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Based on document reviews, interviews and observations, it was determined that the hospital did not obtain approval from New York State Department of Health licensing agency to provide or discontinue services as listed on the facility's Operating Certificate. Specifically, the facility did not obtain approval to provide services at 6 locations, discontinue services at 2 locations, and change location for 2 offsite premises.

Findings include:

1. The facility failed to provide a current operating certificate that lists current services at its main campus and at 3 offsite locations. During an interview conducted on May 24, 2010 at approximately 10:30 AM with the administrative staff, it was determined that the hospital provided Acute Renal Services at its primary location at 1980 Crompond Road, in Cortlandt Manor, NY 10567. During tours of the facility conducted on May 25 and 28, 2010, it was observed that patients were receiving dialysis at this location. However, the Operating Certificate does not list Acute Renal Services as a service provided at this location.

2. The administrative staff further stated during these interviews on May 24, 2010 that physical therapy and occupational services were being provided at Hopewell Junction, an offsite location at 822 Route 82, Hopewell Junction, New York 12533. During a tour of the premises on May 27, 2010 at 11:10 AM, it was observed that 2 patients were receiving physical therapy at this site. During staff interviews conducted with clinic staff at that time, it was revealed that occupational therapy was also being provided at this site. There was no Operating Certificate posted in the facility and the site is not listed on the hospital's Operating Certificate.

3. During tours conducted on May 26, 2010 at 2:15 PM, at 35 South Riverside Avenue at Croton-On-Hudson NY 10520, an offsite location, it was revealed that only radiological diagnostic and imaging services were being provided at this location. During interviews with the Administrator at this time, it was reported that rehabilitation services licensed at this site were no longer being provided at this site but those services were now being provided at 440 South Riverside Avenue, Croton - On -Hudson. Inspection of that site at 3:00 PM that day revealed that a patient was receiving physical therapy at this site. A photocopy of the Operating Certificate posted at the 35 South Riverside Avenue location was observed on a counter at this unapproved site.

4. The hospital's Operating Certificate lists physical therapy services were being provided at 87 Albany Post Road in Montrose, NY 10548. However, Staff #3 stated on May 27, 2010 at 9:25 AM that these services were no longer being provided at this location, but physical therapy was being provided at 2042 Albany Post Road, Springvale, NY 10520. This location is not listed on the hospital's Operating Certificate.

5. The hospital did not provide documented evidence that it followed the necessary steps to inform the State Agency when services were discontinued. A review of the hospital's Operating Certificate on May 24, 2010 at approximately 10:32 AM, revealed Diagnostic Services had been discontinued at the Primary Care Center at 225 Veterans Road, Yorktown, NY 10598. During interviews conducted at that time with the administrative staff, it was reported that services for radiology, physical therapy and a Diabetic Clinic were not being provided at the site. The current Operating Certificate incorrectly indicates primary care services are still being provided at the site. The facility was unable to provide evidence that closure plans for these services were submitted to New York State Department of Health as required.

6. Similarly, Staff #3 stated on May 24, 2010 at approximately 10:40 AM that Audiology and Speech Language Pathology services were not being provided at any offsite locations despite being listed on the hospital's Operating Certificate.

7. During interviews with Staff #3 on May 27, 2010 at 9:30 AM, it was reported that phlebotomy services were being provided at the Waterside Diagnostic Imaging site at Putnam Valley, NY 10579, and PT & Radiology Services at the Cold Spring, NY 10516 location. These services are unauthorized at these sites.

Based on document review and staff interviews, it was determined that the facility failed to provide the complainant written notification of the results of their complaints.

Findings include:

A review of 10 complaints on May 25, 2010 at 3:00 PM revealed that none of the complainants were given written responses to their complaints. During an interview at that time, Staff #2 stated that the facility does not provide written responses to the complainants.

Based on observations and staff interviews, it was determined the facility did not ensure that the Quality Assurance Improvement Indicators of the Environmental Services department were adequately measured, analyzed, and tracked quality indicators, and other aspects of performance that assess services and operations of the department.

Findings include:

A review of the Quality Assurance and Performance Improvement Program (QAPI) for 2009 reveals that the Environmental Services Department was required to submit data to the QAPI program. During interviews with Staff #24, on 5/27/10 at 11:30 AM, it was revealed that the Department was only monitoring patient satisfaction surveys as a means of judging the Department's effectiveness in keeping the facility clean. Staff #24 further stated that the Department was collecting data but was not analyzing or submitting findings to the QAPI program as required. Staff #s 24 and 25 stated that the contribution of the Department to quality assurance program was considered minimal; hence the data was not analyzed nor submitted to the QAPI program.

Based on medical record review, staff interviews and policy and procedure review, the registered nurses failed to indicate on the order sheet the date, time, and signature when an order was picked up, thus also failing to follow the hospital's policy. This was evident in 3 of 35 records reviewed. MR #s 21, 22 and 23.

