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.

UNIVERSITY HOSPITAL AT STONY BROOK HEALTH SCIENCES CENTER SUNY STONY BROOK, NY 11794 May 13, 2015
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
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Based on observations and staff interview, the facility failed to ensure the patients' right to privacy: a) during examinations, treatments, discussions about health situations, and b) the patients' presence, location, and monitoring values. This was observed in the Pediatric Emergency Department, the Pediatric Intensive Care Unit (PICU) and the Medical Intensive Care Unit (MICU).

Findings:

a) During an observation on 04/29/15 at 10:15AM in the Pediatric Emergency Department, Staff #15, in Room 4-125, was observed examining Patient #6's eye and discussing the patient's diagnosis and treatment plan with the patient's mother, without the door closed, and in view of and within hearing distance of the other patients and visitors.

At that time, Staff #1 confirmed this finding.

b) During a tour of the PICU on 04/30/15 at 11:20AM a "Slave Monitor" (the type of Monitor that was hung on the wall) was observed on the wall in the corridor. The Monitor displayed patients' first and last names, location, EKG readings, vital signs, and pulse oximetry values which were visible to other patients, visitors, and / or staff walking in the corridor.

At that time, this finding was confirmed with Staff #1.

During a tour of the Emergency Department Clinical Decision Unit on 04/30/15 at 2:20PM a Monitor was observed on the wall in the corridor. The Monitor displayed a patient's first and last name, which was visible to other patients, visitors, and / or staff walking in the corridor.

At that time, this finding was confirmed with Staff #17.

During a tour of the MICU on 04/28/15 at 11:00AM, a Telemetry Monitor was observed on the wall of the Main Hallway with a total of twenty (20) patients' first and last names in view of patients, visitors and staff in the corridor.

This observation was made in the presence of Staff Members #10 and #11.

When asked if there was only one (1) Monitor, Staff #10 replied "No, we monitor Floors 17N and 9S here also, but they have their own Monitors on their hallway walls". When asked if the 17N and 9S Floors also contained first and last names, Staff #10 replied "Yes".

Review of the Policy titled "Confidentiality of Protected Health Information, dated 02/18/14, documented "All workforce members will keep public health information safe from public viewing and / or overheard conversation".
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VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
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Based on record review, staff interview and observation, the facility failed to ensure that staff complied with the facility's Infection Control Practices to avoid potential sources of cross contamination which increases the risk for the spread of infection. This was evident during observations in the Pediatric Emergency Department, the Pediatric Unit and 14 South.

Findings:

Review of Patient #6's Medical Record on 04/29/15 revealed that on 04/29/15 at 7:29AM the patient presented to the Pediatric Emergency Department with a chief complaint of Right Periorbital Edema. At 8:28AM A Physician's History and Physical revealed the right upper and lower eyelid with diffuse erythema, swelling and blistering lesions and a history of MRSA (Methicillin Resistant Staphylococcus Aureus) skin infections. Resistance to Oral Antibiotics was documented. The patient was placed on Contact Isolation. The sign placed on Patient #6's door revealed that the patient was on Contact Isolation, that a gown and gloves are required when entering the room. Also, ".... hands must be washed before donning (putting on) and after removing gloves, touching the patient or patient's environment, and before taking care of another patient".

Observations on 04/29/15 at 10:15AM in the Pediatric Emergency Department, Room 4-125, revealed Staff #15, the Opthamology Resident, examining Patient #6's eye without a gown on. After Staff #15 was done touching the area surrounding Patient's #6's right eye with his gloved hands, he removed the gloves and without performing hand hygiene donned another pair of gloves.

Staff #15 proceeded to a silver box on the floor in the room. He removed a Portable Slit Lamp from the box and examined the patient's eye. Then he placed the Portable Slip Lamp on the bed side table. Next, he examined the eye with the Occluder (instrument used to examine the eye) and a Snellen (eye chart test). Without removing gloves, performing hand hygiene, and donning gloves, he administered the eye drops from two bottles to the right eye.

