HospitalInspections.org

20003


Based on review of grievance records, policy and procedures, and staff interviews, it was determined the hospital's grievance records lacked documentation of: the complete results of the hospital's grievance investigation, a description of the steps taken to resolve each separate complaint issue, the date of investigation completion, and information for the option of lodging a grievance with the State agency regardless of use of the hospital's grievance process. This was noted in (9) of (15) applicable grievance medical records. [Medical Record (MR) #1, #2, #3, #5, #7, #8, #9, #10, and #21]

Findings include:

Review of the Grievance file corresponding to MR #1 documented that the patient wrote a grievance letter on October 20, 2013, which alleged improper attitude and behavior of phlebotomy staff, complications from intravenous insertion resulting in infiltration, failure to nursing to provide timely care, and environmental concerns, including the failure to dispose of infectious materials in the red bag.

A review of the patient's file lacked evidence that the hospital investigated and addressed the allegations mentioned in the letter.

The hospital wrote two letter of response to the patient. The first letter was an acknowledgement dated 11/12/13, the 2nd letter was dated 12/4/13.


Review of the Grievance file corresponding to MR #3 documented revealed that the patient wrote a letter of grievance to the hospital dated 12/16/13. The patient stated that she had two surgeries at the hospital, March and June 2013. The grievance was primarily related to the 2nd hospitalization.

The patient complained of an IV becoming infiltrated post operatively, failure of nursing staff to assist with toileting and hygiene, failure of staff to respond to call bells, non-working call bells, staff insensitivity, and lack of basic supplies, e.g. blankets, when requested.

The hospital's record provided a letter of acknowledgement the patient dated "January 3rd, 2013."

On 1/16/14, the hospital wrote a second letter to the patient, extending their "sincerest apologies." There is no documented evidence that the hospital investigated the above mentioned allegations and what process was implemented to prevent any re-occurrences.


Review of the Grievance file corresponding to MR #5 documented that the patient wrote an email to the hospital on 11/11/13. He stated that he developed a "life threatening" infection after surgery due to "errors in clinical care and a break in sterile technique."

A review of the patient's file revealed no documented evidence that the hospital conducted an investigation to determine the whether or not the allegation made by the patient was credible.

Review of the Grievance file corresponding to MR #2 documented that the patient wrote a grievance letter to the hospital dated 7/24/13. The patient complained about the quality and temperature of the food served, and about side effects of pain killers and resultant dizziness.

The hospital wrote an acknowledgement letter to the patient on 8/1/13 and a response on 8/15/13.

There is no evidence that the hospital investigated the allegations made by the patient. There is no evidence of any review or interview with staff regarding allegations made by the patient.

Review of the Grievance file corresponding to MR #21 documented that the patient wrote a grievance letter to the hospital on 11/27/13. He complained he was in "great discomfort" during his procedure at the ambulatory surgical center and reported staff's failure to render assistance during his encounter .

The patient's file had no evidence that these allegations were investigated by the hospital. Additionally, there was no evidence whether or not the allegations were substantiated or not.

Upon interview on 3/11/13 at 3:15 PM, Employee #2 stated that all information related the grievances was in the log that was presented to the New York State Department of Health Surveyor. The log had no documented evidence of what steps the hospital took to investigate the above mentioned allegations.

Additional findings were identified for the lack of complete report of investigation outcomes in grievance notification letters as follows:

Review of the Grievance file corresponding to MR#7 documented that the patient wrote in her grievance letter dated 1/29/14 complaints about nursing care and conduct, including delay in cleaning a blood spill. The patient complained of two episodes of delay in the Radiology department related to excessive waiting time.

The grievance file included a report of interview with the nurse but lacked follow up actions taken and lacked investigation of the radiology department issues to prevent recurrence.

A final notification letter, dated 2/19/14, apologized for the nurse's reported conduct. The letter noted no comment could be made on Human Resource issues but each issue was reportedly discussed with the nurse. The response also noted the complaints were also shared with the Radiology manager. This response letter lacked specific findings to determine if the nursing issues were substantiated. The letter did not indicate the results of investigation of radiology complaint, lacked a date of completion, and did not document the option to file a grievance with the Regulatory authorities.

