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.

ST CHARLES HOSPITAL 200 BELLE TERRE ROAD PORT JEFFERSON, NY 11777 June 12, 2015
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
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Based on observations and interview, the facility failed to ensure that the patients' right to privacy was maintained. This includes the patients' presence and location in the facility. This was evident on one (1) of three (3) Units toured.

Findings:

During a tour of 3 North on 06/11/15 at 10:30AM, Telemetry Monitors Stations were observed behind the Nursing Station displaying the first and last names of patients. There were also, four (4) Telemetry Monitors Stations observed positioned on the walls of the hallway displaying the first and last names of patients. These monitors were in full view of anyone waking in the hallway or presenting to the Nursing Station.

During an interview on 06/11/15 at 10:30AM Staff #1 she stated that she was not aware that you could not display the first and last name of the patient.

At 12:05PM a WOW (Workstation on Wheels) was observed unattended in the 3 North Hallway. Attached to the WOW was a Medication Cart displaying the first and last names of patients. This was in full view of anyone walking in the hallway.

During an interview on 06/11/15 at 12:05PM with Staff #1 she stated all WOWs have medication carts attached to them which display the patients' first and last names. The WOWs remain in the hallway, locked, when not in use.

Review of the Policy titled "Full Public Health Information Privacy" dated 06/29/13, documented every inpatient of the facility is guaranteed by law the right to privacy. All staff must treat all protected health information in the most confidential manner.
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VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
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Based on documentation and interview, the Quality Assurance / Performance Improvement (QAPI) Program failed to monitor the effectiveness of the interventions in place for a patient who fell (Patient #4).

Findings:

Review of Patient #4's Medical Record revealed that on 05/15/15 at 7:52PM, the patient was found on the floor under the wheelchair, Posey remained tied to wheelchair. No Orders were noted in the Medical Record for a Posey vest while in the wheelchair and no change in the fall intervention Physician Orders for "all side rails up and Posey vest on" were documented after the fall.

Five (5) days later, on 05/21/15, the patient was again found on the floor of his room, still in his Posey vest. After the incident, the patient's Physician Order remained "all side rails up and Posey vest on for safety". No changes to the Fall Interventions or the Plan of Care were noted in the Medical Record to ensure the patient's safety.

Further review of the Medical Record noted that the patient's Fall Interventions were not changed until 06/03/15, when the patient was placed on 1:1 (one to one) supervision, thirteen (13) days after the second fall, and 2 1/2 (two and one-half) weeks after the first fall.

Review of the patient's Fall Incident Reports and of the QAPI Program's "Falls Index Report" for the 4th Quarter of 2014 and the 1st Quarter of 2015 revealed that while the Program investigated facility falls, it failed to address the effectiveness of the interventions that were in place at the time of the falls.

This was confirmed on 06/12/15 at 11:15AM with Staff #8 during the Medical Record review.

Review of the Policy titled "Fall Prevention Program: Hospital Wide" under "Post Fall Management / Intervention and Documentation" revealed that the Policy lacks instructions to reassess the patient's individual interventions for effectiveness and update with new interventions as needed to ensure patient safety.
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VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on record review, observation, and interview the facility failed to ensure that: a) the Fall Prevention interventions were re-evaluated resulting in repetitive falls, and b) the Fall Prevention Program was effectively implemented for seven (7) of nine (9) patients (Patient #4, #5, #6, #11, #12, #13 and #14).

Findings:

a) Review of Patient #4's Medical Record revealed the patient was admitted on [DATE]. The patient was identified as a fall risk upon admission.

On 05/14/15 at 11:43PM the Nursing Notes documented "4 (four) side rails and Posey vest in place as per MD Order secondary to poor safety awareness and increased risk of falls".

On 05/15/15 at 7:52PM the Nursing Notes documented "Patient found on floor under wheelchair, Posey remained tied to wheelchair". The Nurse failed to reassess the patient's continued risk for falls. No new Orders were noted in the Medical Record for a Posey vest while in the wheelchair and no change in the Fall Intervention Physician Orders for "all side rails up and Posey vest on" were documented after the fall.

On 05/16/15 at 5:10PM, the Nursing Notes documented "Patient was noted by the 4th Floor Elevator. Wander guard placed on patient's ankle. Vest Posey in place".

After the incident, the patient's Physician Order remained "all side rails up and Posey vest on for safety". There was no reassessment or change to the Fall Interventions noted in the Medical Record.

Five (5) days later, on 05/21/15, the patient was again found on the floor of his room, still in his Posey vest. After the incident, the patient's Physician Order remained "all side rails up and Posey vest on for safety". No reassessment or change to the Fall Interventions or Plan of Care were noted in the Medical Record to ensure the patient's safety.

Further review of the Medical Record noted that the patient's Fall Interventions were not changed until 06/03/15, when the patient was placed on 1:1 (one to one) supervision, thirteen (13) days after the second fall, and 2 1/2 (two and one-half) weeks after the first fall.