Without removing gloves, performing hand hygiene, and donning gloves, Staff #15 wiped both eye drop bottles and Occluder with the same Sani-Wipe. Without wiping the small black box that was on the patient's bedside table with a new Sani-Wipe, he proceeded to place the box in a large black bag that was on the floor in the room.

Staff #15 cleaned the Snellen with the same Sani-Wipe and then placed the Snellen in his lab coat pocket. With the same Sani-Wipe he cleaned the Portable Slit Lamp and placed it in a silver box on the floor of the room. Without removing gloves, performing hand hygiene and donning gloves, Staff #15 removed the Portable Slit Lamp from the silver box on the floor and examined Patient #6's eye. Without cleaning the Portable Slit Lamp with a Sani-Wipe he placed it back in the silver box. Staff #15 then removed his gloves, and without performing hand hygiene and wiping the exterior of the silver box and black bag with Sani-Wipes, picked up the box and bag from the floor and exited the room.

Staff #16, the Director of Infection Control, instructed Staff #15 to wash his hands with soap and water and clean the handles of the bag and box with Sani-Wipes. Staff #15 complied.

An interview with Staff #15 at that time revealed that he was aware that the patient was on Isolation for MRSA of the eye. He saw the Isolation Sign on the door and was aware he needed to wear a gown and gloves to enter the room. There were no gowns outside the room. When he asked the Nurse if he needed a gown to enter the room, he was told no. He could not recall the Nurse's name. The eye equipment and eye drops are used on more than one (1) patient. He needs the equipment and eye drops to examine the patients and he takes it to their room. He has used the eye drops on more than one (1) patient whether they have an eye infection or not. A new bottle of eye drops is not used for every patient seen in the hospital or clinic. They see hundreds of patients. That would be a lot of money in eye drops to use a new bottle of eye drops on each patient. Sterile technique is used to administer the eye medications. You avoid touching the eye with the tip of the bottle. He stated that he took the mandatory Infection Control Training and that the Attending Physician taught him how to maintain Infection Control Practice with the equipment. The Residents also teach one another.

Staff #15 complied with giving the eye drop bottles to Staff #1 so they could be discarded.

An interview with Staff #16 at that time revealed that Staff #15 needs to minimize equipment brought into Isolation Rooms. Leave the bags outside the rooms and take only the examining equipment into the room. Equipment should not be placed on the floor. Staff #16 instructed Staff #15 that the equipment needs to be wiped down with Sani-Wipes. The exteriors of the bag and boxes need to be wiped down with Sani-Wipes. The bottle of eye drops needs to be discarded when they are used on a patient with an infection or a potential infection. The Snellen needs to be laminated. Gloves need to be removed, hand hygiene performed, and gloves donned between dirty and clean tasks.

Observations on 04/29/15 at 11:05AM in the Pediatric Emergency Department revealed Staff #18, a Radiology Transporter, with a gown and gloves on in Room 4-125, which was identified as requiring "Contact Precautions", touching Patient #6's arm, ID (Identification) band, bed side rails and sheets. Without removing his gown and gloves and performing hand hygiene, Staff #18 exited the room pushing the patient on a stretcher. Also, without performing hand hygiene, the patient's mother exited the room. An interview with Staff #18 at that time revealed he was not aware he needed to remove his gown and gloves and perform hand hygiene before exiting the room. An interview with the mother at that time revealed she did not receive education to perform hand hygiene before leaving the patient's room.

Observations on 04/30/15 at 10:20AM on 11 North, a Pediatric Unit, revealed Staff #19, a Registered Nurse (RN), inserting a peripheral intravenous catheter on Patient #12. With a gloved hand Staff #19 palpated the vein / site, prepared the site with an antiseptic solution, and without removing her gloves, performing hand hygiene, and donning new gloves, the staff member re-palpated the vein / site and inserted the Angiocatheter.

On 04/30/15 at 10:20AM Staff #1 confirmed this finding.

During an interview with Staff #16 on 04/30/15 at 1:30PM she stated that the Nurse should have removed her gloves, performed hand hygiene, and donned gloves between cleaning the site and inserting the catheter. After a Nurse cleans the site, the Nurse should not re-palpate the site with the same gloves on. She could have removed the gloves, performed hand hygiene, donned gloves and then re-palpated the site because the gloves are clean. You need to change gloves and perform hand hygiene between dirty and clean procedures.