Review of the Grievance file corresponding to MR#8 documented that the mother of a patient filed a written grievance letter that alleged several care issues, which included delay in EEG (Electroencephalography - the recording of the brain's spontaneous electrical activity over a short period of time) that resulted in need for an extra day in the hospital. The parent also complained that an incorrect dose of medication was given, the housekeeper failed to respect privacy of the patient who was using a bedpan, and inability to locate the patient in a computer resulting in denial of a visitor pass.

The response letter dated 8/15/13 reviewed the medication orders and described the process for housekeeping in which the employee was advised about the issue and instructed to knock on doors. The hospital explained that privacy status was activated without the patient's request, which affected the ability for visitation. However, the response notice did not address the allegation of the EEG delay, lacked a date of completion, and did not document the option to file a grievance with the regulatory authorities.

Review of the Grievance file corresponding to MR#9 documented that the patient complained on 12/16/13 of requesting to speak with a cardiologist to discuss his condition following a post operative event involving his alleged loss of consciousness. The complaint was that his request for follow up cardiology consultation was not met. He also complained that the physician he spoke with held an incorrect chart belonging to another patient with the same surname. He claimed an orthopedic MD did not respond appropriately to patient's concerns, in which it was allegedly stated to the patient that he worked 36 hours and was tired.

The hospital's notification letter dated 1/15/14 contained an apology in that the patient's physician took accountability for failure in communication. The response did not include interview with other staff who was alleged to have responded improperly and did not investigate or report on the outcome of staff's reference to an incorrect medical record.


Review of the Grievance file corresponding to MR#10 documented that the patient complained in writing on 9/18/13 that she sustained post operative complications following surgery including staph infection, urinary retention, and facial scarring. Additional complaints involved premature discharge, delay in care, and an unclean environment.

The response provided to the complainant dated 10/24/13 indicated the complaint is being reviewed by the insurance carrier and that a forthcoming letter from medical liability insurance would be provided. The note indicated the Department of Patient Experience would be removed from this communication and directed the complainant to correspond to the insurance carrier. The written response provided to the patient lacked explanation of outcome of the hospital's investigation.

The Hospital's Policy and Procedure #00.12, titled: "Management of Complaints and Grievances" was reviewed on 3/12/14. This policy states that "Every effort will be made to respond to all grievances within 7 days upon receipt." Responses shall be made in seven days which include the facility contact person, steps taken to investigate the complaint, results of the complaint process, and the date of completion. If this time frame cannot be met, the policy notes that the facility shall notify the patient or their representative in writing or by phone that the grievance is being reviewed and that a response shall follow in 30 business days of receipt of the original grievance. If needed, another notification is made at 30 days advising of the need for 60 business days for a response.

The policy further notes that in instances of dissatisfaction with the initial response of the grievance investigation by the complainant, information concerning the right to call a regulatory agency will be documented in a letter on response following a re-review of a grievance.

A review of the hospital grievance records revealed that the hospital failed to completely investigate or address patients' grievances. Grievance records and response letters lacked information in order to determine conclusions with respect to whether each issue was substantiated or not. Letters of response consisted mainly of apologies in lieu of documented results of the hospital's investigation process.

20003

Based on document review and interview, there is no documented evidence that the hospital effectively analyzed grievance data collected in order to identify systematic problems and develop remedial actions for improvement. This was evident in the review of the complaints and QAPI (Quality Assurance Performance Improvement).


Findings include:

Review of the 2013 Department of Patient Experience report for Complaints and Compliments on 3/11/13 found 813 complaint cases were measured in 2013 compared to 681 cases in 2012, and this represented a 27% increase in volume. The report notes the number of letter volume was "flat" in 2013 when compared to 2012.

The number of complaint issues were also reported based on the number of issues assigned to general categories, such as communication, responsiveness, and care. However, there was no analysis undertaken to assess the possible reasons for the observed increase in number of patient complaint cases.

The facility's Grievance QAPI does not analyze the data collected by the facility, which calculates on a monthly basis the average number of days each month for grievances to be closed from the date of receipt..

Review of logs for patient grievances on 3/13/14 found that the facility tracks the date that written grievances were received, dates that letters of acknowledgement were sent, due dates, and dates the grievances were completed. An average number is generated on monthly spreadsheets that measured the number of business days between grievance receipt and closure. However the 2013 Grievance QAPI report did not discuss the reasons for average time frames for grievance turnaround times greater than seven days.

During follow up interview with Staff #2 on 3/14/14 at approximately noon, it was reported that while the average number of days to resolution of grievances are written on monthly spreadsheets, plans are in progress to incorporate this discussion into Quality review meetings about the grievance resolution turnaround time frames.

