HospitalInspections.org

Based on findings from document reviews and interview, the governing body, known as the Board of Directors (Board), has not ensured oversight of all contracted services.

Findings include:

During interview on 12/13/12 at 12:35 pm, the Corporate Compliance Officer (COO) reviewed with the surveyor the hospital's list of 501 contracted clinical and nonclinical services. The list contained, for example, three different agencies providing per diem nurse staff and Computrition, a dietary management service. The COO verified that the hospital does not currently have a process to evaluate its contracted services to assure the services are provided in a safe and effective manner and to incorporate such information into the quality improvement program.

Based on findings from document review and interviews, in 3 of 3 current inpatient psychiatric medical records (MRs) reviewed and in 2 outpatient clinic services evaluated, the hospital did not ensure that patients were provided required information about patients' rights.

Findings include:

-- Per review of the MRs on 12/11/12 at 1:30 pm of Patients A, B and C, who had been admitted to the psychiatric inpatient unit from the Comprehensive Psychiatric Emergency Program (CPEP), each patient's Admission Authorization And Consent form contained documentation indicating the patient did not receive "Patient Handbook" information (the documentation entries were witnessed by either Secretary #1 or Secretary #2).

During interviews on 12/11/12 at 2:45 pm, Secretaries #1 and #2 (who work on the inpatient psychiatric unit and are involved in the admission process for these patients) confirmed that the hospital's admission packet of patients' rights consists of 2 booklets titled "Patient Handbook" and "Your Rights as a Hospital Patient in New York State" and that evidence the patient has received such information is documented on the Admission Authorization and Consent form. Each verified that Patients A, B and C did not receive the required patients' rights information because they were admitted from CPEP and the CPEP staff give this information to patients being admitted.

However, during interview on 12/13/12 at 2:10 pm, the CPEP Nurse Manager indicated that CPEP staff do not provide the Patient Handbook (patients' rights) information to patients being admitted to the hospital's inpatient psychiatric unit. He/she noted the patients are supposed to receive this information from the inpatient secretarial staff.

-- Per review of the admission packets distributed to patients at the hospital's extension clinics located at the Northeast Medical Center, specifically the Ambulatory/Surgical Center (ASC) and the Wound Care Center (WCC), they lacked the pamphlet prepared by the New York State Department of Health (NYSDOH) entitled "Appointing your Health Care Agent - New York State's Proxy Law," which also contains a sample health care proxy form contained therein. NYSDOH regulations at 10 NYCRR 400.21(d)(1)(ii) require this information to be provided to inpatients and outpatients.

During interviews on 12/11/12 of the ASC's Registrar at 1:00 pm and the WCC's Clerical Staff #1 at 1:30 pm, they acknowledged the findings above and stated that a patient requesting the information would be able to obtain the information from their primary care physician.

Based on findings from document review and interviews, the hospital did not provide in-service education to clinical staff regarding its policies and procedures (P&Ps) related to advance directives as required by the New York State Department of Health (NYSDOH).

Findings include:

--Per review of 28 of 28 personnel files and training records for clinical staff, they each lacked documentation that education regarding the hospital's P&Ps for advance directives was provided.

--During interview on 12/12/12 at 2:00 pm, the Human Resources Director stated only information contained in the Patient's Bill of Rights regarding a patient's right to formulate an advance directive is included in orientation; no additional information regarding the facility's P&Ps concerning advance directives is provided.

--NYSDOH regulation in Title 10 NYCRR at 400.21(d)(4) requires hospitals to provide in-service education to staff about its P&Ps regarding advance directives.

--During interview on 12/12/12 at 2:05 pm the Chief Nursing Officer acknowledged the above findings.

Based on findings from document review and interviews, respiratory therapy medication errors are not tracked by the Respiratory Therapy Department. Additionally, the hospital's policy regarding Medication Related Occurrences does not address reporting of medication errors by respiratory therapy staff into the quality assurance program.

Findings include:

--During interview on 12/13/12 at 12:30 pm, Respiratory Therapist (RT) #1 indicated that at the end of every shift the Respiratory Therapy Department receives a generated report that contains a hospital wide list of medications that were not scanned (signed for) at the time they were scheduled. The RT shift coordinator reviews the list for respiratory therapy medications and notifies the respiratory therapist to follow up and reschedule the medication or document the reason that the medication was not signed for.

