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Based on grievance files and hospital policy, it was determined that although the facility has a grievance process for the resolution of patient grievances, it failed to review, investigate and provide prompt written response to each patient's grievance . This was evident in eight (8) of twenty three (23) grievance files reviewed.
Findings include:
Grievance #1 was reviewed on 4/23/14. It was noted that the patient's daughter filed a complaint with the facility on 11/4/2013 alleging that "she noticed bruising on her mother's left arm and she also had scratches". The daughter was also upset about the back brace that the patient needed for discharge. It was noted that the Office of Patient Relations department received a response from the physician on 11/5/2013. It was noted that this staff spoke to the patient's daughter on 11/6/2013 and gave the physician's explanation. The file was closed on 11/6/2013. It was noted that the facility did not conduct a thorough investigation of the patient's bruises. In addition, the daughter was not provided with a written response on the outcome of the investigation. It was noted that the daughter obtained a copy of the medical record which included pictures of the patient's bruises. The daughter filed a second complaint with the facility dated 12/3/2013. It was noted that it was not until the second complaint that a written response with the explanation for the bruises was sent to the patient's daughter . The written response was dated 12/13/13, over 30 days, after the initial grievance was filed.

Grievance file # 2 was reviewed on 4/23/14. It was noted that the patient contacted the Office of Patient Relations Department, on 8/27/2013, alleging that he was assaulted by a staff member. It was noted that the facility completed the investigation on 8/30/13. However, a copy of the written response to the complainant was not located in the file.

Grievance file # 3 was reviewed on 4/23/14. The grievance file indicated that on 9/5/2013 the patient went to the Office of Patient Relations very upset, with issue concerning a provider in the OB/GYN (Obstetric/ Gynecologic) clinic. This patient alleged that the provider refused to provide her with medication for the outbreak of herpes in her mouth. It was noted that the file was opened on 9/20/2013 and it was closed on 9/26/2013. It was noted that the Patient Relations staff spoke to the patient on 9/26/2013. This patient required a written response on the outcome of the investigation.

Grievance file #4 was reviewed on 4/23/14. It was noted that the patient filed a complaint with the Office of Patient Relations alleging that she had a colonoscopy done on 7/24, 2013 and she came for a follow up on 10/22/2013. The patient alleged that the result showed that she had two hemorrhoids; she felt that the physician dismissed her question/concerns/request regarding having the hemorrhoids removed. It was noted that the file was opened on 11/6/2013 and it was closed on 11/12/2103. A copy of the written response to the complainant was not located in the file.

Grievance file # 5 was reviewed on 4/23/14. It was noted that the patient filed a complaint with the Office of Patient Relations alleging that her confidentiality was breeched. This patient also had several nursing care issues. The file indicated that the case was opened on 12/12/13 and it was closed on the same day, 12/12/2013. The file indicated that the issue was addressed immediately. However, it was noted that this complaint was forward to the appropriate department for an investigation. It was noted the investigation was dated 12/24/13. Therefore, this complainant required a written response on the outcome of the investigation.
Similar findings for lack of written response for grievance file # 8, in which the patient's daughter filed a complaint with the facility on 11/1/2013, regarding discharge issues and the social services staff. It was noted that the complaint was sent to the Social Work (SW) Department for investigation and the SW Department e-mail response was dated 11/6/13.

Grievance file #6 was reviewed on 4/23/14. It was noted that the patient's son filed a complaint with the facility's Office of Patient Relations on 2/9/2014 alleging that his father developed bedsore because the staff was not properly caring for him. It was noted that the investigation was dated 2/21/14 and the filed was closed on 2/24/2014. It was also noted that a copy of the acknowledgement letter to the son was dated 2/9/2014. However, the written letter to the complainant on the outcome of the investigation was not located in the file.
Similar findings for grievance file # 7, dated 7/8/2013. There was an acknowledgement letter dated 7/2/2013, but written response on the outcome of the investigation was not located in the grievance file.

Hospital's Policy & Procedure - Subject: Responding to Patient Complaints and Grievances; Revised January 24, 2014, was reviewed on 4/23/2104. It was noted that this policy indicated that a complaint does not require a written response. Based on CMS guidelines,
"If a patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance for the purposes of these requirements". All grievances required written responses.

Based on staff interviews, and review of Patients' Grievance Files from January 2013 - March 2014, Patient Quality Assurance Committee Minutes to the Governing Body 2013 and hospital's policy, it was determined that the facility failed to have an effective grievance process which included prompt resolution of all grievances that the facility received. This was evident fifteen (15) of twenty three (23) Grievance Files reviewed (Files #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14 and #15).

Findings include:
Twenty three (23) of thirty (30) patients'/patients' representatives complaints selected from complaint files submitted for reviewed ,on 4/23/14 at 3:00 PM, met the criteria for grievances. Of the twenty three (23) grievances files reviewed, eight (8) grievance Files (#1, #2, #3, #4, #5, #6, #7 & #8) lacked written responses to the complainant, as required. Four (4) grievance files were not timely. In addition, three (3) Grievance files (#9, #10 and #11) had written responses, but these responses lacked all the of regulatory elements such as: the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Quality Assurance Committee Minutes to the Governing Body for Meeting Date: April 5, 2013, June 14, 2013, October 4, 2013 & December 6, 2013 were reviewed on 4/23/14. It was noted that there were discussions on Patient Satisfaction and Survey Results (tabulated by Press Ganey - an independent company). In addition, data submitted to the Quality Assurance Committee on complaints only list the number of complaints that the facility received monthly. Timely responses and the content in the responses to the complainant were not discussed in these minutes.

Staff # 12 and staff # 13 were interviewed on 04/24/14 regarding the facility's grievance process and the facility's Grievance Committee. Staff # 12 stated that the facility does not have a Grievance Committee. It was brought to the staff's attention that the hospital's Governing Body must review and resolve grievances, unless it delegates this responsibility in writing to a grievance committee.

Staff # 13 stated that, as per hospital policy, the Executive Director / Network Senior Vice President are responsible for complaints and grievances as designated by the Governing Body. She also stated that the complaints/grievances are addressed in Executive Committee Meetings and Hospital Wide Quality Assurance Meetings.

