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 April 5, 2017
VIOLATION: LICENSURE OF PERSONNEL Tag No: A0023
Based on findings from document review and interview, in 2 of 3 credentials/personnel files, the hospital did not ensure emergency department (ED) staff (providers and nurses) had current required training in accordance with New York Codes, Rules and Regulations (NYCRR). This lack of current training could potentially lead to inadequate care of patients presenting to the ED with a emergency medical condition.

Findings include:

-- Per NYCRR Title 10 (405.19), it requires ED staff (providers and nurses) to be currently trained in Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS).

-- Per review of Staff A's (ED Medical Director) credentials file, it lacked evidence Staff A had current training in ACLS and PALS.

-- Per review of Staff B's {(ED Registered Nurse (RN)} personnel file (employed since 5/4/15), it lacked evidence Staff B had current training in ACLS.

-- Additionally, the "Job Description/Performance Evaluation Tool" for registered professional nurses (RNs) in the ED indicated PALS certification is highly recommended, not required.

-- During interview of Staff C (Vice President, Quality Management) on 4/5/17 at 2:00 pm, he/she acknowledged the above findings.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on findings from observation, interview and document review, the hospital did not comply with the Parents Bill of Rights as required by New York Codes, Rules and Regulations (NYCRR), Title 10, 405.7. Specifically, the emergency department (ED) lacked signage of the Parent's Bill of Rights, ED staff lacked education and training about the Parent's Bill of Rights and the hospital did not have a policy and procedure (P&P) for the Parent's Bill of Rights. This could lead to pediatric patients and their parents not knowing their patient rights.

Findings include:

-- Per observation in the ED on 4/4/17 at 8:30 am, there was no signage in the ED waiting room and ambulance entrance for Parent's Bill of Rights.

-- Per interview of Staff D (Registration Clerk) on 4/4/17 at 8:45 am, Staff E {ED Registered Nurse (RN)} on 4/4/17 at 9:40 am, Staff F (ED RN) on 4/4/17 at 9:55 am, Staff G {ED Physician Assistant (PA)} on 4/4/17 at 10:15 am and Staff B (ED RN) on 4/5/17 at 8:00 am, all indicated they had not received training regarding the Parent's Bill of Rights.

-- Per review of personnel files on 4/4/17 for Staff B (ED RN), Staff E (ED RN) and Staff H (Registration Clerk) all lacked education and training about the Parent's Bill of Rights.

-- Per interview of Staff C (Vice President, Quality Management) on 4/4/17 at 11:50 am, he/she acknowledged the facility did not have a P&P for the Parents Bill of Rights and acknowledged the above findings.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on findings from interview and document review, the facility did not ensure medication preparation was done in accordance with acceptable standards of practice. This could place patients at risk for infection.

Findings include:

-- Per interview of Staff E {Emergency Department (ED) Registered Nurse (RN)} on 4/4/17 at 9:40 am, multidose vials (MDV) of insulin are brought to the patient's bedside to withdraw the medication. The medication vial and patient's wristband have to be scanned prior to administration.

-- Per interview of Staff F (ED RN) on 4/4/17 at 9:55 am, insulin doses have to be double checked by 2 nurses prior to administration. Insulin is drawn up at the patient's bedside, the vial and patient's wristband are scanned prior to administration. He/she wipes the MDV with alcohol after use.

-- Per review of the hospital's policies and procedures (P&P) titled "Registered Professional Nurse Responsibilities for Medications," dated 10/2016 and "Insulin Subcutaneous Injection," dated 9/2016, both did not address that MDV should not enter the immediate patient treatment area and that if brought in to the area, the vial must be dedicated for single patient use and discarded immediately after use in accordance with acceptable standards.

-- During interview of Staff C (Vice President, Quality Management), on 4/5/17 at 2:00 pm, he/she acknowledged the above findings.