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.

LONG ISLAND JEWISH MEDICAL CENTER 270 - 05 76TH AVENUE NEW HYDE PARK, NY 11040 April 4, 2019
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 document review, Medical Record review and interview, in four (4) of five (5) Medical Records, the Nursing Staff inconsistently assessed and scored the patients' Braden Scales [tool used to predict pressure ulcer risk].

This inconsistent scoring of the Braden Scale may lead to delays or a lack of treatment and care.

Findings include:

The facility's Policy and Procedure titled "Pressure Injury: Prevention Assessment and Management" last revised 03/06/19 stated: "a risk assessment will be performed on all patients upon entry ... minimally daily ... or when there is a significant change in the patient's condition ... A valid and reliable tool will be used based on the age of the patient ... Braden Scale [for] Adult Patient Population Age 9 and above."

The facility's current Nursing Education material titled "Risk Assessment and Prevention: Reaching Zero Pressure Injuries" stated: "The Braden Scale for predicting pressure injury risk has been the tool most extensively studied and the tool used most often nationally and internationally."

Review of Patient #1's Medical Record identified the following information: This [AGE]-year-old patient was admitted with a history of Dementia, Atrial Fibrillation, Coronary Artery Disease, Hypertension (HTN) and Gastric Reflux Disease (GERD). The patient was sent to the emergency room (ER) by his Primary Physician for an elevated Bilirubin and had a past medical history of [DIAGNOSES REDACTED].

The Nursing Adult Plan of Care dated 03/16/19 at 6:54AM stated the patient was alert and oriented times two (2), tachycardic and hypertensive at times with low oxygen saturation that improved on nasal oxygen. The patient denied shortness of breath, dizziness or chest pain. The patient was receiving intravenous fluids and antibiotics.

The Nursing Adult Assessment and Intervention (A&I) Flowsheet dated 03/16/19 at 9:45AM stated the patient was on fall precautions, was confused but able to follow commands and had an expiratory wheeze with dyspnea on exertion. The patient was noted to have bilateral trace edema and generalized weakness. His abdomen was noted to be distended with hypoactive bowel sound and the patient was NPO (nothing by mouth).

The Physical Therapy Note dated 03/16/19 at 11:29AM stated the patient tolerated therapy well, was in no apparent distress and had stable vital signs.

The Braden Scale dated 03/16/19 at 9:54AM had a total score of 12 (twelve) for "slightly limited perception (3), occasionally moist skin (3), bedfast (1) with very limited mobility (2), probably inadequate nutrition (2) and a problem of friction and shear (1)."

The next Braden Scale dated 03/17/19 at 10:05PM had a total scored of 17 (seventeen) for "slightly limited perception (3), occasionally moist skin (3), walks occasionally (3) with slight limited mobility (3), adequate nutrition (3) and a potential problem of friction and shear (2)." However, there was no documentation showing improvement of the patient's condition in the Adult Plan of Care or A&I.

The Nursing Adult Plan of Care dated 03/17/19 stated that the patient remained alert, oriented times two (2), and denied shortness of breath, dizziness or chest pain.

The A&I Flowsheet dated 03/17/19 at 10:05AM stated that the patient was more confused, continued on fall precautions, still had dyspnea, had increased edema, moderately impaired mobility and was still NPO.

Review of Patient #12's Medical Record identified the following information: This [AGE]-year-old with a past medical history of [DIAGNOSES REDACTED][DIAGNOSES REDACTED] due to Sepsis. The patient was obtunded, minimally responsive, hypotensive and NPO due to her mental status. The patient was admitted in the Intensive Care Unit on Vasopressors [medication that constricts blood vessels to increase low blood pressure], intravenous fluids and had a urinary catheter placed.

The Nursing A&I Flowsheet dated 04/02/19 at 11:00PM stated the patient was obtunded and lethargic. The patient was on bedrest and positioned with two-person assistance. The patient had moderate generalized edema, cool extremities, was incontinent of stool, had a urinary catheter and has moderately impaired mobility.

The Braden Assessment Scale dated 04/02/19 at 11:30PM had a total score of 13 (thirteen) for "very limited perception (2), very moist skin (2), bedfast (1) with very limited mobility (2), adequate nutrition (3) and no apparent problem of friction and shear (3)."