Coney Island Hospital Administrative Policy and Procedure Manual: "Responding to Complaints and Grievances": revised 1/24/14 was reviewed on 4/24/14. This policy indicted "The Executive Director / Network Senior Vice President is a Corporate Officer and is designated by the New York Health and Hospitals Corporation Board of Directors to represent the Corporation regarding complaints and grievances. As per CMS guidelines, a committee is more than one person.

Based on observation and review of documents, it was determined that the facility failed to ensure compliance with its policy for the appropriate use of restraint for a patient who is cognitively impaired. This was observed in one of one applicable patient in the inpatient Medical Telemetry unit. (MR #4)


Findings:
On 4/25/14, a tour of the T4W unit was conducted at approximately 12:15 PM and Patient Medical Record (MR) # 4 was observed to be OOB, seated on a chair and a belt was used to immobilize the patient to the chair. Bilateral wrist "restraints" were applied to the patient wrists but they were untied. Review of the Electronic Medical Record (EMR) revealed this patient was admitted to the facility on 4/21/14; Diagnoses: Chest Pain, R/O Acute Coronary Syndrome, and Atrial Fibrillation. H/O Depression, Dementia; the patient's Mental Status was assessed to be Alert/Disoriented.
The Nursing Care Plan initiated on 4/21/14 documents patient Alert/Disoriented and the need for patient safety was identified. A physician order was entered on 4/22/14 at 6:00am for Wrist Restraint; patient tried to get OOB and pull Heplock and there are ongoing orders and monitoring for the use of the wrist restraints. However, there is no order for the use of a belt restraint.

The facility's Policy For the Use Of Patient Restraints And Seclusion states: self-releasing lap-belt (safety belt) is considered restraints; however, "these safety belts will not be used in patients who are cognitively impaired."
Staff #5, who was present, acknowledged this patient is disoriented and is not self-directing and would not be able to self-release the lap belt. Staff #5 stated the lap-belt should not be used for this patient.

The nursing personnel failed to follow this policy for the appropriate use of restraint and to "provide care in a manner that protects the patient's safety while preserving their well-being, dignity and rights."

Based on observation and staff interview, it was determined that the facility failed to consistently ensure the confidentiality of patient's medical record. Specifically, the facility failed to ensure that patient's Electronic Medical Records (EMR) was secured from unauthorized access at all times.

Findings:

During tour of medical/surgical unit Tower 2 West on 4/24/14 and medical/surgical unit Tower 6 West on 4/28/14, computers on wheels (COW) were observed in the hallways left unattended with screens un-locked and were readily accessible by non- clinical staff and other patients.

On 4/24/14 at approximately 12:45 PM two computers on wheels was observed parked at the back of the unit in the hallway. The two computers were observed left unattended, Quadramed (the facilities EMR software program) was minimized on both computers (CTB2WRM W05) and (CTB2WRM W05). Access to patients ' medical record were easily obtained by clicking on the Quadramed icon at the bottom of the computer screens.

This finding was observed and verified with staff member # 6

On 4/28/14 at approximately 1:20 PM COW # CTB6WRMW01 was observed left unattended in the hallway of medical/surgical unit 6 West. Access to patients' medical record were obtained easily by clicking on the Quadramed icon at the bottom of the screen.


At approximately 1:24 PM staff member #7 was observed working at one of the computers on wheels (COW) on unit 6 West in the hallway.
Staff member #7 walked away from the computer, it was noted that the staff member #7 minimized the medical record she was working on. Surveyor was able to gain access to the patients' medical record by clicking on the minimized Quadramed icon. On interview staff member #7 stated that she minimized the screen whenever she leaves the computer unattended.


During interview staff were not sure of the time frame for the computer inactivity timeouts, one staff member stated that the time frame was two minutes and another staff went to ask information technology (IT) for the correct timeframe. On observation it was noted that the computer timed out and went to a lock screen after left unattended for 15 minutes.

Staff member #8 stated that the staff members are instructed to logoff their computers every time they leave it unattended.

These findings were observed and verified with staff member #8.

Based on review of records, observation and staff interview the food service director did not take responsibility for the daily management of the service to ensure that (a) proper safety practices for handling food are maintained, (b) proper sanitary environment is maintained in the kitchen, and (c) dietary staff are trained in their respective duties.


Findings include: During tour of the main kitchen on 4/23/14, the following observations were made.
A. (1) Food items were observed not labeled with the name of the food item, day or date the food was prepared and day or date the food must be discarded. No labels were observed on apple sauce cups, butterscotch pudding cups, coconut apple tart cups, diced pear cups, cottage cheese cups and vanilla pudding cups.

(2) The following expired food was found on the shelves in the dry store room:
One (1) bottle of Knor beef based with 1/29/12 expiration date.
Five (5) packs of Gerber baby carrots with receiving date of 3/21/14 on the box, however, the baby carrot jars all have a 1/2/14 expiration date.

B. (1) Stainless steel table in the main kitchen observed on 4/23/14 wrapped with plastic wrap and therefore could not be sanitized. The top of two measuring scales were observed wrapped with plastic wrap on revisit to the kitchen on 4/24/14.

(2) Food blender was observed standing on one of the stainless steel tables in the kitchen on 4/23/13, the blender was dirty and the cover and the collar were encrusted with food debris. Staff member # 9 # was not able to disassemble the blender when asked. None of the staff accompanying surveyor was able to disassemble the blender. Surveyor was told by a cook that they use the blender to make puree food when it is needed. The cook stated that the blender goes to the steamer then to the pot room. The blender was observed on a shelf with clean pots and pans on 4/24/13, the blender was still not able to be disassembled and food debris was still noted at the collar of the blender.

(3) Pots and pans observed on a clean rack in the dish room were sticky and dirty to touch, they were not protected from contamination via dust and grease.


C. (1) During observation of the food tray line on 4/24/14, surveyor noted different color bars on the desserts cups. Three employees interviewed including a food service supervisor (staff member #10) did not know the correct reason for the color bars. The food service supervisor stated that the green bar meant that the dessert was for a regular diet and the other staff stated that the green was for diabetic. All three food service employees did not know that the color coded bars represents the day the food was produced and the amount of days the item will expire. They were not aware of the Cook Chill Plant Dessert Production Color Code sheet and the sheet was not posted within the vicinity of the tray line.

All findings were observed and verified with staff member #9.

