Staff #1. Staff #1 presented the document " Performance Improvement Calendar " for review on 3/24/11.

A review of the document showed that not all the departments, programs, and divisions of the hospital were scheduled to participate in and report patient-related data to QAPI.

Based on document reviews and staff interviews, the facility did not ensure that the QAPI program was implemented and maintained as defined.

Findings include:

1) The St. John's Riverside Hospital " Plan for Improving Organization Performance " revised 1/09, stated in the Goal Statement that the Governing Body has established a hospital-wide Performance Improvement Program. However, document reviews showed that not all the programs, divisions, and departments hospital-wide reported data to QAPI as defined in the Plan.
2) The Goal Statement further stated in the 1st bullet that it will identify and prevent less than optimal outcome from medical, dental, and podiatric management. These departments did not have selected indicators to study and did not submit reports to QAPI.
3) The Plan further stated in the 4th bullet that it will develop design, measurement, assessment and improvement methodologies, and educate staff about them.
This was not performed as the Housekeeping department ' s quality control survey document was not developed into statistical data that could be submitted to QAPI, and the data was not submitted to QAPI. The data collection tool was not tallied, analyzed, or trended as appropriate.

When the evidence of the involvement of Housekeeping Department and other departments in QAPI was requested, Staff #1 provided the data collection tool. Staff #1 also stated that Housekeeping reported to the Environment of Care Committee. A review of the Environment of Care Committee's meeting minutes showed that the data collected were not incorporated into the minutes. The Environment of Care Committee did not submit data to QAPI but reported to the Board via House and Grounds. A review of the Board minutes did not show data related to the Housekeeping Department under the sub topic.
4) The 10th bullet point of the Plan stated: To identify opportunities to improve the performance of major functions within the hospital. This was not acted upon as evidenced by the SSI (Surgical Site Infection) report. The report was submitted for review upon request as it was not a part of the report from the infection control nurse to QAPI.

Upon the review of the SSI report which covered the 4 quarters of the year 2010, it was found there were no analyses of the findings. The data compiled did not compare the findings to the total population surveyed to establish a performance/incidence statistical baseline for future occurrences. The data did not analyze the reason for the frequent occurrence of E.fecalies organisms for surgeries performed in certain operating rooms, by certain surgeons, and for certain procedures.
5) Structure /organization. The Plan stated: "The Medical Staff, through its officers, departments, and committee, is accountable for the delivery and evaluation of medical staff performance and activity as well as improving patient care processes and outcomes" . Except for data submitted by the Emergency and Anesthesia departments to QAPI, data was not submitted by Medical and Surgical departments. A review of the Medical Board Minutes from March 2010 to February 2011 did not present data in a statistical format and did not analyze data related to patient care outcomes.

Based on medical record reviews, interviews, and policy reviews, it was determined the facility failed to ensure that verbal orders were authenticated by the prescribing physicians. This was seen in 2 of forty medical records reviewed, MR #15 and 25.

Findings include:

1. A review of MR #15 on 3/23/11 at 11:00 AM, revealed that 3 telephone orders written on 3/16/11 had not been authenticated by a physician. The facility's telephone orders policy states telephone, verbal or faxed orders must be authenticated within forty-eight hours. These findings were verified by Staff #5 at the time of review.

2. In MR #25, the patient had been discharged from the facility on 3/21/11, however, at least 8 verbal orders reviewed on 3/24/11 had not been authenticated by a physician at the time of review.

Based on observations and staff interviews, it was determined that expired, drugs, items and biologicals were available for patient use.

Findings include:

1. During a random sample of drugs inspected in the pharmacy at the Dobbs Ferry site on 3/24/11 at 3:55 PM, a tube of Gentamicin 0.1% ointment was noted to have an expiration date of 12/10. This was witnessed by Staff # 6, the Director of Pharmacy at that time.

2. On the medical surgical unit at the Dobbs Ferry location on 3/24/11 at 3:35 PM, two pre-filled 10 cc syringes of Normal Saline solution were noted to have an expiration date of 2/11 on the code cart. In addition, there were two 16 gauge angiocatheters with an expiration date of 2/11 on the code cart. These findings were witnessed by Staff # 7 at that time.

3. During tours on 3/23/10 beginning at 2:33 PM to 2:35 PM at the Hope Center, noted in room #2 were thirteen white top blood tubes with an expiration date of 2/11. In room 4, there were two red top covered blood tubes and several white top blood tubes were noted to have expired on 2/11. Similar findings were noted in room #5. These findings were witnessed by Staff #8 at that time.

4. Observed in the cardiac catheterization lab at the St. John's Andrus Pavilion on 3/22/11 at 1:30 PM, were approximately eighty purple top covered blood tubes with an expiration date of 12/10. This finding was witnessed by Staff #1 at that time.

5. In the ED at the St. John's Andrus Pavilion at 10 :55 AM on 3/21/11, two 10 ml NaCL pre-filled syringes, two yellow top blood tubes and at least 8 blue top blood tubes, were observed on the pediatric code cart, all of which had expired on 2/11. On the adult code cart were one 100 cc bag of 5% Dextrose Water and one 100 ml bag of 0.9% NaCl solution, both of which had been used but had not been discarded. These findings were witnessed by Staff #2 at that time.


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6. Based on observation of the hospital's environment, the following outdated or otherwise unusable drugs and biologicals were observed in the following areas:

