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A) Based on the review of medical record, the medical staff did not ensure that patient ' s medications are reconciled and instructions provided to the patient on the use of medications post discharge. Specific reference is made to MR #1.

Findings include:

This is a 68-year-old male with multiple medical conditions including Diabetes mellitus, hypertension, BPH, dementia, PVD, bronchitis, CVA, ESRD with renal transplant in 2003. The patient was admitted on 8/6/11 with complaints of shortness of breath, changes in mental status and chest pain. Hospital course included treatment for bronchitis, intermittent atrial fibrillation and acute thrombosis; he was ruled out for CVA and MI. At discharge of the patient on 8/29/11, there was no indication that the patient/representative received instructions on medications to be continued at home. A two page " Home Medication Reconciliation List" was initiated on 8/6/11 on admission of the patient. The section of the form required to be completed upon discharge was not filled out. The facility procedure requires that the prescriber reviews Admission Home Medications list and current orders in the Medication Administration Record prior to writing prescriptions at discharge. A list is made of all medications the patient should take upon discharge and is attached to the discharge instructions. Based on a written complaint by patient ' s family, the discharge instructions did not include the "Home Medication Reconciliation list" . The patient's family made a visit to the Transplant Center on 8/30/11 to reconcile patient's medications. Another two-page Home Medication Reconciliation List found in the medical record included discharge medications only. This form was neither dated nor signed by the reviewer as required.



16401

B) Based on medical record review it was determined that the medical staff did not provide care consistent with accepted standard of medical practice. This finding was noted in 1 of 3 applicable medical records reviewed.

Findings include:

Review of MR #2 on 11/16/11 noted that on 7/14/11 about 1:34 PM, the patient, a 32 year-old presented to the Labor & Delivery Unit with complaints of uterine contractions, and intermittent right thigh pain. EDC: 8/7/11, FHR: 140. Bilateral Doppler performed on 7/15/11 was negative for thrombus of the lower extremities. The right thigh pain was relieved with positioning. The patient had Pitocin for augmentation of labor. On 7/17/11 at 3:39 AM, the patient delivered a live female infant via normal spontaneous vaginal delivery (NSVD) and sustained a perineal laceration. The facility conducted an investigation of the patient's complaint regarding repair of the perineal laceration without benefit of an anesthetic agent. The correspondence to the patient dated October 21, 2011 indicated that "appropriate actions and remediation has been taken with regard to the involved personnel." The investigation also revealed that there was no medication taken from the Pyxis system which corroborates the patient's complaint.
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Based on interviews, the review of medical records and other documents, it was determined that the hospital did not consistently communicate Patients' Rights information to persons with limited English proficiency.

Findings include:

1) During tour of the Pediatrics unit on 11/16/11, the mother of a 10 month old patient, MR#3 was approach by an English speaking surveyor for interview, it was noted that she was not able to communicate to the surveyor due to language barrier; she speaks only Spanish. The patient ' s mother was interviewed by a Spanish speaking surveyor. She reported that she does not speak or read English and that she is not able to communicate with the physicians and nurses. The patient's mother reported that her son has been admitted to the hospital before and that on previous admissions they used language phone to communicate with her. She was asked if the Patient Rights package was given to her on admission; she showed the surveyors the package she received. It was noted that the mother was given an English version of the booklet "Your Rights as a Hospital Patient in New York State" which she was not able to read. Based on interview with facility staff on 11/15/11, the booklet is available in Spanish.

Review of MR# 3, noted that consent for Anesthesia in English was signed by the mother with no indication that an interpreter was used to translate the information contained in the consent.

The physician taking care of the patient was asked by surveyor how she communicates with the patient's mother, she was not aware that the mother does not speak English. She informed surveyor that she is now aware and will used the language phone to communicate with the mother.

2) Review of MR# 4, noted that this 70 year old Polish/Russian female was admitted to the facility on 11/7/11. This patient signed consent for general anesthesia on 11/8/11 and another consent for a surgical procedure (Debridement of anterior abdominal wall abscess; removal of mesh; abdominal wall reconstruction, possible bowel reduction, possible colostomy) on 11/9/11. It was noted that the consent form was written in English. There was no documentation that an interpreter was used to translate the information to the patient or the reason why a translation was not necessary.
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Based on staff interview, the review of Patients/Patients' representatives grievances files and committee minutes, it was determined that the facility did not consistently ensure that responses to grievances were timely. This deficiency was noted in two (2) out of ten (10) grievances reviewed.

