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Based on document review, interview, and viewing of facility's video recording, in two (2) of 37 medical records reviewed, it was determined that the facility failed to ensure that its Elopement policy was followed to ensure safety and protection of all patients as evidenced by:

(a) Failure to ensure that patients with cognitive, mental, and physical impairments were assessed for elopement risk;


(b) Failure of the staff to implement elopement interventions, and monitoring of patients identified at risk for elopement.

(c) Ensure that the operating features of the electronic infant protection system was installed and maintained in a manner to provide a safe environment for infants and young children.


See Tag A 144.

These failures may have placed patients at risk for harm.


Findings include:


Review of the video recording (from cameras #22 and #9) dated 6/1/17 for Patient #1 showed: Patient #1 was walking out of the Emergency Department (ED) followed by a Security Officer (Staff G). The patient was walking in a regular pace. The patient was wearing street clothes (light blue jacket, red t-shirt, grayish pants, and white and black sneakers). The video showed Patient #1 and Staff G were interacting. Staff G was observed pointing to the double door exit of the Central Pavilion toward the street.


The medical record review of Patient #1 identified a 61-year old male who was brought to the ED by ambulance on 6/1/17 at 15:40 (3:40 PM) for chief complaints of chest pain.


On 6/1/17 at 21:45 (9:45 PM) ED Physician's Note documented patient was discovered missing.


ED documentation lacked risk assessment for elopement as per facility's Elopement policy.



Patient #2 is a 78 year old male brought to the emergency room by son at approximately:3:15 AM of 6/2/17 for placement into a nursing home. ED resident and attending's notes dated 6/2/17 and signed at approximately 06:40 AM stated patient is alert and oriented x2 (to Person, place or time) with poor judgment, and identified patient as elopement risk. Physician's orders stated patient to be placed on 1:1 observation for safety and admitted to unit.


There was no documentation that the staff implemented the physician's order for 1:1 observation, and there was no documentation that a risk assessment for elopement was conducted as per facility's Elopement policy.


On 6/07/17, during a stimulation testing of the "Infant Abduction Alarm System", it was observed that upon approaching the entrance door with an activated infant abduction tag, there was a delay in the audio and visual alarm response. The Fire Alarm to stairway "D" did not automatically lock as intended. In addition, it was observed that hospital staff members were able to override the Infant Abduction System by using the employee Assess cards.

Based on observation, staff interviews, review of video, document review, and review of procedures it was determined the facility did not:

(a) Ensure that patients with physical, mental, and cognitive impairments were assessed for elopement risk, and managed to prevent elopement in accordance with the facility's Elopement policy.


(b) Ensure that the operating features of the electronic infant protection system was installed and maintained in a manner to provide a safe environment for infants and young children.


Findings include:


(a)

Review of the facility's Elopement Policy, last date reviewed on 3/2017 documented, all patients will be assessed for the risk for elopement at the following times: During ED evaluation, at time of triage; At time of initial assessment on the inpatient unit; Daily until no longer assessed as being at risk for elopement; If the patient requests discharge or in any way makes a statement or action that indicates that the risk of elopement is present.

The facility's policy also defines "Elopement as an event in which a patient who has been identified as cognitively, physically, mentally, emotionally, or chemically impaired, wanders away, walks away, runs away, escapes or otherwise leaves a caregiver environment unsupervised, unnoticed and/or prior to their scheduled discharge, without authorization from the treating staff."

Review of the video recording dated 6/1/17 at 9:16 PM, the camera 22 at Emergency Department (ED) entrance showed Patient #1 (identified by staff) was walking out of the ED followed by a Security Officer (Staff G). The patient was walking out of the ED to the hallway. There camera showed Patient #1 was walking, in a regular pace, and was followed by Staff G, Security Officer. The patient was wearing street clothes (light blue jacket, red t-shirt, grayish pants, and white and black sneakers). The video showed Patient #1 and Staff G were interacting. Staff G was observed pointing to the double door exit of the Central Pavilion toward the street.


