HospitalInspections.org

Based on review of documents and staff interviews, it was determined that the hospital did not monitor contractors of services provided in order to comply with all applicable Medicare Conditions of Participation and standards for contracted services.

Findings include:

The hospital did not fully comply with its procedures that require the annual monitoring of all contracts and for the ongoing amendment and renewals of contracts in accordance with its policies. The hospital did not implement a system that ensured the complete surveillance, updated tracking, and monitoring of the quality of each contracted service or agreement.

Review of the hospital's policy for Contracted Services on 2/3/2012, AD-130, found that there is a requirement for department heads to document an annual contracted services evaluation form and submit to the Department of Organizational Performance. In addition, the legal requirements include the execution ,amendment, and renewal of contracts in accordance with hospital procedure. Review of the contract binder found that annual contract services evaluations were completed for only 11 contracts but that the hospital has approximately 1400 contracts in effect.

It was determined at interview with hospital administrative and legal staff on 2/6/2012 that there are approximately 1391 contracts listed on a database maintained in the legal department. It was stated that the actual number of contracts in effect was an estimate. It was also stated that this database has not been cleaned and maintained with up to date tracking and follow up of each contract. It was stated the responsibility for contract monitoring is required by each department. Review of this list found that each entry noted the name of the contract, nature of service provided, and length of time contracts were in effect with expiration dates, where applicable. It was noted that many of the contracts and companies listed had lacked noted follow up as necessary. No review of the efficacy of each contracted service was evident in this listing.

Interview with QAPI staff on 2/3/12 found that while it was stated that the hospital did not monitor every contract, monitoring is conducted of direct patient care outcomes that are associated with each contract, and as required by the Joint Commission. However, as noted above, documentation of review of the contract performance was limited to 11 contracts.

Interview with the Director of HIM (Health Information Systems) on 2/3/12 found that the department utilizes three contracts for services, including Comprehensive Archives (storage), Healthport (copying and correspondence requests), and Softscripts (transcription services). No documented records of monitoring of the contractors were provided by the department. It was reported that the legal department monitors contract quality. There was no documented review of the contracted services in effect.

Based on review of medical records and interviews, it was determined that the facility did not effectively and consistently inform each patients (or patients' representatives) of patient's rights.
Findings include:
During the unit tour of K-7 (medicine unit) on 1/31/12 at approximately 11:20 AM, hospital staff, two patients and one patient's representative (family member) visiting were interviewed regarding how the facility informed patients/patients' representatives about patient's rights.
? The patient in RM 717-1 was interviewed on 1/31/12 at approximately 11:20 AM. This patient, a 63 year old, stated that she was admitted on 1/30/12 and she was expected to be discharged today (1/31/12). The patient reported that she was not given patient rights information, including the patient's rights package given to patients at admission.
? An attempt was made to interview the patient in RM 707-2. This patient was not an appropriate candidate for an interview due to his medical condition. The family member visiting stated that he did not know if patient's rights information was given to his father. This family member admitted that the information could have been given to his sister.
? Patient in RM 709-2 - This elderly Russian speaking patient was interviewed on 1/31/12, at bedside with an interpreter, at approximately 11:55 AM. This patient reported that she was given some papers at admission for her to read. With the patient's permission, this surveyor had the opportunity to examine the documents given to the patient. It was observed that the patient rights information was written in English. The patient reported that she did not speak English.
The hospital staff interviewed on 1/31/12 at approximately 11:34 AM reported that in this facility patient right's information is given to the patient at admission by the Patient Rep.

Review of MR # 1 noted that this 85 year old patient was admitted to the facility on 9/16/11. The document given to the patient by the Patient Rep was reviewed. This document indicated that the Patient Rep met with the patient and his daughter-in- law regarding Patient's Rights. A copy of the Bill of Rights was given and all questions were answered. This staff documented that the primary language was English.

? The Initial Nursing Assessment dated 9/16/11 indicated that the patient was Russian Speaking. The Interdisciplinary Patient Education indicated that education was done with the patient via a Russian interpreter. There was no documentation why the patient rights information was not provided to the patient in language that the patient could understand or why this was not necessary.
? It was noted that An Important Message from Medicare About your Rights (IM) form was not signed.

