HospitalInspections.org

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Based on observation, interview and record review during the Federal Recertification Survey, it was determined that the Facility did not ensure that persons arriving to the Emergency Department (ED) for "Quick Registration" were provided with an accurate description of the contents of the "Consent for Medical Care and Treatment" form prior to signing (Patients #35, #36 and #48.)

Findings:

During observation of the "Quick Registration" process in the ED Triage Area on 02/11/13, at 10:45AM, the "Walk-In Area" was staffed by a Registered Nurse Coordinator, a Registrar and a Volunteer.

At 10:45AM an ambulatory patient was observed walking into this area of the ED, was handed a clipboard by the Volunteer and instructed to complete the "highlighted areas on the form then hand it to the Nurse".

At the same time a person in a wheelchair arrived (Patient #36) and was greeted by the Nurse who requested the patient sign the form giving "consent to treatment." The patient was then taken through to Trauma Room #1 for treatment of respiratory distress.

Within three (3) to five (5) minutes, four (4) additional people were observed entering the area and several more persons were observed signing the forms and being told "this is consent for treatment" then were directed to the Triage Waiting Room or the Main ED/General Treatment Area.

During an interview held in the General Treatment Area at 1:30PM regarding the Consent form, Patient #35 stated "I was told it was me giving permission so that I could be seen".

During an interview held in the General Treatment Area at 1:45PM regarding the Consent form Patient #48 stated "they told me it was my authorization and registration".

Review of the "Consent for Medical Care And Treatment" form revealed that the highlighted areas included the patient or representative's signature to certify that they "had read and agreed to the contents of the consent and authorization document" which contained:

1. Consent for Medical Care and Treatment.

2. Release of Confidential Information.

3. Assignment of Benefits.

4. Guarantee of Account.

5. Waiver to Release Hospital for Personal Valuables.

6. Acknowledgement of Receipt of Notice of Privacy Practices.

7. Acknowledgement of Receipt Tobacco Free Policy.

8. Acknowledgement of Receipt of Important Billing Information.

There was no evidence on observation or by interview that the patients were verbally instructed regarding Items #2, #3, #4 and #5 or provided with the appropriate literature relative to Items #6, #7 and #8 at the time of signage.
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Based on record review and interview, it was determined that the Facility failed to ensure that a patient with swallowing difficulties, was appropriately fed and monitored by staff (Patient
#61).

Findings:

Patient #61 is an 86-year-old male who was admitted on 11/01/11 with the diagnosis of Atrial Fibrillation/Atrial Flutter and was brought to the Hospital due to progressive weakness with difficulty walking. His past medical history included Alzheimer's Dementia and Hypertension.

Review of the admission orders dated 11/01/11 revealed that the patient was placed on aspiration precautions and required assistance with feedings. A swallow evaluation was ordered on 11/02/11.

The clinical progress note documented on 11/03/11 at 6:06PM and 6:49PM that a swallow evaluation was attempted. The patient was noted to have audible rhonchi and was unable to cough up phlegm therefore the swallow evaluation was held, because the patient was not a candidate for oral trials at that time.

The swallow evaluation was done on 11/06/11 and revealed mild oral Dysphagia (difficulty swallowing). There was mildly increased chewing with soft foods but there was no dentition present. The recommendation was to initiate Dysphagia III Diet - soft solids and thin liquids. In addition, there should be 100% supervision and aspiration precautions.

Another swallow evaluation done on 11/08/11 revealed delayed swallow initiation to valleculae (the depression between the epiglottis and the base of the tongue). There was penetration with thin liquids, residue in the laryngeal vestibule and on the vocal cords that could not be cleared with prompted cough. The patient was advanced to nectar thickened liquids with the Dysphagia III Diet.

On 11/17/11 at 12:38PM, the PA (Physician's Assistant) documented responding to a rapid response for this patient who choked on his lunch. His oxygen saturation was 79% initially and after removal of the foreign body, it went up to 94%.

On 11/17/11 at 12:38PM, the Respiratory Therapist was documented to have suctioned up a two (2) inch by four-five (4-5) inch piece of meat along with secretions from the patient's posterior pharynx and valleculae. There were no chewing marks noted on the meat. The patient was noted to have a few scattered wheezes and central congestion.

The assessment documented aspiration of food with choking episode and Hypoxia. The patient was made NPO (nothing by mouth) until an additional swallowing evaluation was completed.

The Respiratory Therapist also documented at 2:30PM on 11/17/11 that a lengthy piece of meat was removed from the patient's airway via direct laryngoscope with forceps.

The chest x-ray done on 11/18/11 revealed new infrahilar patchy infiltrate and interval elevation of the left hemi-diaphragm.

