HospitalInspections.org

Based on findings from document reviews, observations, and interview, the hospital did not provide accurate information in two self-attestation federal survey documents it submitted to the New York State Department of Health (DOH) for its PPS (Prospective Payment System) excluded psychiatric and rehabilitation units in 2011.

Findings include:

-- See the last finding in Tag A 000.

-- On 7/14/10, the hospital also submitted the following documents to the DOH:

* Rehabilitation Unit Criteria Work Sheet, Form CMS-437 A; and
* Attestation Statement for Exclusion from Prospective Payment System for Fiscal Year Beginning 2011.

The latter document was signed by the President and CEO on 7/14/10. In this submission the hospital attested that the number of beds on the Rehabilitation Unit was 15.

However, during tour of the hospital's PPS Excluded Rehabilitation Unit during the survey on 1/13/11 at 9:15 a.m., it was noted that the unit only had 13 beds.

During interview of the Rehabilitation Department Manager (RDM) on 1/13/11 at 9:20 a.m., he/she verified that the Unit only has 13 beds. Per the RDM the Rehabilitation Unit lost the physical space for 2 beds over a year ago (to accommodate space needed in the Obstetrical Department during a renovation of that department).

Based on findings from document reviews and interview, the hospital assigned functions involving patient assessment activities to Licensed Practical Nurses (LPNs) working at its facility, despite these activities not being in the scope of practice for LPNs (per the New York State Education Department).

Facts and findings include:

-- In New York State, through the Education Department's Office of the Professions (OP), the Board of Regents licenses and regulates 47 professions, including nurses (LPNs and RNs). In its publication entitled "Nursing Guide to Practice," the OP has provided information defining the scope of practice for LPNs and RNs.

-- Per review of the "Nursing Guide to Practice," last revised 3/08, on page 43 it states "Nursing diagnosis by an RN is cited in section 6901 of Article 139 of the Education Law as: the identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen... Nursing diagnosis has been additionally interpreted by the Department as including patient assessment, that is, the collection and interpretation of patient clinical data, the development of nursing care goals and the subsequent establishment of a nursing care plan.... Thus, Licensed Practical Nurses in New York State do not have assessment privileges; they may not interpret patient clinical data or act independently on such data; they may not triage; they may not create, initiate, or alter nursing care goals or establish nursing care plans."

In summary, this information reveals that the scope of practice for LPNs does not include patient assessment activities.

-- However, per review of the hospital's Position Description document for LPNs, undated, [received while onsite 1/12/11 and verified as current by the Vice President (VP) for Patient Care Services (chief nursing officer)], it indicated that the following functions involving patient assessment activities are assigned to LPNs working at this hospital:

* Vital Signs Monitoring - Collects and analyzes cardiovascular, respiratory and body temperature data to determine and prevent complications.
* Nutritional Monitoring - Collects and analyzes patient data to prevent or minimize malnourishment.
* Dysrhythmia Management - Prevents, recognizes and facilitates treatment of abnormal cardiac rhythms.
* Electrolyte Management - Promotes electrolyte balance and prevents complications resulting from abnormal or undesired serum electrolyte levels.
* Medication Administration - Prepares, gives and evaluates the effectiveness of prescription and nonprescription drugs.
* Respiratory Monitoring - Collects and analyzes patient data to ensure airway patency and adequate gas exchange.
* Hyperglycemia Management - Prevents and treats above normal blood glucose levels.
* Hypoglycemia Management - Prevents and treats below normal blood glucose levels.
* Behavior Modification - Promotes behavior change.

-- During interview with the Vice President for Patient Care Services on 1/13/11 at 9:30 a.m., he/she acknowledged that the LPN cannot perform patient assessment functions. Further, when asked about supervision of LPNs in the hospital extension clinic settings, he/she could not describe how this is accomplished.

Based on findings from document reviews, observations and interviews, the governing body has not assured that the nursing service is managed in a manner that assures patients are provided care in a safe environment, all necessary policies and procedures to guide nurses in providing patient care are in place, complete and accessible, and that patient's rights are met. See the findings in Tags A 117, 123, 132, 143, 144, and 392.

Based on findings from document review and interview, the hospital's medical staff lacked bylaws or written policies and procedures (P&Ps) addressing Office of Professional Medical Conduct (OPMC) reporting requirements, to ensure compliance with New York State (NYS) regulations at 405.3(e)(i)-(iii), as well as requirements outlined in section 230 of the NYS Public Health Law (PHL), and by reference, in section 6530 of the New York State Education Law (SEL).

Findings include:

-- Per review of the hospital's Medical Staff Bylaws and the Medical, Dental and Allied Professional Staff Rules and Regulations, last revised 6/23/08, they do not contain language addressing the OPMC reporting requirements referenced above.

-- During interview with the hospital's Chief Medical Officer on 1/13/11 at 12:25 p.m., he/she acknowledged the hospital does not have a P&P addressing the OPMC reporting requirements in NYS.

Based on findings from document reviews, observations and interviews, the hospital has not assured compliance with patients' rights to receive care in a safe environment, to be provided with information about their rights, to have their advance directives acknowledged by the hospital, to privacy, and to be informed about the hospital's findings following investigation of their complaints. See the findings in Tags A 117, 123, 132, 143, and 144.

Based on findings from observations, document reviews, and interview, at 4 out of 5 outpatient extension clinic sites visited, the hospital did not publicly post the Patients' Bill of Rights and information pertaining to advance directives (ADs) as required by New York State (NYS) Rules and Regulations. Additionally, in 1 out of 5 outpatient extension clinics, the clinic staff were not providing patients information about their patients' rights.

