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Based on findings from document reviews and interview, the hospital's policy regarding medication administrations was not consistent with generally accepted standards of nursing practice. Specifically, the medication administration policy lacked a requirement for nursing staff to document anatomical injection sites of medications administered, on the Medication Administration Record (MAR).

Findings include:

-- Per review of the hospital's policy entitled "Medication Administration," last revised 03/09, it does not require nursing staff to document anatomical injection sites on the MAR.

-- During interview of Medical - Surgical Nurse Manager #1 on 4/28/10 at 11:45 a.m., he/she stated that nursing staff do not document injection sites on the MAR and verified that hospital policy does not require it.

Documentation of injection sites is necessary to insure that anatomical site rotation occurs, to avoid the potential complications of inadvertent repeated injections at the same site.

Based on findings from document reviews and interview, in 2 of 6 medical records (MRs) reviewed on the psychiatric units, medical staff orders for anxiolytic and antipsychotic medications did not provide nursing staff with clear parameters regarding how to determine which one of multiple medications, written for the same PRN (as needed) purpose, should be administered to the patient.

Findings include:

-- Per review of the Prescriber's Order Form in the MR of Patient A, who was admitted with Episodic Mood Disorder, it contains a signed telephone order on 4/16/10 at 02:30 a.m. for Geodon 20 mg IM BID (twice a day) PRN for agitation, and a signed telephone order at 5:29 p.m. for Haldol 5 mg po Q(every) 4 hrs PRN for agitation.

Per review of Patient A's Medication Administration Records (MARs) for PRN medications, on 4/16/10 Patient A received Geodon 20 mg IM at 2:57 a.m. and again at 6:44 p.m., for agitation. In the meantime, at 5:52 p.m. that day, Patient A had already received Haldol 5 mg po (by mouth) for agitation. Also, in each instance, the nursing documentation does not indicate why the particular medication administered was chosen.

-- Per review of the Prescriber's Order Form in the MR of Patient B, who was admitted with Bipolar Disorder, it contains signed orders on 4/21/10 at 10 a.m. for Haldol 5mg IM PRN Q4hrs for severe agitation, Lorazepam 2 mg po PRN Q4hrs for anxiety, and Lorazepam 2 mg IM PRN Q4hrs for severe anxiety/agitation "and with Haldol IM injection."

-- During interview with Psychiatric Nurse Manager #1 on 4/28/10 at 10:55 a.m., when asked about a patient's anxiety/ agitation and measuring the severity of the anxiety or agitation, he/she noted that anxiety occurs before agitation. The hospital does not have any type of measurement tool or scale for the nursing staff to use to determine a patient's level of anxiety or agitation (mild, moderate, severe); the nursing staff individually decide the level, and then the medication and route that should be administered.

Based on findings from observations and interviews, the hospital does not consistently provide secure areas for its medical records. Specifically, medical records were stored in an unsecured area, accessible to unauthorized individuals at both of the two hospital sites.

Findings include:

-- Per observations during a tour of Binghamton General Hospital (BGH) on 4/29/10 at 1:00 p.m., the door to the medical records storage area was not locked. Upon entry into the room, medical records were unsecured and accessible. Additionally, no staff presented themselves until several minutes after the surveyor's entry into the room.

-- During interview with Director of Nursing #1 at BGH on 4/29/10 at 1:20 p.m., he/she verified the above findings during the tour.

-- Per observations during a tour of the Wilson Medical Center on 4/29/10 at 3:30 p.m., the door to the medical records storage area was propped open and not locked. Upon entry into the room, medical records were unsecured and accessible. Additionally, staff were located several feet away from the entrance and would not be able to see unauthorized individuals entering and accessing a medical record.

-- During interview with the Director of Health Information Management on 4/29/10 at 4:00 p.m., he/she verified the above findings during the tour.

Based on findings from document reviews and interviews, physicians' signatures were illegible in 4 out of 7 medical records (MRs) reviewed.

Findings include:

-- During MR reviews on the psychiatric inpatient units at the Binghamton General Hospital site, in 3 out of 6 MRs reviewed, 3 physicians' signatures on the Physician's Order Forms were not legible (and the name was not also printed).

-- During interview with Psychiatric Nurse Manager #1 on 4/28/10 at 11:00 a.m., he/she verified the above findings.