a. Intensive Care Unit (ICU)
On 3/21/11 between 11:50AM and 12:00PM witnessed by Staff #18 and 19 were found:
1) 2 size 10 fenestrated trache cuffed tubes with the expiration dates of 02/2011, 1 size 8 with expiration date of 02/2010 and 1 size 9 with the expiration date of 02/2011.
2) Airways, Y connectors and 5 in one connectors that were unwrapped and kept in dusty bins in the storage area.
3) 1 blood culture procedural tray that was opened and left in storage for possible later use.
4) 2 bottles of 1000cc Ringers Lactate IV solutions with the expiration dates of January 2011.
5) 1 bottle of 1000cc Plasma Lyte 56 and Dextrose 5% with the expiration date of November 2010.
6) 1 bottle of 1000cc Potassium Chloride 30 meq with the expiration date of December 2010.
b. Laboratory
On 3/21/11 at 12:10AM to 12:45PM witnessed by Staff # 18 and 20 were found:
1) 1 bottle of 1500cc of opened Normal Saline dated 2/10/11 still in use to titrate specimens in the Chemistry lab.
2) 1 bottle of DIUF water opened on 3/1/11
3) 7 blue Vacutainers, 2 of which expired 05/10, another 2 expired 07/10 and 3 expired on 08/2010.
4) 4 yellow Vacutainers with the expiration dates of 09/2010 and 2 green Vacutainers with the expiration dates of 01/2011.
c. Radiology
On 3/21/11 between 3:25PM and 4:00PM witnessed by Staff #15, 18 and 23 were found in the code cart located in the hallway alcove area in the department:
1) 1 20 G x 1.6 x 1.1 x 30m Angiocath with the expiration date of 12/2010.
2) 1 22G x1 ? Monoject Safety needle with the expiration date of 07/2010.
3) Foley cath tray with the expiration date of 08/2010.
4) 1 Easy cap II CO2 detector with the expiration date of 02/2011.
5) 1 Adult Plus Multifunction electrode pads with the expiration date of 08/2010.
6) 1 16G x 1.16 x 1.7 x 30m Instyle Autoguard with the expiration date of 09/2009.
d. Dialysis
On 3/22/11 between 10:00AM and 12:00PM witnessed by Staff #18 and 24 were found:
1) 4 blood culture procedure trays that were opened and kept in storage.
2) 1 blue Vacutainer with the expiration date of 12/2010.
3) 3 red Vacutainers with the expiration date of 02/2011.
e. Pharmacy
On 3/22/11 between 2:00PM and 2:45PM witnessed by Staff #17, 18 and 22 were found:
1) Aluminum Acetate 16 fl.oz. topical solution with the expiration date of 12/2010.
2) Alkalol ? in water opened with no date of the expiration of the mixture.
3) 15 bags of 500ml IV solution of D5/NS; 13 bags had expired in November, 2010, 2 bags expired in July 2010.
4) 6 bags of 500mls of IV solution with 25,000 units of Heparin per bag (50units/ml) with the expiration date of 1/3/2011.

Based on observation, staff interview and review of the dietary policy and procedures, the facility failed to provide dietary and food services according to the current standards of practice.

Findings include:

During observation and inspection of the kitchen, cafeteria, and food service areas conducted on 3/21/11 through 3/28/11, staff interview, and review of the dietary policies and procedures manual, the following items were noted:

1. During the tours of the dietary areas on 3/21/11 through 3/28/11, cracked and damaged floor tiles were observed throughout the kitchen areas, creating a harborage for insects, and unsanitary and unsafe conditions.

2. During the tour of the kitchen on 3/21/11, a food preparation sink did not have an indirect drain.

3. During the tour of the kitchen on 3/28/11 at 12:10PM, it was observed that two silver fire extinguishers that were hung on the wall, were being blocked by tray carts, preventing unobstructed access to the fire extinguishers.

4. During the tour of the kitchen on 3/28/11 at 12:15PM, the water temperature of the handwashing sink, located near the small paper storeroom, was recorded at 172 degrees F.

5. On 3/21/11, the concentration of the sanitizing solution in the buckets throughout the kitchen was checked using chemical test strips and was found to be excessively high (400ppm). Chemicals used for sanitizing are not to have concentrations which will leave toxic residues on surfaces treated.

6. On 3/21/11, the exhaust hoods over the oven and grill areas were excessively soiled. According to Staff #3, the hoods are cleaned quarterly by an outside contractor. According to the documented tag, the hoods were last cleaned on November 11, 2010.

7. On 3/21/11, the desserts in the reach-in refrigerator were not covered.

8. The exhaust fans located in the outside wall contained gaps and openings to the outside, creating an entrance for insects and rodents to enter the kitchen.

9. On 3/21/11, the reach-in coffee refrigerator had a hole in the door and was in need of repair.

10. On 3/21/11, the inside bottom floor of the reach-in freezer was dirty.

11. On 3/21/11 at 11:15AM, the temperature of the custard desserts in the walk-in produce refrigerator were recorded at above 50 degrees F. The temperature of two milk containers in the same refrigerator were recorded at 48 degrees F and 44 degrees F. Review of the policy entitled, "SJRH HACCP Program" states, "A key aspect of food safety is keeping food out of the danger zone, which is between 40-140 degrees." Under the "Criteria for Control" section, "All food, raw or cooked, held at <41 degrees F." The policy entitled, "Storage of Leftovers" states, "After cooking, food will be maintained above 140 degrees or below 40 degrees until it is needed the day of preparation."

12. On 3/23/11 at 11:45AM, the temperature of the sundried tomato sauce for the crab cakes, located in the cafeteria steam table, was recorded at 130 degrees F. Review of the policy entitled, "SJRH HACCP Program" states, under "Criteria for Control" section, "Food for cafeterias is 140 degrees at time of service."

13. On 3/21/11, the floor of the "food bank" walk-in refrigerator was damaged and in need of repair.

14. On 3/21/11, the sealer machine was dirty and the belt was torn and in need of repair.

15. On 3/21/11 at 11:30AM, the "cleaned" slicing machine contained food debris and was not covered while not in use.

16. On 3/21/11, clean pans were stacked wet and were not being properly air dryed.

17. On 3/21/11, the floors under and around the kitchen equipment were dirty and contained debris.

18. The fire extinguishers in the kitchen were last checked on 12/28/10 according to the tags. The fire extinguishers are to be checked monthly.

19. On 3/21/11, the ceiling tiles above the potwashing area were not securely placed in their tracks, creating openings.

20. On 3/21/11, some of the ceiling tiles in the main store room were stained.

Based on observations, staff interviews and document reviews, it was determined that the facility failed to maintain a safe, sanitary and comfortable environment to ensure that the safety and well-being of patients are not compromised.

Findings include:

1. During observations of the patient floors/areas in Park Care Pavilion from 03/23/11 to 03/24/11 between 10:30 AM to 4:00 PM, it was noted that the grills/heating elements of some heating/air-conditioning units in patient rooms/corridors (such as rooms on the 6th, 5th and 3rd floors) exhibited accumulation of dirt and dust in the grills and around the floor perimeters beneath their edges. Trash (such as paper, candy wrappers and pencil) was found inside the air-conditioning/heating unit resting directly on the heating filament. Furthermore, the filter of the air-conditioning units were also noted getting detached from underneath the unit and lying on the floor (for example, room #664).