Review of the Nursing Orientation Sheet dated 06/17/05, documented that Staff #19 demonstrated competencies in Intravenous Therapy on 06/17/05, approximately ten (10) years ago. Staff #19 did not have current competencies for inserting an intravenous catheter.

During an interview with Staff #22 on 05/04/15 at 11:20AM, the staff member stated that Clinical Education does not have documented evidence that Staff #9 received competencies in Intravenous Therapy Placement after Orientation.

Review of Patient #10's Medical Record on 4/30/15 revealed that on 04/26/15 a culture was positive for Rhinovirus / Enterovirus. The patient was placed on Droplet Isolation. The sign placed on Patient #10's door revealed that the patient was on Droplet Isolation, that a mask, face shield / goggles, gown and gloves are required to enter the room. The sign also indicated that "hands must be washed before donning and after removing gloves, touching the patient or patient's environment, and before taking care of another patient".

Observations on 04/30/15 at 10:40AM on 11 North, a Pediatric Unit, revealed Staff #20, a Nurses Aide, in the doorway of Patient 10's room removing a mask and gloves.

At that time an interview with Staff #20 revealed that he went in the Isolation Room to give the patient colored pencils and paint and was going to round on the other patients. Staff #20 was not aware he also needed to wear a gown and face shield / goggles to enter the room and did not wash his hands before exiting the room.

On 04/30/15 at 10:40AM Staff #1 confirmed this finding.

Review of Patient#11's Medical Record on 04/30/15 revealed that on 04/27/15 a culture was positive for RSV (Respiratory Syncytial Virus). The patient was placed on Respiratory Isolation. The sign placed on Patient #11's door revealed that the patient was on Respiratory Isolation, that a face shield / goggles, gown and gloves are required to enter the room. The sign also indicated that "hands must be washed before donning and after removing gloves, touching the patient or patient's environment, and before taking care of another patient".

Observations on 04/30/15 at 11:50AM on 11 North, a Pediatric Unit, revealed that without cleaning the thermometer in Patient #11's room, Staff #21, RN, exited the room with the thermometer, proceeded to the hallway in front of the Nurses' Station and wiped the thermometer down with a Sani-Wipe.

During an interview with Staff #21 she agreed the equipment should have been cleaned in the Isolation Room before leaving the room and not in the hallway.

On 04/30/15 at 11:50AM Staff #1 confirmed this finding.

Review of the Policy titled "Isolation Precautions" dated 08/07/14 documented that "Gowns are indicated for all patients entering the room of patients who are on isolation for multi drug resistant organisms, hand washing is performed before and after glove use, reusable patient care items used on multiple patients is cleaned after use on a patient and prior to exiting the room, individual disposable digital thermometers are to be used for patients on isolation, and visitors are instructed to wash their hands immediately before entering and leaving the room each time."

Review of the Policy titled "Hand Hygiene" dated 02/08/14 documented that "Hands must be washed prior to donning gloves, as well as after removing gloves, after contact with mucus membranes, body fluids, secretions, or excretions, and non-intact skin surfaces (even when gloves are used), after contact with inanimate sources likely to be contaminated, prior to and after patient contact" and "Change gloves when moving from a contaminated body site to a clean body site."

Patient #17 was admitted to 14 South on 04/27/15. On 04/28/15 in the afternoon, Staff #13, RN, was observed administering a unit of PRBC (Packed Red Blood Cells) to the patient. Staff #13 did not don gloves when spiking the unit of blood or when administering it to Patient #17.

This was confirmed in the presence of Staff Member #12, who acknowledged that the Nurse failed to wear gloves during the procedure.

Review of the procedure titled "Blood Product Administration Procedure Reference" dated 04/2015 (Revised) revealed Instruction #4 states "Perform hand hygiene, don clean gloves" prior to blood administration.
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VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on Medical Record review and interview, the facility failed to: a) investigate allegations of sexual and physical abuse in two (2) out of six (6) cases reviewed (Patients #1 and #19), and b) to develop an Internal Process to assure a timely and thorough investigation when abuse or neglect is suspected or has occurred.