Findings include:

-- During tours of all 5 of the hospital's outpatient extension clinics on 1/11/11 (i.e., Ogdensburg Health Center at 9:45 a.m.; Waddington Health Center at 12 noon; Heuvelton Health Center at 1:30 p.m.; Canton Health & Diagnostic Center (CH&DC) at 2:00 p.m.; and Hammond Health Center at 3:45 p.m.), 4 out of 5 of the extension clinic waiting rooms lacked the required postings of NYS Patients' Bill of Rights and ADs [per NYS regulations at 405.7(a)(3) and 400.21(e)].

-- Per review of medical records (MRs) at the CH&DC extension clinic on 1/11/11, in 2 of 2 MRs reviewed, adult patients had signed a document indicating they had received information about the Patients' Bill of Rights.

-- Per interview on 1/11/11 at 2:30 p.m. of Receptionist #1 at the CH&DC extension clinic, patients are given a packet upon admission which contains the Patients' Bill of Rights. At that time the patients sign the form that is filed in the MR indicating they have received the packet containing the Patients' Bill of Rights.

However, when asked to produce the admission packet containing the Patients' Bill of Rights, Receptionist #1 produced a 2 page document that described how information about the patient may be used and disclosed. This document does not constitute the Patients' Bill of Rights.

Based on findings from document reviews and interview, in 4 of 5 complaint investigations performed, the hospital did not provide complainants with a written response that indicated the findings of its investigation.

Findings include:

-- Per review of the hospital policy and procedure entitled "Complaint Resolution," last revised 1/7/09, it does not require that patients be provided a written response of the complaint investigation findings.

-- Per review of 5 complaint investigation report folders, 4 of the 5 did not include a written response to the complainant about the investigation findings.

-- During interview of the Risk Manager #1 on 1/12/11, he/she verified that not all complainants are provided a written response of the complaint investigation findings.

Based on findings from document reviews and interviews, the hospital's policy and procedure (P&P) addressing advance directives (ADs) did not address providing information about ADs to patients in the outpatient setting. Also, in 3 outpatient medical records (MRs) reviewed, the MRs lacked information regarding whether the patients had any ADs and did not indicate the patients were provided information regarding ADs. Additionally, in 4 of 5 MRs reviewed for inpatients who wished to not be resuscitated in the event of a cardiopulmonary arrest, medical staff did not document patient DNR (Do Not Resuscitate) orders on the appropriate hospital DNR documentation forms.

Findings include:

-- Per review of the hospital P&P entitled "Advanced Directive," last reviewed 11/09, although the P&P addressed ADs for inpatients, it did not address this subject for outpatients.

-- Per interview of the Endoscopic Unit Clinical Coordinator on 1/13/11 at 8:45 a.m., nursing staff do not inquire about a patient's ADs when they come to the endoscopy procedure unit and do not provide patients with information about ADs.

-- Per interview with Anesthesiologist #1 on 1/13/11 at 9:40 a.m., he/she does not inquire about a patient's ADs. If however, a patient wishes to be DNR status, he/she will discuss this with the patient. (This DNR information can be obtained from an inpatient's MR or the previous MR of a patient who was previously a DNR).

-- Per review of the MRs for 3 outpatients who underwent endoscopic procedures, all 3 lacked documentation that the patients were provided information about ADs and lacked
documentation by nursing or physician staff regarding whether the patients had ADs (Patients A, B and C). This information was verified by the Nurse Manager of the PACU, Endoscopy, Pain (NM-PACU) on 1/13/11.

-- Per review of the hospital's P&P entitled "Do Not Resuscitate," last revised 10/09, the hospital has a mechanism for issuing a Do Not Resuscitate (DNR) order for a patient when consent has been obtained. The hospital's forms called "Documentation Sheets" set forth the steps the attending physician must take before issuing a DNR order, and the appropriate sheet the patient must complete before the attending physician can issue a DNR Order. Attached to each Documentation Sheet are the consent forms which may be necessary before a DNR order is issued.

However, per reviews of 4 patients' MRs (Patients D, E, F and G), even though each patient had a DNR order on the Physician's Order sheet, the MRs did not contain the hospital's DNR Documentation Sheets. The MRs of Patients D, E and F contained a New York State Department of Health Nonhospital DNR form (form 3474). Patient G's MR contained a copy of a Living Will which stated that the patient did not want cardiac resuscitation.

-- During interview of the hospital's Director of Quality Management/ Performance Improvement (DQM/PI) on 1/12/11 at 11:15 a.m., he/she acknowledged the lack of the hospital DNR Documentation Sheets in the above patients' MRs as required by hospital policy. Additionally, he/she confirmed that each patient's physician should have used the DNR Documentation Sheets to document the DNR order.

Based on findings from observation, the number of closets provided in room 317 was inadequate to assure that the patients occupying the room had both comfort and privacy.

Findings include:

-- Per observations at 9:30 a.m. on 1/12/11., there was only one closet provided in room 317 which was occupied by two patients. The Director of Facilities Management, who was present during the the survey, verified the presence of a single closet.

Based on findings from document reviews, interviews, and observations, the hospital did not assure the maintenance of a safe environment for all patients. Specifically,
1) Hospital staff allowed patients presenting to the emergency department (ED), and triaged as having a potential for danger to self or others, were allowed to disrobe alone in a room that is not free of ligature (strangulation) hazards and that cannot be accessed by staff at all times (this practice has ceased).
2) The hospital's 2 policies and procedures (P&Ps) regarding staff observations of patients who are a potential danger to themselves or others, and require a heightened level of monitoring, were not clear regarding the circumstances under which each P&P is to be implemented and were not accurately described by a staff person who oversees psychosocial evaluations of patients requiring mental health services in the ED. Further, in a medical record (MR) reviewed, a patient was not observed at the heightened level warranted by her high risk for suicide.
3) The hospital's P&Ps which provide guidance to staff for managing potentially suicidal patients lacked guidance regarding what physical hazards should be removed from the environment and/or possession of these patients. Further, in a MR reviewed, a patient who was admitted to the mental health unit following a suicide attempt was allowed to wear hospital pants containing draw strings at the waist; he/she used these strings from his/her hospital pants to attempt suicide again. (The practice of allowing suicidal patients to wear hospital pants with draw strings at the waist has ceased.)
4) The door handles mounted in the ED mental health holding rooms were not installed correctly and posed a safety hazard (these have been changed).
5) The closet rod holders in several closets in the mental health unit did not adequately protect patients from risk of self-harm (these have been changed).

