HospitalInspections.org

Based on findings from document review and interview, the hospital did not ensure that all patients were afforded their rights as required by regulation and hospital policy and procedure (P & P). Specifically, 22 of 22 current medical records (MRs) reviewed lacked signed acknowledgement that the patient had received the Patient Bill of Rights, and 4 of 4 current MRs reviewed for Medicare beneficiary patients on the Swing Bed Unit (SBU) lacked a signed initial "Important Message from Medicare About Your Rights" (IM) notice (which advises patients and/or representative about discharge appeal rights) within 2 days of admission.

Findings include:

-- Per review of Patients A - V's MRs, all lacked documentation that the patient was provided and signed for his/her Patients Bill of Rights.

--During interview of the Director of Patient Registration/Access on 11/07/12 at 12:45 pm, he/she stated that patients are provided patient rights information during the registration process and the patient's signature acknowledging receipt of the information is in the MR.

--Review of P & P titled "Patient Bill of Rights," last reviewed on 8/2012, indicated "The admitting clerk will request that the patient or his/her representative sign the form acknowledging receipt of the Patient Bill of Rights."

--During interview with the Vice President of Nursing Services (VP-NS) on 11/08/12 at 4:30 pm, the above findings were acknowledged.

--Per review of Medicare Patients W-Z's MRs on 11/09/12, each MR lacked inclusion of a signed and dated initial IM notice within 2 days of admission. In instances where patients were unable to sign, there was no evidence that the IM notice was provided to the patients' authorized representatives.

-- During interview with the SBU Social Worker and Nurse Manager on 11/09/12, both indicated that Admissions staff had responsibility for ensuring the IM notices were distributed. They were unable to explain why the forms had not been signed within the required timeframe.

Based on findings from document review and interviews, in 1 of 1 episode of 4 point restraint use reviewed, the staff did not discontinue the patient's 4 point restraint at the earliest time possible.

Findings include:

-- Per review on 11/08/12 of the MR of Patient AA, admitted to the Mental Health unit for bath salts drug induced psychosis, the Behavioral Restraint Flowsheet and the Physician's Order Behavior Restraint/ Seclusion forms indicated the patient was not responsive to verbal de-escalation, medication or 1 to 1 observation on 8/13/12. Patient AA required placement in 4 point restraint (both arms and legs are restrained) at 6:35 pm due to verbal threats, agitation, and combativeness. Registered Nurse (RN) #1 documented the patient was either calm or calm / sleeping every 15 minutes from 6:45 pm to 8:15 pm (a period of 1.5 hr) when the patient was then released from 4 point restraints.

-- During interview with the Nurse Educator and the Mental Health Nurse Manager (MH NM), on 11/08/12 at 10:45 am, each stated that the hospital does not monitor if patients in 4 point restraint are released at the earliest possible time because all staff know this parameter and follow the policy.

-- Per review of the hospital's policy titled "Behavior Restraint And Seclusion," last revised 2/2011, it indicated that "Patients will be removed from restraints when the criteria are no longer met, either by restored decision making capability or by the elimination of risk."

During interview with the MH NM on 11/09/12 at 12:10 pm, she/he reviewed the involved MR documentation about 4 point restraint use on 8/13/12 beginning at 6:35 pm and acknowledged that Patient AA was not released as soon as criteria for release were met.

Based on findings from document reviews and interviews, in minutes reviewed for monthly meetings of 5 hospital departments from November 2011 through October 2012, the departments did not document actions or follow up aimed at performance improvement (PI), and/or measurements of the success of any PI actions taken in connection with concerns identified.

Findings include:

-- Per review of the Department of Psychiatry Medical Staff (DP) meeting minutes from October 2011 to September 2012, except for the January 2012 minutes, in the Performance Improvement section each states "Internal incidents were reviewed and discussed, suggestions made." However, the minutes lack documentation of the details of concern identified in the incidents reviewed and the actions and/or follow-up suggested.

-- Per review of the Department of Medicine & Family Practice Medical Staff (DM&FP) meeting minutes for November 2011, the Performance Improvement section contains documentation indicating practitioners were not consistently selecting and using the appropriate Medical Orders for Life Sustaining Treatment (MOLST) forms. However, the subsequent meeting minutes through November 2012 lack documentation regarding follow-up of this issue.

-- Per review of the Department of Emergency Medicine (DEM) meeting minutes for November 28, 2011, the Clinical Operations section contains documentation indicating there were problems with physician signature legibility in connection with Medicare guidelines. However, the subsequent meeting minutes through November 2012 lack documentation regarding actions taken and follow-up completed.