The swallow evaluation done on 11/18/11 at 3:50PM revealed delayed swallowing with some residue in the valleculae, cleared with alternating solids and liquids. The recommendation was Dysphagia I - puree diet and honey thickened liquids via teaspoon.

An interview was conducted on 02/15/13 at 1:30PM with the Nutrition Manager (Staff #25). The Manager provided the Department of Nutritional Services Guidelines for the Dysphagia III Diet and stated this would be a regular diet modified to make it soft; someone on this diet would have to have their meat cut up and the meat would have to be soft, not tough.

The Nutrition Manager stated that this patient was 100% fed by staff so his meat should have been cut up.

On 02/15/13 at 1:30PM, review of a copy of the Dysphagia III Diet provided to the patient on 11/17/11, the date of the incident, revealed the patient received braised brisket of beef with diced carrots and boiled potatoes.
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Based on observation, interview and record review during the Federal Recertification Survey, it was determined that the Facility failed to identify mittens as restraints, and failed to include these devices into the Hospital's policy and procedures for two (2) of two (2) patients (Patients #1 and #2).

Finding 1:

Review of the facility's Restraint Policy approved 09/09/12 identified that mittens were not considered restraints, because they were not tied down. There was no document evidence of guidance to staff regarding implementation or use of mittens.

Finding 2:

a. During a tour of Unit 2 CAD on 02/10/13 at 10:15AM, Patient #2 was observed lying in bed with bilateral hand mittens on.

During the observation the Nurse Manager (Staff #17) and the patient's primary Nurse (Staff #18) reported that the patient was received from the Cardiac Care Unit (CCU) during the night with these mittens on, because she was trying to pull out her intravenous line. The primary Nurse further stated they do not require a Physician's Order for the application of the mittens; the use was based on Nursing judgment.

Review of the medical record revealed that this patient was received from CCU on 02/10/13 at 11:33PM with bilateral mittens in place. There is no documented evidence in the computerized medical record and the CCU flow sheet of the use of this device, when it was implemented and under what circumstances.

b. Additional observation in the afternoon of 02/11/13 on 2 CAD revealed that Patient #1 was also observed with bilateral hand mittens on. The patient's primary Nurse (Staff #18)reported that this device was in place because the patient tried to pull out his intravenous line and Foley catheter.

Review of the medical record for Patient #1 revealed a Nurse's note on 02/11/13 at 4:32AM documenting that the patient was pulling his covers off. Bilateral hand mittens and freedom splints were documented to be in place. There was no documented evidence of when these devices were implemented and the indications for their use.
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Based on record review and staff interview during the onsite Federal Recertification Survey, the Facility failed to ensure that the medical staff documented the attempt to secure Autopsies as required by Hospital policy in four (4) of five (5) medical records reviewed (Patients #11, #12, #14 and #15).

Findings:

Review of the medical records for Patients #11, #12, #14 and #15 revealed the section for "Autopsy Discussed With Family" on the form titled "Interdisciplinary Expiration Progress Note" was blank. There was no documented evidence that the Physician or Physician's Assistant attempted to obtain permission for an Autopsy.

Review of the facility's policies titled "Autopsy Criteria" and "Autopsy Service" dated 09/08/12, revealed that all families have a right to request an Autopsy and "when a patient expires, the Attending Physician will attempt to secure permission for a post-mortem examination from a legally responsible survivor".

Review of the Facility's Bylaws of the Medical Staff, dated September 2012, revealed under Part II: Medical Staff - Rules and Regulations #20 - "Requires all staff members are to secure Autopsies whenever possible particularly in all cases of unusual death."

This finding was confirmed with the Director of Nursing Professional Development and
Accountability (Staff #19) during the onsite visit.
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Based on review of medical records, policies and procedures during the Federal Recertification Survey, it was determined that the Nursing staff did not ensure that all patient care needs were fully evaluated upon admission in six (6) of eleven (11) records reviewed (Patients #50, #51, #52, #53, #54 and #55).

Findings:

Review of the current "Nursing Admission Assessment" Policy on 02/13/13 noted that the admission database will be completed as soon as possible, but no later than twenty-four (24) hours after admission. The policy also states that all patients are screened for nutritional risk factors.

The following patients were not screened for nutritional risk by the Nursing staff:

a. Review of the medical record for Patient #50 on 02/13/13 noted that this 89-year-old admitted on 02/09/13 with Diverticulitis was not screened for nutritional risk factor.

b. Review of the medical record for Patient #53 on 02/15/13 noted that this 78-year-old Nursing Home resident admitted to the Hospital on 11/20/12 with Acute Renal Failure was not screened for nutritional risk factor.

c. Similar findings of patients not screened for nutritional risk factors by the Nursing staff was noted in the medical records for Patients #51, #52, #54 and #55.
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Based on medical record review and staff interview during the onsite Federal Recertification Survey, it was determined that the Facility failed to ensure that the "Arrival Information Form" filled out for each patient's visit at the Outpatient Wound Care Center was completed, and reflected any pertinent changes in the patient's health status since the last visit for six (6) of eight (8) records reviewed (Patients #20, #21, #22, #23, #24 and #27). Additionally, the Hospital failed to follow physician's orders for two (2) of two (2) patients reviewed (Patients #39 and #40).