During interview with Staff G, Security Officer on 6/8/17 at 1:00 PM, Staff G stated that he asked if he was a patient, and patient stated that he was, and that he wanted to go home.


The Medical Record (MR) review of Patient #1 identified a 61-year old male who was brought to the ED by ambulance on 6/1/17 at 15:40 (3:40 PM) for chief complaints of chest pain.


Triage Note dated 6/1/17 at 15:42 (3:52) documented that the patient was immediately triaged upon arrival with an Emergency Severity Index (ESI) of III (Urgent).
Review of the ED Triage note found no documented evidence that a risk assessment for elopement was conducted as required by the facility's Elopement policy. The facility's policy directs clinical staff to conduct an elopement risk assessment for all patients, and for the elopement risk assessment to be documented in the medical record including during ED evaluation and at the time of Triage.


Physician's History and Physical Information (HPI) dated 6/1/17 at 16:41 (4:41 PM) documented patient was from a nursing home with diagnoses of altered mental status, and dementia. Neurological status was documented patient was alert, and disoriented to time and place.


The last documented patient encounter was dated 6/1/17 at 16:57 (4:57 PM), when the ED nurse documented that the patient was received alert, and oriented to person, place, and time; breathing even and unlabored.


The Physician's Note dated 6/1/17 at 21:45 (9:45 PM) documented as: "went to reevaluate patient, and patient was not on bed. RN stated that the patient 'walked out,' discussed with security, NYPD was called to help locate patient, and nursing home was notified."


There was approximately a 4 hour and 15- minute gap, from the time that the patient was documented last seen by the nurse at 4:57 PM, to the time that the patient was discovered missing from the ED.


Review of ED Nurse's Note dated 6/1/17 at 22:10 (10:15 PM) documented patient was initially received on shift awake, alert, and responsive to all stimuli with no distress noted. Security Officer saw patient leaving and alerted RN. The patient was not seen around hospital premises as per security
There was no documentation that a Code E activation (Security notification for patient elopement) was called when the patient eloped, as per facility's Elopement policy.


During interviews with Staff A, B, and C, (Triage, and Main ED Nurses) on 6/8/17 from 10:59 AM through 11:45 AM, all of these staff stated that they did not perform an elopement risk assessment, and did not review the nursing home record for this patient.


On 6/8/17 at 11:30 AM, Staff F, ED Nurse Manager was interviewed.
Staff F acknowledged that it is the expectation for the nursing staff to conduct an elopement risk assessment, and implement measures based on the facility's Elopement policy.
Staff F confirmed that the Triage, and ED Nurses did not screen patient for Elopement risk, and Code E was not activated when the patient eloped.
Staff F acknowledged that it is the expectation for the nursing staff to review the transfer record, whether the patient is from a nursing home or from any other facility for a comprehensive assessment.


Review of Park Nursing Home Resident Transfer Form dated 6/1/17 at 3:10 PM documentation showed patient had diagnoses including Altered Mental Status unspecified, and Unspecified mental disorder due to known physiological condition.


Security Department Occurrence Report dated 6/1/17 at 9:15 PM documented that the patient was seen walking out by the elevator going towards the employees' entrance. He was dressed in regular clothes. The patient was asked by the security officer to come back to the ED, and patient said no. Security officer went back to the ED and informed the nurse that the patient walked out.
The facility's Elopement policy dated 3/2017 documented: "In the event that a patient is found outside of the unit where they are a patient, staff who observe a patient unescorted will greet the patient and ask to see the patient's ID to confirm the patient's hospital status. If the patient's ID indicates that the patient belongs to the hospital, Code E is called by the staff member who has found the patient."



Patient #2 is a 78 year old male brought to the emergency room by son at approximately 3:15 AM of 6/2/17 for placement into a nursing home. ED resident and attending's notes dated 6/2/17 and signed at approximately 06:40 AM stated patient is alert and oriented to peron and place with poor judgment, and identified patient as elopement risk. Physician's orders stated patient to be placed on 1:1 observation for safety and admitted to unit.
Emergency room nursing report dated 6/2/17 between 7:55 AM and 9:30 AM stated "patient, awake alert but confused at time with history of dementia and prostate cancer. Safety and comfort measures maintained and that patient will be transferred to nursing unit.


