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Based on medical record review and interview, a written copy of patient's rights is not provided to outpatients as required by this regulation, and by New York State Title 10 regulation 405.7(a)(2), for 9 of 9 patients. (Patients #24-32)

Findings include:

Medical record review on 12/7/11 for outpatient Patients #24-32 did not reveal evidence that they received a written copy of patient's rights.

Interview with Staff #2 on 12/7/11 revealed that a written copy of patient's rights is not provided to patients at the Livingston Health Services site, who all receive services as outpatients.


Based on policy and procedure review, interview and medical record review, the hospital does not ensure consistent distribution of required notices to patients or their representatives upon admission and prior to discharge. (Patients #4, 7 and 35)

Findings include:

Review on 12/6/11 of policy J-14 "Distribution of 'An Important Message from Medicare' " (dated 2/08) revealed that upon admission, the booklet "Your Rights as a Hospital Patient" is given to the patient and the patient signs the acknowledgement form. The "Important Message from Medicare" (IM) notice is given to the patient 48 hours prior to discharge; the patient signs two copies, one of which is placed in the chart and the other which is kept by the patient notifying him of his right to appeal the discharge.

Interview with Staff #11 on 12/6/11 at 2:55 PM revealed it is the facility's practice to deliver the booklet "Your Rights as a Hospital Patient" to patients on Mondays, Wednesdays and Fridays. The patient's signature is obtained on the acknowledgement form to indicate the patient received the booklet. Staff #11 acknowledged they were not utilizing the actual IM form to obtain the patient's signature upon admission, as the facility had not interpreted the CMS regulation to require them to utilize the actual form. However, Staff #11 stated that a copy of the IM is delivered to patients 48 hours prior to discharge.

Medical record review for Patient #4 on 12/5/11, and for Patient #7 on 12/6/11, did not reveal evidence that a copy of the IM notice was provided upon admission.

Medical record review on 12/9/11 for Patient #35 revealed that this 87-year-old male was admitted on 11/29/11 and was discharged on 12/2/11. Athough this was a short stay, there was no evidence that a copy of IM notice had been provided.

Based on policy and procedure review, medical record review and interview, the hospital does not ensure that the condition of a patient who is restrained is assessed and monitored at intervals according to hospital policy, as evidenced for 1 of 1 restrained patient. (Patient #23)

Findings include:

Review on 12/9/11 of policy K-03 "Restraints/Patient Safety Devices in Acute Care" (dated 8/11) revealed that, at a minimum, when physical restraints are used for non-emergent reasons, observations of the patient's condition must be made at least once every 30 minutes or more frequently if indicated. The patient's physical needs, comfort, and safety shall be observed/assessed and attended to at least every 2 hours or more frequently as indicated by the patient. Observations will be documented in the Restraint Flowsheet intervention of the NUR module (in the Meditech electronic medical record system).