Findings include:

1) Patient MR #21 was ordered by the physician: (a) on 5/18/10 at an unspecified time to discontinue Tylenol, (b) on 5/19/10 at 2:30 PM to have Sodium Chloride 0.45% 1,000 ml IV at the rate of 100 ml/hr discontinued, (c) on 5/18/10 at 1:00 PM stat MRCP was ordered for diagnosis of abnormal LFT's, and (d) a complete list of 5 pages of orders written by the physician upon the admission of the patient on 5/17/10 between 4:15 PM to 5:00 PM were not confirmed by the nurse as having been picked up. The orders were stamped with the words "FAXED". There was no date and time of pick-up and there was no nurse's signature indicating the orders were picked up by the nurse.

2) Patient MR #22 was ordered by the physician (a) on 5/17/10 at 8:00 PM to have Normal Saline at 100cc/hr among other orders, (b) on 5/17/10 at 12:18 AM to have blood cultures x 2 in AM, (c) on 5/18/10 at 10:00 AM to cancel invasive radiology procedure for today and (d) on 5/17/10 at 8:00 PM 4 pages of admission orders were written by the physician. None of the orders were picked up by the nurse. The pages on which the orders were written were stamped with the word "FAXED". There was neither date nor time when the orders were picked up. A nurse's signature was also not seen on any of the 5 pages of the faxed orders.

3) Patient MR #23 was admitted on 5/20/10. On 5/21/10 at 3:58 AM to 4:00 AM the physician wrote 4 pages of pre-printed admission orders. There was no evidence that a nurse picked up the orders. It was noted that the orders were "Faxed" on 5/21/10.

4) On 5/26/10 at 2:40 PM, Staff #5 was interviewed concerning the instances where nurses failed to pick up physician orders. Staff #5 stated that the pre-printed admission orders did not provide a space on the form for the nurses to acknowledge picking up the orders and that sometimes the Unit Secretaries affix the stamped "FAXED" on the orders, but the orders still require a nurse's signature, date, and time of pick-up.

5) A review of the facility's policy and procedure "Diagnostic and Therapeutic Orders, Policy # 04-6011-38.5, effective 2/09, revealed that paragraph 2 of the procedure states: "All Registered Nurses who enter physician orders into the Electronic Medical Record shall indicate on the order sheet the date, time and signature. Orders entered by Unit Secretaries shall be reviewed and co-signed by an RN".

6) The facility failed to ensure that the nursing staff indicate on the Physician Order Sheet the date, time and signature of nurses as required by policy when an order is picked up or entered into the EMR.

Based on observations, staff interviews, medical record and facility document reviews, the hospital failed to maintain a complete medical record for each patient, and to ensure the integrity and the security of all record entries. The medical records were not accurately written, promptly completed, properly filed and retained, and accessible.
This was evident in 3 of 35 medical records reviewed: MR # 25, 27, 31.

Findings include:

1) Patient MR # 31 was admitted on 5/18/10. The Braden score on 5/19/10 was 12. On 5/19/10 at 9:10 AM EDT, the patient was described as having wounds 1, 2, and 3. Wound 2 was described as having maceration around the rectum which was cleaned with soap and water and Sensicreme was applied. Wound 3 was described as having blanchable redness of the left Trochanter area and the patient required turning and positioning (T/P) with pillows. A review of the patient's medical record revealed that a position record was not maintained for the patient . During interviews conducted on May 26, 2010 at 10:30AM, Staff #19 revealed that a "Turning Rounds" document is maintained on the unit for all patients who require T/P. Staff # 19 further stated that the document is not a part of the medical record and is discarded after one month.
The facility failed to ensure that the patient's medical record contained documentation of the T/P every 2 hours.

2) Patient MR #25 was admitted on 5/17/10. On 5/18/10 at 10:00 AM, a wound assessment was done. The patient presented with multiple stage II ulcers on the right hip and a stage I ulcer of the sacral area. On 5/26/10, the patient's electronic medical record (EMR) and paper medical record were reviewed with Staff # 21 and it was revealed that:
a) The medical record did not have evidence of turning and positioning every 2 hours.
b) The medical record did not have evidence of physical therapy consult as required per policy.

3) Patient MR #27 was admitted on 5/21/10. On admission the patient was assessed to be a potential for skin breakdown with a Braden score of 16. A care plan was developed on 5/22/10 which included assisting the patient to turn and reposition. On 5/24/10, the patient was noted with a level II pressure ulcer of the sacrum.
A review of the patient's EMR, paper medical record, and care plan with Staff #21
revealed:
a) There was no record that the patient was assisted with positioning every 2 hours.
b) The care plan was not updated to reflect that there is a level II Pressure Ulcer as of 1744 hours on 5/24/10.
c) There was no request for a physical therapy evaluation, as required per "Pressure Ulcer Prevention Protocol" PUPP policy.

The facility policy (PUPP) for Stage II pressure ulcers requires that an order should be entered by the physician for PT evaluation.
On 5/26/10, the medical record for patient #27 was reviewed and the PUPP form could not be found in the medical record.
The nurse who made the observation of the pressure ulcer at 5:44 PM on 5/24/10 did not update the patient's care plan with the findings and did not document that the PUPP form was initiated.
On 5/26/10 Staff #22 stated that she observed the form in the patient's medical record on 5/25/10 but the form could have fallen out of the medical record.
The facility failed to ensure that the nurses initiate the PUPP form when a level II pressure ulcer is identified.