Findings:

a) Medical Record review on 04/29/15 revealed that Patient #1 was a [AGE]-year-old male who was admitted on [DATE] at 11:57AM with a chief complaint of Difficulty Swallowing and had a diagnosis of Herpes Stomatitis.

Review of the "Current Summary" Grievance / Concern Report revealed that the patient's sister registered a Complaint by phone on 01/28/15 (no time documented) stating that her brother reported that he was sexually assaulted by his Nurse on the night shift.

Staff #6 was interviewed on 04/29/15 at 1:00PM regarding the Police Investigation. He provided a document "Titled: Forcibly Touching". This Report listed the Detectives present on the case from University Police who responded to a report of a patient inappropriately touched by staff in University Hospital.

The Police were documented to have arrived at 12:59PM on 01/28/15 to 13 North Bed 020, approximately five (5) hours after the incident was reported. The document states that the patient reported that at 4:00AM on 01/28/15 he awoke from sleeping and he alleges being "fondled". It further states that a Psychiatric Consult has been scheduled.

The surveyor asked if she could read the Investigative Report and Staff #6 advised that the investigation is still ongoing and that the surveyor may not have access to the Report. The Report indicates that the Police have jurisdiction of this case.

An interview on 04/30/15 at 10:00AM with Staff #7 revealed that the patient was advised that a full investigation will be completed.

On 04/30/15 at 10:00AM Staff #1 described the facility's process for investigating sexual assault cases. She stated that "they activate the chain" to Nurse Manager, Risk Management and then the University Police.

During an additional interview with Staff #7 on 04/30/15 at 10:00AM, the staff member stated that the present Process is to escalate the Sexual Abuse Complaint up the chain of command and then the University Police are called to conduct the investigation.

Staff #4 stated that there is a "fire wall" between the University Hospital and the Police.

The surveyor asked if they are notified of the disposition of the case and Staff Members #1 and #14 advised that there is no further communication between the facility and the Police.

On 04/30/15 at 10:30AM, Staff #4 stated that the Nursing Assistant advised Staff #5 that at about 8:00AM on 01/28/15, the patient told him that he was sexually abused by the Night Nurse at around 4:00AM on 01/28/15.

An interview with Staff Members #1, #3 and #7 on 04/30/15 at 10:30AM revealed that the Nurse's Aide advised Staff #5 of the alleged sexual abuse at about 8:00AM on 01/28/15.

An interview conducted with Staff #9 on 04/30/15 at 3:30PM revealed that the Police did not contact her until "one (1) to two (2) weeks" after the incident was reported. Staff #9 also reported that she received a phone call from the facility prior to her next shift on 01/29/15 from 7:00PM to 7:30AM advising her to report to the same Unit but not to take care of Patient #1. She does not recall who called her. The staff member reported she does not know that anyone conducted an investigation of the incident.

Staff Members #4 and #7 were in attendance during the interview with Staff #9.

A review of 13 North's Staffing Schedule revealed that Staff #9 worked on 13 North, where the alleged incident occurred and the patient still resided, on 01/29/15 and 01/30/15 from 7:00PM to 7:30AM.

An interview was conducted with Staff #14 on 05/04/15 at 11:00AM who stated that the complainant alleged that a Nurse woke up her brother and she was "jerking him off". The Nurse Manager, the Risk Manager and the Police were involved. Staff #7 was also advised.

Review of the Grievance Form "Current Summary" from the Patient Advocate Area identified the "File State: Closed" but the disposition of the case investigation was documented as "In Progress".

Staff #14 stated on 05/04/15 at 11:00AM that the File State was noted as Closed "because it was passed on to the Police".

Staff #24, Attending Physician, stated that on 05/04/15 at 11:00AM the Morning Nurse advised her that the patient complained that the "Nurse misbehaved with patient". Staff #24 stated the Nurse in charge asked if she would call for a Psychiatric Evaluation. Staff #24 further stated "I did not feel right about asking the patient" about the incident.