Finding 1:

Review of the"Arrival Information Form" for Patients #20 and #22, revealed that the "Added or Deleted Medications" and the "Any New Allergies" sections were blank.

Review of the "Arrival Information Form" for Patients #21 and #22 revealed the "Pain Management" and "Medications" sections were left blank even though the patients were documented as having pain.

In addition, for Patients #22 and #27 "The Identification" was not verified as evidenced by a blank space on the form.

Review of the "Arrival Information Form" for Patients #21, #22 and #23 revealed the type of service was not filled in or it was covered by the patient's name sticker.

Review of the "Arrival Information Form" for Patients #21 and #24 revealed no Blood Sugar was taken during the visits on 02/06/13 and 09/12/12 respectively despite the patients having a diagnosis of Diabetes.

An interview conducted on 02/13/13 at 10:30AM with the Nurse Manager (Staff #30) revealed that a Blood Sugar is taken on every Diabetic patient's visit to the Wound Care Outpatient Clinic.

An interview was conducted with the Nurse Manager (Staff #30) on 02/13/13 at 11:00AM confirming the missing information on the forms reviewed.

Finding 2:

Patient #40 was admitted on 01/31/12 to the Medical Intensive Care Unit with complaints of difficulty breathing and Alzheimer's.

On 01/31/12 the physician ordered a stool specimen for occult blood.

The Nursing admission assessment documented that the patient's last stool was on 01/31/12.

The Nursing assessment dated 02/01/12 documented that the patient was positive for bowel sounds and having regular bowel movements. On 02/02/12, the Nursing assessment stated that the patient had a bowel movement on 02/01/12.

There was no documented evidence that a stool specimen was collected.

Patient #39 was admitted to Coronary Care Services on 02/07/13 with a diagnosis of Anemia.

On 02/08/12 at 9:52AM a physician's order was written to obtain a stool specimen for occult blood. The physician also documented that the patient was experiencing diarrhea.

During an interview on 02/14/13 at 2:30PM, the Nurse's Assistant (Staff #14) stated that the stool specimen remained incomplete.

During an interview on 02/15/13 at 11:00AM, the Nurse assigned to the patient stated she was aware of the needed specimen, but could not state why it had not been collected.

During an interview with Patient #39 on 02/15/13 at 11:30AM, the patient stated "Yes, I have been moving my bowels regularly and the last time was yesterday, when I moved my bowels in the bathroom. I didn't know they wanted that (a sample) from me".
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Based on record review and staff interview during the Federal Recertification Survey, it was determined that the Facility did not ensure that the medication route was changed from "By Mouth" (PO) to Naso Gastric tube (NG) or from NG tube to PO and that the Nurse clarified the order prior to administering medication in three (3) of five (5) patients (Patients #18,
#29 and #34).

Findings:

Review of the medical record for Patient #18 revealed that on 02/06/13 at 8:30PM, the Physician's Orders documents a NG tube to be inserted, but there was no order for a change in the route of medication from PO to NG.

A clinical Nursing note on 02/10/13 at 3:06AM documents that the patient had pulled out the NG and the Physician was notified that the patient was due for Synthroid via NG tube. The note documents that the Physician stated to attempt to give these meds by mouth and to evaluate if the patient can swallow. Review of the medical record revealed that there was no order written to give medications by mouth.

A Physician's Order on 02/10/13 at 9:55PM documents "NPO (nothing by mouth) except meds", but there is no order to change the medication route.

An interview with Staff #23 on 02/13/13 at 10:45AM revealed that the patient pulled his NG tube out on 02/10/13 and that even though there was no order to change the medication route from NG to PO, the Nurse stated that she administered the medication to Patient #18 in applesauce by mouth on 02/10/13 at 11:12AM.

An interview on 02/13/13 at 11:00AM with the Nurse (Staff #19) revealed that Pharmacy was contacted and confirmed that from 02/08/13 through 02/11/13, there was no order to change the route of medication from PO to NG for Patient #18.

An interview was conducted with the Director of Nursing Professional Development and Accreditation (Staff #19) on 02/13/12 at 3:15PM confirming that there was no documented change in the route of the medication from PO to NG tube.

Similar findings were identified on medical records reviewed for Patients #29 and #34.

Review of the facility's policy titled "Naso-Oro Gastric Tube Insertion" dated 02/01/13 included one of the purposes as a "route" for nutrition and medications.