Based on observations, staff interviews, and review of procedures and records, it was determined that the facility failed to ensure the provision of a fully secure environment for mothers and newborns.
Specifically, one audible alarm that is integral to the electronic infant security monitoring system had failed to activate during an inspection conducted on 1/31/12.

Findings include:

Deficiencies were identified involving the ineffective operation and inadequate monitoring of the hospital's infant security alarm system responsible for protection of newborn infants located on maternal/infant units. This finding affects three maternity units and two newborn nurseries located on the third floor on separate building sections, which are accessible via an interconnected common corridor.

1. During two separate tours conducted on 1/31/2012 of the corridor that linked inpatient post-partum maternity-newborn infant units, it was found that one alarm associated with the hospital's electronic infant security system did not operate. Facility staff was unaware of this matter.
One component audible alarm did not activate during two inspection tests performed of the infant security system. This alarm was positioned proximal to elevators 9 and 10 near the entry to Gellman wing Radiology department and close to stairwell B. This alarm was located in a corridor linking three inpatient maternal infant units located on the third floor.
During the first tour conducted at approximately 1:10 PM on 1/31/12, the audible alarm positioned near the entrance to Gellman wing and stairwell B failed to activate.
Audible alarms rang at two nursing stations located on the post partum units in Kronish and Aron Building wings. However, the audible alarm in the Aron nursing station was of low volume and could only be identified at close proximity to the nursing station.
A second inspection was conducted of this system with two survey inspectors on 1/31/12 at approximately 2:45 PM. The Senior Vice President of the Facilities and Support Services accompanied staff and at that time the audible alarm located at Gellman entrance near stairwell B did not activate during the test as required. It was stated that this alarm should have activated. It was noted during testing that an alarm did initiate at the computer terminal in the Kronish building maternal child unit nursing station, but was inaudible from the elevator corridor. The visible and audible alarms connected to the system on the first floor did operate as required.
In addition, at the entrance of the Gellman Pavilion, located several feet from elevators (#s 9 and 10) in the Aron-Kronish corridor that connected all three maternal units, it was also noted the stairwell door B was not locked. Staff confirmed this exit door leads to the first floor and confirmed this door is not wired into the infant security alarm system. It was stated that this is a fire door and must remain unlocked. The doors along the corridor leading to two maternity units and newborn nurseries are not locked because it is stated there is much traffic in this area and movement of patients from units.
Interview with the VP of Facilities found the alarm near stairwell B should have activated and that while all other components of the system did operate, the manufacturer was called to repair the issue immediately. During follow up interview with the Senior Vice President of Facilities and Support Services on 2/1/12 at 10:40 AM, it was stated that the company's manufacturer was on-site and had identified a loose wire on the audible alarm near stairwell B, which was fixed.
Surveyors conducted a follow-up inspection and testing of the infant security alarm system on the third floor on 2/2/2012 at approximately 10:20 AM. The audible alarm proximal to stairwell B at the entrance to the Gellman did activate and was fully repaired. The VP of Facilities stated on interview that there was a disconnected loose wire which had been fixed. Review of the company repair record on 2/6/2012 found a service ticket for 2/1/12 that confirmed repair of a loose wire at the door controller for the identified problem.

2. The facility did not provide proper surveillance or monitoring of the infant security mechanical system in accordance with its policy titled, "Infant Protection System".
This policy mandates that the security supervisor will conduct a complete inspection of the Prosec system (manufacturer) on a daily basis and report any irregularities or problems to the Engineering Department.
When staff was queried to provide the monitoring records, the Assistant Director of Security had stated at interview on 2/6/12 at 11AM that while rounds are conducted by the staff no written records for the specific monitoring for infant security system were documented.

Based on interviews and the review of medical record, it was determined that Medical Staff failed to review reports of consultations to assure that all patient care needs are met.

Findings include:

Specific reference is made to two patients (MR # 2 and MR # 3) that required management by the Metabolic Support Service (MSS) for mild to severe nutritional depletion. The two records lacked documentation of physician acknowledgement and implementation of nutritional assessment and recommendations.