--During interview on 12/13/12 at 12:45 pm, the Director of Respiratory Therapy indicated that the reason respiratory medications were not administered at the scheduled time is not tracked or investigated, and acknowledged that the Respiratory Therapy Department does not have a specific policy describing medication errors and reporting.

--Per review of the hospital's policy titled "Medication Related Occurrence," last reviewed 3/2011, it indicated that pharmacists, physicians/prescribers and registered nurses should report medication related occurrences (medication errors). The policy does not address reporting of medication errors by respiratory therapy staff.

Based on findings from document reviews and interviews, in minutes reviewed for the Quality Management Review Council (QMRC) meetings from December 2011 through September 2012, the QMRC did not document descriptions of actions or follow up aimed at performance improvement (PI) in connection with concerns identified or PI projects underway.

Findings include:

-- Per review of the 02/21/12 QMRC meeting minutes, they contained a two page power point titled "DOH Plan of Correction (POC) for Rapid Response Documentation" that indicated 100% compliance. However, neither the minutes nor the power point contained details of the issues that required correction in the POC, the corrective actions taken, a description of what met 100% compliance, or any follow-up planned. Additionally, no other QMRC meeting minutes or related PI documentation contained this information.

-- Per review of the 03/20/12 QMRC meeting minutes, they contained a 7 page power point titled "Quality Management Review, CPEP (Comprehensive Psychiatric Emergency Program) Restraint Reduction Project" that included data elements showing a 53% reduction in restraint use between January - March 2012 (as compared to the same months in 2011), that 74% restraint use was occurring on Monday-Wednesday -Friday, and 56% was occurring on the day shift. Also, the goal benchmark was identified as 0% restraints. There were no descriptions of the PI measures underway (including ones targeting the days of the week and the shift identified as having heavier restraint use), and no indication of the target date for reaching 0 % restraint use. Additionally, no other QMRC meeting minutes or related PI documentation contained this information.

-- Per review of the 09/21/12 QMRC meeting minutes, they listed the topic, "Patient Grievances." The minutes indicated that an update on grievances was presented but did not describe specific data or information about tracking and trending. In the "Action" column, the minutes indicated that no action was required by the QMRC.

-- During interview on 12/13/2012 at 11:45 am, the Director of Quality Resources acknowledged that the documentation of the QMRC meeting minutes was not descriptive, and noted the facility was already in the process of developing a template to assist QMRC members to become more detailed in describing issues, PI actions and followup plans.

Based on findings from document reviews and interviews, in 14 of 14 practitioner credentials files reviewed, the medical staff appraisal procedures did not include evaluation of any peer reviews completed and any complaints received about the practitioner.

Findings include:

-- Per review of electronically maintained credentials files for 13 practitioners (Physicians #1 - 13) and one allied health professional (Registered Physician Assistant #1), each file lacked information about any peer reviews completed or any patient care complaints involving the practitioner.

-- During interview on 12/13/12 at 12:10 pm, Provider Credentialing Specialist (PCS) #1 indicated that during the credentialing /recredentialing process the information in each practitioner's electronic credentials file is compiled for review by the medical staff's credentialing committee (before they make a recommendation on each individual). The PCS acknowledged that peer review and patient complaint information is not added to the credentials file.

-- During interview on 12/13/12 at 1:20 pm, the Director of Quality Resources acknowledged that practitioner quality assurance information, such as peer reviews and patient complaints, is maintained in the quality assurance department but not included in the credentials file that is reviewed by the credentialing committee.

Based on findings from observations and interview, the condition of the physical plant and the overall hospital environment was not maintained in a manner that ensured the safety and well-being of patients.

Findings include:

--Per observations at 12:20 pm on 12/10/12, the bathroom door handles and the patient room door handles in the Comprehensive Psychiatric Emergency Program (CPEP) wing of the hospital posed a ligature hazard to patients. The bathroom door handles had the ability to hold a substantial amount of weight and the patient room handles were improperly installed with the corridor side of the paddle up instead of down, creating a looping hazard. In each instance, the handles were not consistent with design guidance from the New York State Office of Mental Health (Patient Safety Standards Materials and Systems Guidelines Recommended by the New York State Office of Mental Health, May, 2009).