Review of the facility's policy titled "Medication Administration" dated 02/01/13, documents that the general guidelines for noting of and verifying of medication orders must contain the following: the name of the medication, dosage, route and frequency.
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Based on observation, record review, and interview during the Federal Recertification Survey, the Facility did not ensure that expired medications and biologicals were not available for patient use.

Findings:

An inspection of the Ambulatory Surgery Unit (ASU) Medication Room on 02/12/13 at 9:50AM revealed the following expired medications and biologicals:

1. One (1) 20 gauge angio catheter expired 08/05.

2. One (1) 1000cc bag of Sterile Water expired 05/06.

3. Two (2) 24 gauge angio catheter expired 11/06.

4. One (1) 20 gauge angio catheter expired 04/07.

5. One (1) IV tubing expired 05/07.

6. One (1) 500cc bag of .9 Normal Saline expired 06/07.

7. One (1) second IV set expired 07/09.

8. One (1) 18 gauge angio catheter expired 07/09.

9. One (1) extension set expired 08/09.

10. One (1) IV tubing expired 09/09.

11. One (1) 500cc bag of .9 Normal Saline expired 11/09.

12. One (1) syringe safety glide syringe expired 12/09.

13. One (1) primary IV set expired 07/10.

14. One (1) primary IV set expired 08/10.

15. One primary IV set expired 09/10.

16. Two (2) 18 gauge angio catheters expired 11/10.

17. One (1) box of about 50 safety glide syringes 1ml expired 09/11.

18. One (1) 18 gauge angio catheter expired 03/12.

19. One (1) 500cc bag of .9 NACL expired 03/12.

On 02/12/13 at 10:20AM Staff #22 confirmed these findings.

Review of policy titled "Disposal of Meds" dated 09/05/12 revealed all expired medications shall be disposed of or returned to the Pharmacy.
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Based upon observation, interview and review of the Facility's policies and procedures and other facility documents, it was determined that the Facility failed to be constructed, arranged, and maintained to ensure the safety of patients. Therefore, the accumulative effect of the Hospital Regulation Standard Level Deficiencies as well as the Life Safety Code Deficiencies is that the Condition of Participation for Physical Environment is not met as evidenced by:

1. Failing to maintain the physical plant to assure patient safety and well-being (See A701).

2. Failing to meet Life Safety Code standards (See Tags A710 and Tags K11, K15, K17, K18, K25, K29, K34, K38, K62, K69, K76, K130 and K147).

3. Failing to maintain adequate Facilities for its services in accordance with all Federal, State and local laws, regulations and guidelines (See A722).

4. Failing to ensure that expired equipment was not available for patient use (See A724).
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1. Based on observation and interview during the Federal Recertification Survey, the Facility did not ensure that all ceiling finishes in the Hospital Building were maintained in good repair. Reference is made to water damaged ceiling tiles and walls that were noted in several areas.

The findings include, but are not limited to the following examples:

a. On the morning and afternoon of 02/11/13, stained ceiling tiles were noted in the following areas of the T-Wing Building:

-One (1) stained tile noted in a 4th Floor corridor near Exit Stair "F".

-One (1) stained tile noted in Room #319 on the 3rd Floor.

-One (1) stained tile noted in a 2nd Floor corridor near Exit Stair "E" and a patient toilet room.

As per concurrent interviews with the Facility's Director of Engineering and Director of Support Services, they will have all of the damaged ceiling tiles replaced as soon as possible.

b. On 02/11/13 at 2:18PM, a stained ceiling tile was noted in one (1) of the two (2) storage rooms inside the East-Wing Building 2nd Floor Outpatient Procedure Room.

As per concurrent interview with the Facility's Director of Engineering and Director of Support Services, they will have the damaged ceiling tile replaced as soon as possible.

c. On the morning and afternoon of 02/12/13, stained ceiling tiles were noted in the following areas of the T-Wing Building:

-Three (3) stained ceiling tiles, each of which also exhibited a black colored mold-like growth, were found in a 1st Floor Radiology Department Soiled Linen Chute Discharge/Storage Room.

-One (1) stained tile noted in a 1st Floor corridor near Exit Stair "B".

As per concurrent interviews with the Facility's Director of Engineering and Director of Support Services, they will have all of the damaged ceiling tiles replaced as soon as possible.

d. On the morning and afternoon of 02/12/13, stained ceiling tiles were noted in the following areas of the East-Wing Building:

-One (1) stained tile in the 1st Floor Central Sterile Department Decontamination Room.

-One (1) stained tile in the 1st Floor Dietary Dry Goods Storage Room.

As per concurrent interviews with the Facility's Director of Engineering and Director of Support Services, they will have all of the damaged ceiling tiles replaced as soon as possible.

e. On 02/12/13 at 2:48PM, a stained ceiling tile was noted in one (1) of the two (2) storage rooms in a corridor in the ED (Emergency Department)-Wing Building Lower-Level (vicinity of the Behavior Health Services Unit that is currently under construction).