All findings were verified with Staff #25 and Staff #26 at the time of observation.

2. During observations from 03/23/11 to 03/25/11 between 10:30 AM to 4:00 PM, it was noted that the exhaust ventilation vents in different areas of Park Care and Dobbs Ferry pavilion were very dirty, which leads to environmental contamination. Examples include but are not limited to:
i. On 03/23/11 at 11:00 AM during the tour of the 6th floor in the Park Care pavilion, it was noted that the exhaust vent in the housekeeping closet was very dirty with a thick accumulation of dirt and dust.

The findings were verified with Staff #25 and Staff #26 at the time of observation.

ii. On 03/25/11 at 11:45 AM during tour observation of the OR suite in the Dobbs Ferry Pavilion, it was noted that the exhaust vents in OR #2 & 3 was very dirty and dusty with excessive dust accumulation.

The findings were verified with Staff #12 at the time of observation.

3. During the survey from 03/21/11 to 03/24/11 between 10:30 AM to 4:00 PM, it was noted that the facility did not ensure that the environment around the premises and the equipment used were maintained in a sanitary condition, and free of dust and dirt to prevent transmission of infection and contamination. Furthermore, the facility did not ensure that the physical plant was kept in good repair to ensure a sanitary environment.

Examples, including but not limited to, are:

a. The electrical closet in the Emergency Department was noted excessively dirty and dusty (Andrus Pavilion).
b. The electrical closet on the 6th floor (Park Care Pavilion) was dirty and dusty.
c. The ceiling tiles in the room #376 (Park Care Pavilion)
d. The floors and walls of Greenburgh Alcohol Center were noted to be in massive disrepair and dirty. The vinyl coving were missing in the day rooms revealing the underneath structure. The floors were broken in many areas. Furthermore, at the time of survey on 03/23/11 at 3:30 PM, no hot water was present at the handwash sink.
e. The MD treatment table in the detox admitting suite (Park Care Pavilion) had torn upholstery.
f. Use of sticky tape was found in many places around the facility. Tapes were found stuck on stretchers, OR door, upholstery of chairs/mattresses and similar other places. If tape and its sticky residues are not cleaned properly, they are a means of cross-contamination.
g. The chair and the floor in the Dental treatment room (Park Care Pavilion) was noted dusty and dirty.
h. The floor and corners of the Laboratory in Dobbs Ferry Pavilion were noted very dirty and dusty.

All findings were verified with Staff #25, Staff #26 and other unit staffs at the time of observation.

4. During the survey from 03/21/11 to 03/24/11 between 10:30 AM to 4:00 PM, it was observed that several ceiling tiles on different floors of the hospital showed signs of old leaks. Examples include, but are not limited to:
a) Four-five ceiling tiles in the Pharmacy at Park Care were stained and dirty.
b) Many ceiling tiles at Greenburgh Alcohol Center were noted stained and dirty.

All findings were verified with Staff #25 at the time of observation.

NOTE: If ceiling tiles are not replaced and stay humid/wet, they may harbor the growth of mold/fungi and contribute to environmental contaminants. Also, stained ceiling tiles need to be investigated for potential leaks above, as it may be an indication of a problem with the plumbing/sprinkler system or of insufficient insulation around the steam pipes supplying heating to the facility.

5. During the survey on 03/28/11 at 11:00 AM, it was determined that the facility failed to ensure that the facility's environment remains free from accident hazards to the staff and patients. The facility did not ensure that the temperature of hot running water at the hand wash sink in the kitchen used by the staff, was maintained at acceptable levels [not to exceed 110 degrees Fahrenheit (F)] to prevent potential burns. Hot water temperature of 175*F was noted in the kitchen.

Findings were verified by Staff #1.

6. The kitchen and dietary area were not maintained to ensure an acceptable level of safety and quality for the patients and staff.
See A 620.

7. Two radiators on a patient unit were not maintained in good repair. On 3/23/11 at 10:35 AM, 2 radiators in the day room on 3 East at the Andrus Pavilion were noted to be emitting steam. One of the radiators had been covered with sheets in an attempt to prevent physical harm to the patients. This was witnessed by Staff #5 at that time.

8. Air conditioner units were missing covers. On unit 3 East at the Park Care Pavilion, in room 349 on 3/23/11 at 10:53 AM, the air conditioner unit was noted to be missing the cover and instead, the unit was covered with a towel and a sheet. Also, on the unit at that time, the air conditioner unit in room 351 was also missing its cover. This finding was also noted in other rooms on the unit. These findings were witnessed by Staff #5 at that time.

9. On 3/21/11 at approximately 3:00PM, during a tour of the maternity unit, sharps containers were observed in patient rooms 324 and 326 on the counter and therefore were not locked or secured to a wall. Interview with Staff #17 on 3/21/11 at 3:15 PM, confirmed that the sharps containers were not secured in all the patient rooms on the maternity unit.

10. On 03/21/11 at 2:45 PM, it was noted that the electrical outlets in the Pediatric waiting area of the Radiology Department were not tamper proof.

Based on observations, record reviews and staff interviews, it was determined that the facility failed to meet the applicable provisions of the Life Safety Code, NFPA 101, 2000 edition.

The findings include:

During the survey of the facility from March 21-28, 2011, Life Safety Code deficiencies were noted in multiple areas of the Code requirements and were cited under the following Fire/Life Safety Code K-Tags:

K-12 (Structural elements not completely protected /fire proof);
K-34( Guard rails of the stairs had gaps more than 4 inches);
K-46 (Maintenance of Emergency Battery power backup lights for off-site clinic locations could not be verified);
K-50 (Fire drill not performed under varying conditions);
K-52 (Fire alarm system not inspected as per NFPA 72):
K-62 (Sprinkler system not tested as per NFPA);
K-64 (Portable fire extinguishers not easily accessible in all areas);
K-67 (Fire dampers not maintained in operational condition);
K-69 (Kitchen hood reports not reviewed to ensure compliance);
K-77 (Medical gases not maintained in reliable condition);
K-104 (Penetrations in smoke/fire barriers not completely sealed/protected);
K-130 (Generator room had no battery back up light and had storage of combustibles);

Based on observation and interview, it was determined that regulated medical waste was not secured and handled in a manner to prevent unauthorized access (as required by State law, thus Federal).

