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Based on review of procedures, grievance documents, and staff interview, it was determined the facility did not consistently provide all patients/patients' representatives with written notices of decisions on resolution of grievances, as required. This finding was noted in 2/2 relevant records. (MR #s 5, 7).

Findings include:

The facility did not conform to its policy and procedure for Management of Complaints and grievances, which states written grievances will be responded to within 30 business days of receipt and which must include a report of the hospital ' s investigation activities and results of the complaint process. Examples include:

1. Specific reference is made to the complaint file corresponding to medical record # 7. Review of the patient complaint file on 7/26/11 found the facility never responded in writing to a written complaint submitted by this patient ' s daughter. The grievance file included a written document of complaint dated 9/14/10, which detailed complaints about medical and nursing care issues as follows:
- it was alleged staff performed a venipuncture on the patient ' s left arm, which was contraindicated secondary to history of mastectomy;
- an employee was alleged to have responded in an unprofessional manner in response to family ' s request for social work services;
- request for pain medication was not responded to appropriately by nursing staff;
- alleged failure of staff to notify the patient ' s family of serious changes in the patient's condition, which resulted in the need for restraint and sedation.

The facility ' s complaint file indicated that the patient advocate had met with the patient's
daughter on 9/15/10 and on 10/7/10. The file noted reassurance was provided and described interventions to advise the daughter about discharge planning and referrals to Social Security Administration for Medicare. No documentation of a written response was evident nor investigation of the remaining nursing and medical care issues as noted in the written complaint.

At interview with the Nursing Administrator and Director of Patient Advocacy on 7/26/11, it was reported that the hospital did not document a written response to the complainant.











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2. Review of Patient Relation Department file on the patient in MR #5, on 7/26/11 at approximately 10:30 AM, noted that the patient ' s Health Care Agent filed written complaints with the facility dated November 1, 2010 and November 9, 2010 regarding inadequate care rendered to the patient. It was noted that the facility ' s investigation was not located in the file. During the survey on 7/26/11 at 11:30 AM, the surveyor inquired about the hospital investigation; a copy of an Employee Warning Notice dated 11/4/10 was presented. However, a copy of the written response to the complainant was not given. The staff interviewed reported that the outcome of the investigation was discussed verbally with the complainant. The day and time that this response was not provided. On reviewing the second letter dated November 9, 2010, it was noted that the complainant alleged that the facility had not respond to the initial complaint.
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Based on medical record review, it was determined that the facility did not meet the patient 's pain management needs.

Findings include:

Review of MR#8 on 7/25/11 noted an adult patient was hospitalized with an admitting diagnosis of headache on 12/19/10. The patient was on the pain medication Vicodin PRN at home. While the patient was discharged home on 12/21/10 with prescription for Vicodin ES, the hospital course was noted for inconsistent management of the patient ' s pain. Nurse Progress Note on 12/20/10 at 5PM noted patient refused pain medications 500mg Acetaminophen and Tramadol, Nurse Progress Note on 12/21/10 stated the patient refused pain medications Tylenol and Tramadol, and Physician Progress Note on 12/21/10( time not noted) noted patient refused all pain medications. It was noted the patient was demanding Vicodin for pain management.

On 7/25/11, the surveyor interviewed a Pharmacist and collaboratively reviewed a medication administration document, which contained a record of all pain medication administered to patient. The patient received Vicodin on two occasions only: on 12/20/10 at 1800 and 12/21/10 at 0200. It was not clear in the medical record why the pain medication Vicodin was restricted. Physician Progress Note on 12/20/10 at 11AM noted for patient neuro-migraine give Imitrex, Tramatol PRN, Dilaudid PRN and Vicodin as outpatient. There was no further documentation to explain why Vicodin was not provided . There was no evidence of communication between patient and medical staff concerning patient 's pain management or patient' s inclusion in pain medication care plan.
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Based on record review it was evident that the facility did not provide sufficient information to the patient in order to effectuate informed consent.