Based on observations and staff interview, the facility failed to maintain the physical plant on the Main Campus in a manner to provide a safe and sanitary environment for the treatment of patients.

Findings include:

A. (1) During the tour of the Primary Care Clinics on the 4th Floor of the main building, it was noted that the sharp containers in Triage/Assessment cubicles were not mounted, they were stored on desks of the nurses.

Tour of the clinics revealed that the floor of the clinic were dust laden and strewn with debris (plastic caps, paper wrappings, paper towels etc). For example: the Room "phone follow up for crisis management (Rm.#4N68)" was found to be heavily soiled. The cove base of the wall and the perimeter of the floor was grimy and black in color.

Similar findings were revealed during the tour of an ultrasound room (Rm. # 809B) and in an Endoscopy procedure room (8W13B) on the 8th floor .

In addition, it was also noted that a soiled utility room used in the storage of biohazard and soiled linen was being used as communicating space between two primary care clinics. The two doors of the room were kept wide open for staff members to pass through, thereby not maintaining the required negative pressure. Upon interview, Senior Executive Director of the hospital admitted that this arrangement was potential of causing cross contamination.

(2) During the tour of the decontamination room of the Outpatient Urology on 5 North on 04/28/14, it was noted that the staff did not have access to a hand washing sink in the room to perform hand hygiene after manual washing and soaking of the endoscopes. Upon interview of the nurse-in charge of Urology service,it was stated that the staff used the one and only sink to manually wash the scopes and to wash hands.
In addition, the staff were storing clean supplies (clean urine collection cups, gloves, tubes,etc.) on the countertop, adjacent to this decontamination sink.

It was also noted that a big elongated blue basin with a scope soaking in the enzymatic solution was being rested on a hopper, used to flush urine. On interview, the nurse in charge stated that this arrangement existed due to lack of space on the countertop.

(3) Tour of the gym area in the Outpatient physical therapy area also revealed that there was no hand washing sink in the area. The Director of the service, upon interview stated that the staff used the hand sanitizers to perform hand hygiene and that they used the hand washing sink in the electrical stimulation area, when necessary.

(4)Tour of the Dental clinic on 04/25/14 at approximately 3:00PM, it was noted that there were three bays where dental work was being performed on patients. All three bays were found to be cluttered with biohazard containers, regular garbage containers. a clean supply cart etc. It was also noted that the facility did not maintain separation between clean and dirty. It was noted that the clean supplies, a container containing dirty instruments soaked in disinfectant, and a small biohazard container were being stored on a counter top located in front of the treatment chair of the three bays.
In addition, the facility was observed to be stacking clean plastic containers with clean and sterile instruments on a cart located behind the receptionist desk. This arrangement of storing clean instruments were exposed them to the potential of being knocked off the cart and dropping on the floor.
Upon interview of the Senior Associate Executive Director on 04/25/14, it was revealed that the clinic did not have a clean storage room and dirty utility room. This interview also revealed that this clinic was relocated from another outpatient site after hurricane sandy disaster and that this service was not listed as an approved service on the Operating Certificate of the Hospital.

Based on observation and staff interview, the facility failed to comply with all provisions of Life Safety Code as recommended in NFPA101 2000 Edition.

Findings include:


(1) During the tour of the Audiology clinic on 04/25/14 at approximately 3:30PM on the 4th Floor of the hospital, it was noted that the audiology booth and the clinic did not have strobes. Strobes are required in this area to alert patients,who are hard of hearing in an event when the fire alarm system is activated. This finding was again confirmed with the Senior Associate Executive Director.

(2) During the tour of the Primary Care Clinic Suite on 04/25/14 at approximately 11:00 AM, it was noted that the width of the egress path in the Primary Care clinic 2 was reduced to three and half (31/2) feet by the storage of computer station, weighing scale and a clean supply cart.

Similar observation was also made in the Primary Care clinic 3.

Based on review of records and staff interview, the facility failed to ensure that the product water from the portable Reverse Osmosis System is free from all chemical contaminants prior to use on patients.

Findings include:


Review of test results for chemical analysis on 04/25/14 for RO #6 revealed that the level of aluminum in the product water was .017 in April.. The maximum allowable level of aluminum according to AAMI standards is 0.01. The facility did not conduct a follow-up test to confirm the previous test result nor remove the equipment from treatment area until the aluminum level was confirmed to be below the AAMI limit.
The chief technician, responsible for the monitoring and maintenance of the equipment was not available for interview.

It was revealed that the test results were reviewed and signed by the Medical Director, with no date and there was no comment regarding the high level of aluminum. The Vice President Of Nursing for the contracted service (Big Apple Dialysis) upon interview stated that she was not made aware of this high level of aluminum by her staff members.

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Based on observations during tours of the facility and staff interview, it was determined that the facility failed to monitor and implement Infection Control practices related to the environmental design of the facility, in order to prevent the potential for cross contamination and spread of infections and the facility failed to ensure a safe environment consistent with recognized Infection Control Practices and prevention of cross contamination.

Findings include:

1. (a) During the tour of the 8th Floor Med-Surge Unit-Tower on 04/24/14 at 11:45 AM, it was noted that the only dedicated Isolation Room #832 did not exhibit negative air pressure when tested with smoke and tissue paper. As per the Nurse Manager of the floor as per her understanding the Isolation Room is always on negative air pressure. Senior Associate Director Facilities (SADF) asked his engineering staff to find out why the room was not negative since it is supposed to have negative air-pressure at all times. The console outside the room used for pressure monitoring was not alarming and did not indicate any issue.

(b) During the tour of the Pediatric unit on 2nd floor-Tower on 04/24/14 at 12:00 PM it was noted that the two isolation rooms were not negative (as tested by smoke and tissue paper) and the monitors installed outside were reading a positive (+) reading. There were no patients in the room. The SADF stated that he will find out why the system is not working as it should for negative pressure in such rooms at all times.

(c) During the tour of the Med-Surge Unit 2nd floor-Tower on 04/24/14 at 12:30 PM, it was noted that the two isolation rooms were reading positive (+) in the monitoring console outside. The SADF got his engineering staff on the floor and the staff pointed out via smoke test that the room is indeed negative, however they did not know why the monitor was reading positive. The engineering staff after few minutes did some adjustment to the monitor console and then the monitor exhibited negative pressure reading.