-- Per review of the Department of Pediatrics Medical Staff (DPeds) meeting minutes from January 2012 to September 2012, "Performance Improvement" (PI) was only addressed twice in this timeframe. The PI meeting minutes from March and May 2012 document "a case review by a Nurse Practitioner will be done." However, the subsequent meeting minutes lack documentation of any case reviews (with notation of findings, actions taken and/or follow-up completed).

- Per review of the Infection Control Committee (ICC) meeting minutes for January 2012, 8 sharps injuries and 5 exposures were documented. There was no analysis of these findings and the section in the minutes for follow up indicates "none."

-- During interview of the Director of Quality Improvement on 11/9/12 at 1:00 pm, he/she acknowledged the findings above.

Based on findings from document review and interview, physicians' orders and physicians' notes were not dated and/or timed in 4 of 7 medical records (MRs) reviewed for patients who had a surgical procedure.

Findings include:

--Per review of Patient D's MR, an order written on 11/02/12 for intravenous (IV) fluids was not timed. The patient's pre-anesthesia evaluation and post-anesthesia evaluation lacked times. These findings were acknowledged by the Maternity Unit Nurse Manager on 11/08/12 at 2:30 pm.

--Per review of Patient J's MR, Pre-Admission Testing (PAT) orders and an order for IV Toradol dated 10/07/12 each lacked a time. This finding was acknowledged by the Operating Room Nurse Manager (OR NM) on 11/07/12 at 11:30 am.

--Per review of Patient K's MR, contained two copies of PAT orders. One set of orders lacked a date and time; the second set of orders lacked a time. This finding was acknowledged by the OR NM on 11/07/12 at 11:30 am.

--Per review of Patient L's MR, PAT orders and an order for IV Toradol dated 10/08/12 each lacked a time. An order written for IV fluids was not dated or timed. Additionally, the patient's pre-anesthesia evaluation dated 10/19/12 lacked a time. These findings were acknowledged by the OR NM on 11/07/12 at 11:30 am.

Based on findings from observations, interviews, and document review, it was determined that 1) drugs which were outdated and/or opened but incompletely labeled (regarding date opened, etc.) were available for patient use, and 2) the hospital did not ensure pharmacy inspections of nursing station areas were performed at least monthly.

Findings regarding 1) above include:

-- Per observations on 11/08/12 at 10:00 am, the emergency department's skin/suture care kit located in the closet contained an opened 500 cc bottle of 0.9% Sodium Chloride with an expiration date of 7/2012 and two 4 ounce (oz) Safe-gel hydrating wound dressings with expiration dates of 7/2010 & 10/2011.

-- Per observations on 11/08/12 at 2:00 pm in the rehabilitation department, the medication cabinet contained 8 oz tubes of Safe-gel with an expiration date of 1/2012 or 8/2012, a 240 cc bottle of Cal State Alcohol with an expiration date of 3/2003, four 50 cc vials of multidose injectable Lidocaine 1% - two dated 9/29/12 & 9/30/12 and two undated, and one 4 oz tube of Hydrocortisone 1% cream with an expiration date of 9/2011.

--Per observations on 11/08/12 at 11:00 am, the controlled substance storage area of the main pharmacy contained chlordiazepoxide capsules with an expiration date of 10/31/12, Tylenol #4 tablets with an expiration date of 9/31/12 and Tylenol #2 tablets with expiration date of 8/31/12.

--Per observations on 11/08/12 at 1:15 pm, the obstetrical operating room (OR) contained 2 intravenous (IV) bags of gentamicin with expiration dates of 11/01/12 and 1 IV bag of gentamicin with expiration date of 10/01/12.

During the tours involved, the accompanying staff (the Director of Quality Improvement, the Director of Rehabilitation, the Pharmacy Director and Pharmacy Technician #1, respectively, acknowledged the above findings.)

--Per observations on 11/07/12 at 9:10 am in OR #3, an expired multi dose vial (MDV) of Esmolol (dated 7/07/12) and two undated open MDVs of Labetolol and Neostigmine were found in the Omnicell.

Per review of the hospital's P & P titled "Dating of Sterile Containers," last reviewed 7/2011, it stated "Multiple Dose vials - Discard vials ...when suspected or visible contamination occurs, or AFTER 28 DAYS from date vial opened. Vials will be dated with expiration date."
The OR Nurse Manager (OR NM) was present at the time of the above observations and acknowledged the findings.

--Per observation on 11/07/12 at 9:30 am on unit 2 South, an unlabeled, undated Lantus (glargine) insulin pen was inside Patient H's medication drawer in the medication cart.