Based on observation and interviews, the hospital failed to ensure that medical records from the Methadone Outpatient clinic were properly secured and free from unauthorized access.

Findings include:

An observation made on 5/26/10 at 10:00 AM revealed that 5 file cabinets containing closed medical records were stored in a patient waiting area adjacent to a walkway which led to the exit. The cabinets were locked but were not in a secure area to prevent physical tampering by unauthorized individuals.

Interview with the Program Manager at that time revealed that the file cabinets contain closed files which have been there for 25 years.

Based on observation, interview and record review, the hospital failed to ensure that Methadone in the outpatient extension clinic was dispensed and administered in accordance with acceptable standards of Pharmacy practice.

Findings include:

1. Observations made on 5/26/10, from 10:15 AM to 11:15 AM, revealed that the nurse pre-poured Methadone diskettes and tablets. The diskettes and tablets are taken from the stock supply stored in the safe, and medications are then prepared from this supply. This practice is considered dispensing of medications.

2. During interview at that time, the nurse indicated that she counts 10 tablets of 40 mg Methadone diskettes and places them in 10 plastic cups with 10 tablets each, or 100 tablets total. Individual 5 mg Methadone tablets are stored in a dispenser. This supply of 40 and 5 mg Methadone tablets and diskettes are kept on the counter, while patients report to receive their medication. No labels are prepared to identify the individual dose for each patient arriving at the counter. When a patient appears at the window for his/her dose of Methadone, the nurse accesses the patient's name on the computer, which displays the dosage of Methadone to be given. The nurse then counts out the equivalent value of the dose in 40 and 5 mg tablets and places the tablets, diskettes in another plastic cup. Some 40 mg Diskettes are given in 1/4 and 1/2 tablets according to the nurse's calculation for that patient. These tablets have to be split as needed on the counter to obtain the required dose.

The tablets and diskettes that have been prepared for administration are then mixed with hot water, stirred and given to the patient to add additional water to cool, stir and then take while standing at the window. The patient does not acknowledge the dose to be taken in the cup, before mixing with water, and receives the medication already mixed with water at the window.

Medication for home use is prepared by putting the tablets and diskettes in a bottle, mixed with water, shaken and labeled with the dose and strength. The bottle is then given to the patient.

3. A review of the policies for the Administration of Methadone, and Procedure for Medication indicates that the nurse is to remove from the safe "an amount adequate for the day..." The nurse is therefore dispensing Methadone from this amount before actually administering the medication.

4. The current process for the dispensing and administration of Methadone was validated in an interview with the Pharmacy Director on 5/28/10, and preliminary plans to revise the process for these high risk medications were presented.

5. In addition a further review of the Policy and Procedure for Medication indicates that Medication Occurrences should be reported to the Nursing Supervisor, Administrative Director and Medical Director, but this policy excludes the Pharmacy Director. However, since the hospital operating certificate includes the Methadone Clinic as an extension clinic, pharmacy oversight is necessary by the Pharmacy Services Department.

Based on observations, the facility did not ensure that unusable drugs and biologicals were not available for patient use.

Findings Include:
1. An observation tour of the medical surgical units was conducted on 5/24/10 between 11:20 AM and 2:30 PM. The following observations were confirmed by Staff #7:
A) Bellinger Unit (3 West)
1) At 11:30 AM, it was noted in room 302 that the patient was receiving IV therapy. The IV line and 0.9 NS solution were not labeled.

B) Unit 3 East
1) A bottle of opened, undated 250cc 0.9 Sodium Chloride was noted in room 322 at 12:05 PM. Staff #14 also witnessed the observation.
2) On 5/24/10 at 12:10 PM, in room 340, the IV solution line was observed dated 5/20/10 to 5/23/10.
3) On 5/24/10 at 12:30 PM, in room 311, a bottle of IV 0.9 Normal Saline was noted hanging by the patient with the line dated 5/20 to 5/21.
4) At 2:30 PM during observation of the emergency cart, 1 opened tracheal tube was found in one of the drawers. Also at 2:21 PM, 1 uncovered yellow mouth gag was observed.

2. During observations at various lab locations, the following observations were made and confirmed by Staff #6 and #7:
A. Pre-admission Testing Lab.
1) On 5/25/10 at 10:20 AM, 1 blue top Vacutainer with the expiation date of 01/10 and a red and black top Vacutainer with the expiration date of 02/10 were found in a storage cabinet.
2) On 5/25/10 at 10:25 AM, 50 Microtainer with the expiration date of 03/2010 were found in the EKG room.
3) On 5/25/10 at 10:35 AM, 41 red top Vacutainer with the expiration date of 11/09 were found in the mobile Phlebotomist cart.