(d) On 04/25/14 at 11:00 AM , the SADF stated that the reason why the isolation rooms were not exhibiting negative air pressure on the day of 04/24/14 was because of ongoing damper work in the facility that affected the HVAC system and the air pressure.

During the tour of the Medical Intensive Care Unit 7th floor-Tower on 04/25/14 at 12:25 PM, it was noted that the room #730 was occupied by a 'confirmed' air-borne patient. This room did not exhibit negative air-pressure via a smoke test and tissue test. The monitoring console indicated the room was negative yet the SADF stated that the room pressure reading appeared more of a neutral. The nursing staff stated that they rely on the 'audible' alarm to indicate if the room was not exhibiting the correct air-pressure and confirm by seeing the green visual alarm turning to red.

Facility was requested to fix the issue of this particular room as soon as possible and provide an 'Incident Report' indicating what happened and how is it going to be fixed.

An incident report was provided at 3:30 PM along with the daily smoke check of the room which indicated that the room had earlier passed the smoke test.

The report stated that "@ Approx 12:15 PM a negative pressure check of Tower Building Rm 730 ( isolation room) revealed that the negative pressure was insufficient. This was a a result of testing/Work that was being conducted on all dampers. A complete reset and adjustment rectified the aforementioned problem". The report did not indicate how many air exchanges there were or how did the facility determine that the negative air-pressure was insufficient. Also no information and answer was provided during the survey regarding how the facility at all times ensures that the isolation rooms not only have negative air-pressure but also maintains 10 air-exchanges per hour as per AIA 1996-97 Table 2.

(e) On 04/28/14 at 11:15 AM, the SADF stated that the reason why no alarm went off was because the pre-set value of the negative pressure did not fall below the set limit. SADF was asked what was the limit or range, he stated that it is pre-set by the manufacturer. The Director of Engineering was asked regarding when the work on the dampers started and when was the issue identified that the HVAC system is not working. He answered that the work on the dampers started on Monday 04/21/14 and the issue was not found until the surveyor found the issue on 04/24/14.

During the re-check of the room #730 at that time, it was noted that the room was exhibiting negative air pressure.

(f) It was observed at the time of re-checking room #730 that the adjacent isolation room #731 had a command reading on the console of the monitoring system as 'No Isolation'. The SADF was asked what that means and he asked the engineering staff responsible for these console to explain since he was not aware. The engineering staff stated that the isolation room is negative at all times however the alarms are not activated till the room is actually used for a air-borne isolation patient. When the nurses receive a patient requiring air borne isolation then the engineering/facilities staff has to come up to activate the console by programming it.

Facility staff was asked how the programming is done and what are the limits for alarms. The facility staff responded that the limits of the alarm were pre-set by manufacturer and that the activation of the alarms at the console was according to facility policy and procedure, which would be provided to the surveyor. The facility mentioned to another member of the survey team that the visual alarm is seen in the central monitoring station when the air-flow is not at a required level. However, that alarm is not audible.

(g) During tour of the 2nd floor Med-Surge-Tower on 04/24/14 at 11:30 AM, it was noted that the monitoring console outside air-borne isolation room #223 was not indicating any red light or green light in the console. SADF stated that it appears that the console lights were broken.

(h) A policy and procedure regarding how to activate the room for an air-borne isolation patient and the manufacturer's specification for alarm limits was requested by the surveyor throughout the survey and after the discovery of the issue, however, the policy and procedure was not provided until the Exit Conference.
In reviewing the manufacture's guidelines for PresSura Room Pressure Controller Models 8639-SC & 8630-PC it was noted that on page #5 of the manual it is stated "PresSura Controller has a visual (red light) and audible alarms to inform you of changing conditions. the alarm levels (set point) are determined by hospital personnel, which could be the infection control group, charge nurse or a facilities group depending on the Hospital Organization. The alarms, audible and visual will activate whenever the preset alarm level is reached. Depending on the PresSura model installed, programmed alarms will activate when the room pressure is low or inadequate, when room pressure is high or too great or when the supply or exhaust air-flow is insufficient. When the isolation room is operating safely no alarm will sound".

Therefore, based on above manufacture recommendation, the alarm pre-set point is not determined and set by the manufacturer as it was being told to the surveyor during the survey. Furthermore, as per SADF the value for negative air-pressure did not go down to preset alarm limit and thus it did not alarm. However, in the incident report the facility acknowledges that the negative pressure was insufficient and the facility also stated during interview that the damper/HVAC work was the cause of the issues. However, as per manufacturer, if the exhaust air-flow is insufficient the alarm should go off at the door, but it did not go off during survey when the negative air-pressure was insufficient.

(i) During review of the facility's policy titled 'Isolation room Isolaide Fan/Filter Unit and Negative Pressure Monitors' dated 03/03/14 under bullet #2B it is written that "Negative air-pressure alarm parameters are (set as -0.0001 as room get close to neutral) in accordance with manufactures guidelines, in addition to room design and CFM settings of isolade units".

As mentioned before the manufacturer has not set an alarm limit and has left it to facility to determine the limit. If the room design and CFM settings of isolade units in the facility are different than the policy does not indicate exactly what parameters are to be expected at each air-borne isolation room monitor.

Furthermore in Appendix A of manufacturer guidelines the manufacture has provided a default reading and range for low alarm and high alarm. It is to be noted that the value provided for both low and high is -0.19500 to +0.19500 which means that the control unit is capable of being 'set' from a negative point value of -0.19500 to positive point value of +.0.19500 . This is not the actual range that should be set (since a negative air-pressure room can not go from a negative value to a positive value and still provide negative air-pressure). Facility has adopted this default range in it's above mentioned policy under bullet #2A and described the acceptable range of negative air-pressure room as going from negative value to positive value of -0.19500 to +0.19500. It is to be noted that when the room is neutral it means that the room does not have the required air-exchanges between supply and exhaust, and that it is important to be aware of the drop of required air exchanges in order to safeguard staff and visitors in the area from exposure.

No other range was noted in the hospital specific policy that accurately describes what will be the acceptable range for a room to remain sufficiently negative and provide 10 air-exchanges as required by AIA 1996-97. By providing a value of alarm as
-0.0001 (the facility adopted a value lower than the default value stated in the manufacturer manual which is -0.001, which is stated to be close to neutral), the facility did not ensure and indicate the actual alarm/reading geared to the facility's HVAC system.