Findings pertaining to 1) above include:

-- Per review of the hospital P&P entitled "Psychiatric Triage," last reviewed 2/09, it states "As the patient presents to triage and it is determined that the patient is in need of psychiatric care ...safety checks and procedures will be initiated either in the triage room or in the assigned patient room depending on the acuity of the patient. 1) The patient will disrobe and hospital pajamas will be provided and 2) The triage nurse and/or the primary nurse will complete a contraband check as the clothing is changed...."

-- However, per interview of ED Registered Nurse (RN) #1 on 1/12/11 at 11:30 a.m., when a patient with psychiatric issues presents to the ED, they are triaged, bought to the ED public bathroom and instructed to disrobe and change into hospital pajamas alone (i.e., not in the presence of staff). This is the routine practice for all psychiatric patients (including those who may be a potential danger to themselves or others). This routine practice was confirmed during interview with the ED Director on 1/12/11 at 4:00 p.m.

-- Further, per observation of the ED public bathroom referred to above, on 1/12/11 at 11:35 a.m., the door was lockable from the inside (which denies access if someone is in need of assistance), a hook was attached to the wall (presenting a means for a patient to hang themselves/ defined as a ligature hazard), and a pull cord measuring approximately 2? to 3 ft was attached to the wall (another ligature hazard).

Findings pertaining to 2) above include:

-- The hospital has two (2) P&Ps addressing various levels of observing patients who require a heightened level of visual monitoring, i.e., constant or periodic observations. The P&Ps are entitled "Close/Constant Patient Observation - Sitter Program," last revised 10/21/10, and "Patient Observation-Constant Observation (1:1)," last revised 5/21/08. While duplicative in many respects they also contain differences; regardless, these P&Ps do not specify under what circumstances each is to be implemented. Further, during interview of ED Psycho-Social Assessor #1 at 2:30 p.m. on 1/12/11, he/she described observation procedures that only partially matched one of the P&Ps and then also described procedures that were not in either P&P.

-- Further, per MR review, Patient H was brought to the ED by law enforcement for a mental health evaluation as he/she had expressed suicide ideation to a friend. At 4:55 a.m. the ED physician medically evaluated Patient H and documented the estimated suicide risk of this patient as "high" Three and half (3?) hours later, at 8:30 a.m. ED Psycho-Social Assessor #1 evaluated Patient H as "low" risk for suicide. There was no documentation of constant (continuous) observation of the patient during the 3? hour interval when the patient was thought to be a high risk for suicide.
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-- During followup interview with the ED Director, he/she confirmed that hospital policy was not followed when Patient H was not assigned a sitter after being designated a high risk for suicide. He/she did also note, however, that Patient H was placed in a room which had 2 walls with glass windows and was fully in view of the nurse's station at all times (inferring the patient was nevertheless under constant observation).

Findings pertaining to 3) above include:

-- Per review of the hospital P&P entitled "Assessment of Suicidality," last revised 11/10, it indicated that patients identified as high risk for suicide will be monitored and provided with treatment and placed on the appropriate observation level as deemed by the psychiatrist. The P&P also described psychosocial and clinical risk factors "for careful consideration of suicidality." However, this P&P (or any other hospital P&P) did not include guidance for staff regarding what physical hazards need to be removed from the hospital environment or possession of a potentially suicidal patient.

-- Further, per review of the MR of Patient I, this patient was admitted on 12/30/10 at 2 a.m. for depression with suicide attempt (involving a medication overdose); he/she admitted to continuing thoughts of hurting himself/herself at 1:30 p.m. that day. At 1:04 a.m. on 12/31/10 RN #2 documented that staff found Patient I "to have a string from his/her hospital pants tied around his/her neck. Staff was able to put fingers in between the string and patient's neck and the strings were untied. Patient had his/her clothing taken away and was placed in hospital gown with no strings."

-- Per interview with RN #2 on 1/26/11 at 4:05 p.m., Patient I was admitted to the Mental Health Unit (MHU) from the ED clothed in hospital garb consisting of pants with a string tie and a hospital gown. The MHU does not have appropriate size elastic waist pants for small sized patients. So, since Patient I was known for using "head banging" to hurt himself/herself (from repeat past hospitalizations), the fact that he/she was wearing hospital pants with strings was not identified as a safety hazard.

Findings pertaining to 4) above include:

-- Per observations of the ED mental health holding rooms #1 and #2 on 1/12/11 at 10:35 a.m., the handles on the hall door and the bathroom door in each room were incorrectly installed (in the upright position) posing a ligature (safety) hazard to patients. The Director of Facilities Management, who was present during these observations, verified that the handles were not installed correctly.

Findings pertaining to 5) above include:

-- Per observations on 1/12/11 from 9:00 a.m. to 9:30 a.m., several closets in the MHU (for example, rooms #308, 312) contained securely fastened, protruding rod holders that represented a potential ligature hazard. The Director of Facilities Management, who was present at the time during the survey, verified the presence of the protruding rod holders.