B. Microbiology Lab.
1) On 5/25/10 at 10:40 AM, a bottle of 1000cc of Sterile Water was found opened with no date.
2) On 5/25/10 at 10:41 AM, a bottle of 1000cc Normal Saline was found opened with a date of 5/19/10 written on the bottle.

C. Cytology Lab.
1) On 5/25/10 at 10:50 AM, a bottle of 1000cc Normal Saline was found opened with a date of 8/21/09 written on the bottle.
2) On 5/25/10 at 10:52 AM, a bottle of 1000cc of 0.9 Normal Saline was found opened with no date.

D. Histology Lab.
1) On 5/25/10 at 11: 00 AM, a bottle of 1000cc of Sterile Water was found opened with no date.
2) Lugol's Iodine Working Solution with the expiration date of 11/20/09 was found on 5/25/10 at 11:05 AM. Also found at the same time were Ether Acetone with the expiration date of 1/8/2010 and Crystal Violet with the expiration date of 1/23/2010.

Based on observation, staff interview and review of the dietary policy and procedures, the facility failed to provide dietary and food services in a sanitary manner:

Findings include:

During observation and inspection of the kitchen and food service areas conducted on 5/24/10 through 5/27/10, staff interview and review of the dietary policies and procedures manual, the following items were noted:

1. On 5/24/10, potentially hazardous cooked turkey breasts weighing greater than 8 pounds were not cooled by an adequate method to ensure that every part of the turkey breast reached the desirable temperature within the required timeframe. According to Staff #11, turkey breasts, weighing at least 8 pounds, were cooked on 5/23/10. On 5/24/10 at 11:45 AM, the turkey breasts were observed being cooled in the walk-in refrigerator. The temperature of the turkey breasts were 46?F.

Review of the Hospital's "HACCP Critical Control Point Daily Temperature Log" states, "Food must be cooled quickly from 140?F to 70?F within 2 hours and then to 40?F or below within an additional 4 hours (total cooling time 6 hours). "Corrective Action: Product that does not reach 40?F within 6 hours must be discarded."

Review of the Food and Nutrition policy entitled, "Food Storage," states that "Perishable foods are stored at the temperature ranges indicated." "Meat and Poultry "are to be stored at "35-38 degrees F."

2. On 5/25/10 at 1:30 PM, the operation of the "Low Temperature" dishwashing machine was observed. The current temperature of the final rinse cycle was observed to be below 120?F. According to the "Dishwashing/Warewashing Machine Temperature Log," which was posted in the dishwashing area, the temperature requirements for the rinse cycle for "Low Temperature" dishwashing machines is greater than 140?F and the chemical sanitizer requirements are at concentrations between 50-100 parts per million. Review of this temperature log for May 2010 showed recordings of rinse temperatures of less than 140?F in 17 out of 24 days.

At this time, Staff #11 used test strips to check the concentration of the sanitizing solution. The results of the test strips showed 0 ppm chlorine concentration of the sanitizing solution. Therefore, there was no method available to assure that adequate chemical concentrations were achieved to provide for proper sanitation of the dishwashing machine.

On 5/25/10 at 3:35 PM, the Ecolab representative made a service visit. According to the Ecolab report, the final rinse temperature gauge was broken and the part was ordered. The sanitizer system needed to be primed.

On 5/26/10 at 1:30 PM, the results of the test strips showed that the required 50 ppm chlorine concentration of the sanitizing solution was obtained.

3. On 5/24/10, the rubber gasket of the walk-in freezer was in need of repair.
4. On 5/24/10, clean pots, pans and coffee urns, being stored on shelves, were observed stacked, stored and wet and were not being properly air-dried.
5. On 5/24/10 at 12:15 PM, raw, fresh eggs were observed on the top shelf of a reach-in refrigerator in the cafeteria, above fresh salad items and prepared sandwiches.

Based on observations, staff interviews and document reviews, it was determined that the facility failed to maintain a safe, sanitary and comfortable environment to ensure that the safety and well-being of patients are not compromised.

Findings include:

1. During observations of the patient floors between 05/24/10 and 05/27/10 between 10:30 AM to 3:00 PM, it was noted that the heating units in patient rooms exhibited an accumulation of dirt and dust around the floor perimeters of the heating/air-conditioning units beneath their edges. Also, the grills/heating elements of some heating/air-conditioning units in patient rooms (such as room #333 on 3rd floor) exhibited an accumulation of dust, dirt, and excessive lint. Staff #29 stated at that time that the heating/air-conditioning units were on a quarterly preventive maintenance schedule. The PM for the heating/air-conditioning unit in room #333 was done on 04/2010 as indicated by the document 'Dual Temp Unit Filter PM Schedule', however at the time of survey, the unit was dirty.

All findings were verified with Staff #4 and Staff #29 at the time of observation.

2. During observations made from 05/24/10 and 05/27/10, it was noted that the exhaust ventilation vents in different areas of the facility were very dirty, which leads to environmental contamination. Examples include but are not limited to:
i) On 05/27/10 at 11:15 AM, it was noted that the ventilation exhaust grills in the Cardio Pulmonary Rehab suite (ground floor) were dirty with a thick, black accumulation of dirt.
ii) On 05/26/10 at 10:55 AM, it was noted that the breast feeding supply storage room in the Maternity suite had a heavily soiled/dirty vent immediately above the area where clean breast-feeding supplies were stored.

