HospitalInspections.org

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Based on document review and interview, in one (1) of seven (7) lease agreements and contracts reviewed, the Governing Body did not ensure that the terms of a rental lease agreement with a private building management was monitored to ensure the safety of their patients.

Findings include:

The lease agreement between facility "Montefiore Medical Center and the Landlord, "One Fordham Plaza LLC", dated May 2013 states in page 30 states that the "Common Areas" which include stairwells shall be maintained and repaired by the Landlord. In EXHIBIT E, page 3 states that landlord would "check all stairwells and escalators nightly throughout the entire demised area and keep in clean condition."

Review of medical record for Patient #1 revealed the patient had an outpatient clinic visit for nutrition evaluation on 8/16/2023. The outpatient clinic appointment information noted Patient #1 start of visit was 12:41 PM and her checked out time was at 2:07 PM.

Review of video footage dated 08/16/2023 and timed 1:59 PM showed a female individual (identified as Patient #1) wearing dark colored glasses and ambulating with a rollator from the Registration/Reception area of POD A/B/C to the end of the hallway towards Stairwell G.

Building Management log revealed that on 8/21/2023 at approximately 9:30 AM, Patient #1 was found deceased between the 4th and 5th floor landing of Stairwell G.

There was no indication that Stairwell G was inspected between 08/16/2023 when the patient was last seen on the video recording heading towards Stairwell G to when she was found deceased on 08/21/2023 at 9:30 AM.

On 10/3/23 at 2:13 PM during interview with the facility leadership staff, Staff A, Administrative Director; Staff D, VP, Montefiore Medical Group; Staff E, Senior Director of Operations; Staff F, Medical Director/Regional Medical Director; Staff G, Chief Clinical Services; Staff H, AVP Environmental Health and Safety; Staff J, Director of Security; Staff K, Senior Director of Operations they acknowledged the incident with Patient #1 and reported that Stairwell G was the responsibility of the landlord and not theirs as indicated in the lease agreement.

The facility leadership staff members were unable to provide documented evidence of the landlord's compliance to the terms of the lease which indicated that the landlord would check all stairwells and escalators nightly throughout the entire demised area ...
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Based on observations and staff interview, the facility did not provide drinking water in the waiting area of the facility in accordance with Facility Guidelines Institute (FGI) 2010 edition,3.1-6.1.6.

Findings include:

During the tour of the facility on 10/2/2023 at 11:30 AM, it was observed that there was no provision for drinking water in the waiting area of the facility.

Review of Facility Guidelines Institute (FGI) 2010 edition,3.1-6.1.6 notes that the Provisions for Drinking Water shall be conveniently accessible in the public areas in outpatient facilities.

This observation was identified in the presence of Staff B, (Environmental Health & Safety) and upon interview, Staff B acknowledge findings.