MR # 2, a 79 year-old male was admitted on 01/12/12 with multiple medical conditions including sepsis. The initial "Comprehensive Nutritional Assessment" of the patient completed on 01/13/12 by MSS revealed severe protein calorie malnutrition (PCM) as indicated by an albumin of 2.0 gm/dl. The patient was on Jevity 1.0 at 70 cc/hr x 24 hrs. MSS noted the formula was inappropriate for the patient secondary to elevated glucose possibly due to the treatments with steroid as patient was not diabetic. The plan recommended by MSS was to change tube feeding to Glucerna 1.2 at 30 cc/hr and increase goal rate to 65 cc/hr to provide 1560 Kcal, 78 Protein. Also, add Pro-stat 64, 30ml, twice daily to provide 30 gm of protein.

Follow up assessments by the MSS on 01/19/12, 01/24/12 and 01/30/12 revealed that the patient was maintained on Jevity 1.0 at 60 cc/hr and the patient was tolerating feeds with no residuals. During a tour of the unit on 01/31/12, the patient was on Jevity 1.0 at 60 cc/hr which provides a total of 1440 kcal. The recommendation for daily caloric intake of 1781 kcal, 74 gm protein and an additional 30 g protein from Pro-Stat was not implemented. The patient's albumin remained low at 2.4 gm/dl.


Examples: MR # 3, a 74 year-old female was admitted on 1/25/12 for evaluation of changes in mental status. The patient was orally intubated prior to admission secondary to respiratory failure. The initial comprehensive nutritional assessment on 1/25/12 showed that the patient was NPO with mild Protein Calorie Malnutrition (PCM) evidenced by Albumin 3.2 gm/dl. The recommendation by the Metabolic Support Service was for Glucerna 1.2 Cal at 30 cc/hr to reach a goal rate of 60 cc/hr x 20 hrs providing 1,440 Kcal daily.

A follow up assessment by MSS on 1/29/12 revealed tube feeding with Glucerna 1.2 at 35 cc/hr x 24 hrs was initiated on 1/25/12. The feeding received by the patient provides only 50 calories of protein and a total of 1000 kcal daily which was inadequate to meet the patient's calorie requirements. Recommendation was made by MSS to increase the rate of tube feeding to 50 cc/hr x 24 hrs which will provide 1440 calories. In addition, Pro-Stat 64 (liquid protein nutrition), 30ml, twice daily as patient's albumin had dropped to 2.5 gm/dl. Upon review of the medical record on 01/31/12, it was noted the patient was on Glucerna 1.2 at 50 cc/hr. However, the protein supplement recommended by MSS was not ordered by the medical staff responsible for the care of the patient.

At interview with an attending physician on 01/31/12, the physician stated that the patient had no medical conditions that would prevent the implementation of the MSS recommendation for increase protein intake.

Based on Record review, it was determined that the facility did not consistently ensure that the all nursing interventions and patient responses were properly documented. This finding was noted in two of three applicable medical records reviewed (MR # 4 & MR # 5)
Findings include:
While touring the unit (K-5) on 2/1/12 at approximately 10:45 AM, MR # 4 was reviewed. It was noted that on 1/28/2012 at 15:00 it was documentation that the patient was given 650 mg Acetaminophen (2 tabs). Review of the Medication Administration record noted that there was an order for Acetaminophen (ordered as Tylenol) on 1/28/12 at 13:38 every 4 hours, PRN for pain. The pain assessment entered in the medical record on 1/28/12 at 15:04 was reviewed. It was noted that the patient had pain in the right arm and the pain scale was 6. There was no documentation that there was a reassessment 4 hours after the intervention to determine if this intervention was effective. Continuing review of this record noted that the pain assessment/ intervention and pain scale were documented. However, the patient's responses to the interventions and reassessments after the interventions were not documented.

Similar findings noted for the patient in MR # 5. In addition, the pain assessment documented in this record on 1/18/12 at 06:45 indicated that the patient complained of pain but the pain scale was not documented.





27378



Based on medical record review, staff interviews and review of hospital policies, it was determined that nursing staff did not adhere to their hospital policy on pressure ulcer management.

Findings include:

Review of MR # 6 on 2/1/12 noted that an elderly patient was admitted to the hospital on 1/20/12 with a chief complaint of foot pain for two weeks. The Initial Nursing Assessment on 1/20/11 at 0035 noted a Braden Score of 12 which included a Nutrition Score of 1. The Nutrition Screen noted the patient had unintentional weight loss of 10 # or more. The "Start of Skin Assessment" documented by nursing stated that the patient currently has pressure ulcers and also a history of pressure ulcer. This information was not documented in the Nutrition Screen. A nutrition referral was not initiated in SCM. The hospital's policy states that if the nutrition part of the Braden score is less than 2 or if the patient has a pressure ulcer, a referral for nutrition intervention will be initiated in SCM. The hospital policy on nutrition referral was not followed.