-- During MR reviews in the Neonatal Intensive Care Unit (NICU) at the Wilson Medical Center, in 1 out of 1 MR reviewed, 2 physicians' signatures on the Physician's Order Form were not legible (and the names were not also printed).

-- During interview with NICU Nurse Manager #1 on 4/30/10 at 3:00 p.m., he/she verified the above findings.

Based on findings from document reviews and interviews, in 8 of 23 medical records (MRs) reviewed, verbal orders given by practitioners were not authenticated (signed) within 48 hours.

Findings include:

-- Per MR review on 4/28/10 at 10:45 a.m., Patient A's MR contained a verbal order obtained on 4/16/10 for Haldol 5 mg po (oral) Q4hrs (every 4 hours) PRN (as needed) for agitation, which was still not signed by the practitioner 12 days later.

-- Per MR review on 4/28/10 at 11:45 a.m., Patient C's MR contained a verbal order obtained on 4/20/10 at 1:55 a.m. to hold intravenous (IV) fluid until further notice, and to obtain portable chest x-ray the following morning, which still was not signed by the practitioner 8 days later. Additionally, there were 2 other verbal orders obtained for Patient C on 4/22/10 that were still not signed by the practitioner 6 days later.

-- Per MR review on 4/29/10 at 4 p.m., Patient D's MR contained a verbal order obtained on 4/15/10 at 1:45 p.m. for Normal Saline at 100 ml per hour for 2 liters, which was still not signed by the practitioner 12 days later. A verbal order written on 4/16/10 at 12:46 p.m. for Zofran 4 mg sublingual 4 times daily as needed for nausea, was also still not signed by the practitioner 13 days later.

-- Per MR review on 4/29/10 at 12:30 p.m., Patient E's MR contained a verbal order obtained on 4/23/10 at 10:00 a.m. to change Vancomycin to 1 gram IV Q12hrs and obtain Vancomycin peak and trough levels with 4th dose, which still was not signed by the practitioner 6 days later. Additionally, there were 5 other verbal orders obtained for Patient E on 4/23/10 that were also still not signed by the practitioner.

-- Per MR review on 4/29/10 at 9:20 a.m., Patient F's MR contained a verbal order obtained on 4/21/10 at 11:20 a.m. to discontinue Ultram, which still was not signed by the practitioner 8 days later. Additionally, there were 2 other verbal orders obtained on 4/24/10 that were also not signed.

--Per MR review on 4/29/10 at 9:20 a.m., Patient G's MR contained a verbal order obtained on 4/22/10 at 8:55 p.m. for one physician to consult with another physician the following morning regarding Heparin. This order was still not signed by the practitioner 7 days later.

-- Per MR review on 4/30/10 at 2 p.m., Patient H's MR contained a verbal order obtained on 4/19/10 at 7:15 a.m. that stated "May obtain Vanco trough via fingerstick," which still was not signed by the practitioner 11 days later. Additionally, there were 2 other verbal orders obtained for Patient H on 4/19/10 and 4/20/10 that were also not signed by the practitioner.

--Per MR review on 4/28/10 at 11:00 a.m., Patient I's MR contained a verbal order obtained on 4/21/10 at 9:48 p.m. for Zofran 4 mg IV Q6hrs PRN, which still was not signed by the practitioner 5 days later. Additionally, there were 5 verbal orders obtained on 4/21/10 and 4/22/10 for Patient I that were also not signed.

-- Per interview with the Vice President for Patient Care Services/Chief Nursing Officer (VP for PCS/CNO) on 4/30/10 at 10 a.m., he/she indicated that obtaining the practitioner signatures on verbal orders is an issue which the hospital continues to address.

Based on findings from observations, the trash room located in the southwest wing of the Krembs Building at Binghamton General Hospital was not properly ventilated.

Findings include:

-- Per observations at 12:00 p.m. on 4/28/10, there was no fan to exhaust air from the trash room located in the southwest wing of the Krembs Building. The UHSH Facilities Coordinator was present at the time the observation was made and verified that the trash room was not equipped with an exhaust fan.

Based on findings from observations, the clean room located in the support corridor of the 4th floor of the North Tower at Wilson Medical Center was not properly ventilated.

Findings include:

-- Per observation at 12:05 p.m. on 4/29/10, air in the clean storage room located in the support corridor on the 4th floor of the North Tower was being exhausted. Airflow was, therefore, negative with respect to adjacent areas such as the hallway. The UHSH Facilities Coordinator was present at the time the observation was made and verified air was being exhausted from the room and that this condition could allow unclean air to enter the room from adjacent areas.


