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.

AUBURN COMMUNITY HOSPITAL 17 LANSING STREET AUBURN, NY 13021 Sept. 23, 2015
VIOLATION: USE OF VERBAL ORDERS Tag No: A0407
Based on findings from medical record (MR) review, facility document review and interview, in 6 of 8 MRs reviewed (Patients E, F, G, H, I, and J) verbal/telephone orders were not cosigned by the provider within 48 hours as required by the facility's policy and procedure (P&P).

Findings include:

-- Per MR review, Patient E's MR contained a physician telephone order dated 9/18/15 at 5:35 pm to discontinue Dilaudid, Benadryl 50 mg intravenous every 6 hours as needed, and 1:1 supervision. This order remained unsigned 5 days later on 9/23/15.

Patient F's MR contained a physician telephone order dated 9/20/15 at 4:20 pm for Tylenol 650 mg every 6 hours and Topamax 100 mg. This order remained unsigned 3 days later on 9/23/15.

The same lack of authentication of verbal/telephone orders within 48 hours was found in the MRs of Patients G, H, I, and J.

-- The facility's P&P titled "Physicians Orders," last revised 1/2012, stated "Verbal orders must be authenticated by the ordering physician within 48 hours."

-- During interview on 9/22/15 with Staff #6 at 11:35 am, the above findings were acknowledged.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on findings from document review, medical record (MR) review, interview, and observation, in 1 of 14 MRs (Patient A) nursing staff did not complete a fall risk assessment. In 2 of 14 MRs (Patient's B and C) documented fall prevention interventions were not implemented. Also, the hospital's policy and procedure (P&P) regarding patient fall assessments did not reflect current practice as observed. These lapses may have placed patients at an increased risk to fall.

Findings include:

-- The hospital P&P titled "Risk/Fall Program" last revised 10/2012, indicated that a fall risk assessment is completed on all patients upon admission, every shift, upon transfer or change in condition.

-- However, per MR review, Patient A's MR did not contain documentation of a fall risk assessment being performed on admission or during hospital stay.

-- During interview on 9/22/15 at 11:30 am with Staff #1, he/she indicated fall risk assessments are not done on obstetrical patients.

-- The hospital P&P titled "Risk/Fall Program" last revised 10/2012, indicated the patients identified as a high risk to fall will have a yellow identification bracelet, be provided slip resistant yellow socks, a yellow star will be placed on the patient assignment board at the nurses station and on the board outside the patient's room.

-- Per MR review, Patient B was identified as a high risk to fall. The MR identified the following fall prevention interventions: a call bell within reach, slip resistant yellow socks and a yellow fall bracelet. However, during observation on 9/22/15 at 2:15 pm, Patient B did not have his call bell within reach, a yellow identification bracelet, and was not wearing yellow slip resistant socks. Additionally, a yellow star was not on the assignment board outside his room.

-- During interview with Staff #2 on 9/22/15 at 2:15 pm, he/she indicated that when a patient is a high fall risk, in addition to interventions listed in the above P&P, a pull tab on the board outside of the patient's rooms is pulled out revealing a symbol (i.e., a patient falling) identifying the patient as a high risk to fall. Staff #2 acknowledged that Patient B did not have all fall interventions in place including pull tab symbol for risk to fall pulled over.

-- Also, per MR review Patient C, was identified as a high risk to fall. The MR identified the following fall prevention interventions: slip resistant yellow socks and a yellow fall bracelet. However, per observation on 9/23/15 at 3:00 pm with Staff #3, Patient C did not have a yellow identification bracelet and was not wearing yellow slip resistant socks. Additionally, there was no yellow star outside his room, and the pull tab symbol to identify Patient C as a high risk to fall had not been pulled. Staff #3 acknowledged these findings.

-- During interview with Staff #4 on 9/22/15 at 3:00 pm, he/she confirmed the use of the boards outside the patient rooms that contains a pull tab revealing a symbol (i.e., a patient falling) identifying the patient as a high risk to fall and acknowledged the Fall P&P did not reflect current practice.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on findings from medical record (MR) review, document review and interview, staff did not adequately perform and document pain assessment or reassessment in 1 of 5 MR. Additionally, the hospital pain management P&P was not consistent with generally accepted standards of nursing care.

Findings include:

-- Per review of Patient D's MR, nursing administered oral opioid pain medication on 9/21/15 at 8:03 pm due to a pain level of 7/10 (0-10 scale, 10 worst pain) for lower left quadrant abdominal pain. No re-assessment of Patient D's pain level was documented. Patient D was next medicated for pain on 9/22/15 at 6:37 am, over 10 hours later. There is no documentation that his pain level was assessed at that time and no reassessment of his pain after medication administration.

-- Per review of hospital's P&P titled "Pain Management," last revised 2/2011, healthcare providers choose the pain scale that adapts best to their patients. All scales are based on 0-10. Patient self report using 0-10 scale will be documented. Re-assessment of pain must be done after each pharmacological or non-pharmacological intervention recommended within one hour.

The P&P lacked instruction to staff to document re-assessment of pain after pharmacological or non-pharmacological intervention.

-- During interview with Staff #5 on 9/22/15 at 11:50 am, the above findings were acknowledged.