HospitalInspections.org

Based on staff interview and documents review, it was determined the hospital failed to ensure that compliance to Federal and State Education law requirements for Dietitian service were met.

As a result, Dietitians are performing functions outside of their primary functions.

Findings include:

During interview with Staff E, Director of Nutrition Services on 5/8/18 at 11:00AM, the hospital policy titled "Diet Order Adjustment" revised 2/18 was reviewed. "The policy provides a mechanism for the Registered Dietitian (RD) to adjust diet orders as approved in the Rules and Regulations of the hospital staff of Mount Sinai". This policy also states "This policy meets the criteria put forth by The Centers for Medicare and Medicaid Services, giving the Registered Dietitian the privilege to adjust protocols authorized by the hospital governing body".

The updated Centers for Medicaid and Medicare Services (CMS) Regulations and Interpretative Guidelines related to ordering privileges for the Registered Dietitian (RDN), effective July 11, 2014 states "all patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff and in accordance with State law governing dietitians and nutrition professionals".

Dietitians in New York State are not licensed and do not have a Scope of Practice. New York State Education, (NYSED) Office of the Professions provides a Certification in Dietetics and Nutrition (CDN), not a license. The NYSED, "Education Law, Article 157, Dietetics and Nutrition," states: "The primary function of a certified dietitian or certified nutritionist is the provision of nutrition care services that shall include: (a) Assessing nutrition needs and food patterns; (b) Planning for and directing the provision of food appropriate for physical and nutrition; and (c)Providing nutrition counseling.

There is no allowance in the "Education Law, Article 157..." from the Office of the Professions that approves the certified dietitians to write, or adjust physician's diet orders in the medical record as a practitioner. This was brought to the attention of hospital administration.

Based on observation, staff interview and document review, the facility failed to: (a) implement an effective surveillance system for protection of infants on Labor and Delivery (L&D) and Pediatric units, in order to minimize or prevent the potential risk of harm or abduction, and (b) to provide effective monitoring of all exits from L&D unit within the facility.

As a result, patients safety is potentially at risk.

Findings include:

During a tour of the Labor and Delivery Unit (L&D) on the 2nd floor of KP building on 5/11/2018 at 11:30 AM, the state surveyor asked the facility's staff to demonstrate how the Infant Security System functions. The facility's staff activated one band of the Electronic Infant Security System and this band was held by Staff O, Associate Director of Security and Infrastructure. The state surveyor and Staff O exited the L&D unit with the activated band through Stairwell W and exited the hospital to the street, unchecked or unstopped by any of the hospital's staff or security.


See findings at A 0144

Based on observation, document review and interview, the facility failed to implement its policy and procedure to minimize the potential risk for harm or abduction of infants on Labor and Delivery (L&D) and Pediatric units.

Findings include:

Review of the hospital policy and procedure; Subject No. GPP-427 - titled, 'Response to pediatric Security Alerts,' last revised on 01/18, states:
Upon receiving an alert of infant/child abduction, the Security Communications Center (SCC) will:
1. Announce to all Security personnel via hand-held radio that an infant Security is in effect.
2. Security personnel posted in the lobby entrances will immediately lockdown egress points. All
persons, bags and packages must be inspected prior to exiting the building.
3. The SCC will instruct Telecommunications to broadcast an Infant Security Alert on the
overhead page ...


During a tour of the Main Campus, Labor and Delivery unit (L&D) on the 2nd floor of KP building on 5/11/2018 at 11:30 AM, the observation and the testing of the facility's Electronic Infant Security System was conducted in the presence of Staff N, Vice President of Engineering; Staff P, Assistant Nurse Manager; Staff Q, Nurse Manager and Staff S, Senior Director of System Services.
The facility's staff activated one band of the Electronic Infant Security System which is used as part of its infant abduction system to prevent babies and children's abduction throughout the hospital. This band was held by Staff O, Associate Director of Security and Infrastructure. The Infant Security System triggered an alarm as Staff O went through the door of the Stairwell W. The staff and the state surveyor continued through Stairwell W to the ground level and walked to the outside of the building (KP) to the courtyard. The state surveyor and Staff O exited the hospital to 5th Ave street through Perimeter G door of the Courtyard.

There was no security or other staff member who checked or stopped Staff O from when he exited stairwell W, to the time he exited the hospital.

After the testing of the infant abduction system on 5/11/18 at approximately 12:00noon, Staff N, Staff O, Staff P, and Staff S acknowledged that exit doors E and W from the L&D unit were not monitored or otherwise configured to prevent the abduction of infants from the unit.