Findings include:

Review of MR#3 found no evidence that the patient was informed that a procedure ( colonoscopy and polypectomy ) was to be performed by an unlicensed physician practicing under an exemption referenced in the Education Law Article 131 (Medicine ) - Section 6526 titled " Exempt Persons " Part (4).
There was no evidence that the patient was advised of the presence of manufacturers' representatives in the OR to advise on the use of new equipment and that the procedure would be shown via videoconference live to an audience at a hotel entitled " Tough Challenges-Practical Solutions ". A portion of the program was entitled " The Difficult and Challenging Polypectomy ".
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Based on staff interview and review of pertinent records, it was determined that the facility failed to provide care to the patient in a safe environment.

Findings include:

Medical record and staff interview revealed that patient MR# 4 underwent T7-T12 Laminectomy fusion on 3/2/11. Patient was transferred from the operating room via stretcher to the post anesthesia care unit (PACU) at 4:45 PM. Interview with staff # 2 revealed that it is the hospital practice to order a bed for patients who are having certain type of surgery and that the bed is labeled and awaiting the patient to be transferred onto after surgery. She stated that patient MR#4 met the criteria for the ordered bed. However, there was no bed ordered and available for patient MR# 4 to be transferred to after surgery.

It was noted that an order to admit the patient to neurosurgery stepdown nursing unit was written on 3/3/11 at 8:53 AM. Based on interview with staff #2 it was determined that there was no available bed so patient was transferred via stretcher to same day surgery admission unit. Staff #2 stated that it is the hospital policy that in the event a patient is discharged from the PACU and there is no space available to receive the patient, the patient is sent to the same day admission unit and that the patient is monitored by PACU nurse in accordance with the existing standards for the unit to which the patient was admitted to. On 3/3/11 at 8:30 AM nursing noted that patient was received from PACU.
Same day admission nurse manager (staff #3) on interview stated that he found a bed for the patient sometime around 12:00PM on 3/3/11. The admitting census showed a bed was assigned to the patient at 6:43 PM on 3/3/11 and the patient was transferred to 8 Lachman nursing unit.

The hospital failed to provide a safe environment for patient MR#4 in that they did not provide him with a bed for comfort for 26 hours after undergoing a T7-T12 Laminectomy, instead he was on a stretcher.
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l. Based on record review it was evident that the hospital medical staff did not recognize complications of a procedure in a timely manner and perform emergent surgery.

Findings include:

Review of MR# 3 on 7/25/11 found that the patient sustained a perforation of the colon during colonoscopy and polypectomy which was referred to in the colonoscopy report as a "defect " to which 2 " endoclips " were applied.

When the patient exhibited severe abdominal pain and edema of the neck and face upon recovery from anesthesia, the physicians ordered IV Benadryl twice for an " allergic reaction " . The edema was found to be subcutaneous emphysema which was symptomatic of a perforation. The patient was evaluated by surgery,. X-ray demonstrated a large pneumoperitoneum and found to be in need of emergent operation. At operation, the patient was found to have a bowel perforation. The endoclips placed during the initial procedure were missing.

There was no evidence that clinical correlation of the pain and edema to the " defect " referred to on the colonoscopy was made. There was a delay in emergent operative intervention. Once the defect was identified, the endoscopist should have informed the medical staff that a perforation was made and to observe for any relevant complications.

2. Based on record review, it was evident that visiting medical staff performed a procedure in a manner that deviated from current standards of practice.

Findings include:

Review of MR#3 on 7/ 25 /11 found the endoscopist proceeded with attempted resection of a sessile polyp despite clinical evidence that the polyp did not elevate in a normal manner and then clipped the mucosal defect with only 2 endoclips which was not sufficient given the large size of the defect.

Based on medical record review and staff interviews it was determined that nursing documentation failed to demonstrate a working relationship among medical staff, nursing staff and staff of other departments.
Findings Include:

Review of MR # 1 on 7/25/11, documentation indicated a stage two (2) sacral decubitus ulcer on 7/24/11, noted to be 1 cm, red, no drainage and no odor. There was no current physician ' s order for decubitus care. Upon interview on 7/25/11 about 11:30am, staff stated that the patient had no sacral decubitus, the area was only reddened. However, this was not noted in the nurse ' s progress notes.

