HospitalInspections.org

New York State Sanitary Code Subpart 14-1, Food Service Establishments, Section 14-1.140 Plumbing, requires that " all plumbing is to be constructed and maintained to prevent contamination of the potable water supply, food, equipment, utensils, the premises, contents, employees and patrons. There is to be no direct connection between the sewage system and any drains originating from fixtures and equipment used for storage, preparation or processing of food or drink. Waste lines from equipment requiring indirect drains are to be installed so as to prevent backflow from sewers and drains from other fixtures."

Based upon observation and interview, hospital staff failed to maintain compliance with applicable State and local laws and regulations regarding plumbing.

FINDING
On 1/04/12 at 1530 hours during a tour of the hospital with physical plant management it was observed that ice machines in the hospital staff dining room and in the inpatient care unit had drains which were directly connected to the municipal sewage system.

This finding was confirmed during interview on 1/04/12 at 1530 hours with the manager of facilities.

Based upon observation and interview hospital staff failed to maintain the facility in a clean and orderly condition.

FINDING
On 1/05/12 at 1100 hours during a tour of the hospital with physical plant management, a large amount of water had accumulated on the floor underneath an air handing unit located in the maintenance shop area of the hospital.
This finding was confirmed during interview 1/05/12 at 1100 hours with the manager of facilities.

Based on medical record review the facility failed to properly execute consent forms.

Findings:

In 2 of 11 medical records reviewed lacked the date and time that the general consent was obtained.

In 2 of 11 medical records reviewed lacked the surgeon's signature on the surgical consent form.

The surgical consent form lacked a designated area for the surgeon's name, signature, date and time.

C-0320

Based on medical record review and interview the facility failed to ensure pertinent patient information was available pre and post-operatively.

Findings:

1. Based on the review of 1 of 1 open medical records, the facility failed to ensure that a completed history and physical was in the medical record prior to surgery. At the time of the review the surgery was completed and the patient was in recovery.

2. Operative reports were lacking in 2 of 11 medical records reviewed.

Based on document review the facility failed to ensure that the operating register included all required information.

Findings:

Review of the operating room register revealed the lack of the total time of the operative procedures.

This was confirmed on interview with the nurse manager on 1/5/12 at 1400.

C-322

Based on medical record review and interview the facility failed to have anesthesia complete all required information.

Findings:

In 5 of 11 medical records reviewed the beta blocker form was not signed, dated and timed by anesthesia.

In 1 of 11 medical records reviewed the post-op anesthesia evalutation was not completed prior to the patient being discharged.


This was confirmed on interview with the nurse manager on 1/4/12 at 1100.