HospitalInspections.org

Based on document review, medical record (MR) review and interview, in 2 of 2 MRs (Patient #1 and Patient #2) who were Medicare beneficiaries admitted to the hospital, each lacked documentation that "An Important Message from Medicare" (IM), was provided within 2 days of admission and within 48 hours of discharge. This could cause patients to be unaware of their rights.

Findings include:

-- Review of the hospital's policy and procedure (P&P) titled, "Notification of Hospital Discharge Appeal Rights Important Message from Medicare," last revised 11/2012, indicated all Medicare covered inpatients should receive the IM at or near admission, but no later than 2 calendar days after admission. A copy of the IM must be maintained in the MR. The admissions clerk will be responsible for delivering the IM notice Monday - Friday 8:00 am - 4:00 pm. The charge nurse will be responsible for providing patients the IM after 4:00 pm on weekdays and on weekends and holidays. A follow-up copy of the notice should be provided to the patient within 48 hours of discharge, when admission is longer than 2 days.

-- Review of Patient #1's MR, revealed she was admitted on 11/16/19 and discharged on 11/19/19, there is no documentation that she was provided the initial IM on admission or follow-up IM prior to discharge.

-- Review of Patient #2's MR, revealed he was admitted on 4/5/19 and discharged on 4/9/19, there is no documentation that he was provided the initial IM on admission or follow-up IM prior to discharge.

-- During interview of Staff A, Registered Nurse (RN) on 12/4/19 at 11:30 am, he/she indicated registration staff used to have patients sign the IM notice, but does not know if it is being done now. The nurses are not required to get the IM signed.

-- During interview of Staff B, Medical Assistant in registration on 12/4/19 at 11:40 am, he/she does not get the IM signed and is not sure who is responsible.

-- During interview of Staff M, EMR (emergency medical record)/ EP (emergency preparedness) Coordinator on 12/4/19 at 2:30 pm, he/she acknowledged the above findings.

Based on document review and interview, in 3 of 9 credential/personnel files, the hospital did not ensure emergency department (ED) staff and nursing staff had current required training in accordance with New York Codes, Rules and Regulations (NYCRR) and hospital registered nurse (RN) job description. This lack of current training could potentially lead to inadequate care of patients.

Findings include:

-- Per NYCRR Title 10 (405.19), ED staff (providers and nurses) must be currently trained in Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS).

-- Per review of the hospital's job description for a Registered Professional Nurse, last revised 1/2019, Basic Life Support (BLS) certification is required and ACLS and PALS should be completed within 6 months of hire.

-- Per review of Staff C's, ED physician credential file, it lacked evidence he/she had current training in ACLS and PALS.

-- Per review of Staff D's, Director of Nursing, ED/Acute Unit Registered Nurse [RN]) personnel file, it lacked evidence he/she had current training in ACLS.

-- Per review of Staff E's, ED/Acute Unit RN personnel file, it lacked evidence he/she had current training in ACLS.

-- During interview of Staff F, Executive Assistant & Medical Staff Coordinator on 12/5/19 at 2:00 pm, he/she acknowledged the above findings.

Based on observation, document review and interview, the hospital did not ensure emergency equipment, emergency carts and supplies were maintained by staff and available for patient care. This could lead to a delay of care for patients in an emergency situation.

Findings include:

-- Per observation on 12/3/19 at 11:20 am, the emergency cart for the acute inpatient unit and swing bed unit contained the following expired items:
- 2 sets of pediatric defibrillator pads, expired 10/2016 and 6/2018

The clean supply room contained the following expired items:
- 3 stool culture collection vials, expired 10/2019
- 1 box of 4 x 4 sterile gauze pads, expired 6/2019
- 8 packages of Vaseline gauze, expired 4/2019

-- Per observation on 12/3/19 at 11:50 am, the adult emergency cart for the emergency department (ED) lacked adult defibrillator pads (no other pads were available on the unit). Additionally, the emergency cart contained the following expired items:
- 2 - 8 millimeter (mm) endotracheal tubes, expired 4/2019
- 1 - 8.5 mm endotracheal tube, expired 12/2018
- 1 - 7 mm endotracheal tube, expired 5/2019
- 1 - multi-lumen central venous catheter tray, expired 8/2019

The ED pediatric emergency cart contained the following opened sterile supplies:
- 1 - #4 Macintosh blade (used to insert a breathing tube)
- 1 - pediatric feeding tube

-- Review of the form titled "Medical/Skilled Nursing Crash Cart Checklist," dated 2019, revealed the monthly inspection of the emergency cart in the acute inpatient unit/swing bed unit was not done for August 2019 and October 2019.

-- Review of the policy and procedure (P&P) titled "Crash Cart," dated 12/10/18, indicated the responsibility of pharmacy and nursing staff is to include restocking and checking for outdates. Pharmacy should do monthly emergency cart checks to verify medication expiration dates. Nursing staff should verify emergency carts are available and secured with a red lock each shift.

-- During interview of Staff D, Director of Nursing on 12/3/19 at 1:00 pm, he/she acknowledged the above findings.