Findings include:

On 03/24/11 at approximately 02:45 AM, the storage area for the medical waste was inspected. Numerous plastic bins labeled regulated medical waste were noted in the storage room. These bins were full and waiting to be loaded/transported. This area was unsupervised at the time of inspection. It was noted that the storage area was accessible for unauthorized access from outside since the door had a padlock which was not latched positively. Findings were verified with Staff #30.

Based on observation and staff interviews, it was determined that the facility did not ensure that proper humidity levels were provided and monitored in the ORs and that proper ventilation was provided to other areas of the building. Furthermore, the facility failed to accurately monitor negative pressure in the isolation rooms.

Findings include:

1(a) During observations of the ORs of Dobbs Ferry Pavilion on 03/25/11 at 10:40 AM, it was noted that the humidity monitor/gauge in OR#1 was indicating humidity level below 10%. A similar finding was noted in OR #2 and 16% humidity in OR #3. On interview regarding how the humidity was monitored, Staff #12 was interviewed regarding how the temperature and humidity are monitored. Staff #12 stated that the nursing staff takes the temperature and humidity at the beginning of each surgery day.

NOTE: During observation, a procedure for Laparoscopic Gastric Binding was being done in OR #2, and a procedure for Knee Orthoscopy was being done in OR #3.

(b) Staff #12 was requested to provide the humidity log for the month of March 2011. During review at that time, it was noted that the humidity in OR #1 was 12% on 03/24/11. Staff #12 stated that she had notified the Engineering Department and it was looking at the issue to resolve it.
Later that day, Staff #30 was interviewed regarding the action taken to correct low humidity . Staff #30 stated he was not aware of the issue and also he was not aware 'IF' humidity was being regulated in the ORs. Staff #30 (employee in the facility for many years) stated that he will need to check on this matter. Staff #26 (recently employed in the facility) stated that there must be a method and it is not possible that humidity is not being provided and maintained in ORs.

(c) On 03/25/11 at 2:45 PM, Staff #5 accompanied the surveyor with an independent humidity monitoring device. It was noted that the humidity in all three ORs was between 11-15%. The values were not in the range of 20-60% as per AIA Table 2 and CDC guidelines. This leads to the conclusion that the humidity monitor devices installed in OR #1 and OR #2 were out of calibation/not accurate.

On 03/28/11 at 11:00 AM, Staff #25 and Staff #26 stated that the ORs in Dobbs Ferry Pavilion are provided with a humidity control mechanism and that the facility will look into the issue of bringing the humidity up to the required range.

Furthermore, this surveyor was provided with the temperature and humidity logs for Dobbs Ferry Pavilion ORs for the year 2010. No discrepancy was noted in the logs. However, keeping in mind that the humidity monitors were not accurate at the time of survey, and Staff #30 was not aware of any humidity regulating/monitoring mechanism, it cannot be determined if the humidity was always in the correct range last year during surgical procedures to control infection control issues.

2.(a) On 03/25/11 at 12:15 PM, during observation of the isolation room in the Emergency Room, Staff #29 was unaware how the negative pressure is attained and maintained in the room. Staff # 29 stated that the room is a dedicated air-borne isolation room, thus it must have continuous negative air pressure. Staff #30 indicated a toggle switch by the door that turns the negative pressure on. If the switch is not turned on, the room does not have negative pressure since the exhaust is not on.

(b) During the survey of the Med/Surg unit of Dobbs Ferry Pavilion on 03/24/11, it was noted that the two isolation rooms did not exhibit negative air pressure after performing a simple tissue test to check air flow. Staff #30 stated that these two rooms were on continuous exhaust, and thus should have negative air-pressure at all times.

Furthermore, it was noted that the pressure monitor outside the rooms was indicating negative pressure (As per Staff #30, green color on monitor means room has negative pressure). At the time of survey, it could not be determined the monitor was not working or if there was any other reason for the discrepancy.

3. During the survey, of Park Care (PC) Pavilion and Dobbs Ferry(DF) from 03/23/11 to 03/25/11 between 11:00 AM to 4:00 PM, it was noted that non-patient areas that may contribute to the spread of infections/contamination did not have the required ventilation/air-pressure as per AIA 1996-97 Table 2.
Examples include, but are not limited to, the following:
a) Soiled Utility Room on the 3rd floor (PC) had neutral pressure instead of negative.
b) Soiled Utility room on the 6th floor (PC) had positive pressure instead of negative
c) Clean Sterile Supply (DF) had negative pressure instead of positive.
d) Clean Utility room on 2nd floor (DF )in Med/Surg had neutral pressure instead of positive.

Findings were verified with Staff #25 and Staff #26.

It was also noted that on 03/25/11 at 11:15 AM, the sub-sterile room between OR #1 and OR #2 had negative pressure instead of positive. Finding was verified with Staff #12.

A. Based on observations and staff interviews, it was determined that facility's staff failed to provide an environment that would control and minimize infections.

Findings include:

1. Potentially infectious conditions were noted at the facility. Stored in Room #8 which is used for isolation of potentially infectious patients, and to treat pediatric patients in the ED at the Andrus Pavilion on 3/21/11 at 11:05 AM, were at least sixty-four 2 oz bottles of infant Similac formula and twenty-three bottles of 2oz bottles of Pedialyte solution. Also stored in the room was a box of opened clean gloves and at least fifteen VHS tapes. There was also a red top blood tube with an expiration date of 12/10. These findings were acknowledged by Staff #2 at that time.

2. Stored on unit 6 South at the Andrus Pavilion at 2:20 PM on 3/21/11, was an opened box of gloves on each of the 2 sharps containers. A similar finding was also noted at 2:25 PM that day on 6 West at this site. These conditions pose a risk of splatter and contamination of the gloves when used and contaminated sharps are placed in the containers. These findings were observed by Staff #9 at that time.

3. Five splatters of dried blood were noted on the radiology fluoroscopy unit in the corridor of the OR suite on 3/22/11 at 11:00 AM at the Andrus Pavilion. The equipment, which was ready for use, poses a risk of contamination during surgical procedures, since it is the facility's policy to clean equipment after it has been used. Ten minutes later, an excessive amount of residual adhesive from tapes was observed on a cautery machine in a room in this OR suite. This does not facilitate thorough cleaning. These findings were acknowledged by Staff #10 at that time.

