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MOUNT SINAI SOUTH NASSAU ONE HEALTHY WAY OCEANSIDE, NY 11572 July 3, 2015
VIOLATION: STANDARD TAG FOR OUTPATIENT SERVICES Tag No: A1081
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Based on record review, document review and interview in four (4) of five (5) patients receiving Chemotherapy, and three (3) of four (4) patients with Advanced Directives, the facility failed to ensure that Outpatient Services met the standards of care by failing to provide services in accordance with policies and procedures.

Findings:

Review of the Medical Record for Patient A revealed that on 06/11/15 the patient presented to the Outpatient Chemotherapy Center from his Group Home for Chemotherapy Infusion. During the Infusion of Treanda (Antineoplastic Agent), Patient A's peripheral intravenous line infiltrated. The left forearm was described as hard to touch and not red.

Review of the Lexicomp Online for Bendamustine (Treanda) revealed extravasation management included "to elevate the arm, and apply dry cold compresses for 20 (twenty) minutes 4 (four) times daily". There was no documented evidence that the patient received this treatment at the Center.

Review of the Intake / Output Record revealed that the patient urinated four (4) times. The urine amount, color and clarity were not documented as per policy.

The Physician ordered Ondansetron 8mg. every twelve (12) hours for three (3) doses to start 8:00PM tonight.

There were no Discharge Instructions for Patient A for the Group Home regarding the administration of the Ondansetron, treatment of the infiltration, and signs and symptoms that needed to be reported to the Health Care Team.

Review of the Medical Record for Patient E revealed that on 07/02/15 the patient presented to the Outpatient Chemotherapy Center for Chemotherapy Infusion via a peripheral intravenous line. There was no Order for the peripheral intravenous line. The Intake / Output Record revealed that the patient urinated twice and the amount was not documented as per policy.

Review of the Medical Record for Patient B revealed that on 07/02/15 the patient presented to the Outpatient Chemotherapy Center for Chemotherapy Infusion via a central line. The Intake / Output Record revealed that the patient had voided three (3) times via nephrostomy tubes and leg bag drainage that were emptied by the patient. The amount of urine and description of urine were not documented as per policy.

Review of the Medical Record for Patient C revealed that on 07/02/15 the patient presented to the Outpatient Chemotherapy Center for IV Chemotherapy. The Intake / Output Record revealed that the patient had voided two (2) times and neither the amount nor the description were documented as per policy.

During interview with Staff #4 (Nurse Manager F3) on 07/02/15 at 3:00PM, the staff member confirmed the findings.

During interview with Staff #4 (Nurse Manager F3) on 07/02/15 at 12:15PM, the staff member confirmed the findings.

Review of the Policy titled "Medication: Chemotherapy", last revised 07/13, directed staff to maintain strict output during the treatment and to note urine color and clarity. Education included signs and symptoms of Chemotherapy extravasation and circumstances for which to notify / consult the Health Care Team.

Review of the Policy titled "Occurrence Reporting", last revised 01/15, stated the following; an occurrence is an "incident resulting in an unintended adverse and or undesirable outcome or the risk there of". Patient occurrences must be reported on an "Occurrence Tracking Report".

Record review on 07/02/15 at 2:40PM revealed that Patients L and M did not have Advanced Directives assessed during their initial visits to the Wound Care Center. The Yes / No check boxes on the Wound Care Center's Admission Assessment Form were left blank for the question asking, "Do you have an Advanced Directive?"

For Patient N, the "Yes" box was checked, but no copy of the patient's Advanced Directive was found in the Medical Record.

During interview with Staff Members #1, #2 and #3 on 07/02/15 at 3:00PM, they confirmed the findings. Staff #2 stated that the Advanced Directives "may not have been assessed since the Wound Care Center does not honor Advanced Directives".

The Policy titled Wound Care Center Admission Assessment, last revised 01/15, stated the following under Advanced Directive, in the Procedure Section of this Policy, it directs staff to: "Query the patient as to whether or not he / she has an Advanced Directive. If so, request a copy for the record ... ".