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Based on observation and interview, the facility does not ensure that all essential mechanical, electrical, and patient care equipment is maintained in safe operating condition, as evidenced per the following: 1.) the facility does not label all zone valve medical gas shutoffs with required identifying information; 2.) the facility does not maintain all exhaust ventilation; 3.) the facility does not maintain the kitchen floors in a clean manner; 4.) the facility does not maintain the facility at an acceptable level of safety and quality.

Findings include:

Finding #1:
During facility tour on 04/23/13, it was observed that the zone valve medical gas shutoff did not have a statement attached indicating that it should only be shut off in an emergency. The gas lines had attached to them a "label maker" sticker indicating rooms served. This labeling was not readily visible without removal of the plastic cover, which was broken.

This finding was verified with Clinical Operations and Outcomes Coordinator Staff #3 on 04/23/13.

Finding #2:
During facility tour on 04/23/13, it was observed that the janitor's closet located in the emergency department suite had no exhaust. Interview with Staff #3 at 1:00 PM revealed that there is an exhaust, but it is located above, and obstructed by, the drop ceiling.

During facility tour on 04/24/13, it was observed that the exhaust fan in the janitor's closet on the external medicine side of the primary care extension clinic was not operational.

These findings were verified with Staff #3 on 04/24/13.

Finding #3:
During tour of the kitchen on 04/24/13, it was observed that the floor underneath the grill and the service line had a layer of grease and filth.

This finding was verified with Staff #3 on 04/24/13.

Finding #4:
- During tour of the emergency department on 04/22/13, it was observed that outside of room "3/4", four floor tiles were broken, exposing an area of the sub-floor of approximately one inch by one inch.
- This finding was verified with Staff #3 on 04/24/13.

- During tour of the post-anesthesia care unit on 04/23/13, it was observed at the nurse's station that three electrical wires were sticking out from a hole in the wall.
- This finding was verified with Staff #3 on 04/23/13.

Based on observation and interview, the facility does not properly store trash.

Findings include:

During facility tour outside of the hospital on 04/23/13 at 2:30 PM, there were multiple items of waste observed in the area adjacent to the rehabilitation unit:
- various large pieces of scrap metal
- a recliner chair
- PVC piping
- three empty 55-gallon drums
- a vehicle tire
- a gurney

This finding was verified with Clinical Operations and Outcomes Coordinator Staff #3 on 04/23/13.

Based on policy and procedure review, observation, medical record review and interview, the facililty does not ensure that health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law, as evidenced per the following: 1.) a written statement of patients' rights is not posted in clearly viewable areas, nor provided to patients, as required per New York State regulation (NYCRR 407.7), and as evidenced for 7 of 8 patients (Patients #13, 14 and 16-20); 2.) facility staff did not ensure that Patient #32 received timely assessment following application of a restraint, as required per policy.

Findings include:

Findings #1:
Review on 4/24/13 of policy "Patient Bill of Rights" (last reviewed/revised 1/2010) revealed posters of the Patient Bill of Rights will be posted in the ED/Admissions Department waiting room area, on each nursing unit and on the wall directly across from the elevator. A copy and explanation of the Patient Bill of Rights will be placed in the admission packets given out by the admission department. It will be reviewed with each patient that is admitted and documented on the admission assessment by the admitting nurse. No evidence of a policy specific to the primary care setting was found.

Observation on 4/24/13 at 8:30 AM of the primary clinic waiting room, treatment rooms and hallways revealed no evidence of the Patient Bill of Rights posted prominently and conspicuously for patient view.

Medical record review on 4/24/13 at 9:00 AM for Patients #13, 14 and 16-20 revealed no evidence they received a written statement of patients' bill of rights.

Interview on 4/24/13 at 10:25 AM with RN Staff #24 revealed the Patient Bill of Rights is given given to a patient in the admission folder and receipt should be documented on the "acknowledgement sheet" on admission.

Findings #2:
Review on 4/24/13 of policy "Restraints" (revised 01/17/13) revealed a restraint shall be ordered by a Licensed Independent Practitioner (LIP). An LIP shall see the patient face-to-face within one hour after initiation of the intervention.

Medical record review on 4/24/13 for Patient #32 revealed the following:
- A restraint order dated 04/23/13 at 2345 revealed a verbal order for a vest for danger to self and/or others, preventive protection of dislodging of invasive lines and confusion. Duration is up to 24 hours. The verbal order was signed by a physician on 04/24/13 at 0956.
- The Nursing Restraint Flow sheet dated 04/23/13 at 2345 showed documentation of the initial event as 04/23/13 at 2345. The Posey vest was removed at 0445.
- A physician progress note dated 04/24/13 at 0947 documented physician assessment of Patient #32.