The findings were verified with Staff #4 and Staff #3 at the time of observation.

3. During observations made between 05/24/10 and 05/27/10, it was observed that several patient and visitor bathrooms on different floors of the hospital did not have the appropriate emergency nursing call bell pull cords as required by AIA 7.32.G2. The emergency pull cords were either short in length, were tied to a grab bar, or were bunched together. This practice does not provide easy access for patient safety.
Also, it was noted that the emergency call bell cords were covered with an accumulation of dirt. Examples include but are not limited to:

a) On 05/25/10 at 11:00 AM during survey of the Ambulatory Surgery unit, it was noted that the emergency nursing pull cords in the bathroom were very short, not providing easy access to a patient who might collapse on floor.
b) On 05/25/10 at 2:00 PM, during survey of the Emergency Department it was noted that the emergency nursing pull cord was very short, not providing easy access to a patient who might collapse on floor.
c) On 05/26/10 at 10:50 PM, during survey of the Maternity suite it was noted that in the patient room bathroom (such as 212, 218 and others) the emergency nursing call bell was missing the pull cord, thus not providing any access to a patient who might collapse on floor.
d) On 05/26/10 at 11:15 AM, during survey of the Maternity suite it was noted that the emergency nursing call bell cord in the bathroom of room #208 was very long and wrapped around the grab bar, thus not providing easy access to a patient who might collapse on floor.

The findings were verified with Staff #4 and Staff #3 at the time of observation.
4. During survey of the handicap accessible patient bathrooms in the facility, it was noted that:
a. The drain pipes underneath the handwashing sink were not protected/insulated to prevent patient leg contact against hot water pipes. (ADA 4.24.6);
b. The mirrors in patient handicap accessible bathrooms were mounted such that the bottom edge of the reflecting surface was more than 40 inches above the floor, and thus are not in compliance with ADA 4.19.6; and

5. During the survey of the facility, from 05/24/10 to 05/26/10, it was noted that many medicine/specimen and pantry refrigerators had ice/frost build- up/accumulation which indicated that they had not been defrosted. Examples, including but not limited to, are:

a) On 05/25/10 at 11:25 AM, during survey of the ED, it was noted that the refrigerator in the nourishment area was dirty, had a broken gasket and broken base. Furthermore, there was ice build-up in the freezer compartment.

b) During survey of the lab from 05/24/10 to 05/21/10 at 03:30 PM and 10:55 AM, it was noted that the various specimen refrigerators in the lab had excessive ice built up in the freezer compartment. One of the refrigerators was noted to have a broken handle exposing a sharp edge.

c) On 05/26/10 at 11:20 AM during tour of the Neonatal Intensive Care Unit, it was noted that the refrigerator/freezer used for the storage of breast milk had an excessive build-up of ice.

All findings were verified with Staff #4 and Staff #3.

6. During the survey from 05/24/10 to 05/27/10 from 10:30 AM to 4:00 PM, it was noted that the facility did not ensure that the environment around the premises, and the equipment used, were maintained in a sanitary condition and free of dust and dirt to prevent the transmission of infection and contamination.
Examples, including but not limited to, are:

a) On 05/27/10 at 11:15 AM, during tour of the Cardio Pulmonary Rehab suite (ground floor) it was noted that the exercise machines in the room and the pulley installed on the wall were dirty with a thick accumulation of dirt and dust.

b) On 05/26/10 at 11:30-12:00 PM, it was noted that the Labor and Delivery rooms in the Maternity suite had walls that were dirty with orange stains on the wall behind the bed, and by the trash cans. A black residue and dust marks were on various parts of the walls around the room. Furthermore, the base coving was missing from room #2 LDR.

c) On 05/25/10 at 2:15 PM, during the tour of the Emergency Department (ED), it was noted that on the floor by patient rooms (labeled as trauma 1, 2 and 3) there was an accumulation of dust and dirt around the corners and perimeters of the door, and floor. Excessive dirt was found around the floor at the site that was blocked off from the new/expanded ED construction site.

d) During the tour of the facility, it was noted that various electrical closets/Information Technology closets were dirty with dust on the floor and around the equipment, which may lead to environmental contamination.

e) The use of adhesive tape was found in many areas around the facility. Tapes were found stuck on stretchers, refrigerators, chairs/stretchers and other places. If tape and its sticky residues are not cleaned properly, they are a means of environmental cross-contamination.

All findings were verified with Staff #4 and Staff #3.