Based on findings from observations, the humidity in operating rooms 8, 1, and K at the Wilson Medical Center Hospital was not within the generally accepted range of 30% to 60%.

Findings include:

-- Per observation at 2:30 p.m. on 4/29/10, the humidity was 21% on the digital recording device hanging on the wall in operating room 8.

-- Per observation at 2:34 p.m. on 4/29/10, the humidity was 19% on the humidity recording device hanging on the wall in operating room 1.

-- Per observation at 2:38 p.m. on 4/29/10, the humidity was 21% on the humidity recording device hanging on the wall in operating room K.

Each of the humidity measurements was verified by the Performance Improvement Quality Improvement (PIQI) Coordinator who was present at the time the observations were made.

Based on findings from interview, the hospital has not assured a sanitary environment for preventing and controlling infections. Specifically, equipment (glucometers) utilized in routine patient care has not been cleaned after each patient use, and outpatient primary care locations have not been included in the hospital-wide infection control surveillance program.

Findings include:

--During interview of the Hospital Infection Control Officer (HICO) on 4/30/10 at 9:15 a.m., he/she responded that the hospital wide infection control surveillance does not include outpatient settings (i.e., primary care medical offices). He/she also responded hospital staff do not clean glucometers between patient use (as required by generally accepted standards of infection control practices).

Based on findings from document reviews, observations and interviews, staff in the hospital's cardiac catheterization laboratory did not undertake all steps necessary to minimize microbial contamination and prevent cross contamination between procedures, as required by generally accepted standards of infection control and hospital policy. Specifically, staff in the cardiac catheterization lab did not wipe down an equipment table with germicidal solution after a patient procedure was completed. Additionally, while the patient was on the procedure table and the sterile field was open, multiple staff members were entering the room without donning a surgical hat or mask. Also, the circulating nurse did not wear a surgical hat or mask during the procedure.

Findings include:

-- Per review of the hospital policy entitled "Cleaning of the Invasive Cardiology Laboratory," last revised 12/09, it states "Procedure and equipment tables are to be wiped down with hospital approved germicidal solution between cases."

-- Per observation of Scrub Technician #1 on 4/29/10 at 10:05 a.m. in the cardiac catheterization lab, a protective paper/cloth barrier and soiled materials and instruments were removed from an equipment table, and then an unopened sterile pack of supplies was set on the same equipment table in preparation for the next procedure. This equipment table was not first wiped down with a germicidal solution after the soiled material and instruments were removed.

-- Per interview of Scrub Technician #1 in the cardiac catheterization lab on 4/29/10 at 10:10 a.m,. he/she indicated that equipment tables are not routinely wiped down with a germicidal solution between cases because the material that was on the table is sterile and the unopened pack of supplies is sterile.

-- Per review of the hospital policy entitled "Infection Control," last revised 3/08, it states under Section III. Masks/Eyewear, "Mask will be worn in surgical environment where open sterile supplies or scrubbed persons may be located..."

-- During a tour of the cardiac catheterization laboratory at Wilson Medical Center at 9:30 a.m. on 4/29/10, while the patient was on the procedure table and the sterile field was open, 2 staff were observed entering the procedure room without first donning surgical hats or masks. Also, the circulating nurse did not wear a surgical hat or mask during the procedure.

-- Per interview of the Hospital Infection Control Officer (HICO) on 4/30/10 at 9:00 a.m., he/she acknowledged that cardiac catheterization lab staff should be wiping down any surface that contains soiled material/instruments with a germicidal solution after a procedure. He/she also indicated that when the patient is on the procedure table, the door to the procedure room should be closed with minimal staff entering the room. Additionally, the HICO stated that it is not hospital policy to require a circulating nurse in the cardiac catheterization lab to wear a surgical hat and mask during a procedure. He/she indicated that, based on literature review and evidence based practice, there is no evidence that requiring a circulating nurse to wear a surgical hat and mask reduces the risk of infection for the patient.

However, the latter information discussed / provided by the HICO is not consistent with generally accepted standards of infection control in the cardiac catheterization laboratory setting, established by the Association of periOperative Registered Nurses (AORN). The cardiac catheterization laboratory is considered to be a surgical environment when catheterizations are being performed. As such, surgical hats and masks are required.