Patient pressure ulcers were not documented by nursing in the Nutrition Screen neither was a nutrition referral sent to the Nutrition Department. Similar findings were noted in
MR # 7, # 8 and # 9.

Based on medical record review, staff interview and hospital policy, it was determined that the nutritional needs of patients with pressure ulcer were not addressed.

Findings include:

The Food and Nutrition Department did not have a Nutrition Protocol for Dietitians to follow when calculating the needs of patients with pressure ulcers at different stages.

1. Review of MR # 10 on 2/1/12 noted an elderly patient admitted on 1/17/12 with multiple pressure ulcers on the sacrum-stage III, Ischium left, unstageable, left foot, -unstageable and right foot unstageable). Nutrition assessment on 1/18/12 addressed the needs of the pressure ulcer however Nutrition Reassessment thereafter (1/22/12, and 1/26/12 at 12:30 PM) did not follow up on the status of these pressure ulcers.
The Nutrition Reassessments did not indicate the presence of the pressure ulcer, its current status or the additional nutrient needs necessary for the healing of these pressure ulcers.

The following medical records were observed to have similar findings:

2. MR # 11 (sacrum-stage II, Rt. Ankle-stage Unstageable, Rt. and Lt. heel-Unstageable). Nutrition reassessment on 1/29/12 did not address the pressure ulcer status or its current needs for healing.

3. MR # 8 (Lt. heel-stage III, LT. Buttock-Stage III). The Nutrition Reassessment on 1/24 was late and it did not address the patient ' s pressure ulcers.

4. MR # 12 (sacrum-Unstageable). Nutrition Reassessment did not note pressure ulcer status on 1/11/12, 1/17/12, 1/19/12, 1/20/12, 1/22/12, 1/26/12, and 1/30/12.

5. MR # 6 had a Lt. heel- stage III pressure ulcer. There was 2-Nutrition Assessment found by two different Dietitians on the same date- different times. One Nutrition Assessment on 1/20/12 at 11:00 does not note the patient ' s pressure ulcers. The second Nutritional Assessment on 1/20 was done by Metabolic Support which noted the patient's pressure ulcer however the Nutrition Reassessments that followed (1/21/12, 1/22/12, 1/23/12, 1/24/12, 1/25/12) did not mention the pressure ulcers or its current status.

Based on observation, document review and staff interview, it was determined that the facility did not maintain the hospital environment in such a manner that the safety and well-being of patients are assured.

Findings include

Gellman building - 4th floor:

1. There were 11 oxygen cylinders and 7 carbon dioxide cylinders stored next to the entrance door of the surgical holding area with a soiled linen cart and another clean linen cart. Storing the clean and soiled items together next to the oxygen cylinders imposes the risk of infection control and fire hazard.

2. The clean supply room on the 4th floor of the new building was observed to have one ceiling tile that was missing and two other ceiling tiles were observed to have holes.

3. The clean supplies were stored close to the ceiling tiles in the sprinklered room not leaving 18 inches as required. The storage of clean supplies near to the ceiling tile impend the function of the sprinkler.

4. The operating room #7 was observed to have a rusty and dirty IV stand.

5. The soiled utility room of the operating suite was observed to be very crowded with biohazard containers and the hand washing sink was blocked by those containers.

The Endoscopy Suite:
1. The decontamination room 129 C of the endoscopy suite was observed to have positive air flow instead of the required negative air flow. This is an infection control concern.

2. The breakdown room of the dialysis unit where the dialysis machines are serviced and disinfected was used for storing clean supplies. Storing clean supplies next to dialysis machines has a potential for spreading infection.

Gellman building - Second Floor:

1. On 2/1/2012 at 3:15 pm, during a tour of the second floor of Gellman building, it was observed that the floor of room 234 was dirty especially around the periphery of the room where the walls meet the floor.

2. The chute of the ice machine in the nourishment room 5251 was observed to leak water and the inside of the chute was not clean.

Also, the isolation room B 246 was noted to have a positive air pressure instead of the required negative air pressure.