--Per observations at 4:00 pm on 12/10/12, there were approximately eight holes in one wall of the soiled room in the Oncology unit located on floor 3 of building 2 of the hospital. The walls were, therefore, not scrubbable as required by Title 10 Part 712-1 titled Standards for General Hospital Construction Projects Completed on or after October 14, 1998.

--Per observations at 4:05 pm on 12/10/12, the clean room on the 3rd floor of building 2 did not have a door. By definition, a clean room constructed prior to 1988 must have a door to maintain the appropriate number of air exchanges as specified in Table 2 of the Guidelines for Design and Construction of Hospital and Health Care Facilities (American Institute of Architects, 1997).

--Per observations at 8:50 am on 12/11/12, clean pharmaceutical supplies were being stored in cardboard shipping cartons. According to the Association for the Advancement of Medical Instrumentation (AAMI), Standard 79, shipping containers should not be used for the storage of clean and sterile supplies.

--Per observations at 12:10 pm on 12/11/12, there was no signage to indicate that patients transported from building 8, floor 1 of the hospital have left the hospital to enter an attached private Medical Office Building for radiotherapy treatment. Boundaries between public and private areas should be well marked or implied and clearly distinguished according to the Guidelines for Design and Construction of Health Care Facilities Guidelines 2010 edition, Chapter 1.

--Per observations at 1:30 pm on 12/12/12, the sink faucets and door hardware in the psychiatric unit, building 6 floor 3 of the hospital, posed a ligature hazard to patients. The sink faucets presented a looping hazard as they could hold a substantial amount of weight, and were not consistent with design criteria published by the New York State Office of Mental Health (Patient Safety Standards Materials and Systems Guidelines Recommended by the New York State Office of Mental Health, May, 2009). Thumb latches on the patient room doors on six patient room doors were also found to present a ligature hazard due to substantial weight bearing capacity.

--The Director of Facilities who was present at the time the above observations were made confirmed these findings.

Based on findings from observations during tours of the hospital's Physical Therapy (PT) extension clinic and Comprehensive Psychiatric Emergency Program (CPEP), multiple patient care supplies were outdated and available for patient use.

Findings include:

-- Per observations during a tour of the CPEP on 12/10/2011 at 2:15 pm, the following outdated supplies were available for patient use:

* Exam Room #3: 72- blue top blood draw tubes with expiration dates of 08/2012, 37- green top blood draw tubes with expiration dates of 09/2012, 30 - yellow top blood draw tubes with expiration dates of 11/2012.

* Medication Room: 100 - yellow top vacutainers with expiration dates of 10/2012, 50 - 23 gauge 3 ml retracting syringes with needles with expiration dates of 07/2012.

These findings were acknowledged by the CPEP Nurse Manager at the time of the tour.

-- Per observations during a tour of the Northeast Medical Center PT extension clinic on 12/11/12 at 8:30 am, 3 boxes of >40 outdated electrodes (utilized with transcutaneous electrical nerve stimulation units) were observed in the cabinet near the water cooler, available for patient use. The expiration dates ranged from 2/2010 through 5/2011.

These findings were acknowledged by the Director of Physical Medicine and Rehabilitation at the time of the tour.

Based on findings from observations, document reviews and interviews, infection control practices at the hospital do not ensure avoidance of sources and transmission of infections and communicable diseases. Lapses in generally accepted infection control practices were identified relative to the cleaning of glucometers between patients, consistent tracking of patient use of endoscopes, and use of single-dose and multiple-dose vials of medication. Also, the hospital policy & procedure (P&P) for blood glucose monitoring was not consistent with generally accepted infection control measures.

Findings include:

--During a tour on the hospital's Northeast Medical Center Wound Care Clinic (a hospital extension clinic) on 12/11/12 at 10:50 am, a glucometer was observed sitting on the counter. In response to questions during interview on 12/11/12 at 10:55 am, Registered Nurse (RN) #1 indicated the glucometer was not always cleaned between patients.

In February 2009 and again in 2011, the New York State Department of Health (NYSDOH) issued a health advisory to healthcare facilities and providers indicating that blood glucose monitors should not be shared between patients, but when they are, they should be cleaned and disinfected after every use.