Based on findings from document reviews and interviews, the hospital's Quality Assurance Program (i.e., Performance Improvement Committee of the Board (PI)] does not review complaints received at the hospital.

Findings include:

-- Per review of the PI Committee minutes from 1/10 to 12/10, they lacked reference to the committee reviewing any complaints.

-- During interviews with the Director of Quality Management / Performance Improvement (DQM/PI) and the Risk Manager on 1/13/10 at 2:00 p.m., they each confirmed that although the Risk Manager does review patient complaints, the complaints are not brought forth to the PI Committee for analysis, tracking and trending at the hospital-wide level.

Based on findings from document reviews and interview, in 5 of 5 credential files reviewed for mid level Allied Health Professional (AHP) medical staff, the hospital did not use peer review information to evaluate each staff member's ongoing competency prior to reappointment every 2 years.

Findings include:

-- Per review of credential and quality assurance files for the following mid level AHP medical staff members, each file lacked evidence that peer reviews, chart reviews, and/or annual evaluations were reviewed prior to reappointment:

* Physician Assistant (PA) #1;
* Certified Prosthetist/Orthotist (CP/O) #1;
* Certified Registered Nurse Anesthetist (CRNA) #1;
* Doctor of Podiatric Medicine (DPM) #1; and
* Nurse Practitioner (NP) #1.

-- During interview with the Chief Medical Officer on 1/13/11 at 12:15 p.m., he/she acknowledged the findings above.

Based on findings from document reviews, observations and interviews, the nursing service has not assured that patients receive care in a safe environment, staff competencies in providing care are documented, all patients' rights are met, medication errors are documented in patients' medical records, and that nursing personnel are provided complete guidance (via complete and accessible policies and procedures) in all patient care activities. See the findings in Tags A 144, 392, 397, and 449.

Based on findings from document reviews and interviews, the policies and procedures (P&Ps) manual in the nursing service department did not provide sufficient guidance to nursing staff regarding patient care related activities and tasks. Specifically, various P&Ps in the service's manual were incomplete (4) or lacking in clarity (2), 3 P&Ps were lacking altogether, and 1 randomly chosen P&P was not accessible to nursing staff.
-- Regarding incomplete P&Ps addressing advance directives, disposal of wasted controlled substances, and verification of correct procedures and sites, see the findings in Tags A 132, 494, and 951, respectively.
-- Regarding an incomplete P&P addressing cardiac alarms in the telemetry setting, interview of Critical Care Tech (CCT) #1 on 1/11/11 at 12:25 p.m. revealed he/she sometimes adjusts the yellow (non critical) heart rate alarms if the patient's heart rate stays elevated or decreased, and the alarm continues to sound. He/she first notifies the unit nurse by phone with the patient's heart rate and "usually" then adjusts the heart rate parameter by 5 beats per minute until the heart rate parameter does not alarm.
However, per review of the P&P entitled "Telemetry," last revised 7/08, it does not address adjustment of alarms by staff.
During interview of the Vice President for Patient Care Services on 1/13/11 at 2:45 p.m., he/she acknowledged the findings above.
-- Regarding lack of clarity between 2 P&Ps addressing close observations of patients on a continuous or frequently periodic basis, see the findings in Tag A 144.
-- Regarding lack of P&Ps addressing rotation of subcutaneous injection sites, physical hazards in the environment or in the possession of potentially suicidal patients, and medication errors, see the findings in Tags A 404, 144 and 449, respectively.
-- Regarding not all P&Ps being available to the nursing staff: Per interview of the Nurse Manager of the Medical Surgical Unit on 1/11/11 at 3:10 p.m., all nursing P&Ps are available to staff on the intranet; there are no nursing P&P manuals kept on the nursing units. However, it was acknowledged by the Director of Compliance and Accreditation on 1/11/11 at 4:00 p.m. that the hospital policy entitled "Medication Orders," randomly chosen by the surveyor, was not available to the nursing staff on the intranet.

Based on findings from document reviews and interviews, the hospital did not include documentation in a critical care tech's (CCT's) personnel file indicating he/she received education in, and was deemed competent to perform, cardiac telemetry monitoring for patients in the intensive care unit (ICU) and medical surgical (MS) units. Additionally, the hospital's CCT job description/performance appraisal did not indicate that cardiac telemetry monitoring was included as a job responsibility for the CCT position.

Findings include:

-- Per interview of the ICU Nurse Manager on 1/11/11 at 11:30 a.m., Critical Care Tech (CCT) #1 was assigned to watch the cardiac monitors that day (during the day shift from 7 a.m. to 7 p.m.). The CCT had previously completed 6 weeks of orientation to cardiac monitoring, during which time he/she was assigned to perform cardiac telemetry monitoring with an experienced monitor technician.

-- However, per review of CCT #1's personnel file, there was no documentation describing the education/orientation received for cardiac monitoring. Also, there was no documentation describing evaluation of CCT #1's competency to perform cardiac monitoring (during the orientation described above) prior to performing this task independently.

-- During interview of the Vice President for Patient Care Services on 1/13/11 at 2:45 p.m., he/she acknowledged the lack of cardiac monitoring competency documentation in CCT #1's personnel file, and that competency should have been verified and documented prior to CCT #1 being assigned to perform cardiac monitoring.

Based on findings from document reviews and interviews, in 2 of 2 medical records (MRs)reviewed, nursing staff did not document injection sites on the medication administration record (MAR) in accordance with generally accepted standards of practice for documenting medication administrations. Specifically, documentation on the MAR did not identify the injection sites used when subcutaneous (SQ) medication (Heparin 5,000 units) was administered. This lack of documentation posed a risk of patient harm from nursing staff unknowingly and repeatedly using the same injection sites.