This was confirmed on 06/12/15 at 11:15AM with Staff #8 during the Medical Record review.

Review of the Policy titled "Fall Prevention Program: Hospital Wide" under "Post Fall Management / Intervention and Documentation" revealed that the Policy lacks instructions to reassess the patient's individual interventions for effectiveness and update with new interventions as needed to ensure patient safety.

b) Review of Patient #6's record revealed on 06/07/15 the patient presented to the Emergency Department with a chief complaint of sustaining a fall at home in the bathtub. On admission the patient's Fall Risk Assessment Score was 60 (sixty) and she was identified as a High Risk for falls. However, Fall Prevention Interventions were not documented. On 06/10/15 at 3:06AM when the patient was transferred from 3 West to 3 North, a Risk Assessment was not documented as per facility Policy.

On 06/11/15 at 2:22PM and 3:00PM, Staff Members #6 and #7, respectively, could not identify why the Interventions and the Risk Assessment were not documented.

On 06/11/15 at 1:50PM, a review of the Electronic Medical Records with Staff #6 revealed:
Patient #5 had a Fall Risk Assessment of 70 (seventy).
Patient #11 had a Fall Risk Assessment of 70 (seventy).
Patient #12 had a Fall Risk Assessment of 115 (one hundred fifteen).
Patient #13 had a Fall Risk Assessment of 45 (forty-five).
Patient #14 had a Fall Risk Assessment of 75 (seventy-five).

All of the patients, including Patient #6, had a Fall Risk Assessment Score above 45 (forty-five) and were identified as High Risk for Falls. However, observations on 3 North between 10:00AM and 2:00PM revealed that the patients did not did not have a yellow band on and leaves were not above their beds as per facility's Policy.

On 06/11/15 at 11:00AM Staff #2 confirmed that Patients #5, #6, #11, #12, #13 and #14 did not have yellow bands.

During an interview with Staff #1 on 06/11/15 at 1:40PM, the staff member stated that "patients identified as High Risk for Falls consistently won't have leaves over their beds. I was not aware this was in the Policy".

Review of the Policy titled "Fall Prevention Program" dated 03/21/15, documented a Fall Risk Assessment Score of 45 (forty-five) > or higher indicates the patient is at High Risk for Falls. This requires implementation of appropriate Nursing interventions, which includes, but is not limited to, a yellow band and falling leaf above the bed. Risk for Fall Assessment and Risk for Injury are completed on transfer.
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VIOLATION: SECURE STORAGE Tag No: A0502
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Based on observation, interview and record review, the facility failed to ensure that medications and biologicals were secured in one (1) of three (3) Units toured (3 North).

Findings:

At 12:05PM a WOW (Workstation on Wheels) was observed unattended in the 3 North Hallway. Attached to the WOW were baskets filled with a Sodium Chloride 9% bottle, three (3) 5% Dextrose 1/2 (one-half) Normal Saline Intravenous bags, seven (7) Normal Saline syringes, two (2) Angiocatheters and Intravenous tubing.

Another WOW had six (6) Normal Saline syringes, three (3) Normal Saline Intravenous bags and Angiocatheters.

During an interview with Staff #1 on 06/11/15 at 12:05PM, the staff member stated that all of the WOWS throughout the facility have the baskets on them filled with equipment. The staff member also stated that the WOWs remain in the hallway when not in use.

Review of the Policy titled "Medication Administration" dated 12/12/13, documented medications are securely stored.
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VIOLATION: THERAPEUTIC DIETS Tag No: A0629
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Based on one (1) out of two (2) Medical Records reviewed, the Dieticians failed to implement the patient's nutritional intervention as documented in the Dietary Weekly Assessment, resulting in a lack of monitoring of a patient's weight loss.

Findings:

Review of the Medical Record for Patient #1 revealed that the patient was admitted from the hospital to the Acute Rehab Unit on 01/08/15. The patient's weight upon admission was documented by the Registered Dietician (RD) as "85.73kg (189 lbs)" "weight obtained by RN (Registered Nurse) on 01/07/15" on the Nutrition Initial Assessment. The RD documented in "Nutrition Intervention #1" to "monitor weights".

Additional Nutrition Assessments were completed weekly by an RD with a nutrition intervention to "Monitor weights". However, no weights were documented on the Assessments from 01/09/15 until 03/20/15.

Review of the patient's Medical Record Flow Sheet revealed that the patient had no documented weight for ten (10) weeks after admission to the Unit. Upon re-check on 03/18/15, the patient was noted to weigh 69.4kg (152.68 lbs). The patient had a total loss of 16.33kg (35.93 lbs) during that time.

Review of facility Policies also revealed that there is a Nursing Policy titled "Weights" that requires weekly weights on all acute rehab patients.

