HospitalInspections.org

Based on findings from document review and interview, the hospital's Governing Body (GB) has not approved the Quality Assurance Performance Improvement (QAPI) program indicators selected for review and the frequency of data collection.

Findings include:

-- The GB meeting minutes for 2014 and for the first meeting in 2015 were reviewed. With the exception of the indicators specifically incorporated into the hospital's 2014 and 2015 Strategic Plans (e.g., all cause 30 day Medicare readmissions), they lacked discussion and approval of the indicators the individual hospital departments planned to review and report to the QAPI program, prior to initiation.

-- This finding was confirmed during interview of the Director of Quality Improvement on 2/26/15 at 12:00 pm.

Based on findings from document review and interview, the Governing Body (GB) has not ensured that all hospital departments and services are collecting and reporting Quality Assurance Performance Improvement (QAPI) data to the hospital-wide QAPI program.

Findings include:

-- The meeting minutes for the Performance Improvement Steering Committee, the hospital-wide QAPI committee, from 2/6/14 to 1/20/15 were reviewed. They did not contain reports from the dietary, respiratory, and rehabilitation departments regarding the QAPI data being collected by those services.

In connection with organ, tissue and eye procurement activities at the hospital, the Finger Lakes Donor Recovery Network and the Central New York Eye and Tissue Bank perform death record reviews and on a monthly basis provide performance improvement data to the hospital. The meeting minutes for the PI Steering Committee lacked indication this data was being reviewed / addressed by the Committee.

-- The findings above were acknowledged by the Chief Nursing Officer and the Director of Quality Improvement during interviews on 2/25/15 at 1:00 pm and 2/26/15 at 12:00 pm, respectively.

Based on findings from medical record (MR) review, facility document review, and interview, in 1 of 1 MR nursing did not document a complete initial physical assessment of a newborn infant. Also, the facility's policy and procedure (P&P) regarding initial newborn care lacked instructions regarding handling of cord blood.

Findings include:

-- Per review of Patient A's MR, it lacked documentation on the "Perinatal Information" form, dated 2/24/15, indicating the presence of 3 vessels in the umbilical cord and if cord bloods had been sent to the laboratory.

-- Per review of the facility's P&P titled "Initial Care of the Newborn," last revised 5/2014, "...document number of blood vessels in the cord." The P&P lacks instructions regarding sending cord bloods to the laboratory.

-- During interview with the Nurse Manager for Obstetrics on 2/24/15 at 11:30 am, the above finding was acknowledged.

Based on findings from medical record (MR) review, facility document review, and interview, in 7 of 12 MRs (Patients B, C, D, E, F, G, and H) verbal / telephone orders were not cosigned by the Provider within 48 hours as required by the facility's medical staff rules and regulations. Also, the facility's policy and procedure (P&P) in this matter was inconsistent with the medical staff rules and regulations.

Findings:

-- Per MR review, Patients B - H lacked provider signatures for telephone / verbal orders within 48 hours. For example:

Patient B - a telephone order from a physician on 2/20/15 at 7:00 pm for "Nasonex Nasal spray BID PRN for nasal congestion" remained unsigned 4 days later, and

Patient C - a telephone order from a physician on 2/17/15 at 5:00 am for "Foley Catheter" remained unsigned 7 days later.

-- The facility's "Medical Staff General Rules and Regulations," last reviewed 3/2013, stated "Verbal orders must be authenticated within 48 hours by the prescribing practitioner..." However, the facility P&P titled "Orders Transcription-Verbal and Telephone," last reviewed 8/2012, stated "All telephone or verbal orders must be signed within 24 hours."

-- During interview with the Nurse Manager of the Intensive Care Unit (ICU) and Telemetry on 2/25/15 at 11:15 am, the above findings were acknowledged.

Based on findings from observation, medical record (MR) review, and interview, 1 of 1 MR reviewed (Patient I) lacked timely documentation of the care provided by an emergency department (ED) physician (Physician #1). Specifically, documentation by Physician #1 regarding Patient I's physical examination, treatment, diagnosis and disposition were not in the MR 24 hours after the patient's presentation to the ED and subsequent admission to the Intensive Care Unit (ICU).

Findings include:

-- During observation on 2/25/14 at 9:27 am, Patient I presented to the ED via ambulance with reported acute respiratory distress. Physician #1 attended the patient upon arrival and until his inpatient admission to the ICU at 1:02 pm.

-- Review of Patient I's MR on 2/26/15 at 8:59 am in the ICU (24 hours later) revealed ED documentation consisting of physician orders by Physician #1, and notes regarding nursing, respiratory, laboratory and radiology care provided to the patient. The MR lacked documentation describing Physician #1's evaluation of the patient and findings. This was confirmed by the ICU Nurse Manager.