Per review of the hospital P&P titled "Insulin Glargine (Lantus Insulin) Administration Policy," undated as to last review/revision, it indicated a patient label should be attached to the insulin pen and the pen dated when first used.

During interview with RN #2 on 11/07/12 at 9:30 am, he/she acknowledged these findings.


Findings regarding 2) above include:

--Per review of the hospital P & P titled "Nursing Station Inspections," last reviewed 7/2010, it indicated that the purpose of the policy was to promote better patient care and safety by the removal and replacement of deteriorated, outdated, improperly stored or otherwise unsuitable drugs for administration. Each month a representative from the pharmacy department or a designated ancillary department will inspect each patient care area and other designated medication storage areas. Records of inspection (Nursing Station Survey Forms) of each unit should be filed in the pharmacy office.

However, review of the Nursing Station Survey Forms reveal that medication room inspections were not done monthly, they were only performed in February, May and September of 2012.

During interview with the Vice President for Nursing Services on 11/09/12 at 11:45 am, the above findings were acknowledged.

Based on findings from document review and interviews, the hospital does not have two doctors of medicine or osteopathy as members of its Utilization Review (UR) Committee as required.

Findings include:

-- Per review of 5 sets of minutes of the UR Committee for meetings from 1/05/12 to 10/30/12, the only physician present is the Vice President of Medical Affairs (VPMA).

-- Per review of the list of the medical staff committee assignments in 2011-2012, there are no physicians assigned to the hospital's UR committee.

-- During interviews on 11/07/12 with the current chairperson of the UR Committee at 1:40 pm and the past chairperson (that is, committee chairperson through 10/30/12) on 11/09/12 at 10 am, both acknowledged that a second physician has not attended a UR Committee meeting in 2012.

-- During interview with the VPMA on 11/08/12 at 10:20 am, he/she acknowledged that the medical staff's committee assignment list of 2011 - 2012 did not include the UR committee but should.

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

Findings include:

--Per observations on 11/07/12 at 10:30 am, a considerable amount of dust was present on the overhead piping in the area of the basement that is being used to store clean and sterile supplies. Also, the floors, walls, and ceiling in the sterile/clean supply area in the basement were not smooth and cleanable for infection control purposes. The walls consisted of porous concrete, the concrete floor contained cracks in numerous locations, and the unfinished ceiling contained multiple exposed pipes.

--Per observations on 11/07/12 at 10:30 am, supplies maintained in inventory in the basement and considered to be clean and/or sterile, are being stored in corrugated cardboard boxes used as shipping containers. (Per the Association for the Advancement of Medical Instrumentation, Standard 79, for infection control purposes, shipping containers should not be used as containers in sterile storage areas.)

--Per observations on 11/07/12 at 10:35 am, the exhaust vent in the medical gas room was incorrectly located. Per NFPA 99, the mechanical exhaust inlet should be located near the floor and adjacent to the medical gas cylinders.

--Per observations on 11/07/12 at 11:55 am, the closers on the doors to emergency department (ED) rooms 11 and 12 (that are used as holding rooms for the psychiatric evaluation of patients), did not comply with New York State Office of Mental Health requirements for door closer construction. Additionally, the air diffusers in ED Rooms 11 and 12 were not of the break-away type thereby representing a safety hazard.

--Per observations on 11/07/12 at 12:25 pm and 11/08/12 at 10:40 am, the door to the nurse/recovery room in the first floor Imaging Department and the 4 doors in the ICU, were not equipped with positive latching hardware to prevent rebound of the door when being closed, as required by NFPA 101 (2000), Section 19.2.

--Per observations on 11/08/12, approximately 20 vinyl flooring tiles in various hallways throughout the hospital were in poor condition (cracked, stained) and could not be cleaned.

--Per observations on 11/08/12 at 10:05 am and 12:00 pm, regarding the doors leading to Rooms 206 and 209 in unit 2 South and the OR entrance doors, several sections of laminate on these doors were missing, making them not easily cleanable due to the uneven, rough, porous surfaces created by the missing laminate.

--Per observations on 11/08/12 at 10:35 am, the patient admission area of the endoscopy suite lacked corridor handrails as required by the American with Disabilities Act (ADA) of 1990 as amended. Also, the surfaces of the corridor handrails leading to the endoscopy suite were too wide and not grippable. (Per ADA, 1990: A handrail or grab bar shall be 1-1/4 to 1-1/2 inches (32 mm to 38 mm) in diameter, or the shape shall provide an equivalent gripping surface. If handrails or grab bars are mounted adjacent to a wall, the space between the wall and the grab bar shall be 1-1/2 inches/38 mm).