4. Observed stored on 7 West on 3/21/11 at 12:15 PM, on each of the 2 sharp containers, was a bag of 100 ml Normal Saline Solution. Similarly, on this unit was an excessive amount of residual adhesive on the isolation cart at that time. These findings were witnessed by Staff #11 at that time.

5. The faucet from the water dispenser in the Fast Track area of the ED in the Andrus Pavilion was observed to be covered with a 4" x 2" tape on 3/21/11 at 10:45 AM. This finding was witnessed by Staff #2 at that time.

6. In the ED of the Dobbs Ferry Site (Rooms 2 and 3), clean and sterile supplies were stored in a location that would potentially facilitate contamination from splashes. The following items were stored in plastic containers which were located near the handwashing sink: opened and closed packets of gauze, bottles of normal Saline Solution, bottles of Betadine Solution, sterile gloves, tongue depressors,bandages and other clean supplies. All of these items are used for patient care. These findings were witnessed by Staff #12 at that time.

7. Food was not stored in a clean environment. Observed stored in a refrigerator that had a significant amount of grayish-colored residue on 3/25/11 at 2:52 PM, at the Alcoholism Treatment Services center in Greenburgh, were at least 4 packages of waffles. This finding was witnessed by Staff #13 at that time.


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B. Based on observations, the infection control officer did not develop a system of controlling infections.

Findings include:

1. On 3/22/11 at 10:00AM to 12:00PM, staff working in the Dialysis unit were observed cannulating patients. Staff #24 was observed cannulating a patient with a left forearm fistula. Staff # 24 was observed changing his gloves 6 times during the cannulation procedure and was observed picking up an item from the floor but never sanitized or washed his hands before donning sterile gloves to perform the cannulation. Upon the completion of the procedure, Staff #24 was reminded that hand hygiene is required every time a fresh pair of gloves is donned during cannulation. Staff #24 responded that he was confused and was familiar with sanitizing or washing his hands only if he moved from one patient to another.

A review of the policy from the Hemodialysis Department on Handwashing revised January 2009, page 1, bullet #4, says: "Hands will be washed immediately or as soon as feasible after removing gloves or other personal protective equipment ... ... "

Similarly, a review of the facility's Infection Control Department "Hand Hygiene "policy # E8 states in the policy statement, bullet #3: " If hands are not visibly soiled, health care personnel must use the hospital provided alcohol based hand rub for routinely decontaminating hands in these clinical situations: Before donning sterile gloves when inserting ... ... ...After contact with a patient's intact skin. After contact with inanimate objects in the immediate vicinity of the patient. Decontaminate hands after removing gloves " .

Staff # 24 touched the patient to take blood pressure, placed a barrier between the patient's arm and the bed, touched the dialysis machine, palpated the fistula site and changed gloves, but did not sanitize his hand. He also failed to sanitize his hand before donning the sterile gloves and performing the actual cannulation procedure.

2. It was also noted that the Dialysis unit kept 4 opened/used blood culture procedure trays in the storage area. During interview with Staff #24, he stated that he was saving the contents for use at a later date.

3. SEE ADDITIONAL FINDINGS AT A0505.


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C. Based on observation and staff interview, it was determined that the facility did not ensure a safe environment consistent with recognized infection control practices, prevention of cross contamination by keeping clean supplies separate/away from dirty areas, and that all patient care equipment is in good repair to prevent infection.

Findings include:

1. On 03/24/11 at 2:45 PM during survey of the Central Sterile supply room at the Dobbs Ferry Pavilion, it was noted that the ceiling tiles in the room were porous/had holes that may retain dirt (they were not monolithic) and thus were not as per AIA 7.28.B8. Such porous ceiling tiles compromise thorough cleaning which is required to keep the environment of Central Sterile as clean/sterile as possible.

a. The Dobbs Ferry Pavilion has 2 isolation rooms located on the Med/Surg units. During observation of these units on 03/24/11, it was noted that the two isolation rooms did not comply with all requirements of Section 7.2.C4 for isolation rooms. Section 7.2.C4 states that 'air borne infection isolation room shall have self-closing devices on all room exit doors'. In addition, the ceiling tiles were made of a porous material that would not minimize the retention of dirt as required by 7.28.B8 and would not be thoroughly washable/cleanable.

Similarly, the isolation room in the Emergency Department lacked non-porous ceiling tiles and also did not have self-closure on the sliding exit doors of the room.

Note: By not having a self-closure at the door, the room will not to be able to maintain optimum negative pressure as required, and may contribute to contamination of the corridor outside the isolation room.

All findings were verified with Staff #25, Staff #26 and Staff #30 at the time of observation.

b. During survey of the 7th floor in Andrus Pavilion on 03/22/11 at 10:30 AM, it was noted that there is no room/arrangement for patients who are immunocompromised/Neutropenic and require protective environment/positive air-pressure room on the Med/Surg floor. As per Staff #11, the facility does treat such patients/community and the procedure has been to use a regular room and use HEPA filters.

Note: As per AIA 7.2.D, the Infection Department needs to assess the community's need for such room based on the frequency/ volume of treatment to such patients, and if the numbers are high enough, should at least provide one such room.

2. On 03/21/11 at 10:30 AM during tour of the Radiology Department (Andrus Pavilion), it was noted that the hot water valves at the handwash sink in the bathroom were not trimmed with healthcare type wrist blades. They were regular valves that require use of hand/pinching/grasping, thus imposing a risk of cross contamination.

3. On 03/25/11 at 11:30 AM during the tour of the OR suite at Dobbs Ferry Pavilion, it was noted that the suite was very dusty and dirty.
a. The floor by the Emergency Exit door had thick accumulation of dust and dirty and similarly, all the perimeters of OR #1 were covered with a thick layer of black dirt. Of special mention is also the ex-magnetic door holder on the floor that is now decommissioned as per Staff #12. This holder had a very thick layer of dust and dirt all around.
b. The attached sub-sterile room also had dust and dirt behind the blanket warmer and the sterilizer.
c. There was a small office in the suite housing clean scrubs. A power strip was noted in that room that had a very thick accumulation of dust, thus environmentally contaminating the clean scrubs.

All findings were shared with Staff #12.

4. On 03/24/11 at 2:30PM during the tour of the Endoscope Processing room at Dobbs Ferry Pavilion, it was noted that the plumbing pipes in the room were very dirty and dusty.