As per concurrent interview with the Facility's Director of Engineering and Director of Support Services, they will have the damaged ceiling tile replaced as soon as possible.

f. On the morning of 02/14/13, stained ceiling tiles were noted in the following areas of the T-Wing Building:

-Three (3) stained tiles in the 2nd Floor OR (Operating Room) (two {2} in the service corridor outside ORs #4 and #5, one (1) in the service corridor outside ORs #2 and #3).

-One (1) stained tile in the 2nd Floor PACU Electrical Room.

-Sheetrock ceiling in a 1st Floor Electrical Room (vicinity of the Cardiac Catheterization Laboratory service corridor) was found to be stained and to exhibit a black colored mold-like growth.

As per concurrent interviews with the Facility's Director of Engineering and Director of Support Services, they will have the damaged ceiling tiles and sheetrock ceilings replaced as soon as possible.

g. On the morning and afternoon of 02/14/13, stained ceiling tiles were noted in the following areas of the ED-Wing Building:

-Three (3) stained ceiling tiles on the Main Floor of the ED Main Treatment Area (one {1} vicinity of Cubicle #12, two {2} vicinity of Cubicle #16).

As per concurrent interviews with the Facility's Director of Engineering and Director of Support Services, they will have the damaged ceiling tiles and sheetrock ceilings replaced as soon as possible.


2. Based on observation and staff interview during the survey, the Facility did not ensure that all door finishes in the Hospital Building were maintained in good repair. Reference is made to damaged doors that were noted in several areas.

The findings include, but are not limited to the following examples:

a. On the morning of 02/11/13, the exterior surfaces of several doors on the 4th Floor of the T-Wing Building (e.g., the doors to Patient Rooms #424, #425 and #426) were noted to be in disrepair due to being chipped/damaged and/or had delaminated surfaces.

b. As per interview with the Facility's Director of Engineering on 02/11/13 at 11:28AM, he will inform the facility's Administrator of these issues.

42 CFR 482.41(a)
10NYCRR, 405.24 (a) (1)


3. Based on observation and interview, the Facility did not ensure that all door and ceiling finishes in buildings housing Hospital-Operated Outpatient Clinics were maintained in good repair. Reference is made to water damaged ceiling tiles and walls that were noted in several areas.

The findings include:

a. On 02/13/13 at 8:05AM, a wired-glass vision panel in a door inside the 2nd Floor of the Wound Care and Hyperbaric Medicine Outpatient Clinic was noted to be cracked. As per concurrent interview with the Facility's Director of Engineering, he will have the damaged door vision panel replaced as soon as possible.

b. On 02/13/13 at 8:58AM, one (1) stained ceiling tile was noted in the Chief of Bariatric Medicine's Office in the Hospital's Bariatric Medicine Outpatient Clinic. As per concurrent interview with the Facility's Director of Engineering, he will have the damaged ceiling tile replaced as soon as possible.

c. On 02/15/13 at 8:31AM, one (1) stained ceiling tile was noted in the CAT Scan Room in the 1st Floor Diagnostic Radiology Suite in the Cardiac Rehabilitation Center Outpatient Clinic. As per concurrent interview with the Facility's Director of Engineering, he will have the damaged ceiling tile replaced as soon as possible.

42 CFR 482.41(a)
10NYCRR, 405.24 (a) (1)
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The Hospital did not ensure that the Life Safety from Fire Requirements were met (See Life Safety Code Survey Tags K11, K15, K17, K18, K25, K29, K34, K38, K62, K69, K76, K130 and K147).

42 CFR 482.41(b)
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1. Based on observation and staff interview during the Federal Recertification Survey, the Facility did not ensure that accessible Facilities were designed and maintained in accordance with Federal, State and local laws, regulations and guidelines.

The findings include, but are not limited to, the following examples:

a. On 02/12/13 at 9:02AM, the hot and cold water control valves located underneath a hand wash sink in a designated, by signage, accessible patient toilet room located on the Main Floor of the ED (Emergency Department)-Wing Building were found to lack required protective insulation to protect against contact with hot and/or sharp or abrasive surfaces.

As per concurrent interview with the Facility's Director of Engineering, he will have insulation installed on these exposed control valves as soon as possible.

b. 10NYCRR, 711.2 (c). Design standards for the disabled. The Americans with Disabilities Act of 1990 (ADA) extends comprehensive civil rights protection to persons with disabilities. Health Care Facilities must comply with the ADA and the regulations which implement it. Title 28 of the Code of Federal Regulations, Public Health Parts 35, Non-Discrimination on the Basis of Disability in State and Local Government Services, and Part 36, Non-Discrimination on the Basis of Disability by Public Accommodations and in Commercial Facilities, including Appendix A, "Standard for Accessible Design", 2004 Edition. 28 CFR Part 36 ADA Standards for Accessible Design: 4.24.6.