Medical record review on 12/8/11 of Patient #23's Restraint Flowsheets dated 12/5/11-12/8/11 revealed the that nursing did not document the restraint assessments in a timely manner. The following documentation was written with time of occurrence and time of documentation: "the patient was in soft wrist restraints to prevent removal of lines, yes, restraints were checked every 30 minutes and released at least every 2 hours".
These time of these activities were documented as follows:
On 12/5/11 8:00 PM, recorded on 12/6/11 at 12:35 AM
on 12/5/11 10:00 PM, recorded 12/6/11 at 12:35 AM
on 12/6/11 12:00 AM, recorded 12/6/11 at 5:48 AM
on 12/6/11 2:00 AM, recorded 12/6/11 at 5:48 AM
on 12/6/11 4:00 AM, recorded 12/6/11 at 5:48 AM
on 12/6/11 6:00 AM, recorded 12/6/11 at 8:38 AM
on 12/6/11 6:14 AM, recorded 12/6/11 at 6:15 AM
on 12/6/11 8:00 AM, recorded 12/6/11 at 10:22 AM
on 12/6/11 10:00 AM, recorded 12/6/11 at 10:28 AM
on 12/6/11 12:00 PM, recorded 12/6/11 at 2:11 PM
on 12/6/11 2:00 PM, recorded 12/6/11 at 2:14 PM
on 12/6/11 4:00 PM, recorded 12/6/11 at 11:14 PM
on 12/6/11 6:00 PM, recorded 12/6/11 at 11:15 PM
on 12/6/11 8:00 PM, recorded 12/6/11 at 11:15 PM
on 12/6/11 10:00 PM, recorded 12/6/11 at 11:15 PM
on 12/7/11 12:00 AM, recorded 12/7/11 at 2:37 AM
on 12/7/11 2:00 AM, recorded 12/7/11 at 2:50 AM
on 12/7/11 4:00 AM, recorded 12/7/11 at 4:17 AM
on 12/7/11 6:00 AM, recorded 12/7/11 at 6:51 AM
on 12/7/11 8:00 AM, recorded 12/7/11 at 10:41 AM
on 12/7/11 10:00 AM, recorded 12/7/11 at 10:50 AM
on 12/7/11 12:00 PM, recorded 12/7/11 at 1:39 PM
on 12/7/11 2:00 PM, recorded 12/7/11 at 2:07 PM
on 12/7/11 4:00 PM, recorded 12/7/11 at 6:01 PM
on 12/7/11 6:00 PM, recorded 12/7/11 at 6:01 PM
on 12/7/11 8:00 PM, recorded 12/8/11 at 12:09 AM
on 12/7/11 10:00 PM, recorded 12/8/11 at 12:09 AM
on 12/8/11 12:00 AM, recorded 12/8/11 at 5:27 AM
on 12/8/11 2:00 AM, recorded 12/8/11 at 5:33 AM
on 12/8/11 4:00 AM, recorded 12/8/11 at 5:37 AM
on 12/8/11 6:00 AM, recorded 12/8/11 at 6:23 AM
on 12/8/11 8:00 AM, recorded 12/8/11 at 12:09 PM

During interview on 12/8/11 at 12:30 PM, Staff #24 revealed that Patient #23 who was in restraints was checked on at least every hour, and the 8:00 AM assessment documentation had just been completed because she was behind. Review of Patient #23's Restraint Flowsheet at that time revealed there was no additional documentation since the 8:00 AM documentation.

Based on policy and procedure review, observation, document review and interview, the hospital does not ensure that medications are available for use when needed, as evidenced on 2 of 4 medication carts. (pediatric emergency department crash cart and obstetric epidural cart)

Findings include:

Review on 12/9/11 of policy R-10 "Checking the Crash Cart, Oxygen Tank and the Defibrillator" (dated 8/10) revealed that daily checks of the crash cart include checking to be sure the cart is locked--if not, Pharmacy must be notified to replace any needed contents, and a new lock must be placed on the cart. Weekly checks will be done to check the outdating of medication on the crash cart.

Review on 12/9/11 of policy PHARM-37 "Medication Storage Area Inspections" (dated 8/11) revealed that pharmacy technicians will complete area inspections on a monthly basis. Crash cart boxes should be adequately and properly supplied with medications. If medications in the emergency box are expired, the Technician will replace the expired medication drawers at the time of the monthly division inspection.

Observation on 12/5/11 at 1:30 PM during tour of the ED revealed 6 pre-filled sodium chloride syringes in the pediatric crash cart that had expired 10/2010. Additionally, review of the Daily Crash Cart Checklist dated 12/11 revealed documentation that the cart was locked 12/1-12/5/11; however, the cart was unlocked. These findings were verified by Staff #2 at that time.

Observation on 12/8/11 at 2:38 PM during tour of the OB unit revealed that there was not evidence that the epidural cart was checked consistently on a daily basis per facility policy. The OB Epidural Cart check form dated December 2011 was not completed on 12/3/11. In addition, the OB Epidural Cart check form was not completed 11/1/11-11/6/11, 11/8/11-11/13/11, 11/27/11, 11/30/11, 10/27/11, 10/30/11, 10/31/11, 8/19/11, 8/28/11, 8/30/11, 7/2/11-7/12/11, 7/14/11, 7/15/11, 7/20/11, 7/21/11, 7/24/11 and 7/29/11. These findings were verified by Staff #2 at that time.

During interview on 12/8/11 at 2:40 PM, Staff #28 revealed the epidural cart should be checked everday.