Community Mental Health Building - 6th Floor:

During a tour of the inpatient units on the 6th and 4th floors of the Community Mental Health Building, the followings were identified in the presence of the Nurse Managers of the 6th floor and the Senior VP of facilities and Support Services who acknowledged the findings and promise to correct them.

1. Protruded screws of tooth brush holders were observed in all the patient bathrooms which is a potential of patient harm.

2. The paper towel holders in all the patient bathrooms were observed to be rectangular in shape, mounted to the walls at > 4 feet above the floor, firmly attached to the walls that enable them of holding >25 pounds and their metal covers were loose in many rooms. Those paper towels imposed a risk of looping hazard.

3. There were thermostats attached to the wall in many rooms of the 6th floor and they imposed a risk of looping.

4. The cord of the pay phone on the 6th floor was more than 3 feet long that could impose a looping hazard.

5. There were gaps between the handrails and the walls of the corridors and the hallways on the 6th and 4th floors. This is a looping hazard.

6. The soiled utility room of the 6th floor of the community mental health building was observed to have positive air flow instead of the required negative air flow for this type of room.

7. There were two open areas used by a secretary or a clerk on each of the 4th and 6th floors next to the elevator. Each open area (office) has a disk, many office supplies and other items on top of the disk and on shelves behind the disk. The secretary used areas that have small partitions that is <3 feet high and is completely open from one side. These areas are located on the hallway and in front of the elevator. These open areas/offices have a potential of being accessed by patients and therefore imposed a risk of self or other harm.

8. There was a printer plugged into an electric outlet on the corridor outside the soiled utility room of the psychiatric unit on the 6th floor. That printer was accessible to the patients.

9. There were some small flies observed on the psychiatric unit on the fourth floor of the Community Mental Health Building.

10. The hardware features of the handicapped bathroom had a shower head that was connected to a hose which was approximately 7 feet in length. Also, the rest of pluming fixtures did not have safety features and imposed a looping hazard.

11. The sprinkler heads on the psychiatric unit of the fourth floor was not of the safety type and imposed a risk of looping hazard.

12. There were three fire alarm bells on the psychiatric unit on the fourth floor
that are mounted on the wall leaving gaps between the bells and the wall of approximately two inches which has a potential of looping.

Kitchen:
During a tour of the kitchen on the afternoon of 2/2/2012, it was noted that refrigerator #50 had a temperature of 50.4 F and was rechecked after 30 minutes later and found to have a temperature of 53 F. It should be noted that that the temperature exceeds the temperature requirement for safe food as set by the CDC guidelines and per the facility policy and procedure.

Emergency Department (ED):

During a tour of the emergency department (ED) on the morning of 2/3/2012, the followings were identified in the presence of the Senior VP of facilities and Support Services and other members of the hospital staff who acknowledged the deficiencies and promised to correct them:

1. The isolation room # 38 was observed to have a positive air pressure instead of the required negative air pressure for this type of room.

2. The nursing call bell of the pediatric bathroom did not have an audible alarm at the nursing station.

3. A huge garbage container exceeding 100 gallon in capacity was noted to be stored at the back of the ED- Kronish stair B (Basement). Storage of containers that exceed 32 gallons outside a room of 1 hour fire rated walls is a fire hazard.

4. The men and women handicapped restrooms on the adult ED were found lacking audible nursing calls and they did not annunciate any alarm at the nursing station or elsewhere.

5. The nursing call bell at patient Bay 7 of the adult ED did not work.

6. Three huge containers (each one was 6 ft x 5 ft x 3 ft in diameter) of clean linen were noted to be stored in front of the staff lounge room. This is a potential of fire hazard.

7. 16 medium sized oxygen cylinders and one big oxygen cylinder were stored at the ambulance entrance door of the ED. This is a potential for fire hazard.

Central Sterile Supply:

1. In the central sterile supply area on 2/3/2012 at 12 20 PM, the following was noted.The decontamination room did not have negative air pressure in relation to the vestibule of the central sterile supply.

2.There were two sinks in the decontamination area used for washing instrument and there was no hand washing sink for the staff to wash hands.

3.There were penetrations that lacks fire stop in the electric closet of Kronish Basement.


Labor and Delivery Department (LDR):

11 oxygen cylinders were stored in the corridor of the LDR outside the environmental closet. Storing oxygen cylinders in this area has a potential of fire hazard and infection control problem.