The facility did not effectively review the management of grievances, particularly to evaluate the causes for noted increase in complaints and to determine the reasons for extended times of the average resolution times for grievances completed in greater than seven days.

Based on observation, staff interview and review of medical records and documents, it was determined that the facility failed to ensure provision of nursing services by failing a) to supervise the assignment of nursing care to other nursing personnel and b) to evaluate the patient's response to interventions. This was evident in MR #13 and #15.


Findings include:

a) On 3/11/14 at 3:30 PM at the Cardiac Care Unit, Staff #12 was observed performing finger stick procedure for MR #13, Room 505. Copy of the physician order for finger stick was requested and provided by Staff #2 at approximately 4:00 PM.

Staff # 2 stated the order for finger stick for MR #13 was discontinued on 3/10/14 at 4:30 PM. The morning Nursing Attendant (NA) was not available to give this report to Staff #12 and the finger stick should not have been performed.

A Registered Nurse failed to supervise the assignment of nursing care to other nursing personnel and to ensure that the physician orders are executed.

b) On 3/12/14 at 12:30 PM at 6UR, review of the medical record #15 revealed that the patient was transferred to the unit on 3/10/14 at 16:10, approximately 5 hours Postpartum.

Review of the postpartum pain management revealed the patient was assessed for pain follows; 3/11/14 at 01:00 (1:00 am), 09:17 (9:19 am) and at 17:12 (5:12 PM); 3/12/14 at 06:10 (6:10 am) and 08:39 (8:39 am). The RN's document the patient's pain scale, patient's request for pain medication and the administration of PO (oral) analgesia at the time of each assessment.

However, there is no documentation that the patient was reassessed after each administration of the pain medication. This finding was acknowledged by Staff #14 who stated, the patient was not reassessed after the pain medications were given.

The facility's policy: Pain Management: Assessment and Reassessment states The RN and or appropriate Health Care Provider will reassess the patient's response to interventions at appropriate intervals. For PO analgesia the interval is "one half to one hour." The policy also states ongoing assessment should occur at minimum of every 4 hours when a patient's initial assessment or ongoing assessments are indicative of pain.

This patient was not provided ongoing pain assessment and reassessment to determine response to the intervention for pain management.

Based on observation, staff interview, and review of policy and records, it was determined the facility staff failed to provide continuous monitoring of inpatients as ordered in order to maintain patient safety. This was observed in one of one applicable patients who was assigned to constant observation in the inpatient psychiatric unit. (MR #20)

Findings include:

During tour of inpatient psychiatric unit 8 (Behavioral Health) on 3/11/14 at approximately 10:25 AM, it was observed that a female patient (referenced in MR#20) who was ordered to have constant observation was not under direct visualization within arm's length by the male nurse aide (Staff #23) assigned to observe her.

Upon entry to the room, a male nurse aide reported the patient was in the bathroom. When asked if he could see the patient, he replied he can see her moving through small horizontal openings in the bathroom door. The door was closed.

Staff #22 was interviewed at approximately 10:30 AM, as she entered the room.
She stated the procedure is for the employee to monitor always at arm's length and this includes leaving the bathroom door ajar when the patient is in the toilet and that the aide should always be able to visualize the patient's hands to ensure no self harm occurs. The manager spoke with the aide to communicate this directive in the presence of the surveyor.

Review of MR #20 on 3/11/14 at approximately noon determined this patient had been admitted for severe depression with psychosis, fall history, and confusion. Constant observation was ordered during her hospitalization for safety as she was deemed at risk for harm to self and others. She had a fall while hospitalized and according to interview with staff #22 on 3/11/14 at 11 am, the patient had reported periods of aggressive and violent behavior.

Review of policy titled: "Constant Observation/Enhanced Supervision" on 3/13/14 found that the patient must be maintained in direct continuous visual observation and within one arm's length at all times, unless increased to a distance of 15 feet for agitated patients. The staff observed on 3/11/14 did not follow this policy.

Based on observations and staff interview, the Food Service Director did not ensure that the daily operation of the Food Service Department is maintained in a sanitary manner.