There was no documentation that the staff initiated the ED physician's order for 1:1 observation.


Interviewed unit nurse manager Staff F on 6/9/17 at 11:33 AM, Staff F stated "patient had an order for elopement, patient was sent to floor without a 1:1 coverage. Patient was observed going into the elevator less than 45 minutes to an hour upon arrival to the floor; staff RN assigned activated Code E, notified security that patient is on the elevator. Patient was brought back to the unit."


Interview with Staff G, patient's nurse on Tower 11 Unit on 6/13/17 at approximately 08:45 AM. Staff G stated "He was admitted for dementia. Patient came roughly around 10:30 AM to 10:45 AM." Staff stated that she left the patient in his room.

The policy requires to have elopement risk assessment documented in the chart. Elopement management include: patient may be placed on a 1:1 for Elopement; patient off personal clothing and given a specific gown which identifies them at risk for elopement; all attempts will be made to place these patients closest to the nurses' station, and away from exits. When a patient is determined to be missing: Staff will activate Code E immediately by calling *22.


(b)

During the tour of the Mother & Baby and Nursery Unit on the 7th Floor in the morning of 06/07/17 at approximately 11:00 AM, it was revealed that the facility used an electronic tag system "Cuddles" to augment safety and tracking of Pediatric patients on the 7th Floor.

During observation on 6/07/17 it was noted that this Unit entry and exit is only possible by employee card reader. This door was armed with a sensor for the electronic tag system The secondary exit from this unit was through Stairway "D" (located across the corridor from the nursery) and the door was connected to the fire alarm system.


The electronic tag system has an electronic device which is attached to a special bracelet placed around the wrist or ankle of the infant on the unit. When a tagged child is located in close proximity to any one of the two exit doors; and when the bracelet is cut and/or loses skin contact, the alarm will be immediately activated.


Upon simulation testing #1 of the system with a test tag (activated tag) on 06/07/17 at approximately 11:30 AM, it was observed that the door locking function operated upon approach to the entrance door, with a delayed audio and visual alarm at the door.


The fire alarm to the Stairway "D" was deactivated for the purpose of the test and it was noted that the door did not lock, when the tag approached the entrance door.


There was a delay of the audio and visual alarms.


Observations also revealed that the employees were able to exit the unit and override the locking system on the front door using the employee access card.


In addition, audio and visual alarms were not activated when the test tag was brought in close proximity to exit stairway Door "D" during simulation testing #2. Visual signal or message did not appear on the monitor located at the nursing station of the nursery at this time.


Another simulation test #3 was conducted with the door ajar, upon which it was revealed that the system did not activate any alarms upon bringing the test tag in close proximity to any of the doors.


Also, simulation test #4 performed found the second component of the system failed to activate the alarms and lock the doors immediately as required when the band lost skin contact. The alarm message or signal was not observed on the monitor located in the nursery's nursing station. Interview of Staff P, Director of Maternity and Child Services at approximately 12:00 Noon, it was stated that the system was upgraded in the month of May and the unit received new tags. Staff P confirmed that the system was not tested after the upgrade, and therefore the staff was not aware of the loss of the protective features that occurred during the upgrade of the system.


Interview of Staff P, the Director of Maternal and Child Services on 06/07/17 at approximately 11:45 AM revealed that the electronic system "cuddles" was not programmed to activate alarms when an infant is close to the Exit Stairway Door, due to the possibility of activation of false alarms when mothers strolled with their infants through the corridor.


Interview with Staff T, the Vice-President of Facilities on 06/07/17 at approximately 11:30 AM confirmed that that the electronic device system is not linked to the elevator system, so that if an abductor bypasses the lock feature of the double doors at the entrance of the Pediatric Unit, the elevators would not stop operating. This would increase the potential risk for infant/child abduction via elevators.