Based on unit tours, patients review of medical records, Patients' Grievance file and interviews, it was determined that the facility did not consistently ensure that discharge plan requirements were met. This finding was noted in six of seventeen applicable medical records reviewed.
Findings include:
1. During the unit tour K-7 on 1/31/12 at approximately 2:30 PM, the staff reported that the patient in MR # 13 was to be discharged today (1/31/12).

Review of MR # 13 noted that this 82 year old patient was brought to the facility from home by ambulance on 1/26/2012 at 23:59. The chief complaint was general weakness and unable to ambulate x 3 hours. The nursing initial assessment dated 1/27/12 indicated that the patient had no home care services prior to admission. The nursing initial assessment was contradictory to the Case Management initial assessment dated 1/28/2012 which indicated that the patient had home care services prior to admission but the patient did not recall the agency.

The Social Work Assistant (SWA) noted that discharge options were discussed with the patient. It was noted that the options discussed with the patient were not documented. The SWA indicated that the patient did not have any discharge needs and the discharge plan was to return to prior home (convent). SWA also noted that the patient was unsure who will assess her when she returns to the convent. The initial discharge evaluation was inaccurate as the patient did have discharge needs. This patient was admitted with new onset of the inability to walk. This issue was mentioned but not addressed in this assessment.

An incomplete transfer form was located in the record. The Case Management documentation regarding the facility where the patient would be transferred to was not located in the record on 1/31/12 at approximately 3:30 PM.

MR # 13 was re-reviewed on 2/1/12 at 9:00 AM. It was noted that the copy of the
transfer form dated 1/31/12 indicated that the patient was transferred to Lutheran Rehab. It
was documented on this form that the staff and family were aware of the discharge. It was unclear when the patient's / patient's representative was made aware of this discharge plan.
The case management reassessment note dated 1/30/201 at 12:11 indicated that "on
discharge the patient will go to Maria Regina Residence". The discharge reassessment did
not include if there was a discussion with the patient / patient's representative regarding
the process and the selection of rehabilitation placement. On 1/31/2012 at 17:05, the patient
was discharged to Lutheran Augustana Center for Extended Care & Rehab. The final
discharge evaluation did not include when the discharge plan was changed from Maria Regina
Residence to Lutheran Augustana. It was noted that the determination was made and
the patient's representative was informed of the placement after the selection.

2. During the unit tour of K-5 (Med unit) at approximately 10:30 AM, the patient in RM 509-1 was interviewed. The patient reported that she was scheduled for discharge and she was packed and ready to go home. The patient reported that she was having difficulties walking "wobbling". The patient reported that although she lives with her daughter she is alone during the day and she will need some assistance at home. When inquired if the hospital staff assisted in discharge planning, the patient reported that she met with someone from the Case Management Department a few days ago. The patient produced a document stating that the staff gave her this document and the staff's business card. The patient reported that she was waiting for clarification and information regarding the request for home care services. Upon reviewing this document, it was noted that this was information on Home Care Provides. It was also observed that three agencies were highlighted. The patient reported that the document was received already highlighted.

Review of MR # 14 noted that this 54 year old patient with medical history included Breast cancer, hyperlipemia, and hypertension was sent from cancer clinic because of fluids in her lungs. The patient was admitted on 1/24/12.

The Case Management Initial Assessment dated 1/26/12 at 12:25 was reviewed. The SWA noted that the patient stated that she needed assistance with her daily living activities. The SWA noted that the patient was provided with list of home care. There was no documentation that the process of obtaining this requested service was fully explained to the patient. There was no documentation that the patient was educated on how to choose from the home care list.

While reviewing the record, the MD placed his final note in the record. He stated that the patient was to be discharged today with home care services.

The surveyor left the unit on 2/1/12 at approximately 1:00 PM. It was observed that the case management staff had not seen the patient to discuss the final discharge plan.

MR # 14 was reviewed on 2/2/1 at approximately 9:30 AM. It noted that the Case Management final discharge disposition dated 2/1/201 at 16:43 indicated that the patient was discharged with home care services from First to Care Home Care Agency. The SWA documented "patient to be discharged today First to Care accepted case for RN ". It was noted that although it was documented that the patient had difficulties with her gait the final discharge assessment did not address this issue. There was no documentation that the patient had a Physical Therapy evaluation or why this was not necessary. There was no physician's order for Physical Therapy/Rehabilitation evaluation or why this was not necessary.

