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 CATHERINE OF SIENA HOSPITAL 50 ROUTE 25A SMITHTOWN, NY 11787 Oct. 31, 2018
VIOLATION: SECURE STORAGE Tag No: A0502
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Based on observation, document review and interview, the facility did not ensure that medications were secured.

The presence of medications left unattended in Unit hallways placed patients at risk for potential harm.

Findings:

Observations in the facility's CSU during a tour between 10:15AM and 11:15AM on 10/29/18 identified the following:

Outside Room 222 an unattended medication cart was found in the hallway with the drawers opened. Inside the drawers were the following medications: Xopenex, Albuterol and Ventolin.

At the time of observation, Staff D (Respiratory Therapist) returned to the cart. She stated, "I went to the office to get medication".

Similar findings of unattended medication carts with unsecured medications were observed outside Room 223; and on 10/30/18 at 10:50AM, outside Room 224.

These findings were confirmed by Staff B (Nursing Director) and Staff A (Nurse Manager CSU) at the time of observation.

The facility Policy and Procedure titled "Medication Administration", last revised 01/16, stated the following: "Medication carts and medication rooms must be kept locked."
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VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on observation, document review and interview, the facility did not ensure that staff provided care in accordance with the acceptable standards of Infection Control Practices, specifically: Isolation Precautions, use of Personal Protective Equipment (PPE), handwashing and equipment storage.

This placed patients at increased risk for potential infection.

Findings:

Observations in the facility's CCU between 9:30AM and 10:15AM on 10/30/18 identified the following:

Patient #11 was on Contact Precautions. The Contact Precautions sign outside the patient's room directed staff to "...don gown and gloves upon entry". Staff E (Hospitalist) was observed in the Isolation Room without gown and gloves. She was holding the bed controls with both hands and her clothes were in direct contact with the patient's sheets. When the Administrator informed her that she needed to wear a gown and gloves in the room, she replied, "Oh, the patient's on isolation?"

Without performing hand hygiene, Staff E exited the room. The Administrator instructed her to perform hand hygiene. Staff E performed hand hygiene less than the required fifteen (15) seconds. Staff E repeated the inadequate hand hygiene during a subsequent observation.

Patient #12 was on Contact Precautions. Staff G (Ultrasound Technician) was observed performing a procedure on this patient. Without removing her gown and gloves and performing hand hygiene, Staff G exited the Isolation Room. With her "dirty" gloves, she removed the wipes from the Sani Wipe container, contaminating the container. She entered the Isolation Room with the wipes and disinfected the machine.

The Policy and Procedure titled "Isolation Precautions/Cohorting Patients", last revised 12/15, stated the following: "All healthcare providers who enter the patients' room and have contact with the patient or environment are required to wear a gown or gloves for contact precautions."

The Policy and Procedure titled "Isolation Precautions/Standard Precautions", last revised 05/15, stated: "Contact Precautions: remove gloves before leaving the patient's environment and wash hands immediately with soap or a waterless antiseptic agent. Remove the gown before leaving the patient's environment."

The Policy and Procedure titled "Hand Hygiene", last revised 11/15, stated: "When washing hands ... rub hands together vigorously for at least 15 seconds. Decontaminate hands before and after contact with a patient's intact skin. Decontaminate hands before donning and after removing gloves."

Observations in the facility's CSU between 10:15AM and 11:30AM on 10/30/18 identified the following:

Two (2) patients occupied Room 222. There was an IMED pump on a pole between the beds having contact with the curtain. Another IMED pump on a pole was behind a patient bed.

During interview with Staff B (Nursing Director) and Staff A (Nurse Manager CSU) at the time of the observations, Staff B stated the medication pumps and poles remain in each room. Housekeeping cleans them when the patient is discharged . Staff A stated, "neither patient was on IV (intravenous) antibiotics or fluids." They [medication pumps and poles] are stored at the bedside "in case they [staff] need them."

In Room 230, a CPAP (Continuous Positive Airway Pressure) machine was next to the window. There were two (2) patients in this room.

During an interview at 8:45AM on 10/30/18 Staff F (Vice President Regulatory Affairs) stated, "the patient that was on the CPAP machine was discharged on [DATE]."

This CPAP machine was observed in the room on 10/29/18, five (5) days after the patient was discharged , and other patients were assigned to the room.

Similar findings of equipment stored at the bedside were observed in Rooms 227 and 241.

Staff F and Staff H (Nurse Manager CCU) confirmed these findings at the time of observation.

The Policy and Procedure titled "Cleaning and Disinfection of Unit Based Patient Care Equipment", last revised 05/15, stated: "After a patient is discharged , all unit-based equipment that needs to be cleaned will be placed in the Soiled Utility Room. It will be cleaned and disinfected by Environmental Services and then placed in the Clean Utility room for use. Nursing will remove pump from IV pole when pump is no longer needed. Nursing will place the pump in the Soiled Utility Room."
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on observation, document review, Medical Record review and interview, the facility did not ensure that: a) in five (5) of five (5) observations, patients identified as high risk for falls had a yellow fall risk band and/or fall prevention signs posted outside their rooms and above their beds, and b) in five (5) of six (6) Medical Records, patients signed the facility required "Patient Fall Prevention Agreement".

The lack of fall prevention interventions places all patients at increased risk for injury.

Findings pertinent to (a) above:

The Policy and Procedure titled "Fall Prevention" last revised 02/23/18, states the following: "High Risk Interventions" include but are not limited to "Yellow Fall band applied to patient's wrist. Fall prevention sign posted outside the patient room and above the patient's bed."

Review of Patient #3's Medical Record identified that on 10/23/18 the patient was admitted , and she was identified as a high risk for falls. The Medical Record documented on admission and daily thereafter that the fall risk band was on the patient. However, observation of the patient on 10/29/18 revealed there was no yellow fall risk band on her wrist and no fall prevention signs posted outside her room and above her bed, six (6) days after admission.

During observations in the CSU between 10:15AM and 2:30PM on 10/29/18 the following was identified:

The same lack of patients identified as high risk for falls without a fall risk band and/or fall prevention signs posted outside their rooms and above their beds was identified for Patients #2, #4, #5 and #6.

Staff F (Vice President of Regulatory Affairs) and Staff C (Nursing Education) were present at the time of the observations and Medical Record reviews and acknowledged the findings.

Findings pertinent to (b) above:

The Policy and Procedure titled "Fall Prevention", last revised 02/23/18, instructs "At the time of admission, the nurse will provide and explain the "Patient Fall Prevention Agreement" to the patient/family" and "the patient/family will be requested to sign the agreement."

Review of Patient #1's Medical Record identified that the patient was admitted on [DATE] and was identified as a high risk for falls. The Medical Record lacked evidence of a "Patient Fall Prevention Agreement" signed by the patient or family, as per facility Policy.

The same lack of signed Patient Fall Prevention Agreements was identified for Patients #9, #10, #13 and #14.

These findings were confirmed by Staff I (Director of Performance Improvement) on 10/30/18 at 2:00PM.
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