7. During the survey between 05/24/10 to 05/27/10, it was observed that several ceiling tiles on different floors of the hospital showed signs of old leaks. Examples include, but are not limited to:
a) On 05/21/10 at 12:30 PM, during observations of the ground floor near the Environmental Services department, three ceiling tiles were noted stained in the storage/supply room.

b) On 05/21/10 at 02:00 PM, two ceiling tiles were noted stained in the Central Sterile supply room. Also, two ceiling tiles were noted stained in the Decontamination room.

c) On 05/25/10 at 11:00 AM, one ceiling tile was noted very stained in the storage room (ex-terrace converted to the storage room) in the Ambulatory Surgery suite.

d) On 05/26/10 at 2:15 PM, it was noted that room #254 in the Progressive Care Unit had 4 ceiling tiles that were stained.

If ceiling tiles are not replaced and stay humid/wet, they may harbor the growth of mold/fungi and contribute to environmental contaminants. Also, stained ceiling tiles need to be investigated for potential leaks above, as it may be an indication of a problem with the plumbing/sprinkler system or of insufficient insulation around the steam pipes supplying heating to the facility.

All findings were verified with Staff #4 and Staff #3 at the time of observation.

8. During the survey from 5/24/10 - 5/28/10, it was noted that the facility did not ensure that the physical plant was kept in good repair to ensure a sanitary environment. Examples include:

a. On 05/25/10 at 12:00 PM, during the tour of the Ambulatory Surgical Suite, it was noted that nurse's station desk had exposed/chipped wooden edges.
b. On 05/26/10 at 10:55 AM, during the tour of the Maternity suite, it was noted that the walls in the storage room (which was used exclusively for breast feeding supplies) had holes/unfinished walls, exposing the structure underneath.

c. On 05/26/10 at 10:45 AM, it was noted that the janitorial closet, on the Maternity suite floor, had a portion of wall that was in disrepair.

d. On 05/21/10 at 12:45 PM, it was noted that the soiled utility room on the ground floor (near the environmental services department) had a portion of wall in disrepair.

All findings were verified with Staff #4 and Staff #3 at the time of observation.

9. During the survey of the Maternity Suite on 05/26/10 at 11:00 AM and Med/Surg unit of 2 West on 05/26/10 at 12:30 PM , it was noted that when a nurse call bell was elicited from a patient room, it did not register in the medication room, clean utility room, soiled utility room and other areas as per AIA 7.32.G1.

The findings were verified with Staff #3 and Staff #4 at the time of observation.

Based on observations, record reviews and staff interviews, it was determined that the facility failed to meet the applicable provisions of the Life Safety Code, NFPA 101, 2000 edition.

The findings include:

During the survey of the facility from May 24-28, 2010, Life Safety Code deficiencies were noted in multiple areas of the Code requirements and were cited under the following Fire/Life Safety Code K-Tags:

? K-29 (All hazardous areas not safeguarded by one hour construction or self-closures);
? K-50 (Fire drills not conducted under varying conditions and evaluated/critiqued);
? K-64 (Portable fire extinguishers installed above the required 5 feet/60 inches height);
? K-76 (Bulk storage oxygen not safeguarded per code)
? K-77 (Medical gases not maintained as per NFPA 99);
? K-104 (Penetrations in smoke/fire barrier not completely sealed/protected);
? K-130 (Fire plan not per NFPA 101);
? K-136 (Laboratory fire /emergency plan not comprehensive);
? K-141 (No-smoking signs not posted around the bulk oxygen storage);
? K-145 (Type I EES system branches not distributed as per NFPA 99);
? K-160 (Fire fighter recall feature installation could not be verified for all elevators serving the patients).

Based on observations made during the survey tour, it was determined that the facility did not ensure that all facilities/areas and equipment were maintained in such a way to ensure an acceptable level of safety and quality for both patients and staff.

The findings Include:

1. A broken cabinet handle was noted in the clean utility room in Bellinger unit at 11:45 AM on 5/24/10.

2. On 5/24/10 at 3:10 PM an equipment, Blanket Warmer, with an inspection date of 3/09 and a due date of 3/10 was observed in the Radiology department. Staff #16 witnessed the observation.

3. On 5/25/10 at 10:45 AM, a "GE Health Care Fluorescence Scope with an inspection date of 3/09 and due date of 1/10 was found in the Microbiology lab.

4. During survey of the facility from 05/24/10 to 05/27/10, it was noted that blanket warmers on different floors of the facility exhibited different readings between 120?F to 160?F. As per Staff #4, all the blanket warmers are from the same manufacturer. There was no temperature range posted on most of the blanket warmers and staff were unaware of the required temperature at which the blanket warmer should be maintained. To avoid any injury/burns to the patient, the temperature must be maintained at the required ranges as per the manufacturer's recommendation .

5. During survey of the facility from 05/24/10 to 05/27/10, it was noted that in various parts of the facility, Ambu bags and tubes/pipes were hung on the oxygen flow meter. This practice may lead to the oxygen flow meter getting broken/chipped or may lead to small gas leaks.

6. On 05/25/10 at 10:45 AM, during survey of the blood bank in the lab, it was noted that the eyewash area was obstructed by the presence of a microscope, slides and other similar supplies. Also, a stereo system/radio was installed adjacent to these items. The whole area was cluttered with supplies, making it vulnerable to cross contamination and creating inaccessibility to the eye wash.