5. On 03/24/11 at 10:30AM during the tour of the Dental Clinic (Park Care Pavilion), it was noted that the facility has not ensured that the flow in the sterilization room/area is from dirty to clean. The dental assistant staff, while explaining the way the instruments are handled and cleaned, kept indicating to and fro movement from a clean to dirty, and dirty to clean area. Finding was verified with Staff #27.

Based on observations and staff interviews, it was determined that the ORs did not have a functional call-in system.

Findings include:

The call-in system in the hospital's off site location at Dobbs Ferry Pavilion in all 3 operating rooms was not functioning on 3/24/11 at 2:25 PM. This finding was confirmed during an interview with Staff #12 at that time.

Based on observations and staff interviews, it was determined that the facility failed to maintain a complete operating room register.

Findings include:

The operating register at the Dobbs Ferry Pavilion was missing the post operative diagnoses of patients who had undergone surgical procedures. On 3/24/11 at 2:35 PM, a review of the OR log revealed that the post operative diagnoses were missing for all fifty-nine entries documented between 3/18/11 and 3/24/11 in the OR log. This finding was witnessed by Staff #12 at that time.

Based on document reviews and staff interviews, the facility did not show measurable improvement in indicators for which there is evidence that it will improve health outcomes.

Findings include:

On 3/23/11 at 4:20 PM, Staff #1 stated that not all the departments at the facility were submitting data to QAPI and a list of indicators being reviewed by the Quality Assurance and Performance Improvement Program (QAPI) at the facility was not available for review. Staff #1 also stated that the Medical /Surgical Departments are undergoing corporate culture revamping that will ensure that the departments are represented in QAPI.

A review of the documents reveal that the following departments having direct relationship with improving the health outcomes of patient care did not submit data to QAPI: Medical, Surgical, Housekeeping, Dialysis, Engineering, and Central supplies. The Environment of Care Committee also did not submit data or report to QAPI for review. The following studies were also not submitted to QAPI as indicators for improving patient care: Mortality reviews, and Grievances/Complaints.

A review of the facility's QAPI program description "Plan for Improving Organization Performance" revised 01/09, revealed that it stated on page 1 in #3 under Goal Statement: "To this end, the Governing Body has established a hospital-wide Performance Improvement Program.".

During the pre-exit summation with Staff #1 and Staff #4 on 3/28/11 at 3:07 PM, Staff #4 stated: "Is it required that I have all departments involved in QA?"
The facility failed to ensure that all the departments and programs were involved in QAPI by having them select indicators to collect data that will lead to improved health outcomes for the patients.

Based on document reviews and staff interviews, the hospital did not ensure that all hospital services, programs, and operations collect and measure data, analyze and track quality indicators and other aspects of performance that assess processes of care.

Findings include:

SEE CITATIONS AT A0265

Based on document reviews and staff interviews, the hospital did not ensure that all hospital services, programs, and operations collect and measure data, analyze and track quality indicators and other aspects of performance that assess processes of care.

Findings include:

SEE CITATIONS AT A0265

Based on facility document reviews and staff interviews, the facility did not ensure that quality indicator data, including patient care data and other relevant data, for example, information submitted to or received from the hospital's Quality Improvement Organization, were incorporated into the program.

Findings include:

On 3/23/11 to 3/24/11, the facility QAPI documents were reviewed for the period January 2010 to March 2011. During the review, it was revealed that the infection control officer submitted data to QAPI regularly as scheduled. However, there was no data related to surgical operations or infections in the documents submitted to QAPI. On 3/24/11, Staff #1 was asked if such a document was available for review. Staff #1 submitted the document for review on 3/25/11.

A review of the document showed that data was collected by relevant categories from the 1st quarter of 2010 to the last quarter, but there was no analysis of the data and no trending, and no corrective plans were identified for organisms that were repeatedly identified.

Based on facility document reviews and staff interviews, the facility did not ensure that data collected was used to monitor the effectiveness of service and quality of care.

Findings include:

SEE CITATIONS AT A0274

Based on facility document reviews and staff interviews, the hospital governing body did not ensure that the frequency of reporting was specified for all departments, programs and services.

Findings include:

On 3/23/11 during the review of the facility QAPI documents, the reporting calendar was requested from Staff #1. Staff #1 presented the document " Performance Improvement Calendar " for review on 3/24/11.

A review of the document showed that not all the departments, programs, and divisions of the hospital were scheduled to participate in and report patient-related data to QAPI.

Based on document reviews and staff interviews, the facility did not ensure that the QAPI program was implemented and maintained as defined.

Findings include:

1) The St. John's Riverside Hospital " Plan for Improving Organization Performance " revised 1/09, stated in the Goal Statement that the Governing Body has established a hospital-wide Performance Improvement Program. However, document reviews showed that not all the programs, divisions, and departments hospital-wide reported data to QAPI as defined in the Plan.
2) The Goal Statement further stated in the 1st bullet that it will identify and prevent less than optimal outcome from medical, dental, and podiatric management. These departments did not have selected indicators to study and did not submit reports to QAPI.
3) The Plan further stated in the 4th bullet that it will develop design, measurement, assessment and improvement methodologies, and educate staff about them.
This was not performed as the Housekeeping department ' s quality control survey document was not developed into statistical data that could be submitted to QAPI, and the data was not submitted to QAPI. The data collection tool was not tallied, analyzed, or trended as appropriate.

When the evidence of the involvement of Housekeeping Department and other departments in QAPI was requested, Staff #1 provided the data collection tool. Staff #1 also stated that Housekeeping reported to the Environment of Care Committee. A review of the Environment of Care Committee's meeting minutes showed that the data collected were not incorporated into the minutes. The Environment of Care Committee did not submit data to QAPI but reported to the Board via House and Grounds. A review of the Board minutes did not show data related to the Housekeeping Department under the sub topic.
4) The 10th bullet point of the Plan stated: To identify opportunities to improve the performance of major functions within the hospital. This was not acted upon as evidenced by the SSI (Surgical Site Infection) report. The report was submitted for review upon request as it was not a part of the report from the infection control nurse to QAPI.