Findings include:

-- Per review of Patient G's MR, documentation on the MAR did not identify the injection site used when SQ Heparin 5,000 units was administered on the following hospital days, at the times noted: 1/4/11 - 9:30 p.m., 1/5/11 - 9:55 a.m. and 9:00 p.m.

-- Per review of Patient J's MR, documentation on the MAR did not identify the injection site used when SQ Heparin 5,000 units was administered on the following hospital days, at the times noted: 1/7/11 - 9:00 p.m., 1/8/11 - 9:00 a.m. and 9:15 p.m., 1/9/11 - 8:30 a.m. and 9:10 p.m.

During interview of the Vice President of Clinical Services on 1/11/11 at 4:00 p.m., he/she verified that the heparin injection sites were not documented on the MAR as they should have been in the above MRs.

Based on findings from document reviews and interview, in 5 of 11 medical records (MRs) reviewed, medical staff orders for medications to be administered on a PRN (as needed) basis did not provide sufficient instructions to nursing staff regarding when or how to administer the medications ordered, i.e., regarding how to determine which one of multiple medications ordered for the same PRN purpose should be administered to the patient, or how to determine which one of 2 routes ordered should be used for the administration of a PRN medication.

Findings include:

-- Per review of the Mental Health Center Admission Orders and the Physician's Orders form in the MR of Patient K, there was a telephone order on 12/27/10 at 10 p.m. for Haldol 5 mg and Benadryl 50 mg PO (orally) or IM (intramuscularly) q4hr (every 4 hours) PRN for agitation. The order lacks parameters instructing nursing staff when to give the medication the PO versus the IM route.

-- Per review of the Physician's Orders for Patient L, it contains an order written on 1/11/11 at 9:15 a.m. for Morphine 1 mg intravenously (IV) every 1 hour PRN for pain, and Vicodin 5/500 mg 1 tablet PO every 4 hours PRN for pain.

The orders do not provide specific parameters to nursing staff regarding when each of the 2 medications ordered for pain should be given.

-- Per review of Patient M's medication administration records (MARs) for PRN medications for 1/08/11, it revealed medication orders for pain as "Nalbuphine HCL 10 mg for pain, Ketorolac Tromethamine 60 mg for severe pain X 1 only, Acetaminophen with Codeine #3 for pain." Patient M's MARs for 1/09/11 - 1/11/11 included these 3 pain medications and also an order for "Motrin 600 mg for pain."

These medication orders (transcribed from physician orders) lacked sufficient instructions for when each of 3 out of 4 of the medications ordered for pain should be given.

Based on findings from document review and interviews, in 5 of 5 medication errors and corresponding patient medical records (MRs) reviewed, staff did not document that a medication error had occurred. Additionally, the hospital lacks a policy and procedure (P&P) regarding how to handle medication errors.

Findings include:

-- Following review of a list of medication errors that occurred between 10/01/10 and 12/31/10, generated by the Risk Manager during the survey, 5 medication errors were randomly identified and the patients' corresponding MRs were reviewed. In all 5 patients' MRs, there was no documentation of the medication error occurring with each patient.

-- During interview with the Vice President of Patient Care Services on 1/13/11 at 11:30 a.m., he/she reviewed the 5 patients' MRs for medication error documentation and verified there was no documentation of the medication errors.

-- During interview of the Risk Manager on 1/12/11 at 2:15 p.m., he/she verified that the hospital does not have a medication error P&P.

Based on findings from document reviews and interview, the hospital lacked a policy requiring the medical staff to time all patient care entries in the medical record (MR).

Findings include:

-- Per review of the hospital's Medical, Dental and Allied Professional Staff Rules and Regulations, last revised 6/08, the following statements appear under Section B, Medical Records:

" 5. Upon completion of ordering, providing or evaluating patient care services, each such action shall be recorded and promptly entered in the patient's medical record. All entries... shall be legible, complete, accurately dated with month/day/year and authenticated by the person making the action documented...
12. All clinical entries in the patient's medical record shall be accurately dated and authenticated...
26. A practitioner's routine orders, when applicable, to a given patient shall be reported in detail on the order sheet of the patient's record, dated and signed by the practitioner."

There was no requirement in this document that all patient care medical record entries are to be timed.

Based on findings from document reviews and interviews, in 5 of 23 medical records (MRs) reviewed, verbal orders given by psychiatrists were not authenticated (signed) within 48 hours.

Findings include:

-- Per review of the hospital's Medical, Dental and Allied Professional Staff Rules and Regulations, last revised 6/08, under Section C. General Conduct of Care Number 2, it requires telephone orders for pharmaceuticals and biologicals to be personally authenticated by an attending practitioner as soon as practical but within 24 to 48 hours.

-- Per MR review on 1/11/11 at 12:50 p.m., Patient K's MR contained a set of preprinted admission orders authorized to be implemented over the telephone by a psychiatrist on 12/27/10; the orders were still not signed by the psychiatrist 15 days later.

-- Per MR review on 1/11/11 at 11:45 a.m., Patient N's MR contained a telephone order provided on 1/05/11 at 10 p.m., for 1 to 1 constant observation at a distance for safety of others until 7:30 a.m.; the order still was not signed by the psychiatrist 6 days later.

-- Per MR review on 1/11/11 at 12:10 p.m., Patient O's MR contained a telephone order provided on 12/20/10 at 7:40 p.m. to discontinue the current Diazepam order and to give Diazepam 2.5 mg PO (orally) BID ( twice a day); it was still not signed by the psychiatrist 22 days later. There were 2 other telephone orders, provided on 12/20/10 at 5:20 p.m. and 12/21/10 at 3:50 p.m., clarifying previous medication orders, that still were not signed by the psychiatrist 22 and 21 days later.