During the tour the Vice President of Finance, who was present, observed and concurred with the above observations.

--Per observations on 11/08/12 at 10:40 am, the paint on the walls in the central sterilizer room was peeling and the area underneath one sterilizer was not clean.

The Director of Material Management verified the findings in the sterilizer room at the time of the observations.

Based on findings from interview and observation, the essential electrical system does not comply with NFPA 101 Section 9.1 and the convenience stairwell between the 1st and 2nd floors was not compliant with NFPA 101, Section 8.2.

Findings include:

--Per interview at 11:20 a.m. on 11/7/12, the Vice President of Finance stated that the switch gear associated with the essential electrical system was not code compliant.

--Per observation at 10:30 a.m. on 11/7/12, the wired glass comprising the wall of the convenience stairwell in 2 S exceeded 25 percent of the fire barrier in which it was used.

--The Vice President of Finance who was present observed and concurred with the above observation.

Based on findings from observation and interview, the emergency department (ED) lobby door was not compliant with NFPA 101, Section 19.3 and the hood/duct system in the cafeteria and kitchen were not compliant with NFPA 101, Section 9.2.

Findings include:

--Per observation on 11/07/12 at 12:00 pm, the ED lobby door does not have the appropriate fire resistive rating of at least one hour.

--Per observation on 11/07/12 at 1:25 pm and at 2:45 pm, the commercial cooking equipment in the cafeteria and kitchen was not properly equipped to extinguish a grease fire.

--Per interviews on 11/07/12 at 1:25 pm and 2:45 pm, the Vice President of Finance acknowledged the above findings regarding the ED lobby door and verified that the fire suppression system associated with the exhaust hoods in the cafeteria was not code compliant and would be replaced.

Based on findings from observations, interviews, and document review, the hospital did not ensure that all generally accepted infection control measures were implemented and followed.

Findings include:

--The CDC document titled "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings," indicates "when Contact Precautions are used (i.e., to prevent transmission of an infectious agent that is not interrupted by Standard Precautions alone and that is associated with environmental contamination), donning of both gown and gloves upon room entry is indicated to address unintentional contact with contaminated environmental surfaces...Donning PPE (Personal Protective Equipment) upon room entry and discarding before exiting the patient room is done to contain pathogens." It also indicates "Hand hygiene following glove removal further ensures that the hands will not carry potentially infectious material that might have penetrated through unrecognized tears or that could contaminate the hands during glove removal...Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens."

However, the hospital's policy and procedure (P&P) titled "Transmission-Based Precautions," last revised 4/2012, indicated that when caring for patients on contact precautions, staff should only wear gowns for direct patient care or when direct contact with patient or contaminated environment and/or equipment is likely. It also indicated that for contact precautions, gloves should be worn, hands washed and gown removed prior to leaving the room. The hospital's P & P did not require staff to wear isolation gowns upon entrance to contact isolation rooms.

During interview of the hospital's Nurse Educator on 11/07/12 at 10:00 am, he/she also indicated isolation gowns are not required to be worn when entering rooms of patients who are on contact isolation, if care is not going to be provided to the patient.

--Per observations on 11/07/12 at 4:30 pm, RN #3 was noted in Room 312 on unit 3 South not wearing an isolation gown for a patient on enhanced contact precautions.

Also, per observations on 11/08/12, a Contact Precaution sign was posted prominently outside of Room 253 on the Swing Bed Unit (SBU), a volunteer was observed in this patient's room not wearing an isolation gown. Again on 11/09/12 at 9:30 am, the volunteer was noted in the room at the same patient's bedside (with the same posted door sign) dressed in street clothes with a volunteer vest and a wheeled cart containing hospital literature observed in the anteroom of Room 253.

During interview at the same time with the SBU Nurse Manager and Nurse Administrator (NA), the NA approached the volunteer who backed the cart out of the room and shouted "I've done it a million times...done it for 3 years-- not worn a gown." The volunteer then exited the SBU unit with the cart without performing hand hygiene.

Based on findings from document review and interview, 5 of 6 medical records (MRs) reviewed for patient's who underwent a surgical procedure lacked documented evidence of a pre-anesthesia evaluation performed within 48 hours of surgery or a procedure requiring anesthesia services.

Findings include:

--Per review of Patient D's MR, a pre-anesthesia evaluation was completed on 11/02/12, 3 days prior to a surgical procedure completed on 11/05/12.