The surveyors also noted that the audible alarm of infant Abduction System did not have a distinguishable sound and sounded similar to a functioning medical equipment in the unit. In addition, a monitor for the Infant Abduction System was not installed in the 'Mother & Baby" side of the unit. Therefore, the staff working in this area were not able to know the location of activation without communicating with the staff working in the nursery.

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

Findings include:

A. During the tour of the kitchen on 06/05/17 between 11:00 AM and 12:00 noon, the following observations were made:

(1) 06/05/2017 at 11:40 AM, a heavy built up of dust was observed on the 2 fans in the walk in freezer 2. Concurrent interviews held with the Director Of Food Safety, staff X and the Assistant Director of Food Safety, Staff Y on 06/05/17 at approximately 11:40 AM confirmed these findings.

(2) On 06/05/2017 at 11:45 AM, a heavy built up of dust was observed on the 3 light bulb directly on top of the oven in the food preparatory area in the facility. In addition all the external area of the oven cabinets and the electrical conduits pipe at the back of the oven were observed to be covered with dust. Concurrent interviews held with staff X and Staff Y on 06/05/2017 at 11:45 AM confirmed these findings.

(3) On 06/05/2017 at 11:50 AM, a heavy built up of dust was observed on the Ansul fire extinguishing system directly on the deep fryer in the food preparatory area. Concurrent interviews held with staff X and Staff Y on 06/05/2017 at 11:50 AM confirmed these findings.

(4) On 06/05/2017 at 11:35 AM, 3 holes were observed in the dry goods storage area inside the storage room in the food preparatory area. Concurrent interview with staff X on 06/05/2017 at 11:35 AM confirmed these findings.

(5) On 06/05/2017 at 12:05 PM, some portion of the kitchen food preparatory area was damaged and there was a hole observe as a result. The hole was approximately 20 inches in length. A concurrent interview with staff X and Staff Y on 06/05/2017 at 12:05 PM confirmed this finding.

B. During the tour of inpatient psychiatry (CP 4) and Geriatric psychiatry (Tower 4) on 06/08/17 at approximately 2:00 PM and 06/12/17 at approximately 2:30 PM, the following observations were made:

(1) The door handles on doors of all patient bedrooms were of the type that had the potential of being used to create a ligature to hang on the inside part of the rooms. This was observed on both the Adult psychiatry and the Geriatric psychiatry unit.

(2) The anti-skid was observed to be worn out on the floor tiles and in the shower tub of shower room in the Geriatric Psychiatric unit.

(3) The shower head in the shower room of the Geriatric psychiatric unit was observed to be loose and hanging off the wall.

(4) The patient night stands were observed to be light-weight and were not bolted to the floor. This was observed on both Adult and Geriatric Psychiatric units. Therefore these night stands were potential of being used as weapons to cause harm.

(5) The perimeter of the floors in patient bedrooms were observed to be heavily soiled and grimy. This was observed in patient rooms on both units.

(6) The floor tiles of the patient bathroom in Room 416 on the Adult Psychiatric unit was observed to be discolored and dirty around the toilet.

(7) Upon lifting the mattress off the captain bed in Room # 413 (Geriatric Unit), the surveyor observed a pile of dust and dirt underneath the mattress. Floor tile was also observed to be broken by the door of the room.

(8) All the vents in the Adult psychiatric Unit was covered with dust and lint.

(9) A delaminated covebase of approximately 12 inches long was observed in room 416 of the Geriatric Psychiatric unit. Also the protrude wall angle inside the room was also observed to be damaged ( e.g. broken and chipped off).

(10) The wall by the radiator of Dining Room A in the Geriatric Psychiatric unit was observed to be damaged and broken.

(11) The wall by the door of the dining room B in the Geriatric psychiatric unit was also observed to be chipped off. The floor of this room appeared to be dirty and discolored.