Based on document review and interview, in seven (7) of 20 adverse events reviewed, it was determined the facility did not ensure that adverse events were analyzed to identify areas for improvement.
This was evident for Patients #1, #2, #3, #4, #5, #6 and #7.

Findings include:

Review of the facility's "Medical Events Reporting System" for December 2017 to January 2018, identified documentation of adverse events. These events includes postpartum hemorrhage and a malfunctioned equipment.

The policy titled "Prevention and Treatment of Obstetric Hemorrhage," last reviewed 4/7/18, states: " Stage I Obstetric Hemorrhage is cumulative blood loss >600 ml and Stage III cumulative blood is >1,500 ml."

Review of a sample of 6 (six) postpartum hemorrhage events that occurred between 1/06/18 - 1/25/18, identified the following:
(a) Patient # 1 had a blood loss of 3,169 milliliters and the patient was given approximately 12 units of blood products on 1/21/18.
(b) Patient #2 had a blood loss of 1,713 ml for which the patient was given 3 units of blood products on 1/25/18.
(c) Patient #3 had a blood loss of 932 ml on 1/06/18.
Similar events of postpartum hemorrhage were noted in medical records (MR) #4, #5 and #6.

The facility's policy titled "Guidelines for Incident Reporting/Sentinel Events/NYPORTS," last revised 9/2015,
states: the purpose for investigating adverse patient events is to "identify causal factors and to develop corrective actions in order to avoid a similar occurrence in the future."
There was no documented evidence that this was followed.


An adverse event of equipment failure revealed on 12/27/17, the physician in charge of a cardio-pulmonary resuscitation of Patient #7, was paged. The physician stated the page did not reach his beeper (pager). The incident report indicated that the patient died.

There was no documented evidence that these events were analyzed, nor was there any documented evidence that corrective measures were taken to prevent reoccurrence.

These findings were shared with Staff A, Vice President for Quality Management & Performance Improvement, on 5/11/18 at 3:45 PM.

Based on observation, staff interview, and document review, it was determined that the facility failed to: (a) Oversee the daily maintenance of dietary services to ensure service is provided in a sanitary environment, (b) did not develop a comprehensive Emergency Disaster plan for Food and Dietetic Services and (c) follow Federal and New York State Education Law requirements for Dietitians.

As a result, patients are potentially at nutritional and safety risk.

Findings include:

A. During a tour of the Main/ Kosher on 5/7/18 at approximately 10:35 AM, it was noted that the kitchen was maintained in a unsanitary environment.

B. A review of the department Emergency Preparedness Manual identified that the manual was incomplete and lacked essential information and plan to meet the needs of feeding patients during a disaster.

C. During review of the Food and Nutrition policy titled "Diet Order Adjustment," revised on 2/18, it was found that Staff Dietitians were designated by the facility to adjust diet orders.

See Tag 0620 and Tag 0630

Based on observation, staff interview and document review, it was determined that the Food Service Director failed to ensure: (a) the daily maintenance of the kitchen in a safe and sanitary environment, (b) the development of a comprehensive Emergency Preparedness Plan (Manual) to meet the nutritional needs for all patients, in the event of an emergency.


Findings include:

A. During the tour of the Mount Sinai Manhattan's Main kitchen and Kosher kitchen on 5/7/18 at approximately 10:35 AM the following findings were observed. These finding were acknowledged by Staff D, Director of Food Service, who was present during the tour.

1. All garbage cans were uncovered throughout the kitchen. This promotes the potential for flies to enter the kitchen due to the presence of discarded foods.
2. Flies were observed in the dish room area.

3. Floor throughout the Main and Kosher kitchen were heavily soiled.

4. Walls throughout the kitchen were yellow with accumulation of grease.

5. Two employee personal brown bags with food and water bottles, were found on top of a food cart and reach-in refrigerator. This entry of personal items into the food service area, is a potential risk to the preparation of food for ill patients.
6. Condiment containers found on a rack, had no label containing the date of opening and date of expiration.

7. The floor of the reach-in refrigerators were sticky from old spillage.

8. Three (3) solid metal bins were full of kitchen utensils, sitting in water. This promotes an environment for fungal and bacteria growth.

9. Two (2) acoustic tiles in the ceiling in the dish room were open. These openings are a potential for harboring pests.

10. Three (3) engineer closets (One in the Main kitchen and Two in the Kosher Kitchen) were dark, dirty and full of dust. Kitchen employees were using these closets to store mops, brooms, step ladder and cleaning products. The closet doors were metal, warped and could not close. The doors were closed with utility carts.
One closet in the Kosher kitchen had 2 mouse traps.

11. A dirty mop inside a yellow bucket was located next to a cooking kettle which was cooking mashed
potatoes. This is a potential for food contamination.