Based on policy and procedure review, medical record review and interview, the hospital has not established a protocol for clear and effective communication, verification and authentication of verbal/telephone orders, as evidenced for 2 patients. (Patients #21 and 23)

Findings include:

Review on 12/5/11 of medical staff policy #MS.013 "Verbal/Telephone Orders" (dated 3/11) revealed that verbal/telephone orders will be immediately recorded electronically or reduced to writing, authenticated by the nurse, dietitican, or registered pharmacist and countersigned by the prescriber within 48 hours.

Review on 12/7/11 of nursing policy C-07 "Verbal and Telephone Orders" (dated 8/11) revealed that verbal and telephone orders from a physician or physician's assistant must be co-signed by the physician within 48 hours. The nurse taking a verbal or telephone order or designee will place the authentication label on the order for the doctor to sign.

Medical record review on 12/7/11 for Patient #21 revealed electronic documentation of a telephone order on 11/30/11 at 1:23 PM for Ultram 50 mg po every 6 hours prn for mild pain and Ultram 100 mg po every 6 hours prn for moderate pain, and Vicodin was discontinued. In addition, there was documentation of telephone orders on 12/1/11 at 12:50 PM for Vicodin 5/500 2 tabs po every 6 hours prn for moderate to severe pain and Vicodin 5/500 1 tab po every 6 hours prn for mild pain. As of 12/7/11 at 3:45 PM, there was no evidence that these orders had been authenticated by a provider.

Interview with Staff #23 on 12/8/11 at 11:45 AM revealed that nursing enters telephone orders from providers electronically and the physician will sign it electronically. However, there are some providers for whom the telephone order must also be written on hardcopy and placed in the medical record for the provider to authenticate by hand.

Interview with Staff #24 on 12/8/11 at 12:15 PM revealed that she was unable to verify whether electronic orders for Patient #23 had been authenticated by the providers. Staff #24 was unsure in general of the process to verify whether orders had been electronically signed by providers.

These findings were verified with Staff #2 on 12/8/11.

Based on observation, the facility does not ensure the security of sensitive patient information.

Findings include:

During facility tour on 12/7/11, it was observed that the door to Room #1237 was not secured. This room contained patient information on 4 x 6 inch cards regarding histology and cytopathology testing results. Markings were evident on the door that indicated that a locking device was previously on the door, but the device had been removed. These findings were verified with Staff #4 at that time.

Based on observation and interview, the facility does not ensure that the main entrance, also utilized for patient discharge, is accessible to the disabled patient population.

Findings include:

During facility tour on 12/7/11, it was observed that a patient in a wheelchair was struggling to open the exit door at the main entrance of the facility. It was noted that a second patient held the door to allow the wheelchair-bound patient to exit. Upon further investigation, it was observed that an automatic opening and closing device was not present on this door.

During interview on 12/7/11, Staff #4 verified that these doors are the primary entrance/exit doors for the facility and are also utilized for patient discharge.

Based on observation and interview, the facility does not ensure that adequate infection control techniques are provided at the hospital and at the Livingston Health Services site.

Findings include:

During tour on 12/6/11 at 2:20 PM of the hospital respiratory department, it was observed that a black wheeled chair in front of a respiratory care machine was in disrepair and not easily cleanable. The material along the front sides of the seat was torn and tan foam was exposed along approximately half the length of the sides of the seat. This finding was verified by Staff #17 at that time.

During facility tour on 12/7/11 at the Livingston Health Services site, it was observed that infection control techniques were inadequate, as follows:
---The wall behind the sink in exam room #2 required repair around the mounted soap dispenser. The paper from the drywall had been damaged and a paper towel was wrapped around the dispenser.
---In exam room #1, a blue exam chair required repair and was not easily cleanable. The chair was torn around the seams and allowed for the tan foam in the chair seat to be exposed. An interview with Staff #4 and 52 on 12/7/11 revealed that this chair is utilized by a private physician when the area is not utilized by the After Hours Clinic.
---The top of the vending machines in corridor I-92 had a significant accumulation of debris present and required cleaning.
These findings were verified with Staff #4 and 52 on 12/7/11.