Based on observation, interview and document review, the hospital lacked a current infection prevention program. Specifically, the hospital did not conduct an infection prevention risk assessment. The infection prevention program had not been reviewed/revised. There have been no scheduled meetings of an Infection Prevention Committee. No infections have been tracked and trended. Additionally, the Infection Preventionist lacked training in infection control and prevention. These findings could lead to the spread of infection to patients and staff.

Findings include:

See Findings in Tag C 278

Based on medical record (MR) review and interview, in 20 of 20 MRs (Patient #1 - Patient #20) reviewed, all lacked evidence that patients were informed of their patient's rights and provided a copy as required per New York State Regulation (NYCRR 405.7). This could cause patients to be unaware of their rights

Findings include:

-- Review of Patient #1's - Patient #20's MRs, revealed there was no documentation that patients were informed of their patient's rights and/or provided a copy of their patient's rights when admitted to the hospital or swing bed unit.

-- During interview of Staff G, Nursing Supervisor on 12/4/19 at 9:30 am, he/she acknowledged the above findings.

Based on interview, document review, and observation, the hospital did not follow generally accepted infection prevention practices. Specifically, 1) the hospital lacked a current infection prevention program and a current infection control risk assessment (ICRA). The hospital did not have a current infection prevention committee, committee meetings or meeting minutes. The hospital did not track and trend infections and the Infection Preventionist (IP) lacked training in infection control and prevention. 2) A Patient (Patient #3) with confirmed methicillin resistant staff aureus (MRSA) on droplet precautions was in close contact with multiple non-infected patients. 3) Lapses of hand hygiene were observed. 4) The patient bathtub was unclean. 5) Clean and sterile supplies were not stored and/or separated adequately. 6) A staff member (Staff G) lacked documentation of immunization/immunity to Rubeola (measles). These findings could increase the risk of infection for patients and staff.

Findings regarding 1) above:

-- Per interview of Staff H, IP on 12/3/19 at 2:15 pm and 12/4/19 at 1:00 pm, he/she revealed he/she is responsible for employee health and infection prevention (hired 5/2019). Staff H has not had any infection prevention meetings and does not have an infection prevention committee. He/she was unaware of the infection prevention plan or need to track and trend infections. There are no infection prevention audits presently being done.

-- Review of the hospital's document titled, "Infection Control Risk Assessment 2016," revealed it was last reviewed 6/2018 (over one and a half years ago).

-- Review of the Infection Prevention Committee Meeting minutes revealed, the last meeting was held 9/2018 (over one year ago).

-- Review of the hospital's document titled, "Multiple Drug-Resistant Organisms (MDRO)," revealed the last documented tracking of infections was completed 9/2018 (over one year ago).

-- Review of the personnel file for Staff H, IP revealed, he/she has not had training in infection control and prevention.

-- Review of the hospital's policy and procedure (P&P) titled, "Reporting Communicable Diseases," last reviewed 6/2019, indicated the IP should monitor for compliance through an infection prevention log used in the Emergency Department, Acute Care, Swing and Long Term Care Units.

Findings regarding 2) above:

-- Review of the P&P titled, "Transmission Based Precautions," last reviewed 6/2018, indicated the IP must be notified when a patient is placed on transmission precautions. The IP will review the medical record (MR) to ensure proper precautions are followed. Staff should notify the IP if proper precautions are not followed.

-- Per observation on 12/4/19 at 9:00 am, Patient #3 diagnosed with MRSA in her sputum and on droplet precautions was observed eating breakfast in the dining room with 6 other patients.

-- During interview of Staff I, Licensed Practical Nurse (LPN) on 12/4/19 at 9:00 am, he/she acknowledged the above finding.

Findings regarding 3) above:

-- Review of the hospital's P&P titled "Hand Hygiene," last reviewed 10/2018, indicated staff should decontaminate their hands before having direct contact with patients and after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

-- Review of document titled "Environmental Cleaning Guideline for Clifton-Fine Hospital," dated 7/2016, indicated staff should not wear dirty gloves outside of a patient's room. If staff leave the room after cleaning was started, they should remove their gloves and perform hand hygiene.

-- Per observation on 12/5/19 at 9:25 am, Staff K, LPN did not perform hand hygiene prior entering and exiting a patient's room while administering medications. He/she confirmed the finding at the time of observation.

-- Per observation on 12/5/19 at 9:50 am Staff L, Housekeeping Aide cleaned a patient's room and exited without removing his/her gloves and performing hand hygiene. He/she indicated hand washing was not necessary if gloves were worn. He/she confirmed the finding at the time of observation.

Findings regarding 4) above:

-- Review of the hospital's P&P titled "Operation of Bath Tub," last revised 6/23/16, indicated to remove grease stains, skin debris and hair, use a sponge and soap.

-- Per observation on 12/3/19 at 11:45 am, the bath tub contained dried skin debris around the drain.

-- During interview of Staff M, EMR (electronic medical record)/ EP (emergency preparedness) Safety Coordinator on 12/3/19 at 11:45 am, he/she acknowledged the above finding.