The Dieticians failed to appropriately follow the Nutritional Assessment Plan to monitor the patient's weight. The Dieticians also failed to monitor that weekly weights were being done, and therefore failed to communicate the patient's weight loss to the Physician.
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VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
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Based on record review, interview and observation, the facility failed to ensure that staff complied with the facility's Infection Control Practices.

Findings:

a) Review of Patient #5's Medical Record on 06/11/15 revealed that the patient was placed on Contact Isolation for VRE (Vancomycin Resistant Enterococci). The sign outside the patient's room documented a gown and gloves are required to enter the room.

Observations on 06/11/15 at 11:13AM revealed that while performing a blood glucose test on Patient #5, Staff #3 placed the glucometer on the patient's bed. When she completed the procedure, she placed the Glucometer on the patient's bedside table. Then Staff #3 removed her gown and gloves, performed hand hygiene, and exited the room. Without donning gloves and a gown, Staff #3 re-entered the room and obtained a paper towel.

Staff #3 then cleaned the Glucometer, removed her gloves, and without performing hand hygiene, charted on the EMR (Electronic Medical Record) and prepared medication.

Staff #3 donned gloves and gown and entered the room with her WOW (Workstation on Wheels). She placed Nitro paper with medication on it, an intravenous bag, a vial of fluid and a syringe on the bedside table that was never cleaned after the "dirty" Glucometer was placed on it. She proceeded to wrap the blood pressure cuff around the patient's arm and obtained her blood pressure.

After cleaning the blood pressure cuff, Staff #3 used the same wipe to disinfect the thermometer.

An interview with Staff #3 at that time revealed she was not aware that she used the same wipe to disinfect the cuff and thermometer.

As Staff #3 was getting ready to exit the room, an interview with her at that time revealed that she was not aware that she did not clean the bedside table.

Staff #3 exited the Isolation Room with the WOW. Attached to the WOW were baskets filled with intravenous bags, gauze pads, syringes, Normal Saline bottles, boxes of tissues, spoons, rolls of tape, intravenous tubing and straws.

An interview with Staff #3 at that time revealed that she did not plan on discarding any of this equipment. The WOW is wheeled in and out of Isolation and Non-Isolation Rooms without discarding the equipment.

During an interview with Staff #5 (Director of Infection Control) on 06/11/15 at 12:00 Noon, the staff member stated that everything needs to be thrown out.

During an interview with Staff #1 (Director of Medical Surgical Nursing) on 06/11/15 at 12:00 Noon, the staff member stated that all of the WOWS throughout the facility have baskets on them filled with equipment.

Review of Patient #7's Medical Record on 06/11/15 revealed that the patient was placed on Contact Isolation for MRSA (Methicillin Resistant Staphylococcus Aureus).

Observations on 06/11/15 at 11:35AM revealed that Staff #4 using his stethoscope to auscultate the patient's lungs and abdomen. While the staff member adjusted the bed linens, the stethoscope dangled freely, making contact with the patient's bed linens. Without cleaning the stethoscope, Staff #4 removed his gloves and gown and exited the room with the stethoscope around his neck. He walked down the hall to the Nurses' Station, where he performed hand hygiene. As he entered another patient's room, Staff #1 (Director of Medical Surgical Nursing) instructed Staff #4 to clean his stethoscope.

In the hallway, Staff #4 was observed wearing a glove only on one (1) hand. The staff member then proceeded to clean the stethoscope with both hands. Next he removed the glove, and without performing hand hygiene, donned gloves and proceeded to enter another patient's room. Staff #1 (Director of Medical Surgical Nursing) instructed Staff #3 to perform hand hygiene, of which he complied.

During an interview with Staff #5 (Director of Infection Control) on 06/12/15 at 1:15PM she stated that "it is our expectation that staff entering a Contact Isolation Room need to wear gloves and a gown. You never know what can happen." It is also in the Policy.

Review of the Policy titled "Hand Hygiene" dated 12/23/13, documented that hands must be cleaned after every patient encounter and after removing gloves.

Review of the Policy titled "Infection Control" dated 07/14/14, documented that Healthcare Personnel caring for patients on Contact Precautions should don PPE (Personnel Protective Equipment) gown and gloves upon room entry. Gloves will be removed before leaving the patent's room or environment and hand sanitized immediately. Common equipment will be sanitized.

Observation on 3 North on 06/11/15 at 10:40AM, revealed opened (Glucometer) High and Low Glucose and Ketone Control Solutions that were not tabled when they were opened, making it difficult to ascertain the expiration date of the Control Solutions.

An interview with Staff #2 at that time revealed that the Control Solution is stable for 90 (ninety) days after opening and the bottle should have been labeled. The bottles were discarded by the staff member.

Review of the Policy titled "Blood Glucose Monitoring" dated 04/24/14, documented that "Quality Control Solutions expire within 90 (ninety) days of opening or the expiration date of the bottle, whichever comes first." The Policy does not define the procedure for labeling the Control Solution.