The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

FAXTON-ST LUKE'S HEALTHCARE 1656 CHAMPLIN AVENUE UTICA, NY 13503 March 17, 2015
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on findings from interview, document review, and observation, facility staff did not follow generally accepted standards of infection control practices in connection with use of multi-dose medication vials and maintaining cleanliness of "First Responder" carts/boxes.

Findings include:

-- During interviews with Registered Nurses (RN)s #4, #1, #5, and # 7 on 3/16/15 at 10:50 am, 11:20 am, 2:30 pm, and 3:00 pm, respectively, each indicated multi-dose medication vials are brought into a patient's room and the medication is drawn up at the patient's bedside. (RN # 5 indicated he/she wipes a multidose medication vial with a disinfecting product after it is removed from the patient's room.)

Per the review of the facility's policy and procedure (P&P) titled "Medication Management," dated 5/12/12, it lacked guidance directing staff to not take medications used for more than one patient into a patient's room.

-- Per observation on unit Allen Calder (AC) 1 on 3/17/15 at 10:40 am, the "First Responder" (cart/box #1) was covered in a inch layer of dust with a dirt film.

Per observation on unit AC 2 on 3/17/15 at 11:15 am, the "First Responder" (cart/box #2) was covered in a inch layer of dust with a grey sticky film.

The findings above were acknowledged by RN #2 during times of observation.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on findings from medical record (MR) review, interview and facility document review, pain management practices were not consistent with generally accepted standards of nursing care. Specifically, (1) numerical pain ratings were not consistently documented in 2 of 13 MRs reviewed (Patients M and L), and (2) time intervals between medication administrations and pain assessments were excessive in 1 of 13 MRs reviewed (Patient M). Also, (3) the hospital policies and procedures (P&P) addressing pain management were not consistent and did not provide guidance that would result in nursing reassessing patients for effectiveness of pain interventions in a timely manner.

Findings pertaining to (1) and (2) above include:

-- Per review of Patient M's MR, nursing administered opioid pain medication on 3/16/15 at 8:13 pm due to patient grimacing and moaning; numerical pain rating per pain scale is not documented. Pain next assessed 5 hours 43 minutes later at 1:56 am, noting patient anxious and grimacing - again numerical pain rating not documented. Patient was re-medicated with an opioid at that time. The next pain assessment was documented 5 hours 15 minutes later at 7:11 am.

Per interview of Registered Nurse (RN) #21 and RN # 25 on 3/16/15 at 10:57 am during above review of Patient M's MR, they stated that the patient was nonverbal but cognitively able to communicate. These 2 RNs acknowledged the findings above and that numerical pain ratings should have been documented.

-- Per review of Patient L's MR, on 3/13/15 at 8:20 pm he requested a pain pill for generalized pain. No assessment of the pain is documented even though the patient was medicated with an opioid at 8:20 pm.

Findings pertaining to (3) above include:

-- Per review of hospital's P&P titled "Medication Management Policy," last revised 5/15/12, it stated "Medications administered for pain shall have the pain score associated with the administration documented ...It is the responsibility of the administering nurse to return within 120 minutes to determine if the pain score decreased as a result of the medication and to document this..." (Waiting 2 hours to assess a patient's relief from pain and for potential adverse effects is excessive).

Inconsistent with the above, the hospital P&P titled "Pain Management Policy," last revised 5/16/14, indicated nursing should "assess the patient's pain level at least every 4 hours, utilizing the appropriate pain scale...After an intervention has been initiated, pain reassessment will occur before the next intervention."

--During interview with RN #25 on 3/16/15 at 11:00 am, he/she acknowledged that per the guidance in this latter policy, the pain of a patient who has received a dose of intravenous (IV) morphine for pain might not be reassessed until up to 4 hours later.
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VIOLATION: USE OF VERBAL ORDERS Tag No: A0407
Based on findings from medical record (MR) review, facility document review, and interview, in 2 of 14 MR's (Patients L and M) telephone and verbal orders (TO/VOs) were used more often than "infrequently," and were not authenticated within 48 hours. Also, staff understandings regarding documentation requirements for authenticating TO/VOs was not consistent.

Findings include:

-- Per review of Patient M's MR on 3/16/15 at 9:55 am, 11 TO/VOs flagged with "Sign and Date" yellow tabs were written greater than 48 hours prior and dated back to 3/9/15. They were not signed by a provider.

Per review of Patient L's MR on 3/16/15 at 11:30 am, 24 TO/VOs written greater than 48 hours prior, dating back to 2/17/15, were not signed by a provider.

-- Per review of hospital policy and procedure (P&P) titled "Medication Management," last revised 5/15/12, it stated "verbal orders may be accepted in a patient related emergency. Telephone orders...are acceptable when the physician is unable to be present, but will be used sparingly... The nurse ...[flags the order] to assist the physician to endorse the order as soon as possible but within 48 hours."

-- During interview of Registered Nurse (RN) #25 on 3/16/15 at 10:30 am, he/she acknowledged the findings above.

-- The following interviews with staff revealed inconsistent understandings of how providers authenticate TO/VOs.

-- During interview of RN #21 during chart review of Patient M, he/she placed a telephone call to Information Technology (IT) staff to clarify where to find documentation of TO/VOs having been signed. RN #21 then reported being told that TO/VOs need to be signed on the same paper they were initially documented, not in the computer; as a result, he/she confirmed that 11 outstanding orders had not been signed.

-- During interview of Physician (MD) #1, when asked by RN #23 on 3/16/15 at 3:00 pm about authentication of outstanding TO/VOs, MD #1 stated there is a section in the electronic MR (EMR) for physicians to check for items needing signature. However MD #1 added that he/she isn't sure but believes there is a second place in the EMR for a provider to check for outstanding orders. MD #1 added that a different process at the affiliate hospital contributed to this uncertainty.
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VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on findings from document review, observation, and interview, the facility did not maintain all emergency response equipment and supplies in a manner that ensured an acceptable level of safety and quality.

Findings include:

--Per review of the hospital's policy and procedure (P&P) titled "Policy Maintenance of Code Blue Equipment Procedure," dated 4/30/14, it indicated "Units with first responder carts (Med/Surg) are responsible to clean the cart after each use and ensure replacement of suction equipment and respiratory therapy box." This policy also contained a "Med/Surg 1st Responder Cart Checklist" for daily checks and cleaning.

--Per observation on unit Allen Calder (AC) 1 on 3/17/15 at 10:40 am, the "First Responder" (cart/box #1) lacked a list of contents on the outside. A list of contents was located inside the locked cart/box when the cart/box was opened. The contents inside the cart/box did not match the list. Specifically, 2 Arterial Blood Gas (ABG) kits and a Y connector were not inside the cart/box. The "Med/Surg 1st Responder Cart Checklist" contained daily signatures by nursing staff acknowledging the cart/box had been checked.

Per observation on unit AC 2 at 11:15 am on 3/17/15, the "First Responder" (cart/box #2) lacked a list of contents on the outside. A list of contents was located inside the locked cart/box when the cart/box was opened. The contents inside the cart/box did not match the list. Specifically, 1 ABG kit and a splitter for the oxygen flowmeter were not in the cart/box. Additionally, the 1 ABG kit in the cart/box had expired in 2004.

The findings above were acknowledged by Registered Nurse (RN) #2 during times of observation.

-- During interview with the Director of Respiratory on 3/17/15 at 1:00 pm, he/she acknowledged the findings above.

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