(j) As per Centers for Disease Control (CDC) Prevention "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005" it is stated that:
If a variable air volume (VAV) ventilation system is used in an Airborne isolation room, design the system to maintain the room under negative pressure at all times. The VAV system minimum set point must be adequate to maintain the recommended mechanical and outdoor Air Changes per Hour and a negative pressure =0.01 inch of water gauge compared with adjacent areas.
Therefore -0.0001 set point in facility is lower than the allowable as per CDC recommendation.

2. During observation of the Isolation Rooms on 8th floor Med-Surg Tower and 7th floor MICU Tower, it was noted that the Isolation Room #832 and #731 did not comply with the requirements of AIA Section 7.2.C4 for Isolation Rooms.

The requirement states that "air borne infection isolation room shall have self-closing devices on all room exit doors". The Isolation Room in the unit did not have self-closure or self-closure mechanism installed at the exit door.

3. During the survey of the NICU & Newborn Nursery-8th Floor Tower on 04/24/14 at 11:30 AM, it was noted that the facility does not have any Isolation Room provision for the newborns at any level of Nursery care (as per AIA 7.3.E9) nor was any Policy provided regarding how the facility will handle a baby with an air-borne disease.

4. During the tour of the 6th west Med/Surge floor - Main Building on 04/2514 at 03:00 PM, Nurse Manager stated that on this floor patients that are undergoing Chemotherapy or have an immunocompromised disease are placed in a private room. If a patient is determined to be neutropenic then the engineering staff is called to turn on the switch in the room which will turn it into a positive air-pressure / protective environment room. During survey it was noted that a patient in room #6W7 who was on Chemotherapy (but was not neutropenic) was in a room exhibiting negative air -pressure.

As per AIA 1996-97 Section 7.2.D-Protective Environment Room "Many facilities care for patients with an extreme susceptibility to infection e.g immunosuppressed patients that are extremely susceptible to infection, with prolonged granulocytopenia, most notably bone marrow recipients; or solid organ transplant recipient, and patients with hematological malignancies who are receiving chemotherapy and are severely granulocytopenic."

Therefore the patients who are immunocompromised need to be in a positive air-pressure room and if they are not immunocompromised then the patients are required to be put in a room that is neutral but not negative.

Senior Associate Director Facilities stated on 04/28/14 that these three private rooms on 6West do not have the capability of being turned into a protective room / positive air-pressure room, and that the key switch is for turning the room into negative pressure room..

There is no provision of protective environment for patient who may be immunocompromised.

5. On 04/23/14 at 2:00 PM during survey of the Central Sterile Processing Department on the 2nd floor-Main Building, it was observed that:

i) The Central Sterile Clean Processing Room was exhibiting negative air-pressure.

ii) The sinks in the decontamination room were not labeled/marked for the amount of water used to dilute the enzymatic fluid.

iii) The temperature of the Central Sterile Processing Room was noted to be 82*F. In reviewing the log of April 2014 it was observed that the temperature for this area was always between 80*F to 78*F. As per Central Sterile Processing Room staff and on reviewing the log, the Engineering Department was notified of the high temperature issue. No documentation or follow up was provided regarding the communication of the issue and resolution.

iv) In the sterilizer work area no audible and visual alarm was noted for exhaust system which is intended to alert the staff for the loss of air-flow as required by AIA 1996 7.31.D19.


6. During the survey of the OR/Surgical Suite on 04/23/14 at 11:00 AM, following issues were noted:

i) The Soiled Utility room exhibited neutral air-pressure.

ii) The Soiled Utility room and the Tissue Preparation room did not have wrist blade faucets at the hand washing sinks in the rooms.

iii) A used IV bag was noted being drained in one of the hand washing sinks in the Recovery Area.

iv) Clean supplies such as toilet tissue rolls were noted stored in the Housekeeping closet in the PACU/Recovery area.

v) The perimeter of the PACU/Recovery area was noted to be dusty and dirty.

vi) Two ceiling tiles were noted stained in the recovery area.

7. During tour of the Emergency Department on 04/23/14 at 3:00 PM, it was noted that by the Pediatric Emergency Department area the Soiled Utility room and Room #7 were noted having many stained ceiling tiles.

8. During the tour of the Pediatric Floor - 2nd Floor Tower on 04/24/14 at 11:45 AM it was observed that the gasket of the patient food refrigerator by the nurse's station was very dirty.

9. On 04/25/14 between 11:00 AM to 11:30 AM during the tour of Psychiatric Unit on 3rd & 4th floor-Hemet Building following issues were noted:

i) The perimeters of the in-patient rooms inside and around the corners, doors and behind head rest of patient bed were observed very dusty and dirty. Similar issues was noted in the rooms and corridor of 4th floor. The Dinning room on 3rd was also noted to have dirty floor with food particles on the floor.

ii.) The mechanical vents of the in-patient rooms and toilets were noted laden with dust and dirt inside the grills.

iii. The upholstery of the chair in the nurse's station was noted torn and in disrepair. Furthermore, the perimeter, corners and floor were dirty.

iv) Janitor's closet (room #454 ) on 4th floor was noted exhibiting positive air-pressure.

10. During the tour on 04/24/14 at 3:15 PM of the Main Clean Linen Storage room 1st floor-Main Building it was noted that the room houses clean linen and the perimeters and corners of the room were dirty and dusty.

11. During the tour of the Newborn Nursery-5th at 10:45 AM, it was noted that there was no exclusive Housekeeping Room for the unit as required by AIA 7.4.G. The Nurse Manager stated that the housekeeping closet for the OB/GYN unit on the floor is utilized for this area too.

12. During tour of the Pediatric Clinic-1st floor Tower on 04/25/14 at 2:00 PM , it was observed that the waiting room chairs for adolescent patients had very dirty and dusty upholstery.

13. During tour of the Medical Intensive Care Unit-7th floor Tower on 04/25/14 at 12:45 PM, it was noted that the patient food refrigerator by the nurse's station had a very dirty gasket.


All above findings were verified with Senior Associate Director Facilities and Nurse Managers and other staff escorting the surveyor in the respective areas.