There was no evidence in Patient #32's medical record to indicate an LIP performed an assessment within one hour as required per policy.

Based on interview, policy and procedure review, observation and medical record review, the facility policies for the storage, handling, dispensation, and administration of drugs and biologicals are not always followed, as evidenced per the following: 1.) pharmacy services does not ensure adherence to facility policy for safe and appropriate use of medications brought from home related to home medication verification for utilization during a patient's hospitalization; 2.) the facility does not ensure that outdated, mislabeled, discontinued, expired, or otherwise unusable drugs and biologicals shall not be available for patient use; 3.) the facility does not maintain a log for sample medications distributed to patients, as evidenced for 1 of 9 patients. (Patient #38)

Findings include:

Finding #1:
Interview on 4/22/13 at 12:40 PM with the Director of Pharmacy Staff #18 revealed if home medications need to be administered at the hospital and the pharmacy is closed, a registered nurse and/or nursing supervisor have the ability to verify the home medications. The hospital pharmacist would then re-verify the medications the next day.

Review on 4/24/13 of policy "Patient's Own Medications" (last reviewed/revised 11/15/12) revealed medications brought from home may not be administered to the patient in the hospital unless there is a written order by the provider and the medication has been identified by a hospital pharmacist who will adhere a verification sticker to the medication.

This finding was verified with Clinical Operations and Outcomes Coordinator Staff #3 on 4/24/13.

Finding #2:
Observation during tour of the emergency department on 4/22/13 revealed the following:
At 11:50 AM in room #5:
- 1 urinalysis kit expired 8/31/07.
- 1 urinalysis kit expired 12/31/12.
At 12:00 PM in room #3/4:
- 1 Bard infant feeding tube expired 8/12.
At 12:05 PM in room #1:
- 1 16 Fr Foley catheter expired 6/12.

Observation on 4/22/13 at 12:55 PM during the tour of the rehabilitation unit revealed three opened bottles of hydrogen peroxide located in the storage room were not dated and/or initialed when opened.

Observation on 4/22/13 at 3:00 PM during tour of the surgical suite sub-sterile room revealed one bottle of hydrogen peroxide, one bottle of rubbing alcohol and one bottle of mineral oil not dated and/or initialed when opened.

All of the above observations in Finding #2 were verified with Clinical Operations and Outcomes Coordinator Staff #3 during the tours.

Observation on 4/24/13 during tour of the Primary Outpatient Clinic revealed the following expired items:
Exam Room #8 at 9:00 AM:
- 64 Hemoccult cards, expired 10/2011.
- 1 Hemoccult card, expired 05/2009.
- Open bottle of rubbing alcohol, not dated when opened.
- Hemoccult solution, not dated when opened.
Exam Room #7 at 9:10 AM:
- Triple antibiotic ointments, 5 expired 04/2011, 3 expired 04/2011, 2 expired 12/2011.
- 25 Hemoccult cards, expired 04/2010.
- Iodine swab sticks, 2 expired 06/2012, 2 expired 12/2012.
- Hemoccult solution not dated when opened.
Exam Room #6 at 9:15 AM:
- Hemoccult solution not dated when opened.
- Iodine swab sticks, 5 expired on 09/2011.
Medication Room at 9:20 AM:
- 18G x 1½ needle, 4 expired 12/2012.
- BD Eclipse needle, 6 expired 03/2009
- 25G DD Eclipse needle, 40 expired 08/2008.
- 23G DD Eclipse needle, 32 expired 01/2010.
- Chlamydia probe, 6 expired 12/2012.
Exam Room #3 at 9:50 AM:
- Chlamydia swab expired 12/2012.
Exam Room #2 at 9:55 AM:
- Hemoccult cards, 6 expired 05/2009.

These observations were verified with Clinic Manager Staff #22 and and RN Staff #24 during tour of the Primary Clinic.

Review on 4/24/13 of policy "Outdated Medication" (last reviewed/revised 11/15/12) revealed expiration dates of drugs and devices shall be checked during the routine medication area inspections, and drugs and devices scheduled to expire during the next month shall be removed from stock. This policy did not indicate the frequency of or who was responsible for the monitoring.

Finding #3:
Medical record review on 04/23/13 for Patient #38 revealed a physician office note dated 09/07/12 documenting that two Victoza medication pens were dispensed by the provider. There was no evidence indicating that the manufacturer number/lot number was documented.