Further interview with Staff #24 revealed she called for a Psychiatric Consult for this patient. There is no documented evidence of the Consult or the time it was requested.

Staff #24 stated "I am not aware of any other Protocol that exists".

Medical Record review revealed that the Psychiatrist did not see the patient until 5:09PM on 01/28/15, approximately nine (9) hours after the incident was reported.

The Psychiatric Evaluation performed on 01/28/15 at 5:09PM revealed that the patient was irritable and hostile on exam. He states that at 4:00AM, his Nurse came in, took hold of his penis, and began making him "jerk off". He states he wants to press charges. His insight and judgment is poor as well as his impulse control. He is alert and oriented to person, place and time.

The Psychiatrist's impression was that the patient currently did not present as confused or delirious. However, based on his meds, and given his history, the Psychiatrist believed that it was likely that he was delirious when he woke up at 4:00AM. The plan was a recommendation for a small dose of antipsychotics, if again confused or delirious, and that at present there was no indication for Psychiatric hospitalization .

Review of the Emergency Triage Form for the 01/22/15 admission documents that the patient was not on any psychotropic medications at home. Review of the Final Medication List for the period that the patient was hospitalized documents Haldol 10mg at bedtime and "None Given" in the section for the last dose given.

Review of the Medical Record for the patient's stay from 01/22/15 through 01/30/15 revealed no documentation of the allegation of sexual abuse by the patient.

There is no documented investigation regarding the patient's allegation of sexual abuse or actions taken to protect the patient from future occurrences.

A telephone interview was conducted on 05/13/15 at 9:30AM with Staff #23. The staff member stated that the incident is currently under investigation by the Police. The staff member stated this is a criminal matter and therefore the Police conduct a "separate and distinct investigation".

Staff #23 further stated that the call was made to the Police on 01/28/15 at 12:59AM (approximately 5{five} hours after the facility was made aware of the allegation) by staff on 13 North and the Police were dispatched at 1:02PM.

Review of the "Current Summary" form for Patient #19 on 05/04/15 revealed a [AGE]-year-old female who was admitted to Psychiatric Services on 10/04/14. The patient alleges that a staff member kicked her in the stomach in front of staff and that nothing was done about it. This was classified as a Concern and not a Grievance.

The "Day Clinician" on 10/04/14 was documented to have spoken with staff, but it is not clear as to who was interviewed, and when the interviews took place. It is also documented that the Physician spoke with the patient, but there is a lack of documentation of the investigation and who was interviewed.

There is no evidence that the worker was removed from patient access until the investigation was completed.

The case is documented as Closed but it lacks documentation of whether the allegations are substantiated or not.

b) A request was made for the facility's Policy and Procedure regarding the Investigation Process for patient allegations of physical and sexual abuse by facility staff on 04/28/15.

During interview with Staff #7 on 04/30/15 at 10:00AM, the staff member stated that the present Process is to escalate the allegation of sexual abuse up the chain of command and then the University Police are called in to conduct the investigation. When asked if they are notified of the disposition of the case by the Police, Staff #4 stated that there is no further communication between the facility and the Police regarding whether the case is sustained or not.

The facility provided the Policies and Procedures titled Patient / Visitor Complaints and Grievances, "Original Creation Date" 03/01/1998; Patient Safety Occurrence, "Original Creation Date" 04/14/2004 and Serious Adverse Advents, " Original Creation Date" 01/06/2011.

According to the facility's Policy titled "Serious Adverse Events" with the "Original Creation Date" of 01/06/2011, sexual assault on a patient or staff member within or on the grounds of the healthcare facility is considered a "Never Event". These events are documented in the Policy as "Should never happen to a patient, and require a set of action steps to be taken by the hospital to prevent similar occurrences from happening in the future".