-- During interview with the ED Medical Director on 2/26/15 at 11:00 am, he/she indicated the current practice is for an ED physician to dictate an "Emergency Department Report" after a patient's disposition. The written dictation is transcribed within 24 hours for patients that are admitted, 2-3 days for patients that are not admitted and 1 week for Prompt Care.

The "Emergency Department Report" for Patient I's ED visit was obtained and reviewed during the interview - it had been dictated at 1:30 pm (following Patient I's 1:02 pm departure from the ED).

-- The delay in placement of ED physician dictated reports in patients' MRs is not acceptable - the result is the MRs, for an interim period of time, lack information which supports the diagnosis, describes the patient's progress and response to physician services, and justifies the admission.

Based on findings from facility document review, medical record review and interview, in 1 of 1 MR the hospital's informed consent form for anesthesia did not contain the type of anesthesia planned for the procedure for which consent was being obtained.

Findings include:

-- Per review of the hospital's consent form titled "Anesthetic Consent," last revised 12/2014, it contained the following text: " ... being legally empowered to do so, hereby authorizes the Anesthesia Department at Cortland Regional Medical Center to administer anesthesia and use such anesthetic agents as may be necessary by the department of Anesthesiology on myself... "

-- Per review of Patient J's MR, he was admitted to the hospital on 2/25/15. A consent form signed by the patient for administration of anesthesia during a cystoscopy, right ureteroscopy, laser lithotripsy and stent placement was present in the MR. Patient J underwent general anesthesia during the procedure. There is no documentation on the anesthetic consent form indicating a plan for general anesthesia.

-- During interview of the Director of Anesthesia on 2/23/15 at 12:30 pm, he/she indicated that patients are informed of the type of anesthesia during the informed consent process. Regardless, he/she also acknowledged that the type of anesthesia discussed is not documented on the consent form.

Based on findings from observation and interview, a facility extension clinic did not maintain documentation of the lot numbers or reference codes for medications administered to patients receiving iontophoresis (introduction of ions of soluble salts into the tissues by direct current).

Findings include:

-- During tour of the Cortland Regional Outpatient Rehabilitation Center at 1259 Fisher Avenue, Cortland, New York, on 2/24/15 at 3:00 pm, two (2) 45 cc bottles of Acidic Acid Solution 2% Topical solution, each lacking lot numbers or reference codes, were observed.

-- During interview with the Physical Therapy Supervisor during the above noted tour, he/she was not aware lot numbers for medications should always be documented on the container. He/she indicated the Acidic Acid Solution had been prepared, labeled and delivered to the clinic by the hospital's pharmacy.

Based on findings from observation and interview, the central storage area in the basement and several areas in the mental health unit were not maintained in a manner that assured the safety and well being of patients.

Findings include:

-- Per observation on 2/24/15 at 11:20 am in the area of the basement used to store clean and sterile supplies, dust was present on the overhead piping (e.g., sewer piping, water piping). The ceiling in this area was unfinished and not readily cleanable. Further, medical and surgical supplies (e.g., vinyl connecting tubing, baby bottles, exam gloves, surgical gowns) were but should not be stored under piping where they may become wet, according to the Association for the Advancement of Medical Instrumentation (National Standards and Recommended Practices for Sterilization, 2nd Edition. Arlington, Virginia, 1988).

-- Per observation on 2/24/15 at 11:20 am, clean and sterile supplies were being stored in the basement in corrugated cardboard boxes within which the supplies were shipped. According to the Association for the Advancement of Medical Instrumentation (Standard 79) clean and sterile supplies should not be stored in cardboard shipping containers.

-- Per observation on 2/24/15 at 3:00 pm, the following ligature hazards were observed in the mental health unit: the water control activators in the bathing rooms (shower and bathroom) adjacent to the corridor; and, the towel dispensers in the patient rooms. The type of fixtures present were inconsistent with those listed in Patient Safety Standards Materials and Systems Guidelines Recommended by the New York State Office of Mental Health, May, 2009.

-- The Vice President of Finance, who was present at the time the above observations were made, concurred with these findings.

Based on findings from observation and interview, the sprinkler heads in two rooms in the basement were obstructed.

Findings include:

-- Per observation on 2/24/15 at 1:30 pm and on 2/25/15 at 12:30 pm, the sprinkler heads located in the radiological film room and the medical records storage room (designated the "yellow" room), respectively, were obstructed by radiological films and medical records vertically within 18 inches of the sprinkler deflector. The 2000 Life Safety Code refers to NFPA 13 (1999 edition) for compliance involving sprinkler installation - it states that sprinklers may not be obstructed in the manner similar to that observed in these storage rooms.

-- The Vice President of Finance who was present when the above observations were made confirmed these findings.