--Per review of Patient J's MR, a pre-anesthesia evaluation was completed on 10/31/12, 7 days prior to a surgical procedure completed on 11/07/12.

--Per review of Patient K's MR, a pre-anesthesia evaluation was completed on 11/02/12, 5 days prior to a surgical procedure completed on 11/07/12.

--Per review of Patient L's MR, a pre-anesthesia evaluation was completed on 10/19/12, 19 days prior to a surgical procedure completed on 11/07/12.

--Per review of Patient N's MR, a pre-anesthesia evaluation was completed on 10/31/12, 7 days prior to a surgical procedure completed on 11/07/12.

--During interviews of the Operating Room Nurse Manager on 11/07/12 at 11:15 am and 4:15 pm, the above findings were acknowledged.

Based on findings from observations, document review, and interviews, the hospital did not: 1) have a qualified therapeutic recreation specialist; 2) complete assessments and care plans to identify patients' psychosocial needs; and 3) ensure an ongoing program of activities was provided to meet the interests and psychosocial needs of 6 of 6 patients currently on the Swing Bed Unit (SBU).

Findings pertaining to 1) above include:

-- During an interview on 11/07/12 at 11:45 am, the unit Recreational Therapy Assistant (RTA) stated he/she worked 15 hours a week (Wednesday and Thursday) in the RTA position and worked the remainder of the week as a Certified Nursing Assistant (CNA). The RTA reported he/she did not receive any special training for the position and was not involved in care planning but was familiar with many residents' abilities and interests due to his/her CNA role and shared that information with nursing staff who had responsibility for developing care plans. When asked about activities for cognitively impaired or roombound patients, the RTA said, for those patients he/she tries to do 1:1 visits and bring materials of interest to them when time allows.

Findings pertaining to 2) above include:

-- Review of activity plans in medical records for 6 patients revealed the following:

**For all 6 patients (Patients Z and BB - FF), the "CMNF (Cortland Memorial Nursing Facility) Recreation Assessment" form was incomplete and lacked pertinent information for hand dominance, education, religious affiliation, past occupations, hobbies, interests, etc., as well as whether the patient required assistance to get to activities, and the level of cooperation and attitude regarding recreation.

** For 4 out of 6 patients (Patients Z, CC, EE and FF), the Comprehensive Care Plans (CCPs) lacked any mention of activities, interventions or goals.

** For 2 of the 6 patients (Patients BB and DD), the CCP did include activities but the interventions and goals had not been updated to reflect the patients' current condition, as follows:

-- For Patient BB, an Activities care plan initiated on 9/06/10 noted the patient's sons "have little contact," that the patient likes to be social and will participate in all activities with encouragement, and that she enjoys the company of animals, singing, dancing, bingo, parties, crafts, church services, and exercise. On 6/06/11, the CCP was updated to reflect the patient started a new medication and was "only awake and alert at night... unable to come to activities at this time. 1:1 visits will be provided by staff and family." There was no update of the CCP in the nearly year and a half since the "new medication" was documented.

--For Patient DD, who had been admitted to the facility on 10/17/12 (approximately 3 weeks earlier) - a generic, pre-printed (undated) CCP noted "Unfamiliar with Recreation Therapy routine and programs available." The only listed interventions were to orient the patient to the recreational calendar and invite to groups of interest, ascertain leisure interests and provide materials as needed and introduce to peers with the same interests. The CCP was not updated from the time of admission.

** For all patients (Patients Z and BB - FF), the Patient Plan of Care Sheets revealed no documentation of the patients' specific interests or activity preferences.

During interviews conducted on the morning of 11/09/12, the SBU Nurse Manager (NM) verified that activities had not been consistently included and/or updated in patient care plans and the Nurse Administrator said patient interests/activity preferences should be included and that he/she planned to revise the form to provide an area to document that information.

Findings pertaining to 3) above include:

-- Review of the SBU's November 2012 Activity Calendar on 11/07/12 revealed only one activity per day was scheduled on Fridays, Saturdays and Sundays (church service, Bingo, and "Fun with Emily" or Protestant service, respectively). On Mondays, two activities were scheduled (Bingo and "puzzle hand outs"). On Tuesdays, the one activity scheduled required patients to leave the unit and/or hospital. The majority of activities for the month occurred between 9:30 am and 2 pm. There were no activities scheduled in the evening with the exception of one outside excursion.

-- Although, activity attendance sheets were requested for September through November 2012, attendance records for on unit activity participation were not available.

-- During interview on 11/09/12 at approximately 10:30 am, the SBU NM verified these findings.