Findings include:

A tour of the kitchen at Lenox Hill Hospital was conducted on 3/10/14 at approximately 10:00 AM.
The surveyor was accompanied by Staff # 11 and Staff # 4.. The surveyor was informed by the Food Service Director that the hospital has contracted out the Food and Nutrition Department to the contractor named Sodexho.
The following issues were observed and/or discussed with staff, included, but are not limited to, the following:

A. Unsanitary Environment / Food safety
1- It was observed that three piles of newspaper titled "USA Today" were placed at the bottom shelf of a food rack.
2- Three hand washing sinks in the kitchen had no wastebasket.
3- There were two flies flying where employee's lockers are situated. The employee's lockers are located in a corner, in the kitchen.
4- There are two "Vector" receptacles in the kitchen. These receptacles attract flies and then zaps and kill the flies. The flies fall to the bottom of the receptacle. The Vector receptacle closest to the employee lockers was disconnected from the wall. Staff # 11 , informed the surveyor that there is an electrical problem with the outlet on the wall so the Vector receptacle was not working.
The second "Vector" receptacle had one florescent light not working. There is two florescent light in each Vector receptacle one of the lights was not lit.
5- All plastic garbage receptacles in the kitchen were uncovered.
6- The exterior of the kosher refrigerator was dirty. The top of the refrigerator felt grimy.
Food items were thrown into the refrigerator. The refrigerator was disorganized.
7- The microwave next to the kosher refrigerator had food stuck to the top and sides inside the microwave.
8- The oven next to the microwave, titled "US Range" had grease built-up throughout the exterior of the oven as well as the bottom inside the oven.
9- Warmer oven had grease build-up throughout the oven and was grimy on top of the warmer.
10- There was a food package containing slices of cooked bacon inside the oven.
11- There was a long metal rack below the cook table that had accumulated water. The bottom of the rack felt slimy.
12- The tiles underneath the rack had accumulated dirt on them.
13- The hand sink next to the dish machine had no paper towels.
14- The produce sink in the kitchen had water accumulated at the bottom of the sink. The bottom of the sink was slimy.
15- Floor model Hobart was dusty and had dried food stuck to the part where the whisk connects to the mixer.
16- Walls tiles throughout the kitchen were dirty.
17- Ceiling tiles throughout the kitchen were yellow.
18- The electrical circuit box on the wall directly across the oven had accumulated dust on top of it.
19- The painted ceiling above the steam kettles had rust stains, was cracked and chipping.
20- The ceiling across the steam kettles had one large yellow stain and two other smaller yellow stains.
21- Five jars of soup base and two boxes of plastic gloves were stored in the ledge of the hood above the steam kettles.
22- The edge of the hoods where the steam kettles are located had plastic tape peeling from them.
23- A dirty cart with kosher salt spills contained a multiple of plastic containers of spices (black pepper, onion powder, apple cider vinegar, Worcestershire sauce etc.) These plastic containers with spices had been opened but not labeled with date it was opened or expiration date.
24- Buffalo chopper was dusty and uncovered.
25- Nine wet honeydews were located at the bottom of a sink. No one was present.
26- Cook's drawer was dirty and contained hand cream, rubber gloves and cooking utensils.
27- Two portable weight scales were observed to be dusty and uncovered.
28- Meat freezer plastic curtains had half of them missing and were stored inside the freezer.
29- Condenser in the meat freezer was packed with ice. The floor and wall had ice build-up on them.
30- Chicken fritters and tilapia fish was wrapped in saran wrap without a label.
31- One hand wash sink in the kitchen was blocked with a catering cart in front of it.
32- Open plastic container of Humus, half of an angel cake, bag of meatballs, Californian vegetable blend, three large turkey breast , wrapped tortillas and chicken breast were all found in the freezer wrapped in saran wrap with no label when they were packed or expired.
33- Three pellet plates were observed to be stacked one on top while heating them at the same time during an active tray line.
34- VIP freezer had a multitude of wrapped food items that had expired.
35- Pot washing area had a rack with soup kettles stacked one on top of the other. There were sheet pans wet and piles one on top of the other.
36- Left side of the cafeteria refrigerator had wrapped cheese, wrapped in saran wrap bins with cut cheese, bread; hard boiled eggs, corn and garbanzo were not labeled. The other side of the refrigerator had a rack with a pile of uncovered cheese pizzas leaning toward the other side of the refrigerator. The pile of pizzas was uncovered and not dated.
37- A dusty portable weight scale was observed to be sitting on the window sill in the cafeteria with a roll of tape on top of it.
38- Window sill and curtains on the window sill had accumulated dust on them.
39- Hand washing sink in the cafeteria was blocked with a pan of sodas and the drain was dirty with food debris yet it contain food utensils on it.
40- The floor behind the counter was dirty and had food debris on them.
41- All the cabinets underneath the hot food counters in the cafeteria were dusty and dirty.