The Patient's Discharge Note/Plan form dated 2/1/2012 was reviewed. It was noted that the follow-up care was for Hematologist as outpatient. There was no appointment for a hematologist appointment located on the form or documentation why this was not required.

3. During the unit tour K-5 on 2/1/12 at approximately 10:45 AM, the patient in room 511- was interviewed. The patient spoke limited English. He stated he was to be discharged waiting on his wife to pick him up. The staff interviewed reported that the patient's name was on the list for discharge today (2/1/12).

Review MR # 4 noted that this 77 year old Russian patient with history of hypertension, CAD, Hypertension, COPD, arthritis and Gout was admitted on 1/26/2011 with chief complaint of fever and RUE joint pain with spreading cellulites.
It was noted that there was an anticipated discharge order dated 1/31/12 for discharge on 2/1/12. However, a blank Home Health Face-to-Face Encounter Certification form requiring medical staff completion was still in the record during this chart review.

The Case Management Initial Assessment dated 1/28/2011 indicated that prior to admission the patient had home care services with Revival Home Health Care.

On 2/1/2012, SWA noted a faxed letter of responsibility for Infusion Therapy as requested by Revival Home Care pending attending to complete Face to Face Certification form for home care.

Final Discharge Disposition- the Case management dated 2/1/2012 noted that the patient will be discharged today. The patient was referred back to revival as requested. The final disposition was dated 2/1/2012 at 17:09 (5:09 PM). It was noted that the discharge services was not finalized unit the day of discharge after 5 PM. It was noted that the
patient's home care agency was not given a 24 hours notice of the patient's discharge as required.

4. Review of MR # 15 on 2/2/12 noted that the patient 80 year old patient was admitted to the facility on 10/22/2011 and discharged on 10/31/2011. The chief complaint was withdrawal from "ambient ". Past history included chronic anemia, DVT, (B) cataracts, seizure disorder, anxiety, arthritis, depression, and dementia. It was noted that the patient had a Physical Therapy (PT) evaluation on 10/22/11. The PT assessment indicated that the patient may benefit from a skilled nursing placement.

The initial Case Management Assessment dated 10/24/2011 at 18:01 indicated that the discharge options was home with self care. This assessment did not address the PT evaluation and recommendation that the patient would benefit from a skilled nursing facility placement.

On 10/28/2011 at 11:40, the case management reassessment indicated that the patient was not stable for discharge and that the patient will be followed to determine discharge needs of homecare vs. SNF.

On 10/31/11 at 16:20, Case Management Final Discharge disposition: - " Home care related to admitting diagnosis (HHD), certified homed health agency - visiting nurse service; VNS not FTC " . This assessment did not address the patient's functioning or reason why discharge to home was appropriate for the patient. The discharge needs and services provided by this agency were not included in the assessment. Finally, the documentation did not indicate if the patient was given choice of home care services.

Review of Grievance file for the patient in MR # 16 noted that the patient's daughter filed a grievance with the facility regarding her mother's discharge from this facility on 11/28/2011.

5. Review of MR # 16 on 2/2/12 noted that this 86 year old female with past history of CAD, hypertension, diabetes and blindness was admitted to the facility on 11/21/2011 and discharged on 11/28/2011. The discharge plan dated 11/23/2011 indicated that discharge option was home self care. The SWA noted that the patient appeared alert oriented, blind. SWA noted that the patient lived with her daughter used a cane and she had private home care from Depart of Aging M-F 9-1. The type of home care services was not documented.

The patient had a Physical Therapy (PT) evaluation on 11/25/11. The PT assessment indicated that the patient would benefit from PT. There was no documentation that the patient had a PT reassessment after 11/25/11.
On 11/25/11, the SWA noted patient refused rehab. The dated and time when the treating team recommended rehab placement for the patient was not located in the medical record. There was no documentation that the benefits rehab vs. home care services were fully explained to the patient. On 11/28/11, SWA noted that the patient was discharged today. Patient agreed with the plan. There was no documentation when the home care services will be initiated. The discharge plan assessment did not include the patient ' s discharge needs and the approved services by the home care agency. The discharge assessment did not include if the patient ' s daughter caregiver was able to care for the patient at home when the home care services not available. The documentation did not include if durable medical equipment request by the patient was provided.
The facility's investigation concluded that "after meeting with our Case Management Team, we were confident that all potential services were discussed prior to discharge".