-- Per MR review on 1/11/11 at 12:30 p.m., Patient P's MR contained a telephone order provided on 1/06/11 at 9:30 p.m. for Atarax 100 mg PO X 1 dose NOW for agitation; it still was not signed by the psychiatrist 5 days later.

-- Per MR review on 1/12/11 at 10:20 a.m., Patient Q's MR contained a telephone order provided on 1/05/11 at 9:05 a.m. for "Recovery Room 30 mins then ACU 30 mins then may be discharged as per above"; it still was not signed by the psychiatrist 7 days later.

-- Per interview with the Director of Mental Health Services on 1/11/11 at 1:40 p.m., he/she indicated that obtaining practitioner's signatures on verbal orders is an issue which the hospital continues to address.

Based on findings from document reviews and interview, the hospital was not following its policy and procedure to assure that medical records (MRs) are completed within 30 days following the patient's discharge from the hospital. Further 26 charts involving 8 physicians were delinquent during the 4th quarter of 2010.

Findings include:

-- Per review of the Medical, Dental and Allied Professional Staff Rules and Regulations, last revised 6/08, under Section B Medical Records Number 19, it states:
"The patient's MR shall be complete at the time of discharge. A medical record shall be considered complete when the required contents are assembled and authenticated, including progress notes, any required discharge summary or final progress note, any required complications are recorded without the use of any symbols or abbreviations. Completion includes the transcriptions of any dictated record content and its insertion into the MR. Where this is not possible because final test results, lab or other essential reports have not been received at time of discharge, the patient's record will be available in the MR department for completion. Such records shall be completed within 12 days. If a record remains incomplete, a notice of delinquency shall be issued to the practitioner, e.g., vacation, illness, family emergencies etc. Two written notices and one verbal notice over a 30 day period will be given to a delinquent physician. If charts are not completed within 24 hours, the medical staff will levy a fine of $50, to be doubled every week thereafter until charts are completed."

-- Per review of computerized printouts dated 1/13/11 for the 4th Quarter 2010, describing MRs which were incomplete for > 30 days, they revealed that:

* Physician #1 had 9 incomplete charts (involved discharge dates were 4/16/09 and between 10/21/10 and 11/18/10);
* Physician #2 had 9 incomplete charts (involved discharge dates were between 10/31/10 and 12/2/10);
* Physician #3 had 3 incomplete charts (involved discharge dates were between 10/28/10 and 11/13/10);
* Physician #4 had 2 incomplete charts (involved discharge date was 10/6/10); and
* Physicians #5, 6, 7, and 8, each had 1 incomplete chart (involved discharge dates were 10/8/10, 11/10/10, 11/8/10, and 10/22/10, respectively)

-- During interview with the Director of Medical Records on 1/13/ 11 at 1:30 PM, he/she verified that the policy and procedure (noted further above) regarding fining physicians for delinquent charts, and other actions, was not being followed.

Based on findings from document reviews and interview, the pharmacy's policy and procedures (P&P) regarding disposal of controlled substances was not complete. Specifically, the P&P lacked direction for the disposal of partially wasted doses of controlled substances.

Findings include:

-- Per interview on 1/13/11 at 8:45 a.m. with Registered Nurse (RN) #3, disposal of liquid narcotics requires 2 RNs to witness disposal in the sink; oral medications are disposed in the sharps container.

-- Per interview on 1/13/11 at 9:30 a.m. with RN #4, liquid narcotics are disposed in the sharps container or down the drain; oral medications are crushed or placed in the sharps container.

-- Per interview on 1/13/11 at 9:50 a.m. with RN #5, narcotic pills, patches and liquids are to be disposed of in the sharps container.

-- Per interview on 1/12/11 at 10:30 a.m., with RN #6, the nurses have been instructed by pharmacy to put the extra/wasted parental narcotic medications directly into the trash can, not down the drain, not in the red sharps containers.

-- Per review of the Pharmacy P&P entitled "Controlled Substances Distribution, Storage, and Administration on Nursing Units," last revised 7/10, it lacks directions regarding how to properly dispose wasted narcotics (oral, parental, or topical).

-- Per interview with the Director of Pharmacy on 1/13/11 at 1:00 p.m., nurses are instructed to put the extra/wasted narcotics down the drain, not in the trash, not in the red sharps containers. He/she confirmed that the P&P does not give nursing specific instructions regarding how to dispose wasted controlled substances.

Based on findings from document review, in 1 of 5 medical records reviewed for accuracy in transcribing physician orders onto the patient medication administration record (MAR), pharmacy staff did not accurately transcribe a physician order for psychotropic/anxiolytic medications (Patient K).

Findings include:

-- Per review of the Physician's Orders form in the MR of Patient K, there is a telephone order on 12/27/10 at 10 p.m. for Haldol 5 mg and Benadryl 50 mg PO or IM (intramuscularly) q4hr (every 4 hours) PRN (as necessary) for agitation.

-- However, per review of Patient K's 12/29/10 MAR regarding PRN medications, which was printed by the pharmacy (verified by interview), it contained the following 4 single entries for the above noted physician order:
* Haloperidol 5 mg TAB (5 mg), DOSE: 5 mg PO Every 4 hours as needed PRN for agitation;
* Haloperidol 5 mg/ml vial (5 mg), DOSE: 5 mg (1 ml) IM Every 4 hours as needed PRN for agitation;
* Diphenhydramine HCL (Benadryl) 50 mg CAP (50 mg), DOSE: 50 mg. PO Every 4 hours as needed PRN for agitation; and .
* Diphenhydramine HCL (Benadryl) 50 mg/ml vial (50 mg), DOSE: 50 mg (1 ml) IM Every 4 hours as needed PRN for agitation.