Findings include:

The patient in MR # 5 filed a grievance with the facility's Patient Relations Department on 8/22/2011 regarding treatment rendered in the Hepatology clinic. The response to the grievance was not in the patient's file.
The Patient Relations Staff interviewed on 11/16/11 indicated that there was no response in the file because the case was still open.
The review of "Concerns over Patient Care Committee Minutes" (COPC) dated 9/28/2011, 10/5/11, 10/19/11, 10/26/11, and 11/2/11 noted that this case was discussed on 9/28/11, 10/5/11, 10/19/11 and 10/26/11. The case was not mentioned in the minutes for 11/2/11 and 11/9/11. On 10/26/11, it was discussed that on 9/7/11, Patient Relations provided a copy of the complaint to the Hospitalist and Patient Relations would follow up and then determine if a close out letter could be done.
The hospital is required to respond to the grievances timely. If the patient/patient ' s representative grievance will not be resolved or if the investigation will not be completed within 7 days, the hospital is required to inform the patient or patient's representative that tthe hospital was still working to resolve the grievance".

Similar finding was noted in patient MR # 6; the patient's grievance file submitted for review indicated the grievance was received on 10/3/2011 and closed on 11/9/11. However, there was no written response in the complainant ' s file.
The staff interviewed on 11/16/11 reported that the case was still open therefore there was no response.
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Based on review of patients/patients' representatives grievances, committee minutes and medical records, it was determined that the facility did not consistently ensure that written responses to patients/patients' representatives regarding their grievances fulfill all requirements listed in the regulation.

This deficiency was noted in three (3) out of ten (10) complaint files reviewed.

Findings include:

The facility's Patient Relations Department received a grievance from a patient's (in MR # 7) representative on August 8, 2011 indicating that the patient's family members did not want her placed in a nursing home. The facility's response dated September 27, 2011 did not address the family's allegations as it did not include the reasons why the facility made the decision to place the patient in a skilled nursing facility on 8/25/11 against the family's wishes.

The family of the patient in MR # 8 filed a grievance with the Patient Relations Department on 8/3/2011 regarding the standard of care and treatment while the patient was an inpatient. The response to the patient's representative dated 8/28/2011 noted that the steps taken during the investigation and the results of the grievance were not listed in the response.
It was noted that the decision was made for a physician from the department of Medicine to contact the complainant. However, the complainant was not receptive. There was no evidence that the complainant was made aware that if he was not satisfied with the facility's response that he may file a complaint with the New York State Department of Health.

The patient in MR # 9 filed a grievance with the facility on September 7, 2011. The patient alleged that she was "tested for several problems but never received a diagnosis. One test was positive for nodule located in the left lower tube of the thyroid but I was sent home without out treatment".
The facility's response dated September 21, 2011 indicated that the physician contacted the patient. However, the investigation report did not include the steps taken to address the allegations and the results of the investigation.
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Based on interviews, unit tours, the review of medical records and hospital's policy, it was determined the facility did not consistently ensure that informed consents are properly executed before surgical procedures. This deficiency was noted in four (4) out of ten (10) applicable medical records reviewed.

Findings include:

Review of MR# 4, noted that this 70 year old Polish/Russian female was admitted to the facility on 11/7/11. This patient signed a consent for general anesthesia on 11/8/11 and consent for surgical procedure (Debridement of anterior abdominal wall abscess; removal of mesh; abdominal wall reconstruction, possible bowel reduction, possible colostomy) on 11/9/11.The consent form was written in English. There was no reason indicated why an interpreter was not used to explain the procedure and address the patients concerns. The generalized statement on the form indicated that the physician discussed purposes of the procedure the risks, side effects, possible problems and alternatives. However, the possible risks, alternatives and benefits specific for this procedure were not documented on the consent form.
Similar findings regarding the lack of documentation of the explanation provided to the patient regarding risks, alternatives and benefits specific to the procedure were noted in the following medical records.
MR # 10, a 79 year-old patient under went Mitral valve repair/replacement on 8/22/11.The risk, alternatives and benefits of the procedure were not indicated on the consent form.
MR# 11, a 36 year-old female patient who under went Laparoscopy cholecystectomy, the risk, potential benefits and alternative specific to the procedure were not noted on the consent form.
MR# 12, a 45 year-old female patient who under went microdirect laryngoscopy, biopsy, bronchoscopy esophagoscopy on 11/16/11. Risk, potential benefits and alternative specific to the procedure were not noted on the consent form.
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Based on observation, it was determined that the facility did not ensure that patients' clinical records were always secured and accessible only to authorized individuals.

Findings include:
During the unit tour of an outpatient clinic on 11/16/11, the surveyor noted a medical record was placed outside the Urology Examination Room #2. The record was accessible to clinical and non clinical staff as well as the general public.
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21204

A) Based on observation, document review and staff interview, it was determined that the facility did not maintain the hospital environment in such a manner that the safety and well-being of patients are assured.
Findings include:

During a tour of the Medical Surgical ICU on the 3rd Floor, the following were identified:
1- The door of the isolation room A3-365 was noted not to close or open easily and needed adjustment to maintain the negative air pressure of the isolation room.
2- One ceiling tile of the isolation room was replaced with a non washable ceiling tile.
3- More than 6 ceiling tiles of the ICU unit were observed with their plastic lining peeled off, and making their surface hard to clean.
4- A plastic container that is >96 gallon in capacity was observed outside the storage room A3-379A. This is a fire hazard concern.