Findings regarding 5) above:

-- Per observation on 12/3/19 at 2:30 pm, clean and sterile supplies e.g., IV (intravenous) tubing, syringes, blood lines, Foley catheter trays, and nasal cannula sealed packages, were stored on shelving carts in the basement corridor without required separation or positive pressure supply ventilation.

-- Per observation on 12/3/19 at 2:45 pm, the medical supplies clean storage room in the basement lacked a self-closing fire rated door and positive pressure supply ventilation to maintain a clean environment for storage of medical supplies.

-- During interview of Staff N, Lead Maintenance on 12/3/19 at 2:45 pm, he/she acknowledged the above findings.

Findings regarding 6) above:

-- Review of Staff G's, RN personnel file on 12/5/19 at 1:30 pm, revealed a negative (non-immune) rubeola serological titer test dated 2016. There was no documentation that Staff G received a measles, mumps, rubella (MMR) vaccine booster.

-- During interview of Staff H on 12/5/19 at 2:00 pm, the above finding was acknowledged.

Based on document review, medical record (MR) review and interview, care provided to patients did not meet generally accepted standards of nursing practice or hospital policy and procedure (P&P). Specifically, 1) in 1 of 1 (Patient #1) acute care patients identified as at risk for pressure ulcer development lacked consistent documentation of skin assessment and turning and positioning and 2) 1 of 11 swing bed patients (Patient #3) lacked monthly skin assessments per the hospital's policy and procedure (P&P).

Findings include:

-- Review of the hospital's P&P titled, "Skin Assessment, Reassessment and Wound Care," last reviewed 10/2018, indicated acute care and short term swing bed patients should have skin assessment twice daily and the Braden Scale (risk assessment tool for pressure ulcer development) completed daily by the registered nurse (RN). If the score is less than or equal to 17, (mild risk 15-18, moderate risk 13-14, high risk 10-12 and severe risk 9 and below) the patient should be turned and positioned every 2 hours. Long term care swing patients should have a weekly skin assessment by an RN and the Braden Scale done on admission, weekly x 4 and then monthly and as needed.

-- Review of Patient #1's MR revealed, she was admitted on 11/16/19 from the swing bed unit to the acute care unit with septicemia and sepsis. Her Braden score was 16. The next Braden Scale score was documented 11/19/19 at 8:40 am as 15 (3 days later). Nursing documented the patient was turned and positioned supine on 11/16/19 at 11:46 am. There was no further documentation of turning and positioning of the patient during her hospitalization. (Patient #1 was discharged on 11/19/19.)

-- Review of Patient #3's MR revealed, she was admitted to the swing bed unit on 5/31/19, her Braden score on admission was 19. The next Braden score was documented on 11/6/19 (6 months later).

-- During interview of Staff M, EMR (emergency medical record)/ EP (emergency preparedness) Coordinator on 12/4/19 at 2:30 pm, he/she acknowledged the above findings.

Based on medical record (MR) review and interview, in 1 of 1 patients (Patient #6) on oxygen therapy, nursing staff adjusted the oxygen (O2) level provided to the patient without a physician order. This could cause untoward patient outcomes.

Findings include:

-- Review of Patient #6's MR, revealed he was admitted on 12/2/19 at 10:22 pm with a diagnosis of shortness of breath and a history of chronic obstructive pulmonary disease (COPD). The admission order was for O2 3 liters (L) via nasal cannula (NC). Nursing staff documented on 12/3/19 at 2:19 am and 6:33 am O2 at 4 L via NC. On 12/4/19 at 7:10 am, nursing documented O2 at 5 L via NC.

There was no documentation in the MR that the provider was notified and/or a new order was obtained.
-- During interview of Staff A, Registered Nurse (RN) on 11/4/19 at 11:30 am, he/she acknowledged the above finding and indicated a physician order would be required to change the O2 level.

Based on observation, document review and interview, current swing bed patient's medical records (MR) were stored in an unlocked office. This could lead to unauthorized access to patient's protected health information.

Findings include:

-- Per observation on 12/3/19 at 11:00 am and 12/4/19 at 9:00 am, the office housing 11 swing bed patient MR was unlocked and unattended.

-- Review of the hospital's policy and procedure (P&P) titled "Safeguarding Protected Health Information," dated 7/26/19, indicated MR information should be isolated or locked to restrict access by unauthorized persons.

-- During interview of Staff D, Director of Nursing on 12/4/19 at 9:00 am, he/she acknowledged the above findings.

Based on medical record (MR) review and interview, 20 of 20 MRs (Patient #1- Patient #20) reviewed lacked documented evidence that the patient and/or their representatives were informed of and provided a copy of the hospital's visitation policy and procedure (P&P). Additionally, the hospital did not have a P&P pertaining to visitation. This could cause patients and/or their representative to be unaware of any visitation restrictions.

Findings include:

-- Review of Patient #1's - Patient #20's MR revealed, there was no documented evidence that the patients and/or their representatives were informed of the hospital's visitation P&P.

-- During interview of Staff A, Registered Nurse (RN) on 12/4/19 at 11:30 am, he/she acknowledged the above findings.