Review of hospital's "Environmental Tour" documents dated 1/22/14 and 1/29/14 confirms surveyor's findings.

Based on medical record review, staff interview, and other documents, it was determined that the facility's dietician failed to ensure the implementation of the policy to promote the health and safety of patients to ensure positive outcomes. (MR#16)

Findings include:


Review of medical record # 16 on 3/14/14 at approximately 11:00 AM noted an adult male was admitted to the hospital on 2/17/14 with an admitting diagnosis of cholangiocarcinoma [a form of cancer that is composed of mutated epithelial cells (or cells showing characteristics of epithelial differentiation) that originate in the bile ducts which drain bile from the liver into the small intestine]. The patient was admitted with skin intact. An initial nutrition assessment was performed on 2/18/14 which noted the patient diet was NPO (nothing by mouth) and was at high risk for malnutrition due to a blood serum albumin level of 2.9 grams (levels below 3.5 grams per deciliter are generally considered low), weight below ideal body weight, fasting blood sugar of 139 [the normal blood glucose level (tested while fasting) for non-diabetics should be between 70 and 100 milligrams per deciliter (mg/dL)], and GI (gastrointestinal) issue related to stools.

On 3/1/14, nursing skin assessment noted a healed sacrum pressure ulcer. On 3/2/14, nursing skin assessment noted patient has a stage III pressure ulcer at the sacrum. On 3/6/14 at 10:45 Skin/Wound Care documented in the progress note that patient had a stage IV pressure ulcer at the Sacrococcygeal (a tough fibrous membrane about 10mm long which extends from the inferior tip of the sacrum to the body of the coccyx in humans) measuring 0.5 x 0.5 with 1 cm circumferential whitish hyperkeratinized tissue. On 3/10/14 the patient sacrum pressure ulcer had progress to stage IV at the sacrum.

Nutrition Services Follow-up was performed on 2/26/14 at 12:10 (eight days after the initial assessment) which noted the patient was downgraded to moderate nutritional risk. Patient was again nutritionally follow-up on 3/4/14 at 2:54 (six days after previous note) which noted that patient was at high nutritional risk he had a stage III sacrum pressure ulcer. His diet was 1800 calories DM and his food intake was 50-75%. There was no documentation of protein needs or that protein needs were being met.

The next nutrition follow-up was 3/10/14 at 1:57 (six days after previous note) noted the patient pressure ulcer status had progressed to stage IV at the sacrum. Dietitian noted that the patient diet was 1800 calories DM; food intake had improved to 75-100%. The dietitian noted in the follow-up that the patient's nutritional needs are 2100-2450 calories per day, 84-105 gm Protein/day and 2100-2450 ml/day. Recommendation/ Plan does not contain a request for a diet change instead it states to continue current diet even though the needs are 2100 calories and the prescribed diet is 1800 calories. There was no mention if the diet meets patient's protein needs or how the patient's hydration would be met. Patient's nutrition reassessment timeframes did not promote a positive outcome.

Review of hospital policy titled "Nutritional Screening and Assessment" on 3/14/14 noted that patient are nutritionally screened by nursing within 24 hour of admission. Patients identified at high risk via screen are nutritionally assessed 48 hour of receipt of the referral. A high risk patient will be follow-up every 5 days and moderate risk patient would be followed up every 10 days. Patient at low risk will be followed up in 14 days.

Hospital average length of stay is 4.8 days as per staff member #4 . The above policy timeframe does not promote the health and safety of patients. Patients would be discharged before they can receive a nutrition follow-up prior to discharge.

Based on staff interview, review of master menu and nutrient analysis of menus, it was determined that the Food and Nutrition Department failed to ensure physician prescribed diet met the therapeutic nutritional needs of patients. The finding was noted in 4 of 40 diets reviewed.

Findings include:

An interview was conducted with staff # 5 on 3/10/14 at 12:40 PM, a review of menus and nutrient analysis was conducted:


It was noted during the survey that the nutrient analysis was missing from 4 diets in the hospital diet formulary.

The hospital has a Pediatric diet which encompasses foods and food portions for the adolescent population only. There were no menus or nutrient analysis for the Infant, Toddler or school-age child population.
.