Review of MR # 2 on 7/27/11 patient noted with stage 2 sacral decubitus ulcer. Interview of facility staff on 7/27/11 approximately 11:30am, staff stated that the patient ' s ulcer had been evaluated on 7/26/11 by the wound care nurse, EPC cream was recommended. However there was no current physician ' s order for decubitus care.
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Based on review of medical record and patient ' s grievance file, it was determined that the facility did not consistently ensure that the nursing staff review, evaluate and document the adequacy and appropriateness of nursing care provided for all patients. This deficiency was noted in two of six medical records reviewed (#5 & #6) .
Findings include:
Review of MR #5 on 7/26/11 at 9:00 AM noted that this 68 year old patient presented in the Emergency Department (ED) on 10/25/10 with chief complaint of back pain and lower extremity weakness. The patient was admitted with diagnosis of Pulmonary Embolism. It was noted that this patient was on bedrest needing assistance with ADL's. On 11/4/10, Nursing Assessment and Plan of Care (POC) identified the patient ' s sacral & buttocks areas to be peeling/chafing and on 11/5/10, peeling around the patient ' s buttocks area. It was noted that there was inconsistent nursing documentation on the patient ' s skin condition. For example: on 11/4/10, the nurse documented on the POC form - on the skin assessment section on this form " no skin breakdown evident " . However on the same form, under plan of care, it was documented chafing/peeling around the patient ' s buttocks area.
The nursing documentation failed to consistently address the plan to evaluate the patient ' s skin integrity on 11/6/10 and 11/7/10 as it was noted on 11/6/10 the Braden Scale section of the form was not complete. Additionally, on 11/6/10 & 11/7/10 the patient was identified as having peeling around the buttocks area but the skin care interventions were not documented.

The Patient Relations file for the patient in MR # 5 was reviewed on 7/26/11. It was noted that on 11/1/10 and 11/9/10 the patient ' s family complained to the facility that the staff was not adequately assisting the patient with the bedpan and not assisting the patient with toileting.
- Review of Nursing Assessment/ Plan of Care (POC) form 11/4- 11/6/10 under the heading Toileting: Assess/Offer/Care- it was noted that the nursing staff signed off on the form every two hours. However, the actual care rendered to the patient and the patient ' s responses were not documented.

Review of MR # 6 in the unit CCU on 725/11 at 10:26 AM noted that this 81 year old patient with significant history of CHF & DM was admitted to the facility on 7/22/11. It was noted that the chief complaint was that the patient fell at home, syncope episode. The Nursing Assessment Admission form was reviewed. This form did not indicated that the hospital Fall Prevention Protocol was initiated.
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Based on medical record review, interview and hospital policies, it was determined that the hospital did not ensure patient ' s receiving pain medication receive pain assessment, intervention and reassessment of pain.

Findings include:

1- Review of MR #8 on 7/25/11 found the patient's nursing assessment, reassessment and intervention in administrating pain medication was not documented consistently. Patient received the pain medications Dilaudid 2mg. PO on 12/19/10 at 0600 and Tramadol 50mg PO on 12/20/10 at 0600 and Vicodin on 5mg 12/20/10 at 1800. There was no evidence of documentation of assessment, reassessment and intervention documented in Pain Assessment/ Reassessment section under the Nursing Assessment and Plan of Care (POC). Based on interview with Risk Management Director this form was revised to include pain reassessment.
2- Inconsistency in the documentation of the time frame during pain assessment and pain management when reviewing the medical record. Example of the same follows:
Dilaudid was administered on 12/19/10 at 1400. Pain assessment noted that the patient was assessed at 9AM and reassessed at 10AM.
Dilaudid was administered on 12/20/10 at 10:00. Pain assessment was noted that
the patient was assessed at 11:30AM and reassessment at 12:30PM.
Vicodin was administered on 12/21/10 at 0200. Pain assessment noted that the
patient was assessed at 10:30AM and 3:30PM no time of reassessment was
noted. Inconsistency of the time noted when the medication was administered,
when the patient was assessed and reassessed for pain management.