12. Steam kettles cooking broth/soup had no splatter guard. The motor above the kettle was dirty and dusty. This is a potential for food contamination.

13. Large equipment found not in use such as a commercial blender and floor mixer, were not covered. This allows for the collection of dust and dirt when uncovered. When in use the dust may fall in the food.

14. Ceiling vents were stained yellow with grease, particularly in the Kosher kitchen.

15. The Kosher kitchen freezer contained a cart with a shelf full of foods items including meat, fish and broth, that were wrapped but not labeled with dates. The rotation of food cannot be done without knowing when these foods were wrapped and when they need to be thrown out. This finding was shared with the Kosher Chef Executive who was present during the tour.

16. A solid metal container with kitchen utensils sitting in water, was on top of a rack in the Kosher kitchen. The kitchen utensils were wet and the container had no holes for the water to drain.

17. A "white" board pinned to the wall in the cold prep area was heavily soiled.

18. Roach motels were underneath the sink in the cold prep area in the Main Kitchen.

19. The top of the wall in the hallway outside the catering room and the wall in the dry storeroom was cracked
and open. This is a potential entry for pest.

20. There was a very large black stain (approx.3 feet) above the combo-oven. The Food Service Director was unable to identify the stain.

21. The floor at the entrance to the Kosher storage area was extremely soiled with dirt and grime.

22. The ovens in the kitchen were heavily soiled with dried grease throughout the walls of the oven.



B. A review of the department's Emergency Preparedness Manual identified the following:
There were four (4) days of menus based on a Regular diet only.
The menus were incomplete and lacked essential information, including availability of sufficient water supply.
There were no other menus to reflect any other diets to meet the nutritional needs of all patients.

Based on observation, staff interview and document review, it was determined the hospital failed to ensure compliance to State Education Law regarding Dietitian's primary functions.

Findings include:

A review of hospital policy titled "Diet Order Adjustment,t" revised on 2/18, identified that Staff Dietitians were designated by the facility to "adjust" physicians diet orders. On 5/8/18 at 11:00 AM, Staff E, Director of Nutrition Services was interviewed on this policy. She informed the surveyor that the Physician orders the initial patient diet order and the Dietitian informs the physician of the need to change the diet order. The Dietitian then proceeds to "adjust" the diet order in the medical record as needed. Staff E stated she is aware that Dietitians could not order or change physicians diet orders and that hospital administration was made aware that Dietitians were not licensed nor had the State approved the function of a Dietitian to change Physician diet orders. Staff E presented the surveyor a document from the Rules and Regulations of the Hospital Staff of the Mount Sinai Hospital, titled "Section C. Orders and Results Reporting," revised February 2018. This document authorized Dietitians to make "adjustments" to Physicians diet order.

On 5/9/18 at approximately 10:00AM a meeting was held with hospital administration concerning the finding of Dietitians "adjusting" Physicians diet orders in the medical record. Present at the meeting were Staff H, Senior VP Ancillary Services; Staff I, Chief Medical Officer; Staff J, Senior Director Support Services; Staff K, Senior Assoc. General Council; and Staff L, VP Quality and Regulatory Affairs. The hospital administration personnel informed the surveyor that based on their interpretation of the regulations, a Dietitian, after speaking to the Physician of the need for the diet change, can write the diet change with the co-signature of the physician. Administration personnel stated that just like Nursing Scope of Practice, Dietitians can accept verbal orders or write diet orders if there was a Physician co-signature.

On 5/9/18 at approximately 11:00AM, Staff E, Director of Nutrition Services, provided a demonstration on how Dietitian "adjust" diet orders in the medical record. The demonstration took place in the Rehabilitation Department with Staff G, Associate Chief Medical Information Officer and Staff H Senior VP Mt. Sinai Health System. Staff E accessed a patient's medical record and went to the "Orders" section where the names of hospital diets are available for the physician to choose. The Dietitian went to the patient's diet, which was documented in the medical record and typed in a new diet change, clicked "accept" under Staff G physician's name. It was noted that the new diet order immediately transferred to the active physician order for the patient. The change of diet appeared as if it was ordered by the physician. There is a holding area in the computer that informs the attending physician that a co-signature is needed for a changed diet order. The physician approves the diet change and a physician co-signature is generated. However, the diet order is activated when it appeared in the Physician orders in the electronic medical record, prior to the physician co-signature.


Similar findings concerning diet "adjustments" were found at Mount Sinai- Queens.

Based on observation and staff interview, the facility failed to ensure the overall hospital environment was developed and maintained in such a manner that the safety and well-being of patients are assured.