During a tour of the Labor and Delivery Unit, the following were identified:

The floors of the unit in many of the patient rooms and the corridors were found to be cracked, missing or torn. Example included but was not limited to:
1- The floor of room A2- 522 was broken, and torn in different areas with >1ft x 4 inches in some areas.
2- The Isolation room of the Labor and Delivery Unit did not have negative air pressure as required for this type of room.

On morning of 11/15/2011, the following were identified on the Cardio Thoracic ICU unit (CTICU):
1- Three (3) recliner chairs and two blanket warmers were stored on and obstructing the corridor next to the exit door of the unit.
2- The isolation room of the CTICU was found to have positive air pressure instead of the required negative air pressure for this type of room.
3- The molding (wall base) of the patient bathroom was noted to be broken and falling apart.
4- A plastic container that is >96 gallon in capacity was observed being stored on unit in front of room 2-342. This is a fire hazard concern.
5- Exit signs were missing in the CCU especially in nursing station area.

During a tour of the Post Intervention Recovery Room (PIRR) on 11/15/2011, the following were identified:
1-The soiled utility room did not have negative air pressure as required for this type of room.
2- The fire wall above the exit door of stair #8 was found to have penetration around the sprinkler pipes.
3- A plastic container that is >96 gallon in capacity was observed being stored on unit in front next to the smoke doors and opposite the door of room 2- 585. This is a fire hazard concern.

During a tour of the pediatric area on the afternoon of 11/15/2011, the following were identified:
1- Five rooms/ and or closets were found to have damaged ceilings that have been damaged for long period of time without repair.
2- Those rooms included the Storage room # A4-422, the tub room # A4-419, the shower room # A4-375 the storage room # A4-420A and the storage room # A4-376.
3- According to the Chief of Pediatrics and other staff members, the disrepair of those rooms was due to water leakage that happened more than a year ago. Although the problem was reported to the facility many times, the facility did not take any measures to fix the problem.
4- A storage room A4-400 that is more than 500 square feet in diameter was found to house so many equipment including clean and dirty supplies in addition to oxygen tanks. The amount of supplies in this room create both infection control and fire hazard.
5- During our tour of the Pediatric ICU on the afternoon of 11/15/2011, it was brought to the attention of the state surveyors by the Chief of Pediatrics and the charge nurse that the area in front of the nursing station and the closet behind the nursing station have leaking problem especially in the rainy days. Also, the staff mentioned that this problem is an ongoing one, and that it has been reported to the facility repeatedly without any corrective action plan.
6- Three of the ceiling tiles of the area behind the nursing station and 4 ceiling tiles of the area in front of the nursing station were missing.

During a tour of the Psychiatric Unit on 11/16/2011, the following concerns were identified and brought to the attention of the facility's staff:

1- The strobe boxes and the manual pull stations (square in shape) constitute a looping hazard.
2- The conduits of the fire alarm that are approximately one inch away from the walls, of the newly installed fire alarm system constitute a looping hazard.
3- All the patient beds (34 beds) were observed to have many restraining hooks in each bed. The fact that those beds are not bolted to the floor and the presence of other furniture in the rooms could be used for looping purpose.

During a tour of the 6th Floor - The Medical Unit, the following were identified:
1- The Central Sterile Room# A6-439 did not have positive air flow as required for this type of room. There was no air supply in this room.
2- The chute of the ice machine in room A6-438 was observed to be dirty.
3- The glass on the door of patient room #A6-456 was noted to be broken and taped together by surgical adhesive tape.
4- The storage closet #A6-442 that was not sprinklered and did not have one hour fire rated walls, was observed to have many boxes of combustible items which are a fire hazard concern.
5- The corridor between the two wings of 6th floor (nursing Unit 62) was blocked by two huge garbage containers (>96 gallon in capacity), IV poles, linen hamper reclining chair and wheel chair.
6- The Rubbish Chute outside the nursing unit 62 was noted not to have a positive latch.

Cardiac Catheter Lab:
1- During a tour of the Cardiac Catheter Lab on the morning of 11/17/2011, what appeared to be dried blood drops were observed on the wall of the control room in front the catheter lab equipment.
2- There was no exit sign at the main exit door of the cardiac catheter lab suite.

The Ambulatory Surgical Unit - 2nd Floor:

Many of the ceiling tiles of the waiting area bathroom were noted to have brown stains and the air vent of this bathroom was dust laden. Also, the air vent of the dressing room was observed to be dust laden.


B) Based on interview and the review of hospital logs, it was determined that the facility failed to implement measures to ensure effective pest control.

Findings include:

The review of " Exterminating Action & Resolution Logs on 11/16/11, showed several sightings of flies and other pest in several units from April to November, 2011. It was noted that each sighting of pest documented in the log was followed by an inspection and treatment of the area. However, based on interview with the Director of Environmental Services on 11/17/11, the facility does not have a proactive program aimed at effective pest control. There were no established schedules for the inspection and routine treatment of hospital buildings to address identified problems.
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