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14. A tour of the T2 West and T3West Inpatient units, conducted on 4/23/14 at approximately 11:00 AM and at 2:40 PM, revealed:

a) Intravenous therapy was being administered to patient MR# 1, patient MR# 2 and patient MR# 3 on the T2W unit, and the IV bags were not labeled. Staff #1, who was present, acknowledged that the IV bags should be labeled.
The facility's Policy: Intravenous Therapy, states; the nurse prepares the equipment and labels the bag to include the patient's name, date, time started, stop time,
and nurse's initials. This Policy was not followed.

b) The floor in the Clean Supply Room, on T2W, was dirty and un-swept. Cups, intravenous tubing and paper were on the floor and stains were evident. The clean hand washing sink had white precipates in and around the sink and an infusion pump was stored on the counter. Staff #1, was present and did not know if the infusion pump was clean or dirty and stated the pump should not be there.
A Pleurex Drainage Kit, Expiration Date 10/12/12 was noted on one of storage shelves and it was removed by Staff #1.

c) The floor in the Clean Supply Room, on T3E, was un-swept and covered with brown stains, and the hand washing sink had white precipates in and around the sink.

d) The Soiled Utility Room on T2W, was packed with dirty linen carts, garbage bins, medical waste containers, bedside mats and compression pumps; empty suction canisters were in the sink and on the floor, and 4 (four) suction canisters half - filled with fluid were on a shelf; 2 (two) pleurovac containers filled with brown- tinged fluid were on the floor; and the floor was stained and dirty. Staff #1 stated the suction canisters and the pleurovacs should have been placed in the red medical waste containers, but this was not done. She was off for 4 (four) days and did not know why this was not done, but the environmental staff made rounds this morning around 9:30 AM.

Staff #2 arrived and acknowledged that the room was dirty and the fluid filled canisters were not properly stored. When asked by the surveyor, Staff #2 could not provide data/information regarding when this room was cleaned. Staff #2 stated he was newly appointed to the department and there is shortage of staff to conduct rounding. He also stated there is a dilemma with "solidification of the canisters" which is not being done. A solidifier is to be poured into the fluid filled canisters and then they are placed in the (red) containers. Housekeeping will not touch the canisters for transfer until they are solidified and placed into the red containers, and the nurses are responsible for solidifying the canisters. The solidifying is a new process which the nurses were trained to do; Staff #1 verified that the nursing staff received training.
The surveyor noted that the containers with the Isosorb product for solidifying were in the room.

At interview on 4/25/14 at 2:30pm, Staff #3 stated the facility began use of solidifiers for liquid wastes in the suction canisters. The solidifier cannot be added to the pleurovac because it is a capped container and it is to be placed in the medical waste containers; this was told to the environmental services staff.
Copies of the policy(s) for handling contaminated suction canisters and documentation of training was provided for the surveyor on 4/25/14. This policy was implemented 2/2014 and " Isolyser Solidifier Liquid Treatment System Education " was provided for the nursing staff on 2/7/14, 2/27/14, 2/28/14 and 4/4/14.
The procedure for disposal of liquid medical waste containers by the Nursing Personnel is specified in the policy, Disposal of Liquid Regulated Medical Waste


15. Review of the Infection Control Committee Minutes, February 2013 to January 2014 and the QCEC (Executive Committee) Minutes 2023 - 2014, were completed on 4/25/14 and 4/29/14, and there was no documented reporting from the Environmental Service Department and no evidence that Environmental Service is integrated into the hospital's infection control program and its hospital-wide QAPI program.

At interview with Staff #2 and Staff #4 on 4/28/14 @ 3:30pm and 4/29/14 @ 11:00 AM, it was stated that Environmental Services is a contracted service and was not told they are included in the hospital QA activities. They were told they needed to be on the Environmental Rounding and Safety Committee and a schedule would be provided. Environmental Service conducts and collects data on daily rounds, room inspection surveys, staff survey and patient surveys/complaints and the District Manager prepares a monthly operations report which is given to the COO at CIH.
Review of the monthly reports for February and March 2014, showed there is no action plan for the "concerns" identified and the Patient Satisfaction/Quality Assurance data is not analyzed to identify opportunities for improvement and improving performance.

Based on record review, interview and observations it was evident that the hospital failed to integrate the infection control program into risk assessments of potential exposure to patients during work on systems that may impact adversely to patients.

Findings include:

Review of facility policy and procedure titled "Preconstrution Risk Assessment" (EC 02. 06. 05 - EP2) found that it stated that "representatives of Engineering, Design, Construction Management, affected departments, infection control and safety management will review the scope of work involved. An infection control risk assessment will be performed and its requirements will be implemented."

The attachment titled "Infection Control Risk Assessment : Construction and Renovation" divided the risk into Classes 1,2,3 and 4. It states "maintain negative air pressure within work site using HEPA filtered ventilation units or other methods to maintain negative pressure." This describes the interventions required for the immediate work area, not the isolation rooms with negative and positive pressure requirements that are not part of the work site itself and might be adversely effected by such activities.

On 4/25/14 the hospital adminstrative (Chief Operating Officer) and infection control staff (Assistant Director of Infection Control) were requested to provide the risk assessment for the damper maintenance incident where the pressure in the isolation rooms fell to unsafe levels. That information was not provided to the surveyors. The hospital staff indicated that this project did not have any risk assessment because it was their position that there was no risk to any patients or staff. Cross refer to TAG 0749.

Based on the review of medical records and hospital's policy, it was determined that the facility failed to consistently and timely identify all patients who needed discharge planning so these patients may have complete discharge planning evaluations. This was evident in two of six applicable medical records reviewed (MRs #5 & #6).

Findings include:
MR #6 was reviewed on 4/28/2014. It was noted that this patient, 73 year old female with past medical history of hypercholesterolemia, hypertension, chronic renal disease, vaginal bleeding and chronic heart failure, presented to the facility's Emergency Department (ED) on 1/1/2014 with chief complaint of shortness of breath and vaginal bleeding. The patient was admitted with diagnosis of congestive heart failure. The patient had a GYN (gynecological) consult and an endometrial biopsy was done on 1/3/2014. It was noted that the patient signed out AMA (against medical advice) on 1/5/2014. The endometrial biopsy results revealed squamous cell cancer of the cervix on 1/7/2014. The reason for signing AMA was unclear. Although the patient was an inpatient for five (5) days, this patient did not have an initial discharge planning evaluation.