During interview on 12/12/12 at 1:10 pm with Infection Control Preventionist #1, he/she agreed the glucometer should be cleaned between patients; however, when he/she looked at the hospital P&P titled "Blood Glucose Monitoring" (last reviewed 8/2012) with the surveyor, it only indicated a glucometer needed to be cleaned when soiled or after use in an isolation room.

-- Per observations during a tour on 12/10/12 of the Operating Room, a Medivator (endoscope reprocessing unit) was present in the substerile room. Upon review of the log titled "Scope Log" (used to track disinfection of each endoscope) for time frames dated 11/12/12 to 11/15/12 and 12/7/12 to 12/10/12, 10 of the 30 entries lacked information regarding the patient the scope was used on.

During interview on 12/10/12 at 3:15 pm, the Instrument Room Coordinator confirmed these findings.

--Per observations on 12/11/12 at 10:00 am, an anesthesia cart in Endoscopy Room #4 contained 1 open single-use vial of Propofol. Upon interview on 12/11/12 at 10:05 am, Certified Registered Nurse Anesthetist (CRNA) #1 indicated that a single-dose vial of Propofol is used for multiple patients. This practice was confirmed by Anesthesiologist #1 at 10:10 am.

--During interview on 12/10/12 at 11:00 am, the Medical Intensive Care Nurse Manager acknowledged that multiple-dose insulin vials are taken into patient rooms to be scanned and used for the patient's medication administration; the vials are then returned to the medication refrigerator for use on other patients.

During interview on 12/13/12, the Surgical Intensive Care Unit Nurse Manager described this same practice for using multiple-dose insulin vials in medication administrations.

In the earlier referenced February 2009 health advisory issued by the NYSDOH, healthcare facilities and providers were informed that multiple-dose vials not dedicated to individual patients should not be transported into patient rooms.

Based on findings from observations, document reviews and interviews, the hospital's infection control officers have not ensured that the hospital system for investigating and controlling infections and communicable diseases of patients and personnel incorporates generally accepted infection control practices. See the condition-level findings in Tag A 747.

Based on findings from observation, document review and interview, in 1 of 1 endoscopic procedures observed, surgical services staff did not perform pre-procedure time outs in accordance with generally accepted standards of practice; and in 3 of 3 medical records reviewed for cesarean section patients, the documentation of timeouts was inaccurate and/or contradictory.

Findings include:

--Per observations on 12/11/12 at 9:25 am, Patient D was in endoscopic room #4. Immediately prior to the start of Patient D's colonoscopy procedure, a time out was performed by endoscopy staff. However, all the team members did not cease what they were doing to fully participate in the timeout as Certified Registered Nurse Anesthetist #1 continued to administer medication to the patient.

During interview of the Director of Medical /Surgical /Endoscopy Unit who was present at the time of this observation, he/she verified that staff should cease work and fully participate in the time out.

-- Per review of the medical records (MRs) of 3 patients (Patients E, F, and G) who delivered infants by Caesarean section (C-Section), each MR contained conflicting information about the exact time the time-out occurred prior to the C-Section.

*For Patient E's C-Section, the MR revealed she and the anesthesiologist were present in the operating room (OR) at 1:10 PM on 12/10/12; the surgeon was present at 1:20 PM and the procedure started at 1:27 PM. The time out for Patient E's procedure was recorded as 1:00 PM according to the Verification of Surgical Procedure, Site , and Side documentation; as 1:10 PM on the Anesthesia Record; and as 1:20 PM in the nursing progress notes.

*For Patient F's C-Section, the MR revealed she and the anesthesiologist were in the OR at 9:47 am on 12/06/12; the surgeon was present at 9:59 am; and the procedure was started at 10:05 am. The time out for Patient F's procedure was recorded in the Verification of Surgical Procedure, Site, and Side documentation as 10:10 am.

*For Patient G's C-Section, the MR revealed that she was in the OR at 7:24 am on 12/11/12; the anesthesiologist at 7:22 am; the surgeon at 7:27 am; and that the procedure started at 7:37 am. The time out for Patient G's procedure was recorded in the Verification of Surgical Procedure, Site, and Side documentation as 7:00 am.

During interview on 12/11/12 at 11:10 am, the Surgical Coordinator acknowledged that according to hospital policy the time-out is documented on the Verification of Surgical Procedure, Side, and Site form and that the documentation of times in the 3 C-Section MRs was inaccurate and/or contradictory.