Based on staff interview, review of hospital menus, and the physician diet formulary, it was determined that the prescribed diet orders were not being accurately transcribed on patients menus. Findings were noted in 20 of 40 physician prescribed diets and corresponding menus reviewed. Samples of the 20 diets are listed below:

Findings include:

An interview was conducted with staff # 5 on 3/10/14 at approximately 3:00 PM concerning diets printed on the patient menus. It was observed that the Physician's diet orders were abbreviated on the menus and did not match the physician's prescribed diet orders.

The Clinical Nutrition Manager informed the surveyor during interview that the Food and Nutrition Department utilizes a company named "CBORG" who performs the nutrient analysis of the menus and provides the software for the printing of the menus which includes the prescribed diets printed on the menus.

Consequently diet orders do not correspond or match with the menus. The menu is required to correspond with the prescribed diet. The menu is placed on the patient's tray to identify the diet, foods allowed on the diet and the corresponding portions of foods allowed. The food portions listed on the menu corresponds to the nutrient analysis of the diet. The menu is also an education tool for patients, staff and family members concerning the prescribed diet by the physician.

Examples of abbreviations of prescribed diets on the menus are:

Physician Diet Orders: Abbreviation of prescribed diets on menus:

1- Cardiac, Calorie Control 1500 calories Cardiac CC15
2- Cardiac, Calorie Control 2000 calories Cardiac CC2
3- Cardiac, Low Residue Cardiac Res
4- Cardiac Mechanical Soft Cardiac MS
5- Calorie Control 1500 calories CC15
6- Calorie Control 1500 calories Renal CC15 Renal
7- Calorie Control 2000 calories CC20
8- Calorie Control 2200 calories CC22
9- Calorie Control 2200 calories Clear Liquid CC22 Clear
10- Mechanical Soft MS
11- No Concentrated Sweet NCS
12- No added Salt NAS
13- Renal- 80 gm protein, 2 gm sodium 80-2-2-REN
14-Vegetarian Diet Type of Vegetarian diet not noted
15-Cardiac Diet Diet restrictions contained in this diet were not listed on the menu .

Review of physician diet orders and menu was address with staff #5.

Based on observation, staff interview and record review the facility failed to maintain the physical plant and the patient care environment in a manner to ensure their safety and well-being.

Findings include:

During the tour of the Operating Room #17 and #16 at Manhattan Eye and Ear hospital on 03/13/14 at approximately 11:00 AM, the humidity of the rooms were tested with a hand held hygrometer and it was noted to be at 13% and 10.3%. Review of the "64 th Street Operating Room Temperature/Humidity Log Sheet" revealed that the Engineering staff tested the humidity once a day early in the morning with the hand held hygrometer and it was documented as 20% for both rooms.

Review of the Temperature and Humidity Log dated 03/14/14 for Operating rooms on the 10th Floor of Lenox Hill Hospital revealed that Operating room #s 10,12,16 and 17 had humidity levels below 20%.
Interview of the Director Of Engineering on 03/14/14 at approximately 1:00 PM revealed that this was a Repeat Citation from the Last Recertification Survey and the facility was conducting the Surgical Fire Risk Assessments as Plan of Correction for Low Humidity, as agreed upon by NYSDOH and the facility at that time. The written Plan of Correction from the facility for the last Recertification survey dated 04/08/2011 did not mention the use of Surgical Fire Risk Assessment Forms; instead the facility stated that the temperature and Humidity will be monitored and "Aggregate data will be reported to the Safety/Environment of Care committee and Hospital Performance Improvement Coordinating Group".

However, review of the 10 completed forms surgical fire risk assessments for procedures performed at 64th Street Campus (Manhattan Eye and Ear) provided to the surveyors revealed that the facility did not mention the humidity level in the rooms for any of the surgical cases performed and therefore there was no risk assessment made associating the low humidity and surgical equipment and processes used in each case.

Additionally, the facility failed to maintain a safe environment, free of physical hazards for the treatment of psychiatric patients in the Behavioral Health unit. The following observations were made in the unit:

? The doors of three (3) therapy rooms had pivot hinges which are not continuous and posed a looping hazard in the unit.

? The handrails along the corridor had at least 3 inch gap between the wall and the handrail, potential of causing ligature

? The door of the patient bathrooms in the 16 inpatient bedrooms had transfer grilles with approximately 1/4'' gap between them and was a potential looping hazard.