These observations were made in the presence of Staff V, the Director Of Psychiatry and this staff member upon interview on 06/12/17 at 3:00 PM, agreed that the two psychiatric units needed an environmental upgrade.

C. Tour of Emergency Psychiatric unit on 06/06/17 at approximately 2:00 PM revealed the presence of several looping hazards in the one and only patient bathroom.

(1) A gap of at least 6 inches was observed between the wall and the handwashing sink, This arrangement was determined to be potential looping hazard.

(2) The bathroom had a regular toilet with exposed plumbing . The exposed plumbing posed a risk of creating ligatures and being a potential looping hazard.

(3) The shower head and the shower faucet were of the type that can be used to create ligature and were potential looping hazards.

(4) The outside of the bathroom door had a round type door knob, that could potentially be used to create ligature and hang on the inside of the door.

(5) The bathroom door had regular hinges, which were potential of being used to create ligatures.

D. During the tour of Operating Room Suite and the PACU on 06/08/17 between the hours of 10:30 AM and 11:30 AM, the surveyors noted the following:

(1) During the inspection of OR#1, the surveyor noted that there was half an inch of gap between the floor and the wall all around the room. Therefore the floor was not seamless and therefore allowed the collection of dust in the crevices. In addition these crevices also potential of causing bacterial growth in the OR.

Also the floor by the door in OR#1 was observed to be damaged and broken. The broken area of the floor was of 3 inches by 3 inches in dimension.
These observations were made in the presence of an anesthesiologist , Staff Ss and Staff Q, the Director of Peri-Operative Services.

(2) On 06/08/2017 at 11:05 AM, a delaminated covebase, approximately 20 inches long was observed by bed 6 and 7 inside the PACU area.

(3) On 06/08/2017 at 11:08 AM, a delaminated covebase , approximately 4 inches by 4 inches was observed inside the Anesthesia room.

These observations were made in the presence of the Director of Engineering, Staff S , who confirmed the findings.

E. During the tour of the facility, the surveyors noted areas of the hospital that were in disrepair. The other identified areas of disrepair are the following, but not limited to:.

On 06/06/2017 at approximately 11:25 AM at 2 holes were observed on the wall of the patient room T 729. A concurrent interview with the Director Of Engineering, Staff S on 06/06/2017 at 11:30 AM confirmed these findings.

On 06/07/2017 at 11:24 AM, a large crack on the wall, approximately 10 inches by 18 inches was observed in the vicinity of the cross corridor door T 342. A concurrent interview with staff S on 06/07/2017 at 11:35 AM confirmed this finding.

On 06/08/2017 at 11:28 AM, a missing ceiling tiles , approximately 8 inches by 10 inches was observed missing inside room CP 223. A concurrent interview with staff S on 06/08/2017 at 11:30 AM confirmed this finding.

On 06/08/2017 at 11:30AM, it was observed that the nurse call indicator light outside of room CP 223 was not working. A concurrent interview with staff S on 06/08/2017 at 11:35AM confirmed this finding.

On 06/08/2017 at 11:42 AM, it was observed that 4 ceiling tiles were stained in room CP 228. These stains were approximately 4 inches by 4 inches, 5 inches by 6 inches, 6 inches by 6 inches and 4 inches by 6 inches. A concurrent interview with staff S on 06/08/2017 at 11:45 AM confirmed these findings.

On 06/08/2017 at 12:15 PM, a broken/ damaged wall, approximately 10 inches by 12 inches was observed by the cubicle 1 inside the Ambulatory Surgery Center CP 38. A concurrent interview with staff S on 06/08/2017 at 12:17 PM confirmed this finding.

On 06/12/2017 at 2:16 PM, some portion of the patient bathroom TB056 was observed to be damaged (have holes approximately 40 inches long) at the bottom floor corner near the toilet bowl. An interview with staff S confirmed this finding.

On 06/12/2017 at 2:51 PM, multiple broken/ damaged wall portion were observed inside the recreation room T416. Also, a delaminated cove base was observed inside this room. A concurrent interview with staff S on 06/12/2017 at 2:55 PM confirmed this findings.