7. On 05/27/10 at 11:45 AM, during the tour of the 3rd floor, Acute Renal Care service, Staff #28 was interviewed for the total amount of total chlorine/chloramine allowable in the feed water to make dialysate.

7.a.- Staff stated that he is only aware of the value to be zero (0).

7.b.- In the document, 'H2O Testing/ACDR record' for the month of May 2010 for machine #9, the values of total chlorine were noted to be written inconsistently as < 0.1, 0 or Negative. However, the log states that the total chlorine should be less than 0.1(< 0.1).

7.c.- Staff #28 was asked to show what strips/test method are used to check for total chlorine. The bottle of strips used to test total chlorine in water was 'Residual Chlorine -Tests for Level of residual chlorine in rinse water'. These strips are not the correct type of strips to test for total chlorine/chloramine in the water, since the values in the bottle start from 0, and the next reading is 0.5ppm. The test strip/equipment used for the total chlorine has to be either a qualitative or quantitative test, and staff must be able to read/interpret the reading to be less than or equal to 0.1ppm.

Staff #28 stated that he uses the same strips to check for residual chlorine after the disinfection of the machine with bleach to ensure no bleach is left in the machine. In regards to the question what is unacceptable total chlorine value, Staff #28 stated that anything that is little lighter than the 0.5 indicator in the bottle. When asked regarding the protocol if the total chlorine in the water becomes more than 0 mark, Staff #28 stated that he will keep rinsing the machine until the machine chlorine check becomes negative.
This finding was shared with the Director of Nursing.

(NOTE: Residual chlorine is different from total chlorine. The Residual chlorine test is used after disinfection of the machine and it is measured as negative or positive, whereas, total chlorine is the product of free chlorine and chloramine in water and if it reads more than 0.1ppm, then the patient cannot be treated, as a high total chlorine/chloramine water is deemed unsafe.)

8. On 05/28/10 at 12:30 PM, during document review of the preventive maintenance (PM) for the 5 dialysis machines in the facility, it was noted that the preventive maintenance checklists were not comprehensive and not completely filled out.
Missing information was as follows:
i) 4000 hour annual checklist states to 'Replace DIASAFE filter'. None of the checklist items (such as for machine #6 2kos-5653 dated 12/9/09) indicated when the DIASAFE filter was changed or if it is changed during every PM. There was only a check mark.
ii) The 4000 hour annual checklist provided no information regarding when the Deaeration brushes were replaced (which are supposed to be every 8000 hours). There was a check mark in all the K-machine checklist items, that did not provide any specific information.
iii) Under check conductivity calibration, and under temperature calibration, no information was provided to determine the value. It is important to document the value during PM so that if, during treatment, any problem occurs, it can be referred back to the last PM.
iv) The quarterly PM checklist for H-machines require 'Check temperature with external meter' and 'Check conductivity with external meter'. No values were written for either one.

9 (a). Light fixtures were not in working condition. Observations on May 24, 2010 at 11:45 AM noted that the pull cord for the light fixture in room 17 on the maternity unit was broken and was replaced with a Kling bandage. Furthermore, this poses a risk for infection, as the material connected in this manner does not allow for cleaning.

(b). The overhead light fixture in room 259 in the ICU on May 24, 2010 at 12:15 PM was not in working condition. This finding indicates a lack of sufficient lighting to perform patient assessments and evaluations.

(c). Similarly, in the ICU, light fixtures in room 254 were not functional on May 24, 2010 at approximately 12:25 PM.

Based on observation and staff interviews, it was determined that the facility did not ensure that proper humidity levels were provided and monitored in the ORs and that proper ventilation was provided to other areas of the building.

Findings include:

1.a.- During observations of the ORs on 05/25/10 at 12:00 PM, nursing staff was interviewed regarding how the temperature and humidity are monitored. Nursing staff stated that the engineering department was responsible for central monitoring and no monitoring was done in the OR itself before or during an operation. Staff #4 stated that ORS #1, 2, 3 and 4 are on an old system which cannot generate paperwork output and therefore no logging or trending is done for the values. Engineering staff is responsible to check on the computer and notify the surgical department if any discrepancies occur. Therefore, it could not be determined what temperature and humidity values are maintained, what the values are during surgery, if the values fluctuate during surgery, and how often they fall out of compliance.

1.b.- On 05/28/10 at 12:45 PM, Staff #29 provided the surveyor with a log indicating the humidity level of 78.4% in OR #1; 72.1% in OR #2; 73.7% in OR #3; and 72.4% in OR #4. These values were not in the range of 30-60% as per AIA Table 2. Staff #29 stated that he is aware and will look into bringing these values in compliance. Therefore, it could not be determined how often these values were not in compliance and if they fluctuated during surgery or not.

2. During the survey from 05/24/10 to 05/25/10, it was noted that non-patient areas that may contribute to infection control/contamination, did not have the required ventilation/air-pressure as per AIA 1996-97 Table 2.