The Policies and Procedures lacked an Internal Process for the investigation of allegations of sexual and physical abuse of a patient by staff. The Policies lack Procedures for interviewing staff involved, removing staff from patient access until the investigation is concluded, and to ensure that the patient receives necessary treatment and care which includes immediate Medical, Nursing, and Psycho-Social Assessment.
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VIOLATION: PATIENT RIGHTS: TIMELY REFERRAL OF GRIEVANCES Tag No: A0120
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Based on record review, Policy and Procedure review and staff interview, the facility failed to: a) conduct a complete investigation of Patient Grievances, and b) maintain a Grievance Log in accordance with the facility's Policy. This was found in two (2) of six (6) Grievances reviewed (Patients #1 and #19).

Findings:

Review on 04/30/15 of the Grievance for Patient #1 documented that the Grievance was received on 01/28/15 stating that a family member called to report "that the patient reported he was sexually assaulted by a Nurse on the night shift".

The Grievance was classified as a "Concern". Review of the "Current Summary" printed on 04/30/15, three (3) months after the Grievance was filed, documented "Risk Management, University Police and Associate Director aware and investigation is in progress".

The facility failed to resolve the issue in a timely manner, investigate the allegation, resolve the Grievance and provide a Resolution Letter to the family member as per facility Policy.

Review on 05/01/15 of the Grievance for Patient #19 documented that the facility was contacted on 10/04/14 and a message was left stating that the patient was kicked in the stomach by an unknown person in front of staff.

The Grievance was identified as a "Concern". Review of the "Current Summary" printed on 04/30/15, documented that the Resolution, which was written by staff from "Regulatory Affairs", stated that the "patient was spoken to and the patient could not recall who was present and staff stated they did not observe anything".

The facility failed to conduct a thorough Grievance Investigation and inform the complainant of the Resolution of the Grievance.

Review of the "Patient / Visitor Complaints and Grievances" with the "Original Creation Date" of 03/01/98 documents that:

* "Grievances are thoroughly investigated by reviewing all related records and having interviews with staff and caregivers."

* "All Grievances are addressed as quickly as possible and should be resolved within 7 (seven) calendar days."

* "A Resolution Letter is sent at the close of the investigation, but no later than 30 (thirty) days after the Complaint is received."

The "Patient / Visitor Complaints and Grievances" Policy and Procedure fails to identify the difference between a "Concern" and a "Grievance". The identified Grievances involved physical and sexual abuse but were logged as "Concerns".

An interview conducted with Staff #14 on 05/04/15 at 11:00AM revealed that the cases which involved allegations of violence or sexual abuse should have risen to a level of a "Grievance and not a Concern".

When asked what is the difference between a Grievance and a Concern, Staff #14 stated that a Concern would involve speaking with Clinical Staff in order to get more information from staff before speaking with the patient whereas a Grievance would involve going higher on the chain of command. She stated that a Grievance is a "Formal Complaint".

b) Review of the "Grievance Response Report" reviewed on 05/04/15, identified four (4) Grievances. The Report documented the date of "Notification", a "Description" and a "Classification".

Review of the "Patient / Visitor Complaints and Grievances" with the"Original Creation Date" of 03/01/98 documents that the Grievance Logs include:

a. The name of the individual handling the case.
b. Acknowledgement Letter if appropriate.
c. Patient data, Complaint data, the initial Grievance, the steps taken to resolve the Grievance, including the contacts made to gather information, and the date; the outcome of the Investigation, and the Follow-Up Letter.

No further Grievance Log was presented.

On 05/04/15 at 11:00AM Staff #14 was asked if there was any additional information on the cases discussed regarding any internal investigations and she stated "No". She advised that when it is a sexual or violence allegation that the Process is to close the case because it goes directly to the University Police.
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VIOLATION: PATIENT RIGHTS Tag No: A0115
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Based on record review and interview, it was determined that the facility failed to comply with the Condition of Participation for Patient Rights. This was evident by the facility's failure to: a) conduct complete investigations of Patient Grievances, b) protect the patients' privacy, and c) ensure that all allegations of sexual and physical abuse were thoroughly investigated in a timely manner and developed a Procedure to include an internal investigation.