Findings:

Queens Campus:

On 05/08/2018 at approximately 11:50AM, it was observed that the floor of the Soiled Utility Room, 3 E (in the old building) was in disrepair. An interview with Staff C on 05/08/2018 at 11:5AM confirmed this finding.

On 05/08/2018 at 11:52 AM, the corridor floor of the facility near Rooms 415 and 416 was observed to be in disrepair. A concurrent interview with Staff C confirmed this finding.

On 05/08/2018 between 11:20AM and 11:52 AM, it was observed that all the four (4) Soiled Utility Rooms on the 3rd, 4th and 5th floors of the old buildings, did not have hand washing sinks in the rooms. A concurrent interview with Staff B and C at this time confirmed the findings.

On 05/08/2018 at 11:28 AM, a hole approximately 4 inches by 2 inches was observed in the wall of the patients Pantry Room. A concurrent interview with Staff C confirmed this finding.

On 05/10/2018 at 3:30PM, it was observed that the facility did not have a hemodialysis machine repair room which is required for the maintenance and repair of the dialysis machines. Concurrent interview with Staff B and C confirmed this finding.


Manhattan Campus:

Psychiatric ED and Psychiatric Unit:
During a tour of the Psychiatric Emergency Department (Psych ED) on 5/7/2018 at 12:05 PM, it was noted that the water faucet of the handwashing sink in the waiting and family area did not have hot water.

During a tour of the Psychiatric Unit (Psych unit) on the 7th floor of KCC Building (7KCC) on 5/7/2018 at
2:00 PM, there was some electric outlets in the day room and other patient rooms that were not tamper resistant as required for the psychiatric unit. Examples included but were not limited to C7-2 and C7-12.

Operating Rooms (OR):
During a tour of the operating room suites on the 3rd floor of GP building, it was noted that some scrub sinks did not have hot water and other scrub sinks were not functional. Examples are: scrub sinks next to OR 9, 14 and 15, did not have hot water, and the water temperature at those sinks were approximately 67 Fahrenheit (F) (normal range between 105 F-120 F). This was confirmed with Staff N, VP of Engineering.
The scrub sinks at OR 7, 8, 10 and 21 did not work.
The Soiled Utility Room N3-223, exhibited positive air pressure instead of the required negative air pressure for this type of room.


Pediatric ICU:
During a tour of the Pediatric Intensive Care Unit (Pediatric ICU) on the 3rd floor of 1184 building, it was noted that the air grills at the ceiling of Room P1, was covered by black adhesive tapes at three (3) areas that measure 4 inches x 13 feet, 4 inches x 5 feet, and 4 inches x 6 feet. Covering the ceiling tiles with adhesive tapes, make it difficult to clean and disinfect the ceiling when needed and poses the risk of infection.
The Soiled Utility Room K3-325, exhibited positive air pressure instead of the required negative air pressure for this type of room.
The Procedure Room KP3 Room 324, was used for storage of equipment. Many incubators and many monitors and other equipment were stored in the procedure room.


Neonatal ICU
During a tour of the Neonatal ICU Annex on the 4th floor of 1176 building on 5th Ave, it was noted that the ceiling tiles in the ICU were from the regular ceiling tiles and not the washable ceiling tiles that are required for this type of room. This imposes the risk of infection as it is difficult to clean and disinfect the ceiling when needed and poses a risk of infection.
Room 436 of the NICU was noted to be used as a storage room and there were 13 breast pumps, incubators and other combustible materials. Using this room for storage presents a risk of fire and infection control concern.


Radiology Department:
During a tour of the Radiology Department on 5/12/2018 at 12:00 noon, the following were observed:

a. The Soiled Utility Room AMC 608, was noted to have a positive air pressure instead of the required negative air pressure for this type of room.
b. The floors of the holding area and the waiting area of the inpatient CT Scan area were uneven and broken. Uneven areas and cracked floor present tripping hazards.
c. The metal piece holding the tag of the fire extinguisher that is outside the MRI room, is not a MRI compatible material.
The above findings were identified in the presence of Staff H, Senior VP Mount Sinai Health System and Staff N, VP Operations Engineering,who acknowledged them.



During the tour of the facility's Annenberg building on the 6th, 7th and 8th floor operating rooms, on 5/10/2018 between 11:00 AM to 12:00 PM, it was observed that the water temperatures of the scrub sinks were not maintained between 105 F-120 F as required by Facility Guidelines Institute (FGI), Table 2.1-5.

The finding was identified in the presence of the Staff T, Director of Building Services and the Nurse Manger. They acknowledged that the water temperature from the operating rooms scrub sinks were around 70 F. The low water temperatures may discourage personnel from washing their hands, which can cause a breach in the infection control practices.




35164




36207