Based on findings from interview, observation, and facility document review, the following lapses in acceptable infection control practices were identified at the hospital's inpatient and outpatient settings: (1) ineffective infection isolation precautions, (2) availability of expired or opened single dose medications, (3) operating rooms not terminally cleaned as required, (4) inadequate documentation of hydoculator cleaning, and (5) unavailability of disinfecting wipes for cleaning respiratory equipment.

Findings regarding (1) above include:

-- Per interview with the Swing Bed Nurse Manager on 2/25/15 at 1:10 pm, they have a colored lights unit above the patient room doors. Each different color light indicates something particular (e.g., if a patient is on infection isolation precautions a specific color light will be on in the unit above the patient's door, if a patient is at risk to fall another specific color light will also be on, etc.) The Nurse Manager indicated that hospital staff are aware of the colored light system and know if a patient is on isolation precautions.

-- However, during observation on 2/25/15 at 1:40 pm, 2 staff members (Staff #1 and Staff #2) entered a patient room on the Swing Bed Unit. The colored light lit above the door indicated the patient was on isolation precautions. A nursing staff member called the 2 staff members out of the room and informed them the patient was on isolation precautions and they needed to put on personal protective equipment (PPE) if they were going to come in contact with the patient or the patient's care environment. During interview with Staff #1 and Staff #2 at the time of the observation, both indicated they did not know what the colored light that was on above the door meant.

-- There was no sign on the patient room door instructing visitors (who would not know the meaning of the colored lights above the door) to stop at the nursing station prior to room entry.

-- During interview of Staff #3 on 2/25/15 at 2:10 pm, he/she indicated visitors are caught by staff as they enter the unit and informed if the patient they are visiting is on isolation precautions and are told what PPE they would need to don.


Findings regarding (2) above include:

-- Per review of the hospital's P&P titled "Expiration Dating of Medications," last revised 3/2013, it indicated that single dose vials should be discarded immediately after use and multiple dose vials should be labeled with date opened and discarded after 28 days.

-- Per observation on the swing bed unit on 2/25/15 at 1:55 pm, a medication (med) cart drawer, with sections for different patients, contained 3 opened multi-dose vials of Heparin that were not labeled with the discard date. This finding was verified by the Nurse Manager at the time of observation.

Per observation in operating room (OR) #4 on 2/24/15 at 3:30 pm, the anesthesia Omnicell contained an open single dose 2 milliliter (ml) vial of gycopyrrolate and an open single dose 5 ml vial of lidocaine 2%.

Per observation in OR #1 on 2/24/15 at 3:40 pm, the anesthesia Omnicell contained an open single dose 20 ml vial of esmolol and an open unlabeled multidose vial of Bloxiverz (neostigmine).

-- During interview with the Perioperative Director on 2/24/15 at 3:40 pm, the above findings were acknowledged.


Findings regarding (3) above include:

-- Per interview on 2/24/15 at 2:40 pm with the Operating Room Materials Management RN, operating rooms are not terminally cleaned every 24 hours on the weekends when not used.

-- During interview with the Perioperative Director on 2/24/15 at 3:40 pm, the above finding was acknowledged.


Findings regarding (4) above include:

-- Per review of the Hydroculator Cleaning Log in the Department of Rehabilitation, it lacked staff initials indicating the cleaning of the hydroculator for the months of 1/2014, 2/2014, 3/2014, 9/2014, 10/2014, 11/2014, and 12/2014.

-- During interview with the Director of Rehabilitation on 2/23/15 at 1:55 pm the above finding was acknowledged.


Findings regarding (5) above include:

-- Per observation of the Respiratory Care Department room where pulmonary function testing was performed there were no germicidal products available to clean the non-disposable components of equipment used for patient testing (e.g., connection tubing of the pulmonary function testing equipment).

-- The hospital's policy and procedure (P&P) titled "Pulmonary Function Testing," last reviewed 5/2012, stated "The pulmonary function equipment will be decontaminated using germicidal wipes between each patient use."

-- During interview with the Clinical Specialist of Respiratory Care Services on 2/25/15 at 1:45 pm, the above finding was acknowledged.

Based on findings from medical record (MR) review, facility document review and interview, in 1 of 1 MR reviewed, when Patient K was discharged to a skilled nursing facility (SNF) she did not receive a copy of her discharge instructions. Additionally the facility's policy and procedure (P&P) did not include this requirement.

Findings include:

-- Per MR review, Patient K was transferred to a SNF on 2/8/15. There was no documentation that a copy of the discharge instructions was provided to the patient / representative in addition to the SNF.

-- Review of hospital P&Ps titled "Case Manager Discharge Planning Screen/ Evaluation," last revised 2/2015, and "Hospital Discharge/Transfer Policy for Medicare Patients," last reviewed 5/2014, there was no reference to the need to provide a copy of discharge instructions to patients / representatives in addition to the copy sent to the receiving facility.