Upon the review of the SSI report which covered the 4 quarters of the year 2010, it was found there were no analyses of the findings. The data compiled did not compare the findings to the total population surveyed to establish a performance/incidence statistical baseline for future occurrences. The data did not analyze the reason for the frequent occurrence of E.fecalies organisms for surgeries performed in certain operating rooms, by certain surgeons, and for certain procedures.
5) Structure /organization. The Plan stated: "The Medical Staff, through its officers, departments, and committee, is accountable for the delivery and evaluation of medical staff performance and activity as well as improving patient care processes and outcomes" . Except for data submitted by the Emergency and Anesthesia departments to QAPI, data was not submitted by Medical and Surgical departments. A review of the Medical Board Minutes from March 2010 to February 2011 did not present data in a statistical format and did not analyze data related to patient care outcomes.

Based on observations and staff interviews, it was determined that expired, drugs, items and biologicals were available for patient use.

Findings include:

1. During a random sample of drugs inspected in the pharmacy at the Dobbs Ferry site on 3/24/11 at 3:55 PM, a tube of Gentamicin 0.1% ointment was noted to have an expiration date of 12/10. This was witnessed by Staff # 6, the Director of Pharmacy at that time.

2. On the medical surgical unit at the Dobbs Ferry location on 3/24/11 at 3:35 PM, two pre-filled 10 cc syringes of Normal Saline solution were noted to have an expiration date of 2/11 on the code cart. In addition, there were two 16 gauge angiocatheters with an expiration date of 2/11 on the code cart. These findings were witnessed by Staff # 7 at that time.

3. During tours on 3/23/10 beginning at 2:33 PM to 2:35 PM at the Hope Center, noted in room #2 were thirteen white top blood tubes with an expiration date of 2/11. In room 4, there were two red top covered blood tubes and several white top blood tubes were noted to have expired on 2/11. Similar findings were noted in room #5. These findings were witnessed by Staff #8 at that time.

4. Observed in the cardiac catheterization lab at the St. John's Andrus Pavilion on 3/22/11 at 1:30 PM, were approximately eighty purple top covered blood tubes with an expiration date of 12/10. This finding was witnessed by Staff #1 at that time.

5. In the ED at the St. John's Andrus Pavilion at 10 :55 AM on 3/21/11, two 10 ml NaCL pre-filled syringes, two yellow top blood tubes and at least 8 blue top blood tubes, were observed on the pediatric code cart, all of which had expired on 2/11. On the adult code cart were one 100 cc bag of 5% Dextrose Water and one 100 ml bag of 0.9% NaCl solution, both of which had been used but had not been discarded. These findings were witnessed by Staff #2 at that time.


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6. Based on observation of the hospital's environment, the following outdated or otherwise unusable drugs and biologicals were observed in the following areas:

a. Intensive Care Unit (ICU)
On 3/21/11 between 11:50AM and 12:00PM witnessed by Staff #18 and 19 were found:
1) 2 size 10 fenestrated trache cuffed tubes with the expiration dates of 02/2011, 1 size 8 with expiration date of 02/2010 and 1 size 9 with the expiration date of 02/2011.
2) Airways, Y connectors and 5 in one connectors that were unwrapped and kept in dusty bins in the storage area.
3) 1 blood culture procedural tray that was opened and left in storage for possible later use.
4) 2 bottles of 1000cc Ringers Lactate IV solutions with the expiration dates of January 2011.
5) 1 bottle of 1000cc Plasma Lyte 56 and Dextrose 5% with the expiration date of November 2010.
6) 1 bottle of 1000cc Potassium Chloride 30 meq with the expiration date of December 2010.
b. Laboratory
On 3/21/11 at 12:10AM to 12:45PM witnessed by Staff # 18 and 20 were found:
1) 1 bottle of 1500cc of opened Normal Saline dated 2/10/11 still in use to titrate specimens in the Chemistry lab.
2) 1 bottle of DIUF water opened on 3/1/11
3) 7 blue Vacutainers, 2 of which expired 05/10, another 2 expired 07/10 and 3 expired on 08/2010.
4) 4 yellow Vacutainers with the expiration dates of 09/2010 and 2 green Vacutainers with the expiration dates of 01/2011.
c. Radiology
On 3/21/11 between 3:25PM and 4:00PM witnessed by Staff #15, 18 and 23 were found in the code cart located in the hallway alcove area in the department:
1) 1 20 G x 1.6 x 1.1 x 30m Angiocath with the expiration date of 12/2010.
2) 1 22G x1 ? Monoject Safety needle with the expiration date of 07/2010.
3) Foley cath tray with the expiration date of 08/2010.
4) 1 Easy cap II CO2 detector with the expiration date of 02/2011.
5) 1 Adult Plus Multifunction electrode pads with the expiration date of 08/2010.
6) 1 16G x 1.16 x 1.7 x 30m Instyle Autoguard with the expiration date of 09/2009.
d. Dialysis
On 3/22/11 between 10:00AM and 12:00PM witnessed by Staff #18 and 24 were found:
1) 4 blood culture procedure trays that were opened and kept in storage.
2) 1 blue Vacutainer with the expiration date of 12/2010.
3) 3 red Vacutainers with the expiration date of 02/2011.
e. Pharmacy
On 3/22/11 between 2:00PM and 2:45PM witnessed by Staff #17, 18 and 22 were found:
1) Aluminum Acetate 16 fl.oz. topical solution with the expiration date of 12/2010.
2) Alkalol ? in water opened with no date of the expiration of the mixture.
3) 15 bags of 500ml IV solution of D5/NS; 13 bags had expired in November, 2010, 2 bags expired in July 2010.
4) 6 bags of 500mls of IV solution with 25,000 units of Heparin per bag (50units/ml) with the expiration date of 1/3/2011.

A. Based on observations and staff interviews, it was determined that facility's staff failed to provide an environment that would control and minimize infections.

Findings include:

1. Potentially infectious conditions were noted at the facility. Stored in Room #8 which is used for isolation of potentially infectious patients, and to treat pediatric patients in the ED at the Andrus Pavilion on 3/21/11 at 11:05 AM, were at least sixty-four 2 oz bottles of infant Similac formula and twenty-three bottles of 2oz bottles of Pedialyte solution. Also stored in the room was a box of opened clean gloves and at least fifteen VHS tapes. There was also a red top blood tube with an expiration date of 12/10. These findings were acknowledged by Staff #2 at that time.