Based on document review, medical record review and interview, the hospital does not always notify the OPO in a timely manner of the death of patients, as evidenced for 2 of 7 patients. (Patients #11 and 15)

Findings include:

Review on 12/7/11 of the "Agreement for Organ Procurement and Eye and Tissue Banking Services" (dated 1/30/07) between Finger Lakes Donor Recovery Network (FLDRN), Rochester Eye and Human Parts Bank, Inc., and Nicholas Noyes Hospital, revealed that the hospital shall have the responsibility to notify FLDRN by telephone of a patient whose death is imminent or who has died in the hospital. Timely is defined as a referral made to FLDRN as soon as possible, but no more than two hours after a patient has died or has been determined to meet clinical triggers.

Review on 12/7/11 at 2:40 PM with Staff #2 of the seven November 2011 hospital deaths revealed that the OPO was notified late for 1 death and was not notified for 1 death, as follows:
- Patient #11: date of death was 11/13/11, with time of death 9:30 AM, and time of OPO notification 12:30 PM.
- Patient #15: date of death was 11/27/11, with no notification to OPO.
These findings were verified with Staff #2 on 12/7/11.

Based on document review, medical record review and interview, the hospital does not ensure that all surgical incidents pertaining to surgeons' performance are thoroughly reviewed, as evidenced for 1 of 4 reports reviewed. (Patient #20)

Findings include:

Review on 12/6/11 of 4 "Performance Improvement Documentation" forms that involved the performance of surgeons showed preliminary information regarding the incidents. The cases were then discussed and the medical records were reviewed with Staff #55, Director of Surgical Services. One case, for Patient #20, did not have sufficient resolution or documentation beyond the original preliminary incident report. There was a concern about staff-reported unrelieved pain in the OR and in PACU without action taken by the surgeon. Staff #55 stated that she discussed the case with the surgeon, who had explanation of a non-surgical cause of the pain. However, there was no documentation of the discussion in any hospital files including the physician's credentialing file, or other follow-up, such as inclusion as a topic in a surgical meeting.

Based on document review, medical record review and interview, the hospital does not ensure that an updated history and physical is completed and documented within 24 hours after admission including documentation to show an update was completed and documented before surgery for 1 of 3 patients. (Patient #35)

Findings include:

Review on 12/6/11 of the Medical Staff Bylaws, Article 12, Rules and Regulations of the Medical Staff (includes amendments through 3/11) revealed a complete history and physical examination shall be performed no more than 30 days prior to admission or within 24 hours after admission of the patient. An update to the patient's condition at the time of admission is required when using a history and physical examination that was documented before admission. The history and physical examination shall be completed prior to any surgical procedures.

Medical record review on 12/9/11 for Patient #35 revealed the patient had a physical examination on 11/22/11 as an outpatient in anticipation of surgery and the PA noted that there were no changes. On 11/29/11, the patient was admitted and underwent a right total hip replacement. The bottom of the history and physical documentation did not contain a signature by the surgeon indicating that there was no changes noted prior to surgery. On 12/9/11 at 11:15 AM, Staff #2 was unable to find evidence that an updated history and physical had been performed within 24 hours after admission of the patient.

Based on document review, medical record review and interview, the hospital does not ensure that post-anesthesia evaluations are completed and documented by an individual qualified to administer anesthesia no later than 48 hours after surgery or a procedure requiring anesthesia services, for 2 of 3 surgical patients. (Patients #35 and 37)

Findings include:

Review on 12/6/11 of the Medical Staff Bylaws, Article 12, Rules and Regulations of the Medical Staff (includes amendments through 3/11) revealed a recorded post-anesthesia visit shall be made within 24 hours after the patient has returned to a nursing unit other than the Recovery Room, if the patient is still hospitalized.

Medical record review on 12/9/11 revealed:
- Patient #35's Anesthesia Record contained no evidence that a post-anesthesia evaluation was completed following the right hip total replacement performed on 11/29/11.
- Patient #37's Anesthesia Record showed that although the post-anesthesia check area had a signature, there was no documentation to indicate that a complete post-anesthesia assessment was performed following the left incarcerated inguinal hernia repair performed on 11/18/11.
These findings were verified with Staff #2 on 12/9/11.