? There were 3 phones in the corridor with cords of 34 inches in length. This arrangement is potential of causing ligatures.


Also, testing of the patient call bells in the changing rooms and the patient bathrooms of the Endoscopy suite on 03/12/14 at approximately 10:25 AM, revealed that this system did not enunciate an audible alarm upon activation.

Based on observations, document review, and staff interview during a Federal Allegation Survey, it was determined that the facility failed to meet the Condition of Participation of Infection Control. This was evident by the potential risk for patients to exposure to infectious diseases when the facility failed to follow Infection Control standards and maintain a safe and sanitary environment.

Findings:

The facility failed to follow the policy and procedure to ensure the potency of the Cidex solution used in reprocessing equipment every day prior to the reprocessing of scopes.

The facility failed to ensure that staff followed the procedure for sanitizing the glucometer between patients.

The facility failed to followed the procedure to test the potency for the sanitizer used in the pot washing process.

The facility failed to maintain sanitary conditions in the Operating Room, Ambulatory Surgery Unit, Pediatric Unit, and on the patient care units.

See Tag A 749

Based on observation, staff interviews, and review of medical records and documents, the facility failed to: 1) maintain a safe and sanitary environment to minimize the transmission of infections; and 2) failed to ensure compliance with its infection control practices to avoid potential sources of cross contamination which increase risk for spread of infection.

Findings include:


1) During tour of the Operating Room #5 on the 10th Floor of Lenox Hill hospital on 03/11/14 at approximately 10:30 AM, it was noted that the perimeter of the Operating Room floor was heavily soiled and grimy. The integral cove base of the back wall was cracked creating an opening of approximately 2 inches.

A metal supply cart located in corner of the room (behind the anesthesia cart) was observed to be covered in dust. Two arm rests were observed to be placed on the top shelf of the supply cart and both the arm rests had few pieces of tape stuck on them.

A bair hugger located on the left hand side of the operating table was also observed to be covered in dust and had a reddish brown residue on the interior side.

During the testing of temperature of water of scrub sinks in the Operating Rooms Suite on the 10 th Floor of Lenox Hill Hospital on 03/11/14 at approximately 10:45 AM, it was noted that the temperature of water in the scrub sinks were between 80 Degree Farenheit and 90 Degrees Farenheit. CDC recommendations on pg 49 under 3 b regarding Water Temperature and Pressure of the topic D-Water in Part 1. Background Information: Environmental Infection Control In Health-care facilities states "the hot water temperature in hospital patient-care areas is no greater than a temperature within the range of 105 F-120F".

Similar findings were noted with the temperature of water in scrub sinks outside the Labor and Delivery Procedure rooms located on 6 Wollman of Lenox Hill Hospital.

During the review of the Cidex OPA monitoring log for endoscope reprocessing on 03/11/14 at approximately 11:30 AM, it was noted that the staff failed to follow facility policy and check for the potency of the Cidex solution in reprocessing equipment every day prior to reprocessing the scopes.

Review of the log revealed that the facility did not have documented evidence of potency check of the Cidex solution in Equipment#1 prior to its first use on 03/11/14. Interview of the Reprocessing technician E #19 revealed that this employee had forgotten to document the potency test of Cidex solution in Equipment #1 for that day. Further review of the log also revealed that the facility did not have documented evidence of the potency check again on 01/03/14 on the reprocessing equipment #1.

At approximately 1:15 PM on 03/11/14, the Vice-President for Infection Prevention E#15 for the facility provided the surveyor with a copy of the completed and filled out log. It was stated that the facility staff were maintaining two different logs and the second log had all the entries for each day. The Vice-President for Infection Control was not able to explain the reasons for multiple logs and the frequency of audits on these logs.

During the observation of pot washing process, the surveyor requested the Food Service worker
E#20 to test the potency of Rinse Quat Sanitizer. It was revealed that the test strip did not register the potency of the sanitizer. Interview of this employee revealed that the pot washing sink is emptied and refilled every four hours and that the potency of the sanitizer was checked only once a day.

Interview of the Food Service Director Staff#11 on 03/14/14 at approximately 3:00 PM revealed that the employee was using the wrong strips (hydron strips) to test for the potency of the sanitizer and therefore these strips would not register the concentration of the sanitizer without being exposed to the solution for long time.