Based on observations and staff interview, the facility failed to comply with all recommendations of the Life Safety
Code, As recommended by NFPA 101 2012 Edition.

Findings include:

The facility failed to ensure that stairways and smoke proof enclosures used as exits are maintained in accordance with section 7.2 of NFPA 101-2012 Life Safety Code. Refer to tag K 225.

The facility failed to ensure that an emergency lighting of at least 1.5 hours duration is provided automatically in accordance with 7.9. Refer to tag K 291.

The facility failed to ensure that hazardous areas are protected by a fire barrier having at least 1 hour fire resistance rating (with ¾ hour fire rated doors). Refer to tag K 321.

The facility failed to ensure that manual fire alarm pull stations are provided in the path of egress near each required exit and is easily accessible. Refer to tag K 342.

The facility failed to ensure that fire alarm system is tested and maintained in accordance with approved program complying with the requirement of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and signaling Code. Refer to tag K 345.

The facility did not ensure that automatic sprinkler system are inspected, tested and maintained in accordance with NFPA 25, Standard for the Inspection, Testing and Maintaining of Water-based Fire Protection Systems Refer to tag K 353.

It was observed that the facility failed to ensure that smoke barriers are constructed to a ½ hour fire resistance rating per 8.5 Refer to tag K 372.

It was observed that the facility failed to ensure that electrical wiring and equipment complies with NFPA 70, National Electric Code. Refer to tag K 511.

It was observed that the facility failed to ensure that portable space heating devices are prohibited in all health care occupancies. Refer to tag K781.

The facility failed to protect the Operating rooms with ground fault circuit interrupters(GFCI). Refer to tag K 913.

The facility failed to ensure that there was a documented evidence of any testing and maintenance performed of the Line Isolation Monitor (LIM) installed in the operating rooms. Refer to tag K 914.

The facility's Type 1 Essential Electrical System Distribution was not separated into Critical Branch, Life Safety Branch and Equipment branches in accordance with NFPA 99. This was noted in the distribution panels located on the 2nd and 3rd floor of the Tower building. Refer to tag K 915.

The facility failed to provide a remote annunciator that is storage battery powered to operate outside of the generating room, in a location that readily observed by operating personnel. Refer to tag K 916.

The facility failed to ensure that battery powered back-up lights were provided in the facility's Operating rooms, fire pump room, and the generator room. Refer to tag K 918.

The facility failed to ensure that Power strips are used with general precautions and as stated in the facility's policy and procedure. Refer to tag K 920.

The facility failed to ensure that electrical safety tests were performed on all patient-care related electrical equipment used in the facility. Refer to tag K 921.

Based on observations, record review and staff interview, the hospital failed to ensure that (1) the daily Biological indicator (BI) test results are negative prior to the release of the sterilized load to the operating rooms; (2) all environmental surfaces are thoroughly cleaned and disinfected during the terminal cleaning of patient rooms.

These may have placed other patients at risk for transmission of infection.


Findings include:


(1) The facility did not ensure the completion of required procedures for biological indicator testing to ensure equipment used for patient care is safely and properly sterilized.

During the tour of the Operating Room Suite and the Central Sterile Department on 06/08/17 at approximately 10:30 AM and 2:00 PM respectively, the surveyors noted that the facility had 2 flash Steam Sterilizers in the Sub-sterile area of the Operating Room Suite and 1(one) Steam Sterilizer along with (2) two 100S Sterrads in the Central Sterile Department.

Upon request to review the Biological Indicator (BI) Test Indicator test results, it was revealed that the staff of the Central Sterile Department did not have access and were not aware of the test results. Upon interview of the Director of the Peri-Operative Department on 06/08/17 at approximately 3:00 PM, it was revealed that the Central Sterile Department Staff delivers the test specimen tube and control specimen tube to the laboratory, which is then transported to Northwell-LIJ laboratory (contracted service). It was also revealed that the test results were not communicated to the Central Sterile department staff directly. Instead, the infection control department of the hospital is notified of the test results in batches, which is then forwarded to the Director of Peri-Operative Services.