On 02/12/13 at 9:02AM, the drinking fountain provided in the Waiting Room on the 2nd Floor of the Hospital's Wound Care and Hyperbaric Medicine Outpatient Clinic was noted to be accessible to individuals in wheelchairs, but not accessible drinking fountain for those individuals who have difficulty bending or stooping was provided.

As per concurrent interview with the Facility's Director of Engineering, he will ensure that accessible access to water would be provided to those individuals who have difficulty bending or stooping as soon as possible.

42 CFR 482.41(c)

10NYCRR, 711.2 (c). Design standards for the disabled. The Americans with Disabilities Act of 1990 (ADA) extends comprehensive civil rights protection to persons with disabilities. Health Care Facilities must comply with the ADA and the regulations which implement it. Title 28 of the Code of Federal Regulations, Public Health Parts 35, Non-Discrimination on the Basis of Disability in State and Local Government Services, and Part 36, Non-Discrimination on the Basis of Disability by Public Accommodations and in Commercial Facilities, including Appendix A, "Standard for Accessible Design", 2004 Edition. 28 CFR Part 36 ADA Standards for Accessible Design: 4,1,3 (10) (a), 4.15.

c. On 02/15/13 at 7:50AM, two (2) out of four (4) parking spaces located at the Main Entrance to the Hospital that were designated, by signage, as being accessible were found to lack an access aisle. Access aisles that are at least 60-inches wide are required to serve each accessible parking space (please note that one {1} access aisle can be shared by two {2} parking spaces). As per interview with the Facility's Director of Engineering on 02/15/13 at 8:20AM, he will inform the Hospital's Administrator about this issue.

10NYCRR, 711.2 (c). Design standards for the disabled. The Americans with Disabilities Act of 1990 (ADA) extends comprehensive civil rights protection to persons with disabilities. Health Care Facilities must comply with the ADA and the regulations which implement it. Title 28 of the Code of Federal Regulations, Public Health Parts 35, Non-Discrimination on the Basis of Disability in State and Local Government Services, and Part 36, Non-Discrimination on the Basis of Disability by Public Accommodations and in Commercial Facilities, including Appendix A, "Standard for Accessible Design", 2004 Edition. 28 CFR Part 36 ADA Standards for Accessible Design: 4.6.

d. On 02/20/13 at 7:46AM, eight (8) out of sixteen (16) parking spaces located in the South Visitor's Parking Lot that were designated, by signage, as being accessible were found to lack an access aisle. Access aisles that are at least 60-inches wide are required to serve each accessible parking space. As per interview with the Facility's Director of Engineering on 02/20/13 at 8:00AM, he will inform the Hospital's Administrator about this issue.

10NYCRR, 711.2 (c). Design standards for the disabled. The Americans with Disabilities Act of 1990 (ADA) extends comprehensive civil rights protection to persons with disabilities. Health Care Facilities must comply with the ADA and the regulations which implement it. Title 28 of the Code of Federal Regulations, Public Health Parts 35, Non-Discrimination on the Basis of Disability in State and Local Government Services, and Part 36, Non-Discrimination on the Basis of Disability by Public Accommodations and in Commercial Facilities, including Appendix A, "Standard for Accessible Design", 2004 Edition. 28 CFR Part 36 ADA Standards for Accessible Design: 4.6.


2. Based on observation and staff interview, the Facility did not ensure that Emergency Department treatment cubicles were designed and maintained in accordance with Federal, State and local laws, regulations and guidelines.

The findings include, but are not limited to, the following examples:

a. The Hospital's Emergency Department was constructed in 2002 under New York State Department of Health Certificate of Need Project #982591. New York State Department of Health Regulations (i.e., 10NYCCR) that were in effect at the time of construction required that Emergency Departments be constructed in accordance with the requirements found in the 1996-1997 Edition of the American Institute of Architects Guidelines for Design and Construction of Hospital and Health Care Facilities. Section 7.9.D7 of these Guidelines require that Emergency Department Examination and Treatment Rooms have a minimum floor area of one hundred twenty (120) square feet and that when treatment cubicles are in open multiple-bed areas that each cubicle be provided with at least eighty (80) square feet of space.

b. On 02/12/13 at 8:30AM, it was noted that in the Emergency Department's Main Treatment Area located on the Main Floor of ED-Wing Building that several treatment cubicles (e.g., Cubicle #5, Cubicle #12 and Cubicle #16) that had been constructed in 2002 to be single bed cubicles with one hundred twenty (120) square feet of space per bed had been subdivided into double bed cubicles with only approximately sixty (60) square feet per bed. As per concurrent interviews with the Facility's Director of Engineering and the Director of Support Services, the Hospital had to subdivide these single bed cubicles due to the very heavy volume of patients that their Emergency Department sees on a daily basis. They added that the volume of patients that they are seeing was much higher than what had been anticipated and planned for when their Emergency Department expansion project had originally been approved. They said that the Facility will submit a waiver request concerning this issue.

