HospitalInspections.org

Survey Additional Findings:

Based on medical record review, document review and interview, following the fall of Patient #2, an incident report was not generated and a review of the incident was not conducted in accordance with facility policy.

Findings Include:

Review of the nursing note dated 11/13/14 at 10:54pm revealed the patient had a syncopal episode and experienced a fall following the administration of Toradol.

Review on 4-21-15 of Incident Reports from November 2014 to present revealed no evidence of an Incident Report related to the patient's fall on 11/13/14.

Interview with Staff #6, RN Informatics Analyst on 4/21/15 at 11:00am confirmed that an Incident Report related to the patient's fall had not been filed.

Review on 4/21/15 of the Fall Risk Screening, Assessment and Post Fall Worksheet Guidelines last signed 3-20-15 revealed after a patient falls a Patient Incident Report and a Patient Incident Review is to be filled out and given to the department manager or designee for review.

Based on personnel record review, document review and interview, the facility failed to ensure compliance with employee immunization and annual health assessments in accordance with facility policy for 4 of 5 Emergency Department (ED) providers.

Findings Include:

Review of the facility policy entitled "Annual Employee Health Assessment", last revised 3/21/07 revealed that all employees are required to participate in the Annual Employee Health Assessment as established by the hospital in accordance with the regulations of the New York State Health Department (NYSDOH). The yearly health assessment will include periodic immunizations as required by NYSDOH, as well as additional, optional vaccinations such as the influenza vaccine. The assessment shall include Tuberculosis (TB) skin testing.

Review of the facility Infection Control- Influenza Vaccination Plan last revised 8/14 revealed all persons employed or affiliated with the facility and " who engage in activities such that if they were infected with influenza, they could potentially expose patients to the disease " are required to be immunized against influenza with documentation maintained in the occupational health record. For staff who opt out, they are required to sign a declination and are required to wear a surgical mask in patient areas when influenza is determined to be prevalent.

Review of provider personnel health files on 4/21/15 revealed the following:
-2 of 5 provider health files contained no documentation related to measles, mumps and rubella (MMR) vaccine or immunity (Staff # 22 and 24).
-2 of 5 provider health files contained no documentation of annual influenza vaccination or declination (Staff # 22 and 23).
-4 of 5 provider health files contained no documentation of Mantoux (PPD) testing in the past year (Staff # 20, 22, 23 and 24).
-3 of 5 provider health files contained no documentation of an annual health update for the past year (Staff # 22, 23 and 24).

Interview on 4/27/15 at 9:40am with Staff # 25, Occupational Health Office Manager, revealed that the ED contracted providers are instructed to bring in their updated health records of offsite health assessments and immunizations as they are completed.