MR #5 was reviewed on 4/28/2014. It was noted that the patient, 81 year old male with past medical history of gout, chronic bronchitis, hyperlipidemia, and prostate CA s/p cryosurgery, went to the ED on 1/7/2014. The chief complaint was cough x 2 weeks, fever and shortness of breath. The patient was admitted with diagnosis of pneumonia. It was noted that on 1/10/2014, the physician noted that the patient was medically stable for discharge.
The Social Work Assessment and Discharge Plan for this patient was reviewed. It was noted that the initial Discharge planning evaluation was dated 1/10/2014, the day of discharge.
It was noted that, on 1/10/2014 at 09:14 AM, the social worker noted that the patient was semi-independent, ambulation with assistance of cane, and ADls (activities in daily living). It was noted that prior to admission the patient received home care services . The Discharge plan notes dated 1/10/2014 at 13:28 "as per MD, patient needs 2 Lt. Oxygen at home". It was noted that the oxygen was arranged prior to discharge. On 1/10/2014 at 13:39 (1:39 PM) , the caseworker noted that the patient was medically cleared and ready for discharge back to home with reinstated home care services. It was noted that there was no documentation that there was a discussion with the patient regarding the patient's post-hospitalization needs. The discharge planning evaluation did not include if the prior home care services was still adequate for this patient.

Discharge Planning Policy, policy No. 327 revised March 2013, was reviewed on 4/25/2014. It was noted that this policy describes early identification of those patients who require discharge planning. However, the policy does not include when the screening is done to identify the inpatients needing discharge planning evaluations. It also does not specify the staff responsible for doing the screening.

The Discharge policy submitted and reviewed on 4/25/2014 list the functions of the Medical Social Worker in Discharge planning. Based on CMS guidelines, "If a hospital does not voluntarily adopt a policy of developing a discharge plan for every inpatient, then the hospital must evaluate all inpatients to identify those patients for whom the lack of an adequate discharge plan is likely to result in an adverse impact on the patient's health".
Therefore, the facility's discharge policy should address the screening of all inpatients for discharge planning needs.

Based on staff interviews and review of medical records, it was determined that the hospital failed to ensure that each patient who identified as needing discharge planning that the discharge planning evaluation addressed all of the patient's post-discharge needs. This was evident in three (3) of ten (10) applicable medical records reviewed (MRs #7, #8 & #10).

Findings include:
During the tour of the unit (6W), on 4/23/2014 at approximately 11:33 AM, staff #14 reported that the patient in MR #10 was discharged, today and he had left the unit.

MR #10 was reviewed, in the unit, on 4/23/2014. It was noted that the patient, 56 year old male with history of hypertension, hepatitis C and recently diagnosed lung cancer, went to the facility's Emergency Department (ED) on 4/7/2014. The chief complaint was chest pain. The patient was admitted on 4/7/2014 and he was discharged on 4/23/2014.
The discharge planning evaluation for this patient was reviewed. The Social Work Assessment, dated 4/8/2014 at 11:13 AM, indicated that the "patient was a visitor from Egypt. He arrived to the USA (United States of America) 10 days ago and he had a Visa for six months. The patient's family remained in Egypt. As per patient, the patient was self-ambulatory and performed ADLs (activities in daily living), including medication and finances. Case was referred to Case Management for a skilled nursing needs assessment". The assessment did not include the reasons why the patient required skilled nursing needs assessment. The Discharge Plan notes were reviewed. It was noted that on 4/15/2014 at 10:09 AM, the worker noted "case was discussed in multidisciplinary rounds, as per MD, patient is diagnosed for lung cancer. Patient is waiting for final biopsy result and oncology consults". On 4/22/2014 09:35 AM, "as per MD, patient was medically cleared for discharge. Patient needs radiation and chemotherapy treatments. Patient will continue his radiation at Kings County hospital as an outpatient and receive chemotherapy at a Coney Island Hospital Outpatient Clinic". This patient was a visitor with a six months visa. There was no documentation that these plans were discussed with the patient. The patient's long term goals and treatments were not addressed with the patient.

MR # 7 was reviewed on 4/28/2014. It was noted that this patient, 68 year male with past history of paroxysmal A.fib (atrial fibrillation) and alcohol abuse, was brought to the facility's Emergency Department (ED ) by ambulance on 12/29/2013, after a fall. It was noted that the patient sustained complex comminuted fracture of the right humerus. The patient informed the ED provider that, due to his neuropathy, he was unable to walk without a right arm support. The patient was admitted to Medicine Service. The admitting diagnosis was closed fracture of shaft of humerus. The patient was discharged to home on 1/3/2014.
The physician's discharge summary indicated that the disposition was home (independent). It was noted that the physician discharge summary indicated that the patient was to follow up in outpatient rehab. It was noted that there was no discharge order or appointment for outpatient rehab. In addition, the discharge appointment was as followed "f/u in ortho clinic within a week, f/u in discharge clinic within 1 week, f/u in hematology clinic within 4 weeks". It was noted that the patient was not provided with these appointments before the patient was discharged, as the dates and times for these appointments, were not listed.
It was noted that, on 12/29/2013, the provider indicated that the patient needed more inpatient physical therapy (PT) and that the patient was not safe to be discharged home. On 1/2/2014 at 1434 (2:34 PM), the physical therapist noted "the patient presented with decreased functional ability requires CG assist with transfers and ambulation". It was noted that on 1/3/2014 at 1538, PT evaluation indicated that the patient was not able to tolerate standing, not able to sit or stand and he was not able to tolerated standing. This evaluation was not consistent with the physician's disposition that the patient was independent. There was no documentation that PT cleared the patient for discharge to home.
Social Work Assessment and Discharge Plan dated 12/31/2013 12:49 indicated that: "the patient was undocumented, did not have medical insurance; he resided with a friend who provided assistance with ADLs (activities of daily living) as well as providing food, shelter and financial support". It was noted that the patient reportedly unable to walk due to the fracture to his right arm. It was noted that this additional information was not addressed with this caregiver.
Discharge plan notes dated, 1/3/2014 1549 (3:49 PM), indicated that the patient was medically cleared for discharge back home and agreed with discharge plan as per patient; his present physical condition is his baseline functional status. This documentation is inaccurate as prior to admit the patient had functional upper extremities. The discharge planning evaluation did not include if the discharge plan was safe for this patient.
It was noted that the patient had an Occupational (OT) Therapy evaluation 12/31/2013 at 1031 (10:00 am). The OT therapist recommended the following equipment: standard commode, tub seat with back. The discharge plan evaluation did not include if the patient had the required equipment at home or how the patient would be able to obtain the equipment.
The Discharge Plan Noted dated 1/3/2014 15 :49 ( 3:49 PM) indicated that "the case was referred to VNS (visiting nursing services) for charity for PT visits. Patient is undocumented and does not have medical insurance". The discharge planning assessment did not include if the patient was approved for this service. In addition, it did not include how many visits the patient would receive and when the service would be initiated.
This discharge instruction indicated that the patient was to follow up in ortho clinic, discharge clinic and hematology clinic. The discharge planning evaluation did not include if the patient would have any difficulties in keeping these appointments or if assistance was provided to the patient in order that the patient may keep these appointments.