It was noted that each of the beds in the single bed cubicles that had been converted into two-bedded cubicles have all of the required electrical receptacles, Nurse emergency calling capabilities, and piped in medical vacuum and oxygen outlets as would be required by the Guidelines for multiple bedded construction and that the primary issue is that these cubicles are undersized and do not meet requirements.

42 CFR 482.41(c)

10NYCRR, 711.2 (b) (6) 1996-97 Guidelines for Design and Construction of Hospital and Health Care Facilities, 1996 Edition: 7.9.D7
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Based on observation and interview during the Federal Recertification Survey, the Facility did not ensure that expired equipment was not available for patient use.

Findings:

a. An inspection of the Ambulatory Surgery Unit (ASU) Medication Room on 02/12/13 at 9:50AM revealed a box of "Monitoring EKG Electrodes" that expired on 12/17/06.

On 02/12/13 at 10:20AM the Nurse Manager (Staff #22) confirmed this finding.

b. An inspection of the Ambulatory Surgery Unit (ASU) Code Cart on 02/12/13 at 10:00AM revealed the "Central Access" tray expired January 2013.

On 02/12/13 at 10:10AM an ASU Staff Nurse (Staff #35) confirmed this finding.
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Based on observation, record review, and interview during the Federal Recertification Survey, the Facility did not ensure that isolation precautions were implemented by the staff on one of the Nursing Unit tours (Patient #62 and #63).

Findings:

a. Observations on 02/14/13 at 11:40AM revealed a Contact and Droplet Precaution sign outside Room #404 for Patient #62 in Bed B. The sign indicated that a mask was required when the staff member was within three (3) feet of the patient, a gown was required when soiling was likely and gloves were required for touching infectious material or contact with the patient's environment. PPE (Personal Protective Equipment) was located on the patient's door. A Nurse's Aide (NA) (Staff #36), was observed walking into the patient's room carrying linen without wearing a gown, gloves or mask. The NA placed the linen on the patient's chair and went to the patient's bedside.

An interview was conducted on 02/14/13 at 11:40AM, with this NA when exiting the patient's room that revealed the NA was aware the patient was on isolation precautions. The NA stated she should have worn a mask, gown, and gloves to enter the room. The NA stated she dropped the linens off, took the battery out of the telemetry machine which was at the patient's bedside and had contact with the patient.

An interview with the Infection Control Nurse (Staff #38) on 02/14/13 at 1:30PM revealed the Isolation Precautions sign outside Room #404 was incorrect. The sign documented a gown was required when soiling was likely however it should have documented a gown was required for any patient contact.

b. Observations on 02/14/13 at approximately 2:30PM revealed a Contact Precaution sign outside Room #407 for Patient #63. A Physical Therapist (PT) (Staff #39), was observed donning the appropriate PPE, carrying a walker into the patient's room and placing the walker against the wall. At 2:50PM the PT was observed discarding the PPE and carrying the walker thirty (30) feet to the Nurses' Station without wiping it down. The PT placed the walker against the wall in the hallway and proceeded to the dirty utility room thirty (30) feet away. The PT washed her hands and returned to the walker.

At that time the PT was interviewed and stated the patient had his own walker and did not use the hospital walker. The PT stated she was aware the walker had to be wiped down and proceeded to wipe the walker in the hallway.

An interview with the Infection Control Nurse (Staff #26) on 02/14/13 at approximately 2:30PM, revealed the walker should have never been brought into the patient's room and it should have been wiped down in the patient's room before exiting the room.

Review of the policy titled "Isolation Precautions" dated 03/26/12, revealed healthcare personnel caring for patients on Contact Precautions need to wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Healthcare personnel caring for patients on Droplet Precautions need to wear a surgical or procedure mask for close contact.
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Based on review of the medical records and policies/procedures during the Federal Recertification Survey, it was determined that the Facility failed to ensure that patients were screened to identify those individuals who are at risk of requiring post Hospital service. This finding was noted in seven (7) of eleven (11) records reviewed (Patients #50, #51, #52, #53, #54, #56 and #57).

Findings:

The current Facility policy titled "Discharge Planning" states that every patient admitted to the Facility will have an individualized discharge plan. It also states that the patient's assigned Care Manager and/or Social Worker will complete an initial screen and assessment within twenty-four (24) hours of admission.