Findings:

The facility failed to: a) conduct a complete investigation of the patients' Grievances, and b) maintain a Grievance Log in accordance with the facility's Policy.
(See Tag A 120)

The facility failed to ensure the patients' right to privacy, including the patients' presence and location in the facility.
(See Tag A 143)

The facility failed to protect patients from potential sexual and physical abuse by not developing an Internal Process to assure a timely and thorough investigation of allegations of abuse by facility staff. This was evident in two (2) of six (6) patients with allegations of physical or sexual abuse by facility staff (Patients #1 and #19). This failure places all patients at risk for abuse by facility staff.
(See Tag A 145)
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VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
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Based on observation, record review and interview, the facility failed to ensure that emergency equipment was readily available for staff use. This was evident in the Pediatric Emergency Department.

Findings:

During a tour of the Pediatric Emergency Department on 04/29/15 at 11:50AM, a review of the Pediatric Code Cart revealed that Pediatric Zoll Pads (pads used during defibrillation for resuscitation) could not located on the cart or on the Unit.

During an interview with Staff #17 on 04/29/15 at that time, she stated that we should have Pediatric Zoll Pads on the Pediatric Code Cart but we can use Adult Zoll Pads on Pediatric Patients.

A review of the Pediatric Zoll Pad package documented that "Pediatric Zoll Pads are recommended for patients less than 15kgs (fifteen kilograms) approximately 4 (four) years or less and for patients greater than 15kgs adult electrodes can be used."

A review of the Adult Code Cart List and Pediatric Code Cart List revealed that the Adult Code Cart List included Zoll Stat Padz and the Pediatric Code List did not include Zoll Stat Padz.

During an interview with Staff #1 on 04/29/15 at 12:15PM, the staff member stated that the Pediatric Code Cart List does not include Pediatric Zoll Stat Padz because "I believe it was an oversight".
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
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Based on record review and interview, the facility failed to ensure that data was collected for QAPI (Quality Assurance Performance Improvement) in order to track and trend the information regarding patient allegations of physical and sexual abuse by facility staff to monitor patient safety and quality of care for all patients. This was evident in one (1) of six (6) Grievances involving patient abuse (Patient #1).

Findings:

On 04/30/15 at 10:00AM, during interview with Staff #1, the staff member stated that any incident involving abuse / neglect should be entered into the RL Solution System (facility computer system) and that an Incident Report should be entered into the "Patient Safety Net" (PSN). She stated "In this case (Patient #1), it was never reported".

On 04/30/15 at 10:00AM Staff Members #1, #4 and #7 agreed that an Incident Report should have been written and placed in RL Solutions which is the facility's reporting database.

On 05/04/15 at 11:00AM, during interview with Staff #14, the staff member was asked how these events (sexual and physical abuse) are tracked and trended. Staff #14 stated that the Process is to place the information into the RL Solutions System (the facility's computer system for reporting) and in the Patient Safety Net (PSN). She stated that this data should then be tracked and trended by QAPI. Staff #14 stated the information was not entered in the system for Patient #1.

Review of the facility's Policy titled "Patient Safety Occurrence Reporting" with the "Original Creation Date" of 04/14/2004 documents that "all Employees and Medical Staff are expected to create a report when occurrences are identified" and it should be completed in close proximity to the time an occurrence is discovered. "Occurrence Reports are created by accessing the application via the Home Page Link under Professional Resources."

This failure prevented QAPI from collecting, tracking and trending specific information regarding patient allegations of physical and sexual abuse by staff.
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VIOLATION: INFECTION CONTROL Tag No: A0747
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Based on record review, staff interview and observation, it was determined that the facility failed comply with the Condition of Participation for Infection Control. This was evident by the facility's failure to ensure that staff complied with the facility's Infection Control Practices to avoid potential sources of cross contamination which increases the risk for the spread of infection.

Findings:

Observations in the Pediatric Emergency Department, the Pediatric Unit and 14 South revealed numerous breaches in standards of Infection Control Practices by staff which included a Resident, Registered Nurses, a Nurse's Aide and a Radiology Transporter. These observations placed other patients and staff at risk for exposure to infections and communicable diseases.
(See Tag A 749)
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