Review of the print out sheet of BI test results for December 2016 to May 2017 on 06/09/17 at approximately 10:00 AM , it was noted that the time of incubation and the load control number were not noted in the test results.
Review of the test results also revealed that there was no indication of the date that the test result was reported to the hospital by the contracted laboratory.

Interview of the Director of Peri-Operative Services, Staff Q on 06/08/17 at approximately 2:30 PM, confirmed that the Central Sterile Staff performed the release of the Sterilized load of instruments to the operating rooms, without becoming aware of the BI test results.

Review of the manufacturer's "Instructions For Use" for the Sterrad and the Steam Sterilizer Steris on 06/11/17 at approximately 9:30 AM, it was noted that the recommendations for "Readout Of Results" stated"...Record results after 24 hours prior to 72 hours(3 days) of incubation." Review of the test result print out sheet revealed that the results were not verified in a timely manner in accordance with the manufacturer's recommendations.

Examples include, but not limited to::

The BI test result print out for BI specimen test tube and the Control tube collected from Steam Sterilizer, CS-2 and received at the LIJ (Contracted) Laboratory on 01/10/17 at 1613 hours (4:13 PM), indicated "veri: 01/14 -1336 INFCE". During the interview of the Director of Peri-Operative Service on 06/09/17 at 10:00 AM, it was clarified that the "Ver" meant the date of verification and recording of the test result and "1336" (1:36 PM) was the time of recording.

The BI test result print out for BI specimen test tube and the Control tube collected from Steam Sterilizer, CS-2 on 01/12/17 at 1700 (5:00 PM) and received at the LIJ (Contracted) Laboratory on 01/12/17 at 1745 hours (5:45 PM), indicated "veri: 01/17 -1319 INFCE". During the interview of the Director of Peri-Operative Service on 06/09/17 at 10:00 AM, it was clarified that the "Ver" meant the date of verification and recording of the test result and "1319" (1:19 PM) was the time of recording.

Therefore, it was determined that the BI test result was not verified and recorded prior to 72 hours, as recommended by the manufacturer.
The facility did not have documented evidence of any evaluation of the service provided by the contracted laboratory.

In addition, the Central Sterile Department did not have policies and procedures for recall of instruments from the Operating Room. Upon observation on 06/08/17 at approximately 2:15 PM, it was revealed that all the sterilized pack of instruments were stamped with the load number. However, the facility did not have a mechanism in place to track all instruments on each and every load.

(2) During tour of the ICU, the surveyors observed the terminal cleaning procedures in Room T 328 (ICU room with a commode) on 06/06/17 at approximately 3:15 PM, it was noted that the housekeeper, Staff O did not follow a pattern of clean to dirty while wiping down the environmental surfaces in the room.

The employee was observed to randomly clean the various environmental surfaces in the room.
For example:

Staff O was observed wiping the outer surface of the toilet and the seat with a disinfectant wipe and then this staff member was further observed to wipe the night stand with a new wipe after changing gloves and performing hand hygiene. However, this employee did not change the gown after cleaning the toilet and prior to cleaning the night stand.

Staff O also did not change gloves and perform hand Hygiene prior to reaching into the clean container containing disinfectant wipes.
For example:
After wiping down the back walls of the room, the employee was observed to reach into the clean container of disinfectant wipes to wipe the window sill without changing gloves and performing hand hygiene. Again, she was observed to reach into the clean container of wipes with her dirty gloves to obtain new wipes to wipe the patient monitor. There were other several instances where this practice was observed.

This staff member also did not conduct high-dusting prior to wiping the other areas of the room. It was observed that this employee did not have the tools to perform the high-dusting.

These observations were made in the presence of the Chief Medical Officer, Staff Qq and the Infection Control Officer, Staff Rr.

The employee was instructed to the correct method of cleaning and disinfection by the Director of Housekeeping.