MR #8 was reviewed on 4/28/2014. It was noted that the patient, 77 year old with history of hypertension, diabetes type 2, and skin cancer , went to the facility's ED on 1/31/2014 with complaint of severe headache and weakness. The patient was admitted for pneumonia. The patient was treated for his medical condition and was discharged on 2/7/2014.
The discharge planning evaluation for this patient was reviewed. The Social Work assessment dated 2/1/2014 at 1325 (1:25 PM) notes as following : "the patient resided with his wife. The patient was left ambulatory, independent with managing his finances and medications. Patient stated that he performed his ADL's with assistant of HA 4x8 (mutual with his wife) neither patient nor his wife who present at bedside, was able to provide the name and telephone of the agency. Worker on the unit will follow up. Patient was educated about SNF (skilled nursing facility) placement procedure but he strongly refused. Case was discussed during multidisciplinary during multidisciplinary rounds, referred to case manager for skilled nursing needs. Upon medically cleared patient will be discharged back home with prior HHA 4 x 8 services". It was noted that there was a completed Home Health Services Request form dated 2/5/2014 located in the record. The patient was discharged on 2/7/2014. It was noted that there was no social services follow-up with the patient after 2/1/2014. The patient's discharge needs and required services were not documented in the record.

The issues mentioned above was brought to staff #15 & staff #16 on 4/28/2014.

Based on staff interview and the review of medical records review, it was determined that the hospital personnel failed to ensure that all inpatients who needed discharge planning evaluations that these patients have complete and timely evaluations, and to avoid unnecessary delays in discharge. This was evident in two (2) of ten (10) applicable medical records reviewed (MRs: #9 & #11).

Findings include:

While on the unit (6W), on 4/23/2014 at approximately 12:00 PM, MR # 11 was reviewed. It was noted that this patient, 84 year old male with history of hypertension, hyperlipidemia, coronary artery disease, and pulmonary fibrosis, was brought to the hospital's Emergency Department (ED) by ambulance on 3/29/2014. The chief complaint was for fever and abdominal pain.
The Medical Discharge Summary, dated 4/23/2014 at 12: 52 PM, indicated that the disposition: SNF (skilled nursing facility); discharge date: Tuesday, 4/22/2014.
The discharge planning evaluation for the patient was reviewed. It was noted that, on 4/2/2104 10:37 AM, worker noted "upon medical clearance the patient will be discharged back with reinstated HHA (home health aide) 7 x 5 services. The discharge summary will be faxed to the insurance company. Patient's family will be informed about the patient's discharge". On 4/2/2014 10:38, the worker documented that due to patient's language barrier, patient's wife at bedside, provided patient's information. It was noted that the patient's post hospitalization needs and the appropriateness of the current home care services, were not addressed with the patient's wife during this discussion. It was noted that the discharge plan notes, dated 4/18/2014 09:12 AM, indicated that patient's wife wanted the patient to be discharged to SNF short term rehab and the patient's wife was educated about SNF choices. It was noted that, although this patient had been in the hospital since 3/29/2014, the discharge choices and options were not discussed with the patient/patient's representative until 4/18/2014. On 4/23/2014 12:02 PM, the discharge plan notes indicated that the patient was medically cleared for discharge and PRI (Patient Review Instrument) was requested to case management. There was no explanation, in the discharge planning evaluation, the reason why the medical discharge summary indicated that the patient's discharge date was 4/22/2014, but the PRI was completed on 4/23/2014. This patient remained in the hospital until 4/24/2014.

Staff #11 was interviewed in the unit on 4/23/2014. The staff stated that the patient remained in the unit, because the wife had recently made the decision, on a skilled nursing facility.

MR #9 was reviewed on 4/28/2014. It was noted that this patient, 74 year old male with medical history of diabetes, was brought to the facility's ED on 1/5/2014. The presenting problem was that the patient slipped and fell on ice injuring his left hip. The patient was admitted to medicine and later found to have a hip fracture. The patient underwent ORIF (Open Reduction and Internal Fixation) of the left hip fracture on 1/8/2014.
The discharge planning for the patient was reviewed. It was noted that he Initial Discharge Plan dated 1/7/2014 was reviewed. The worker indicated "upon medical clear the patient is to return home with CHHA (certified home health agency) and PME (Medical equipment), if recommended by rehab. Worker to follow up with any transportation needs". It was noted that the patient's discharge planning evaluation was not reassessed once it was determined that the patient required surgery.
It was noted that the patient was medically stable for discharge on 1/10/2014. There was a discharge and instruction order dated 1/10/2014 at 08:42 located in the record. Discharge plan notes dated 1/10/2014 at 10:42 was reviewed. The social service staff noted "worker contacted patient's son and educated him about sub-acute rehab. List of facilities contracted with Metroplus was left with patient for patient's son. Facility choices are to be provided as discussed and agreed". It is unclear the reason why the choices were not discussed with the patient. In addition, the patient / patient's representative was not educated regarding sub-acute rehab until the date the patient was medically stable for discharge.
It was noted that the patient was placed on alternate level of care on 1/10/2014. It was documented on 1/10/2014 15:55 (3:55 PM) that the patient's son requested Shore View, SNF (skilled nursing facility). PRI (Patient Review Instrument) was prepared and faxed to Shore View on 1/10/2014. The patient was accepted by Shore View on 1/10/2014. However, the patient remained in the hospital pending authorization from the insurance. The patient was discharged on 1/13/2014.