Based on policy and procedure review, medical record review and interview, the hospital does not ensure that respiratory medication treatments are administered in a timely manner to patients in the ICU, as evidenced for 2 of 2 ICU patients. (Patients #22 and 23)

Findings include:

Review on 12/7/11 of policy RT-01 "Plan for Providing Respiratory Care" (dated 8/05, revised 1/07) revealed that the "Respiratory Department works collaboratively with other members of the health care team to ensure the appropriate delivery and effectiveness of respiratory treatment modalities." Under the Quality of Care section, it states that the Respiratory Department has established a quality improvment plan which serves as a mechanism for monitoring ... the timeliness of therapy.

Medical record review on 12/8/11 revealed:
- The Medication Administration Record for Patient #22 dated 12/8/11 showed that Proventil and Atrovent nebulizer treatments were ordered every 4 hours. On 12/8/11, as of 12:05 PM, the 11:00 AM nebulizer treatments had not been administered.
- The Medication Administration Record for Patient #23 dated 12/8/11 showed that Combivent inhaler was ordered every 4 hours. On 12/8/11, as of 12:05 PM, the 11:00 AM dose had not been administered.
These findings were verified with Staff #2 on 12/8/11 at 12:10 PM.

Based on policy and procedure review and interview, the facility does not ensure that Respiratory Services policies and procedures are reviewed and updated as needed.

Findings include:

Review on 12/6/11 of the Respiratory Policy and Procedure Manual did not reveal evidence that the respiratory policies and procedures have been reviewed and updated as needed at least biennially as required. The manual, which currently included 61 policies, had been signed off by the Medical Director of Respiratory Therapy on 8/6/07. The policies were individually dated as last reviewed or updated in 2007 or 2008; for example:
- Policy RT-00, "Infection Control in Respiratory Therapy", dated 11/04, revised 8/07, signed 8/6/07.
- Policy RT-30, "Mechanical Ventilation", effective 9/05, revised 1/07, signed 8/6/07.

During interview on 12/6/11, Staff #17 stated that all the policies in the respiratory services manual are reviewed in March of each year by the Medical Director of Respiratory Therapy, and the Coordinator for Respiratory Services. However, this activity is not documented.

Based on policy and procedure review, observation, document review and interview, the hospital does not ensure that medications are available for use when needed, as evidenced on 2 of 4 medication carts. (pediatric emergency department crash cart and obstetric epidural cart)

Findings include:

Review on 12/9/11 of policy R-10 "Checking the Crash Cart, Oxygen Tank and the Defibrillator" (dated 8/10) revealed that daily checks of the crash cart include checking to be sure the cart is locked--if not, Pharmacy must be notified to replace any needed contents, and a new lock must be placed on the cart. Weekly checks will be done to check the outdating of medication on the crash cart.

Review on 12/9/11 of policy PHARM-37 "Medication Storage Area Inspections" (dated 8/11) revealed that pharmacy technicians will complete area inspections on a monthly basis. Crash cart boxes should be adequately and properly supplied with medications. If medications in the emergency box are expired, the Technician will replace the expired medication drawers at the time of the monthly division inspection.

Observation on 12/5/11 at 1:30 PM during tour of the ED revealed 6 pre-filled sodium chloride syringes in the pediatric crash cart that had expired 10/2010. Additionally, review of the Daily Crash Cart Checklist dated 12/11 revealed documentation that the cart was locked 12/1-12/5/11; however, the cart was unlocked. These findings were verified by Staff #2 at that time.

Observation on 12/8/11 at 2:38 PM during tour of the OB unit revealed that there was not evidence that the epidural cart was checked consistently on a daily basis per facility policy. The OB Epidural Cart check form dated December 2011 was not completed on 12/3/11. In addition, the OB Epidural Cart check form was not completed 11/1/11-11/6/11, 11/8/11-11/13/11, 11/27/11, 11/30/11, 10/27/11, 10/30/11, 10/31/11, 8/19/11, 8/28/11, 8/30/11, 7/2/11-7/12/11, 7/14/11, 7/15/11, 7/20/11, 7/21/11, 7/24/11 and 7/29/11. These findings were verified by Staff #2 at that time.

During interview on 12/8/11 at 2:40 PM, Staff #28 revealed the epidural cart should be checked everday.