Observation during tour of the Medication Room on 04/24/13 at 9:45 AM revealed several boxes of medication pens in the medication room refrigerator. Boxes of Lantus, Victoza, NovoLog and Levemir medication pens were noted.

Interview on 04/24/13 at 9:45 AM with Clinic Manager Staff #22 revealed that one of the providers dispenses insulin/medication pens to patients. There is not a sample log book.

Interview on 04/24/13 at 10:00 AM with Clinic RN Staff #23 revealed the provider has been giving the insulin/medication pens to the patients for about four to five months. There is not a log book where the lot number and/or expiration date is recorded. The provider documents just that an insulin/medication pen was given.

Review on 04/24/13 of policy "Storage and Dispensing of Pharmaceutical Samples" (revised 08/27/12) revealed when a provider gives samples to a patient, the provider shall log the patient name, drug, dosage and manufacturer's number/lot number and amount dispensed in the Sample Pharmaceuticals Given to Patient Log, as well as his/her signature.

Based on document review, medical record review and interview, medical staff did not ensure pertinent clinical information was documented in the medical record timely, to ensure adequate assessment, care and monitoring for admitted surgical patients, as evidenced for 3 of 7 patients. (Patients #29, 30 and 39)

Findings include:

Review on 4/24/13 of the Medical Staff Rules and Regulations (last revised 3/2012) revealed every practitioner or his representative, shall see his patients daily who are on acute level of care. Patients shall be discharged only pursuant to a written or verbal order of the attending practitioner. Patients may not be discharged until a final progress note has been entered in the medical record.

Medical record review on 4/24/13 for Patient #29 revealed the following:
A physician progress note dated 4/9/13 at 1500 indicated an inpatient admission following a STAT appendectomy for a perforated appendicitis with pelvic abscess. On 4/11/13, an ongoing ileus and plan for a CT scan to assess status of surgical site, to rule out developing intra-abdominal or incisional abscess was noted. On 4/12/13, the abdomen was benign and ileus was resolving. No progress notes were found for 4/13/13 or 4/14/13.

The patient's discharge order, instruction sheet, medication reconciliation record and post hospital prescriptions (Percocet and Augmentin) were signed by the physician on 4/12/13.

The discharge summary dated 4/12/13 indicated the plan was for discharge on 4/14/13, if he continues to do well. I will monitor him closely. The report was dictated by the physician on 4/12/13.

Patient #29 was discharged on 4/14/13.

There was no evidence in the medical record to indicate Patient #29's medical condition was evaluated on 4/13/13 and/or prior to discharge on 4/14/13.

These findings were verified on 4/25/13 with Clinical Operations and Outcomes Coordinator Staff #3.

Medical record review on 4/24/13 for Patient #30 revealed the following: an admission order dated 4/16/13 at 1200 documented the patient was in observation status following a laparoscopic cholecystectomy.

The patient discharge order and instructions were dated 4/16/13 by the physician (one day prior to discharge).

There were no physician progress note found prior to Patient #30's discharge on 4/17/13.

There was no evidence found in the medical record to indicate Patient #30 was assessed by a physician/midlevel practitioner prior to discharge on 4/17/13.

These findings were verified on 4/25/13 with Staff #3.

Medical record review on 4/24/13 for Patient #39 revealed the following: the patient was admitted on 4/23/13 for chest pain and rule out myocardial infarction.

There were no physician progress notes found in the record for 4/23/13 through 4/25/13.

During interview on 4/25/13 at 9:45 AM, Staff #3 stated the physician dictated the notes, but has not transferred the notes to the medical record.

Based on medical record review and interview, the facility did not provide documentation of an ongoing program of activities for patients in swing bed status, as evidenced for 2 of 3 swing bed patients. (Patients #23 and 24)

Findings include:

Medical record review on 04/24/13 for Patients #23 and 24 revealed no documentation of an initial activities assessment, ongoing activity assessments or if activities were provided to the patient while on swing bed status.

During interview on 04/25/13 at 10:00 AM, Director of Activities Staff #25 revealed an activities assessment for swing bed patients is conducted within four working days from admission. If the patient wants to go down to activities, the activities they wanted to attend are highlighted on the activity calendar (from skilled nursing) and documented on the assessment sheet. If the patient does not want to go down to activities, the refusal is documented on the assessment sheet, but staff will still provide the patient with supplies; for example, books and tape players. If a patient refuses activities, staff stop by every couple of days or so. The activities assessment and attendance records are kept in the Activities Department, which is located in the skilled nursing facility. Staff #25 was unaware that activities assessments need to be included in the swing bed patient's medical record.