There is no notation in the MAR pharmacy entries linking the administration of the Haldol and Benadryl medications as prescribed by the physician.

Based on findings from observations: 1) sections of the metal ceiling grid in the cafeteria were not clean and in good condition; 2) sections of the rooms comprising Central Sterile were not maintained in good repair and in a clean, sanitary manner; 3) clean supplies were being stored in an alcove across from elevator 3 on the third floor of Building B; 4) the sink in room 306 of the Mental Health Unit was not maintained in good repair; 5) the heat register in room 308 was not maintained in good condition; 6) the baseboard in room 318 was not in good repair; 7) the flooring in the nurse's station of the ICU was not maintained in good condition; 8) doors of rooms 5, 7, and 8 of the ED were not maintained in good condition; and 9) sinks in the medicine, Mental Health holding, and staff toilet rooms of the ED were not clean.

Findings include:

-- For 1) above, per observations at 2:10 p.m. on 1/11/11, sections of the metal drop ceiling grid located in the cafeteria where food is served were discolored and not maintained in good condition.

-- For 2) above, per observations at 2:35 p.m. on 1/11/11, gaps were present around the steam sterilizer in Central Sterile, connecting the dirty and clean areas. The ceiling in the soiled area of Central Sterile was coated with dust/lint, including several of the sprinkler heads.

-- For 3) above, per observations at 3:07 p.m. on 1/11/11, clean supplies (gauze, urinary bags, sponges, etc.) were being stored in an alcove across from elevator 3 on the third floor. The clean supplies were not stored in a sanitary manner that would prohibit the spread of infectious disease.

-- For 4) above, per observations at 9:00 a.m. on 1/12/11, the sink in room 306 of the Mental Health Unit was loose and not properly connected to the wall.

-- For 5) above, per observations at 9:05 a.m. on 1/12/11, the paint on the heat register in room 306 was peeling and not in good repair.

-- For 6) above, per observations at 9:10 a.m. on 1/12/11, the baseboard in room 318 was pulled away from the wall and was not in good repair.

-- For 7) above, per observations at 10:10 a.m. on 1/12/11, the flooring in the nurses' area of the ICU was partially missing and the floor was not easily cleanable.

-- For 8) above, per observations at 10:35 a.m. on 1/12/11, sections of the facing of doors to rooms 5, 7, and 8 were not in good repair and not easily cleanable.

-- For 9) above, per observations at 11:00 a.m., 11:20 a.m., and 11:25 a.m., respectively, the sinks in the medicine room, Mental Health holding room, and staff toilet of the ED were not maintained in a clean and sanitary manner.

-- During interview with the Director of Facilities Management, who was present throughout the survey, he/she verified and concurred with each of the above observations.

Based on findings from observations, in 5 of 5 extension clinics surveyed, the dirty utility rooms at each extension clinic lacked proper ventilation. Additionally, 4 of the 5 extension clinics lacked a clean utility room.

Findings include:

-- Per observations during tours of all 5 outpatient extension clinics on 1/11/11, i.e., Ogdensburg Health Center (OHC) at 9:45 a.m.; Waddington Health Center at 12 noon; Heuvelton Health Center at 1:30 p.m.; Canton Health & Diagnostic Center (CH&DC) at 2:00 p.m.; and Hammond Health Center at 3:45 p.m.., all sites lacked a fan to exhaust air from the dirty utility room that contained trash, dirty laundry, and used sharps containers. The Director of Community Relations and Planning was present at the time of the observations, and verified that the dirty utility rooms were not equipped with an exhaust fan.

Additionally, during the tours noted above, at the OHC site a clean utility room was observed but there was no fan to exhaust air. The remaining 4 extension clinic sites did not have clean utility rooms.

Based on findings from observations and interviews, in 2009 the hospital-wide infection control committee had only 1 meeting, and none of the 5 outpatient primary care locations were included in the hospital-wide infection control program. Additionally, equipment (i.e., patient showers) utilized in routine outpatient care were not cleaned after each patient use.

Findings include:

-- Per review of Infection Control Committee meeting minutes for 2009 and 2010, a meeting of the Infection Control Committee was held on 3/6/09. The next Infection Control Committee meeting was not held until 6/15/10.

During interview of the Infection Control Nurse (ICN) on 1/12/11 at 10:45 a.m., he/she verified the above finding.

-- During interview of the ICN on 1/13/11 at 11:15 a.m., he/she also verified that the 5 outpatient clinics were not part of the hospital-wide infection control surveillance.

-- During tour of the Ogdensburg Health Center outpatient clinic on 1/11/11 at 10:00 a.m., cleaning supplies for the patient showers were not observed.

-- Per interview of the Physical Therapist # 1 at this outpatient health center (that has a pool used for rehabilitative exercising) on 1/11/11 at 10:00 a.m., hospital staff do not clean the showers between patient use (as required by generally accepted standards of infection control practices).

Based on findings from document reviews and interview, the hospital's policy and procedure (P&P) for assuring procedures are performed on the correct site/side was not complete and did not comply with all requirements in the New York State Surgical Invasive Procedure Protocol (NYSSIPP), which establishes minimum standards of care in this matter in NYS. Also, the section of the hospital's operative consent form which addresses laterality was not completed correctly in 2 of 2 MRs reviewed for patients who underwent procedures involving laterality.

Findings include:

-- Per review of the hospital's P&P entitled "TIME OUT Universal Protocol Surgical/Invasive Procedures," last revised 12/07, it did not address all information required by NYSSIPP. For example, it did not describe all team members that are to be involved in the verification process and their role responsibilities. Additionally, the P&P lacked directions regarding when the laterality section of the consent form entitled "Permission for Operative and/or Diagnostic Procedure," last revised 10/05, is to be completed.