-- During interviews with the Director for Discharge Planning and Staff #4 on 2/24/15 at 1:30 pm, they confirmed that upon discharge to another facility the current practice is to provide a copy of patient discharge instructions to only the receiving facility and not additionally to the patient / representative.

Based on findings from facility document review and interview, the hospital's policy and procedure (P&P) addressing skin preparations for antisepsis in the operating room (OR) did not contain all fire risk reduction measures that are required when alcohol based skin preparations are used.

Findings include:

-- The hospital's P&P titled "Skin Preparation," last revised 9/2014, outlined measures to be taken for cleansing and disinfecting the surgical site prior to surgery. The policy indicated that staff should allow sufficient time for complete evaporation of any flammable agent and execute measures to prevent antiseptic agents from pooling beneath patients (i.e., use of folded towels on periphery of prep areas, application of sticky U drapes with pneumatic tourniquet cuffs before prep, coverage of electrodes with adhesive tape). The P&P did not require that when alcohol based skin preparations are used they are packaged to ensure controlled delivery to patient in unit dose applicators, staff ensure that the preparations do not soak into hair or linens, and sterile towels used to absorb the preparation are removed prior to draping. The P&P did not describe the process staff must use to ensure all required measures have occurred prior to initiation of the surgical procedure. The P&P did not require that staff document the measures taken to reduce the risk of fire associated with use of alcohol based skin preparations.

-- During interview with the Perioperative Director on 2/24/15 at 3:30 pm, the above findings were acknowledged.

Based on findings from facility document review, medical record (MR) review and interview, in 3 of 4 MRs for surgery patients receiving anesthesia services (Patients L, M, and H), the MRs lacked documentation that a complete physical examination of the patient was performed as part of the preanesthetic evaluation.

Findings include:

-- Per review of the hospital's policy and procedure (P&P) titled "Pre-Anesthetic Evaluation," last revised 8/2012, an examination of the patient must be performed within 48 hours of the patient's surgery.

-- Per review of Patient L's MR, on 2/24/15 at 7:45 am he underwent right carpel tunnel release while under monitored anesthesia care (MAC). At 7:15 am, Physician #2 had documented a preanesthetic evaluation of the patient. Other than a physical examination of the patient's airway, teeth and neck, no further physical examination of the patient was documented, i.e., cardiovascular, respiratory, and neurological.

-- Per review of Patient M's MR, on 2/24/15 at 8:45 am he underwent a pacemaker battery change while under MAC. At 8:14 am Physician #2 had documented that the preanesthetic evaluation (performed on 2/11/14) was reviewed and updated. However, other than an examination of the patient's airway and teeth, no further physical examination of the patient was documented, i.e., cardiovascular, respiratory, and neurological.

-- Per review of Patient H's MR, on 2/8/15 at 10:38 am she underwent open reduction internal fixation of the left hip while under spinal anesthesia (later converted to general anesthesia). In an untimed entry, Physician #2 had documented a preanesthetic evaluation of the patient. Other than an examination of the patient's airway, teeth, head and neck, no further physical examination of the patient was documented, i.e., cardiovascular, respiratory, and neurological.

-- During interview with the Director of Anesthesia on 2/24/15 at 1:00 pm, the above findings were acknowledged.

Based on findings from facility document review, medical record (MR) review, and interview, in 3 of 3 MRs reviewed for outpatient surgery patients receiving anesthesia services (Patients L, M, and N), they lacked documentation that a complete post-anesthesia evaluation was performed.

Findings include:

-- Per review of the hospital's policy and procedure (P&P) titled "PACU (Post Anesthesia Care Unit) Discharge/Post Anesthesia Evaluation," last revised 9/2014, it required that for outpatient anesthesia, a post operative evaluation should take place and be documented prior to discharge. It also required that the elements of an adequate post anesthesia evaluation be clearly documented, conforming to current standards of anesthesia care and including: respiratory function, including respiratory rate, airway patency and oxygen saturation; cardiovascular function, including pulse rate and blood pressure; mental status; temperature; pain; nausea and vomiting; postoperative hydration; and significant anesthesia related complications.

-- Per MR review, on 2/24/15 at 7:45 am Patient L underwent right carpel tunnel release while under monitored anesthesia care (MAC). Physician #2 later documented "no anesthesia issues" in the post anesthesia note section of the anesthesia record.

-- Per MR review, on 2/24/15 at 8:45 am Patient M underwent a pacemaker battery change while under MAC. Physician #2 later documented "no anesthesia issues" in the post anesthesia note section of the anesthesia record.

-- Per MR review, on 2/24/15 at 8:10 am Patient N underwent hysteroscopy and dilatation and curettage while under MAC. At 9:45 am Physician #3 documented "doing well - without complaints of anesthesia" in the post anesthesia note section of the anesthesia record.

-- During interview with the Director of Anesthesia on 2/24/15 at 1:00 pm. the above findings were acknowledged.