Examples include, but are not limited to, the following:
a) On 05/21/10 at 12:45 PM, the soiled utility room on the ground floor near the environmental services department was noted to have positive air pressure.
b) On 05/21/10 at 01:45 PM, the housekeeping closet and the nutrition office on the ground floor did not exhibit the correct air pressure.
c) On 05/25/10 at 11:45 AM, during observatioin of the OR suite, it was noted that the clean utility room and the soiled utility room in the sterile core did not exhibit the correct air pressure.

Based on observations, it was determined that the facility failed to provide an optimum environment to prevent the spread of infections.

Findings include:

1. Infection control practices were not implemented, creating the potential for infections. Observations made on May 24, 2010 at approximately 12:15 PM, in room 259 in the ICU, revealed there was a suction tube lying on the floor which was connected to a suction container.

2. There was an open box with clean gloves stored on a shelf near to and above the handwashing sink near OR #1. This scenario poses a risk of contamination from splatters during handwashing.

3. In 2 of 2 ORs inspected, potential infection risk conditions were noted. On May 25, 2010 at 11:40 AM, it was observed that there were 4 Yankauer suction catheters without any packaging stored in the top drawer of the anesthesia cart in OR #1. None of the other contents of the drawer were clean or sterile. In addition, small scraps of paper was seen stored in the same drawer.

b. There were 2 Yankauer suction catheters in OR #5, unpackaged and stored in a drawer in the anesthesia cart on May 25, 2010, at approximately 11:48 AM.

4. The sharps container in OR #1 was touching the Ambu bag on May 25, 2010 at 11:40 AM.

5. At least 6 spots of dried red substance were observed on the medication return box which was attached to the medication cart (Omnicell). The sharps container with contaminated bloody syringes and needles was almost touching the medication cart. This was observed on May 25, 2010 at approximately 11:42 AM in OR #1.

6. On May 26, 2010 at 2:15 PM at the Medical Center at Croton , it was observed that the fabric chair was visibly soiled. The fabric does not allow for cleaning between patients, or as needed. Also, 2 objects made of Velcro material were being used to secure markers when mammograms are taken. This finding was verified by the Administrator at that time at this site.

7. See also citation at A724 item #9a.


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8. On 05/21/10 at 02:00 PM, during survey of the Central Sterile supply room, it was noted that the ceiling tiles in the room were porous/had holes that may retain dirt (they were not monolithic) and thus were not as per AIA 7.28.B8. Such porous ceiling tiles compromise thorough cleaning of the ceiling which is required to keep the environment of Central Sterile as clean/sterile as possible.

9 a. As per AIA 7.9.D22, at least one airborne infection isolation room should be provided complying with the requirements of Section 7.2 in the emergency department. Section 7.2.C4 states that 'air borne infection isolation room shall have self-closing devices on all room exit doors'. During the survey of the Emergency Department on 05/25/10 at 2:00 PM, it was noted that the facility does not have any one room designated to be an isolation room complying with all requirements of Section 7.2. Staff mentioned that three rooms in the Emergency Department are designed so that they can be converted into negative isolation rooms when not in use. It was noted that the mentioned three rooms that may be converted into isolation rooms did not have self-closure or self-closure mechanism installed at the exit sliding door.

b. Furthermore, as per AIA 7.2C1, at least one isolation room is required for the nursing/surgical unit (and more may be required as per the infection control committee). The facility has med/surg unit/beds on the second floor and third floor. As per interview with Staff #4, any room may be converted to negative isolation pressure room by putting in a portable HEPA filter. During observation of these units on 05/25/10, none of the rooms complied with all requirements of Section 7.2 for isolation room (such as self-closure at the door). The ceiling tiles were porous and were of such material, that they would not minimize the retention of dirt as required by 7.28.B8 and would not be thoroughly washable/cleanable.

(c) As per AIA 7.4.A6, an airborne infection isolation room is required in or near at least one level of nursery care. During the survey of the NICU on 05/26/10 at 11:30 AM, staff were unable to verify that the only isolation room present in NICU may be used for air borne isolation purposes. Furthermore, it was noted that the ceiling tiles in this isolation room were not of non-porous material as required by AIA 7.28.B8 for an airborne isolation room.

10. On 05/21/10 at 12:30 PM, during the survey of the Environmental Services department on the ground floor, it was noted that a room identified as a storage/supply room by Staff # 24 (the room was not labeled) had an abundant amount of clean supply (such as toilet rolls, paper towels and other such clean supplies) and dirty/used housekeeping supplies (such as floor waxing machine, which had been used; a janitorial bucket and other such items) stored in the same room. The floor of this clean supply was noted very dirty with an accumulation of dirt around its perimeters.

Based on observation and staff interviews, the facility Infection Control officer failed to ensure that there was an effective system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients.

Findings include:

1) A backpack belonging to a discharged patient was found on the floor in the clean storage room in Bellinger unit at 11:20 AM on 5/24/10. Staff #19 said it was waiting to be picked up by the patient. The infection control officer failed to ensure that the patient's personal item was not stored in the facility clean storage room. The personal item is a potential means of contamination for other clean items in storage.

2) One item of linen was noted on the floor next to the linen cart in the same clean storage area.