-- Per interview with the Nurse Manager of PACU on 1/11/11 at 11:00 a.m., the site/side section of the operative consents forms should be signed and dated by the surgical team members on the day of the patient's operation.

-- However, per review of Patient R's MR, the section of the Permission for Operative and/or Diagnostic Procedure consent form that addressed the preoperative surgery site/side verification check was signed and dated by the surgeon prior to the day of the procedure.

Also, per review of Patient S's MR, the section of the Permission for Operative and/or Diagnostic Procedure consent form that addressed the preoperative surgery site/side verification check was signed and dated by the surgeon prior to day of the procedure.

Based on findings from document reviews and interview, in 6 of 6 medical records (MRs) reviewed for patients undergoing a surgical procedure or electroconvulsive therapy (ECT), the informed consent form signed by the patient prior to the procedure was not complete (5 MRs) or the MR contained different consent forms for the same ECT procedure(s).

Findings include:

-- Per review of 5 MRs for patients who underwent surgical procedures, each contained a Permission for Operative and/or Diagnostic Procedure And/or Treatment consent form (the version last reviewed 10/05). These consent forms, for the following patients, lacked the information noted:

* Patient A - physician signature date
* Patient B - physician signature date
* Patient C - physician signature date
* Patient R - physician signature date
* Patient S - physician signature and signature date, anesthesia provider signature date.

Additionally, per review of the MR of Patient T, it contained 3 consent forms for ECT. Two of the forms were entitled "Consent for Electro-Convulsive Therapy, Anesthetics, and Other Services" - one of these forms was signed by the patient on 12/3/10 but not signed by the physician, the other form was partially completed but not signed and dated by the patient or the physician. The third form, entitled "Permission for Operative and/or Diagnostic Procedure and/or Treatment" contained information referencing the ECT procedure and was signed and dated 12/3/10 by the patient and the physician.

--During interview of the Nurse Manager of PACU on 1/11/11 at 11:00 a.m., he/she verified the findings above.

Based on findings from document reviews and interview, in 1 of 6 MRs reviewed, the hospital failed to ensure that a post anesthesia evaluation was completed for each patient.

Findings include:

-- Per review of Patient S's MR, he/she underwent a surgical procedure with anesthesia on 1/11/11. However, Patient S's MR lacked a post anesthesia evaluation prior to the patient's discharge.

-- During interview with the Nurse Manager of PACU on 1/11/11 at 11:45 a.m., the above finding was verified.

Based on findings from observations and interviews, the hospital has not assigned an individual to be responsible for outpatient services, and has not provided adequate oversight of those services. Further, the hospital has not defined in writing the qualifications and competencies necessary to direct the outpatient services.

Findings include:

-- Per observations upon entering the vestibule of the Hammond Health Center extension clinic on 1/11/11 at 3:45 p.m., the door to the clinic was locked even though the sign on the door indicated clinic hours were Monday through Thursday, 8 a.m. to 5 p.m. The receptionist answered the door after survey staff knocked a couple of times. When queried by the hospital's Director of Community Relations and Planning (who accompanied the surveyor), as to whether the clinic was closed, the receptionist responded "yes." However, when queried by the surveyor, Licensed Practical Nurse (LPN) #1 indicated he/she was given permission to leave early. When asked why the door was locked, LPN #1 indicated it sometimes locks on its own, but they were not closed.

-- Per interview with the Director of Community Relations and Planning on 1/11/11 at 9:45 a.m., the current plan for oversight of the hospital's outpatient extension clinics involved both the Vice President (VP) of Clinical Services and the VP of Patient Care Services overseeing the outpatient clinics.

-- Per interview with the VP of Patient Care Services on 1/13/11 at 11:30 a.m., he/she was unable to produce, upon request, written information regarding the qualifications and competencies necessary to direct the outpatient services. Further, when queried regarding the early closure and staff leaving at the Hammond Health Center extension clinic, he/she was unaware they were closing early on 1/11/11 at 3:45 p.m. Also, the staff had not requested time off as he/she would have arranged coverage for the LPN.

Based on findings from observations and interview, the pediatric supplies in the pediatric (Peds) crash cart in the emergency department (ED) contained multiple outdated supplies that were still available for patient use. Regardless, the monthly check list, which is signed when the ED Peds crash cart is checked for expired supplies, was signed for every month, indicating all supplies were complete and usable. Further, laryngoscope handles (used for intubation of patients) were not maintained in a sanitary and secure manner.

Findings include:

-- During tour of the ED on 1/12/11 at 9:30 a.m., while reviewing the monthly check list for the Peds crash cart, although it was signed monthly for the year 2010, the following expired supplies were noted on the cart as well as the cart check list:

* KY Jelly - expired 12/10

* Endotracheal Tube 8.9 mm - expired 9/10

* Endotracheal Tube .5 mm - expired 4/10

Also observed during the tour, on both the adult crash cart and the Peds crash cart, laryngoscope handles were uncovered (unsanitary) and unsecured on the tops of the carts. This haphazard manner of storing the handles could result in the laryngoscope handles not being available when needed emergently for intubation of a patient.

The above findings were verified during visual inspections of the ED crash carts at the time of the tour, by the Director of Compliance and Accreditation.

(The outdated supplies were immediately removed from the Peds crash cart.)

Based on findings from document review and interview, hospital staff did not ensure they were aware of all patients' advance directives. Specifically, in 1 of 3 medical records (MRs) reviewed for patients on the hospital's swing bed program, the patient's advance directives status was not documented.

Findings include:

--Per review of Patient U's MR, it lacked documentation indicating the patient was asked about his advance directives.

--During interview of the Director of Quality Management/ Performance Improvement on 1/12/11 at 11:50 a.m., he/she verified the above finding.