This reviewer was unable to determine if this was accurate.

Review of Grievance File for this patient in MR # 17 noted that this patient filed a grievance with the facility on 1/9/2012 while in the hospital regarding her discharge. In this grievance, she alleged that the reason why she remained in the hospital was because she lived by her self and she did not have anyone to help her at home.

6. Review of MR #17 noted that this 68 year old patient with history of history of CHF, HTN, DM, and ESRD was admitted on 1/6/12 chief complaint difficulty breathing. The initial Nursing Assistance indicated that the patient needed assistance transfers and used assistive device for ambulation. The Case Management initial assessment dated 1/7/12 at 17:07 indicated that the patient resided alone in a 3rd floor walked u apartment. The SWA noted that the patient reported having home care services with Partners in Care.

On 1/9/12, the MD noted that the patient was medically stable for discharge to follow up as an outpatient.
On 1/10/12 at 11:45 AM, the MD noted that the patient OK for discharge seems reluctant to go home for unclear.

There was no documentation that the patient was referred to Social Service Department for an evaluation in order to determine the reasons the patient was reluctant to be discharged.
On 1/11/12 at 12:00 PM, the Nurse noted that the patient was given a 24 hours discharge notice for discharge tomorrow. It was noted that the signed second copy of an Important Message from Medicare about Rights form and signed by the patient was not located in the record.

Final discharge disposition dated 1/13/2012 at 10:31 indicated that the patient was discharged home on 1/12/12. Visiting Nurse of New York will reinstate Visiting Nurse and Home Health Aide. It was noted that this documentation was dated the day after the patient was discharged. There was no explanation that although prior to admission the patient had services with Partners in Care home care services but VNS was reinstating the home care services.

Based on review of records and procedures, it was determined the hospital did not consistently reassess discharge plans for patients in order to fully address risk factors and resolve safety needs prior to discharge.

Specific reference is made to 2 of 10 postpartum maternal and newborn records reviewed for patients with active Child Protection Agency (ACS) cases .

Findings include:

MR # 18, a 16 year old adolescent mother and newborn with an active ACS case were released to home on 12/26/11, prior to obtaining written confirmation of appropriate clearance from the ACS worker who followed the patient in the community.
In addition, confidential information was provided regarding the ACS case to the mother of the baby's father without documented evidence for authorized release of information.

The hospital social worker contacted an Emergency Child Services manager who had no direct knowledge of the case. This worker provided only verbal clearance to the hospital social worker indicating that the newborn could be discharged as there was no legal hold on the baby.

While the maternal grandmother had reportedly advised the hospital social worker of prospective upcoming visit by ACS, this finding was not confirmed with the assigned ACS worker who was most familiar with the case. Only a telephone message was left with the assigned ACS worker to advise of discharge on 12/26/11. In addition, the hospital social worker contacted the State Central Register and reported the birth of the infant and requested the information be added to the already open case file.

The mother and baby were discharged home without obtaining appropriate child protective agency clearance. Direct contact with ACS staff most familiar with this case was warranted since the reported past allegation included conflicting information, including truancy and alleged corporal punishment by the maternal grandmother. In addition, the record noted that the name and telephone number of the assigned ACS worker was provided to the maternal grandmother for future reference.

MR # 19: This record for a 33 year old postpartum mother with 7 children, who was known to have an active ACS case, was discharged home with the newborn on 1/23/12 without any documentation of appropriate social clearance. The psychosocial assessment dated 1/22/12 attributed the case to truancy of an 11 year old daughter. The worker noted a plan to refer the case to Maternal/Child Health to follow up on the case to inform ACS of the birth of the child. There was no documented follow up contact with ACS staff, in order to confirm clearance and to verify that safety needs were met .

At interview with the Case Management on 2/3/12, it was reported there is a process in place for ACS staff to notify the hospital of patients/families with active ACS cases.

However, review of the written procedures for Child Abuse on 2/6/12 finds that once a report is made to the SCR, that the patient may not be discharged pending a disposition with the local child protective agency. The hospital did not conform to its policy for Discharge of Minors, which mandates discharge to ACS approved person or guardian and which includes "social work note placed in the infant's medical chart and proper documentation provided".