Review of current and closed medical records from 02/12/13 to 02/15/13 noted that patients admitted to the Hospital did not have an initial screen and assessment within twenty-four (24) hours of admission and did not have an individualized discharge plan.

Review of the medical record for Patient #56 on 02/14/13 noted that this 78-year-old Nursing Home resident with acute renal failure was admitted to the Hospital on 10/20/12. The patient was not screened and assessed within twenty-four (24) hours to identify his need for post Hospital services and no individualized discharge plan was done. The first Case Management notes were written on the day of discharge, 10/27/12, indicating that the patient will be returned to the Nursing Home.

Review of the medical record for Patient #57 on 02/13/13 noted that this 56-year-old patient with a past medical history of Bariatric Surgery and Diverticulitis was admitted to the Hospital on 02/06/13 for colostomy revision. The patient was not screened and assessed within twenty-four (24) hours of admission to identify if she was at risk for post Hospital service needs and no individual discharge plan was done.

Similar findings of patients with no initial screens and assessments within twenty-four (24) hours of admission and no individualized discharge plans were noted in the medical records for Patients #50, #51, #52, #53 and #54.
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Based on record review and interview during the Federal Recertification Survey, the Facility did not ensure that the Governing Body approved the Organ Procurement Policies.

Findings:

Review of the Organ Procurement Policies and Procedures on 02/15/13 at 9:30AM with Staff #20 and Staff #21 revealed the policies were not approved by the Governing Body.

An interview was conducted with the Director of Nursing Professional Development (Staff
#19) on 02/15/13 at 1:00PM who stated the policies have not been approved by the Governing Body since 2007.
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Based on record review and interview during the Federal Recertification Survey, the Facility did not ensure that patients had complete histories and physicals prior to endoscopic procedures in two (2) out of seven (7) records reviewed (Patients #46 and #47).

Findings:

Review of Patient #46's medical record revealed on 02/13/13 an endoscopy was performed. The history and physical was blank except for the gastrointestinal and abdominal section.

Review of Patient #47's medical record revealed on 02/12/13 an endoscopy was performed. The history and physical was blank except for the abdominal assessment.

Review of the policy titled "History and Physical Examinations" dated 06/12, documented a history and physical will be performed and placed in the medical record prior to procedures requiring anesthesia services.

During an interview the Peri Operative Nurse Manager (Staff #22) on 02/13/13 at 3:00PM agreed the patients' histories and physicals were incomplete.
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Based on observation, record review and staff interview during the Federal Recertification Survey, the Facility failed to develop and implement written policies for the processing and cleaning of respiratory care equipment, including infection control measures for the safe handling, storage, and dispensing of supplies.

Findings:

a. Observations during a tour of the Respiratory Care Department on 02/13/13 at 1:30PM
revealed a Respiratory Therapist (Staff #32) returning used equipment (a Bilevel Positive Airway Pressure (BiPAP) machine with an attached bag containing an Ambu bag and two {2} face masks) to the Department from a Patient Care Area after it had been discontinued. There was no patient identification or labels found on the equipment indicating it was used. The Therapist stated that she was returning the equipment because the BiPAP had been discontinued.

On interview the Department's Director (Staff #33) stated on 02/13/13 at 1:15PM, prior to
the observation and again at the time of the observation at 1:30PM, that all equipment
used in the Patient Care Area was to be disposed of before the machines are returned to the
Department. The Director confirmed that there was no current way to determine the
equipment had been in the Patient Care Area after it had been dispensed or returned to the
Department and no way to ensure that the staff appropriately disposed of the equipment.

b. Additional observations on 02/13/13 at 1:30PM of a computerized work station (CADDY-11) stored in the Respiratory Care Department was found to have a keyboard that was dirty and dust covered. An inspection of the attached wire basket revealed the basket contained multiple pieces of respiratory supplies including a face mask labeled with a staff member's name (Kevin) and a used Albuterol inhaler with a spacer in an unsealed bag belonging to Patient #49 who had been discharged on 01/22/13.

An interview with the Director at the time of the observation revealed that the Respiratory Therapists are responsible for cleaning and maintaining the unit based work stations as well as any equipment used on patients assigned to them.

These observations and interviews were witnessed by the Assistant Vice President of Performance Improvement (Staff #34).

c. Review of the Respiratory Care Service Policy and Procedure Manual revealed that there are no Department specific cleaning policies. There are no policies for the dispensing or disposal of equipment and no policies for cleaning the computer work stations. This was confirmed by interview on 02/14/13 at 10:30AM with the Department Director.

An interview with the Infection Control Nurse (Staff #38) on 02/15/13 at 10:30AM revealed that the Infection Control Manual contains general cleaning and disinfection policies for the facility but that each Department is responsible to develop and implement Department specific equipment cleaning or disinfecting policies and procedures as recommended by the manufacturers.