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 ELIZABETH MEDICAL CENTER 2209 GENESEE STREET UTICA, NY 13501 Oct. 3, 2018
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
Based on medical record (MR) review, document review, and interview, 1 of 13 MRs (Patient #1) lacked a hospital Patient Transfer form (a form used to communicate patient information for interfacility transfers) and a Transfer Consent form. This could lead to necessary medical information not being relayed to the receiving facility at the time of transfer.

Findings include:

-- Per review of Patient #1's MR, he was transferred to an acute care facility (rehabilitation center) on 7/30/18 for care. His MR lacked a Transfer Consent form and a Patient Transfer form.

-- Review of the hospital's policy and procedure (P&P) titled "Interfacility Transfers - MVHS," last revised 8/2018, indicated transfers to another acute care facility should include a consent to transfer form. (The P&P does not require completion of Patient Transfer form.) However, per interview of Staff B, RN, Clinician for CardioThoracic Intensive Care Unit (CTICU) and Progressive Care Unit (PCU) on 10/2/18 at 9:30 am, when patients are transferred to another acute care facility a Patient Transfer form should be completed. He/she verified the lack of Patient Transfer form in Patient #1's MR.

-- During interview of Staff A, Lead Quality Professional on 10/3/18 at 2:00 pm, he/she acknowledged the above findings.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review, medical record (MR) review and interview, in 1 of 13 MRs (Patient #2) the attending physician did not document review of the patient's current Advance Directive form. This lack of review could lead to a patient's wishes concerning their provision of care to not be followed.

Findings include:

-- Per review of hospital policy and procedure (P&P) titled "Medical Orders For Life - Sustaining Treatment (MOLST) and Orders to Withhold/Withdraw Life-Sustaining Treatment (Including "Do Not Resuscitate" (DNR) orders)," last revised 3/2016, it indicated that each patient's DNR orders must be reviewed by the attending physician when medically appropriate, at least every seven days. ... The attending physician must document the review in the patient's MR and/or on the MOLST form.

-- Per MR review, Patient #2, a [AGE]-year-old female was admitted on [DATE] with a leg infection. The patient's completed MOLST form was last reviewed on 9/19/18. The MOLST form indicated Patient #2 had a DNR order. However, on 9/28/18 at 4:00 pm, the physician entered the order "Full Code" for Patient #2 (a telephone order for DNR was entered by a registered nurse (RN) on 9/28/18 at 4:28 pm). There was no documentation that the MOLST form had been reviewed by the physician.

-- During interview of Staff A, Lead Quality Professional on 10/3/18 at 12:05 pm, he/she acknowledged the above finding and confirmed the MOLST form was not updated.
VIOLATION: PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION Tag No: A0133
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record (MR) review, document review, and interview, in 13 of 13 MRs (Patients 1-13), there was no documentation indicating, that at the time of a patient's admission to the hospital, the patient was asked whether he/she wanted a family member or representative and his/her own physician notified of their admission to the hospital. Also, the hospital does not have policies and procedures (P&P) that address these processes. These lapses could negatively impact patient care.

Findings include:

-- Per review of Patient 3's MR, she was admitted on [DATE] with altered mental status. There was no documentation that hospital staff inquired as to whether Patient #3 wanted a family member or representative and her own physician notified of their admission to the hospital.

-- Per review of Patient 4's MR, she was admitted on [DATE] with a cellulitis and [DIAGNOSES REDACTED]. There was no documentation that hospital staff inquired as to whether Patient #4 wanted a family member or representative and her own physician notified of their admission to the hospital.

The same lack of documentation regarding whether patients wanted their family or representative and physician notified about their admission was found in MRs for Patients #1, #2, and #5 - #13.

-- Review of the hospital's P&P did not provide evidence that the hospital had P&P that addressed family/representative and physician notification.

-- During interview of Staff A, Lead Quality Professional on 10/3/18 at 1:30 pm, he/she acknowledged the above findings.
VIOLATION: USE OF VERBAL ORDERS Tag No: A0407
Based on medical record (MR) review, document review and interview, in 2 of 13 MRs (Patients #2 and #5), verbal /telephone orders were not cosigned by the provider. This could lead to inadequate management of patient care.

Findings include:

-- Per MR review on 9/28/18 at 4:34 pm, a registered nurse (RN) entered a telephone order from a physician for Patient #2 for "Code Status- Do Not Resuscitate" (DNR), however, the order remained unsigned by the physician 5 days later (10/3/18).

-- Per MR review on 9/25/18 at 9:15 am, an RN entered a telephone order from a physician for Patient #5 for "Consult Vascular Surgery", however, the order remained unsigned by the physician 8 days later (10/3/18).

-- The facility's policy and procedure titled, "Verbal and Telephone Orders," last reviewed 5/2018, indicated "Verbal and telephone orders must be cosigned by the ordering or attending provider within 48 hours ..."

-- During interview of Staff A, Lead Quality Professional on 10/3/18 at 12:05 pm, he/she acknowledged the above findings.