During the tour of the Sterile Processing Department at Manhattan Eye and Ear Hospital on 03/13/14 at approximately 11:30 AM, it was observed that the air pressure from the sterile side in relation to the corridor was found to be negative instead of being positive.

During the tour of the Emergency Department of Lenox Hill hospital on 03/10/14 at approximately 11:00 AM, it was noted that the air pressure from the dirty utility room ( located on the south side) in relation to the corridor was observed to be positive instead of negative and the clean utility room (located on the northside) had neutral air flow instead of positive air flow.

During the tour of the Ambulatory Surgery center on the first floor of the Lenox Hill hospital on 03/13/14 at approximately 3:45 PM, the surveyor noted a ceiling tile in the sub-sterile stained with reddish brown stain. Interview of the Director Of Engineering Staff#21 revealed that the the ceiling tiles in this sub-sterile area were not cleanable /washable tiles.





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2) Tour of the facility conducted on 3/10/14, 3/11/14 and 3/13/14 revealed failed infection control practice:

a. On 3/10/14 at 2:00 PM, observation on 7 Wollman, Room 733 revealed a commode, partially covered with clear plastic was in the patient's bathroom. Staff #7, stated this was a clean commode that was stored in this bathroom and the commode would be taken out to be used by other patients as needed. The commode would be then be cleaned after patient use and returned to this bathroom. This commode was not being used by the patients who were currently in room 733.

This finding was acknowledged by Staff #2, who was present on the tour. Staff stated the facility does not have a policy to address the storing of clean equipment in the patient use areas.

b. On 3/11/14 at 10:30 am, observation on the Pediatric unit revealed three (3) dirty food trays on a counter in the Soiled Utility Room. Staff #9,stated the food cart is put in the Soiled Utility Room but the cart had already left the floor, and the remaining food trays were put on the counter. The surveyor observed a scale was at the end of the counter and Staff #9, stated the scale is used to weigh patient diapers. At interview on 3/12/14 at 3:09 PM, Staff #10 stated the used food trays are "all dirty" and the dishwashing process will kill the bacteria. Staff also stated there is a policy to address this practice. However, the policy provided, " Nutrition and Food Services" does not address the storing of food trays in a soiled utility room.

During a follow-up interview with Staff #3 on 3/14/14 at 1:00 PM, staff responded that she was not aware that is was occurring.

c. On 3/11/14 at 3:30 PM at the Cardiac Care Unit, Staff #12 was observed performing finger stick procedures on 2 (two) patients, using a glucometer. Staff performed finger stick for patient MR #12, Room 507 followed by patient #13, Room 505 and the glucometer was not sanitized between patient uses. Staff #12 acknowledged that the glucometer should be sanitized between patient uses and this was not done.

At interview on 3/12/14 at 3:09 PM, Staff #10 stated the facility's policy to sanitize glucometers between patient uses.

During a follow-up visit on April 3, 2014, the manufacturers' guidelines for Cleaning and Disinfecting the system was reviewed. The guidelines states,"Cleaning and disinfecting the exterior surface of the meter, is at minimum, recommended daily for dedicated patient use. Meters used with multiple patient may require more frequent cleaning and disinfecting. Follow recommendations form the FDA, CDC and CMC and your facility's policies and procedures for infection control." The facility's policy for Glucometer Cleaning Instructions states the glucometer must be cleaned after each patient use and when visibly dirty; only the approved cleaning product is to be used to clean and disinfect the meter. The cleaning product specified is in keeping with the manufacturer's and EPA regulation.

At interview with Staff #6 at 3:00pm, it was stated that cleaning is required before disinfecting when the meter is visibly dirty. Cleaning first, removes the dirt from the meter and the disinfecting follows.

Staff failed to follow the manufacturer's and facility's ploicy to clean the exterior of the meter after each patient.


d. On 3/13/14 at 2:40 PM observation at the Cardiac Stepdown unit revealed a labeled bag of intravenous fluid on the bathroom sink at Room 520. The Staff, who was assigned to the patient, stated the IV bag was just removed from the MR #14 (bed #1) and was placed there to empty the remainder of the content. The Staff squeezed the remainder of the IV fluid in the sink and stated, when asked by the surveyor, that the remainder of the IV fluid that was removed from the patient, can be discarded in any available sink.

Staff #13 was present and confirmed this practice. However, the facility did not provide a policy to address the discarding of patient waste in a hand washing sink in the patient's room.