2. Stored on unit 6 South at the Andrus Pavilion at 2:20 PM on 3/21/11, was an opened box of gloves on each of the 2 sharps containers. A similar finding was also noted at 2:25 PM that day on 6 West at this site. These conditions pose a risk of splatter and contamination of the gloves when used and contaminated sharps are placed in the containers. These findings were observed by Staff #9 at that time.

3. Five splatters of dried blood were noted on the radiology fluoroscopy unit in the corridor of the OR suite on 3/22/11 at 11:00 AM at the Andrus Pavilion. The equipment, which was ready for use, poses a risk of contamination during surgical procedures, since it is the facility's policy to clean equipment after it has been used. Ten minutes later, an excessive amount of residual adhesive from tapes was observed on a cautery machine in a room in this OR suite. This does not facilitate thorough cleaning. These findings were acknowledged by Staff #10 at that time.

4. Observed stored on 7 West on 3/21/11 at 12:15 PM, on each of the 2 sharp containers, was a bag of 100 ml Normal Saline Solution. Similarly, on this unit was an excessive amount of residual adhesive on the isolation cart at that time. These findings were witnessed by Staff #11 at that time.

5. The faucet from the water dispenser in the Fast Track area of the ED in the Andrus Pavilion was observed to be covered with a 4" x 2" tape on 3/21/11 at 10:45 AM. This finding was witnessed by Staff #2 at that time.

6. In the ED of the Dobbs Ferry Site (Rooms 2 and 3), clean and sterile supplies were stored in a location that would potentially facilitate contamination from splashes. The following items were stored in plastic containers which were located near the handwashing sink: opened and closed packets of gauze, bottles of normal Saline Solution, bottles of Betadine Solution, sterile gloves, tongue depressors,bandages and other clean supplies. All of these items are used for patient care. These findings were witnessed by Staff #12 at that time.

7. Food was not stored in a clean environment. Observed stored in a refrigerator that had a significant amount of grayish-colored residue on 3/25/11 at 2:52 PM, at the Alcoholism Treatment Services center in Greenburgh, were at least 4 packages of waffles. This finding was witnessed by Staff #13 at that time.


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B. Based on observations, the infection control officer did not develop a system of controlling infections.

Findings include:

1. On 3/22/11 at 10:00AM to 12:00PM, staff working in the Dialysis unit were observed cannulating patients. Staff #24 was observed cannulating a patient with a left forearm fistula. Staff # 24 was observed changing his gloves 6 times during the cannulation procedure and was observed picking up an item from the floor but never sanitized or washed his hands before donning sterile gloves to perform the cannulation. Upon the completion of the procedure, Staff #24 was reminded that hand hygiene is required every time a fresh pair of gloves is donned during cannulation. Staff #24 responded that he was confused and was familiar with sanitizing or washing his hands only if he moved from one patient to another.

A review of the policy from the Hemodialysis Department on Handwashing revised January 2009, page 1, bullet #4, says: "Hands will be washed immediately or as soon as feasible after removing gloves or other personal protective equipment ... ... "

Similarly, a review of the facility's Infection Control Department "Hand Hygiene "policy # E8 states in the policy statement, bullet #3: " If hands are not visibly soiled, health care personnel must use the hospital provided alcohol based hand rub for routinely decontaminating hands in these clinical situations: Before donning sterile gloves when inserting ... ... ...After contact with a patient's intact skin. After contact with inanimate objects in the immediate vicinity of the patient. Decontaminate hands after removing gloves " .

Staff # 24 touched the patient to take blood pressure, placed a barrier between the patient's arm and the bed, touched the dialysis machine, palpated the fistula site and changed gloves, but did not sanitize his hand. He also failed to sanitize his hand before donning the sterile gloves and performing the actual cannulation procedure.

2. It was also noted that the Dialysis unit kept 4 opened/used blood culture procedure trays in the storage area. During interview with Staff #24, he stated that he was saving the contents for use at a later date.

3. SEE ADDITIONAL FINDINGS AT A0505.


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C. Based on observation and staff interview, it was determined that the facility did not ensure a safe environment consistent with recognized infection control practices, prevention of cross contamination by keeping clean supplies separate/away from dirty areas, and that all patient care equipment is in good repair to prevent infection.

Findings include:

1. On 03/24/11 at 2:45 PM during survey of the Central Sterile supply room at the Dobbs Ferry Pavilion, it was noted that the ceiling tiles in the room were porous/had holes that may retain dirt (they were not monolithic) and thus were not as per AIA 7.28.B8. Such porous ceiling tiles compromise thorough cleaning which is required to keep the environment of Central Sterile as clean/sterile as possible.

a. The Dobbs Ferry Pavilion has 2 isolation rooms located on the Med/Surg units. During observation of these units on 03/24/11, it was noted that the two isolation rooms did not comply with all requirements of Section 7.2.C4 for isolation rooms. Section 7.2.C4 states that 'air borne infection isolation room shall have self-closing devices on all room exit doors'. In addition, the ceiling tiles were made of a porous material that would not minimize the retention of dirt as required by 7.28.B8 and would not be thoroughly washable/cleanable.

Similarly, the isolation room in the Emergency Department lacked non-porous ceiling tiles and also did not have self-closure on the sliding exit doors of the room.

Note: By not having a self-closure at the door, the room will not to be able to maintain optimum negative pressure as required, and may contribute to contamination of the corridor outside the isolation room.

All findings were verified with Staff #25, Staff #26 and Staff #30 at the time of observation.

b. During survey of the 7th floor in Andrus Pavilion on 03/22/11 at 10:30 AM, it was noted that there is no room/arrangement for patients who are immunocompromised/Neutropenic and require protective environment/positive air-pressure room on the Med/Surg floor. As per Staff #11, the facility does treat such patients/community and the procedure has been to use a regular room and use HEPA filters.

Note: As per AIA 7.2.D, the Infection Department needs to assess the community's need for such room based on the frequency/ volume of treatment to such patients, and if the numbers are high enough, should at least provide one such room.

2. On 03/21/11 at 10:30 AM during tour of the Radiology Department (Andrus Pavilion), it was noted that the hot water valves at the handwash sink in the bathroom were not trimmed with healthcare type wrist blades. They were regular valves that require use of hand/pinching/grasping, thus imposing a risk of cross contamination.

3. On 03/25/11 at 11:30 AM during the tour of the OR suite at Dobbs F