The next Braden Scale, timed ten (10) hours later on 04/03/19 at 9:20AM, had a total score of 6 (six) for "completely limited perception (1), constantly moist skin (1), bedfast (1) completely immobile (1), very poor nutrition (1) and a problem of friction and shear (1)." However, there was no documentation showing changes of the patient's condition related to the Braden Scale scoring in the A&I.

The Nursing A&I Flowsheet dated 04/03/19 at 9:20AM, stated the patient remained sedated, on bedrest, needed two-person assistance for positioning, was still edematous, had cool mottled extremities, had significantly impaired mobility and was now receiving nasal gastric feedings.

The same type of inconsistent in Braden Scale scores were found in the Medical Records of Patients #2 and #13 for the review period of 04/02/19 to 04/04/19.

These findings were shared with and acknowledged by Staff B (Nursing Administrator), Staff C (Director) and Staff D (Director) on 04/03/19 at 2:00PM.
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VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on document review, Medical Record review and interview, the Nursing Staff failed to update a Care Plan and educate a patient on Isolation Precautions, in one (1) of two (2) Medical Records reviewed.

Findings include:

Patient #6's Medical Record identified that on 03/28/19 at 7:23PM, this patient presented to the Emergency Department with a chief complaint of purulent drainage from a right leg ulcer. The patient's White Blood Cell (WBC) count was elevated at 11.34 [normal range is 3.8-10.5 K/uL]. On 03/29/19 a wound culture was obtained, and the patient was placed on Contact Isolation Precautions. The wound culture resulted positive for Methicillin Resistant Staphylococcus Aureus (MRSA), Morganella and [DIAGNOSES REDACTED]. These culture results were called in to the Registered Nurse on the Unit on 03/31/19.

There was no documented evidence that a Nurse had updated Patient #6's Assessment and Intervention (A&I) Flowsheet to include Contact Precaution Interventions, nor provided Isolation Precaution Education to the patient and/or significant other at the time of Surveyor review on 04/02/19.

The facility Policy and Procedure titled "Knowledge-Based Charting (KBC) Documentation" last reviewed 11/28/18 stated, "Assessments and interventions (A&I) will be completed based on the needs of the patient and documented on the A&I Flowsheet."

The facility Policy and Procedure titled "Patients on Precautions, Infection Prevention" last reviewed 06/27/18, stated, "The patients need for education regarding his/her precaution needs shall be assessed and provided by the nursing/medical personnel and ... education shall be provided and documented within the medical record."

These findings were confirmed by Staff D (Assistant Director of Patient Care Services) on 04/03/19 at 1:00PM.
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VIOLATION: BLOOD TRANSFUSIONS AND IV MEDICATIONS Tag No: A0409
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Based on observation, document review and interview, the Nursing Staff did not consistently perform the independent patient and blood component verification process as per facility policy, in one (1) of two (2) blood transfusions observed.

Findings include:

The facility's Policy and Procedure titled "Blood Component Administration" last reviewed 08/01/18 stated, "Two staff members will identify the patient and component prior to administration ... Each staff member will independently [i.e. acting without consultation with or guidance from another staff member] identify the patient using the full name, date of birth and medical record number ... for example, each of two nurses independently compares the patient's name, date of birth and medical record number from the ID (identification) band on the patient with the name, date of birth and medical record number on the form attached to the blood component unit."

During observation of a blood transfusion on the facility's 6 North Unit between 10:00AM and 10:30AM on 04/03/19, Staff G (RN/Registered Nurse) identified Patient #10 by comparing the patient's name, date of birth and Medical Record number from his identification (ID) wrist band to the form attached to the blood component. Staff H (RN) did not independently identify Patient #10 by comparing information on his ID band to the form. Staff H did not interact with the patient to confirm his identity.

On 04/03/19 at 10:30AM Staff E (Nurse Manager) who was present at the time of observation, acknowledged and confirmed that the facility Policy and Procedure indicated blood and blood products should be independently verified by two (2) Licensed Practitioners at the bedside.

The facility did not consistently implement their policy regarding independent patient and blood component verification.
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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, Medical Record review, document review and interview, the facility did not ensure that patients with known risk factors for cross contamination and hospital acquired infections, were not cohorted with patients on Isolation Precautions.

This placed patients at increased risk for hospital acquired infections.

Findings include:

The facility's Policy and Procedure titled "Patients on Precautions, Infection Prevention" last reviewed on 06/27/18 stated, "A private room may be indicated for patients colonized with multi-resistant bacteria such as ... MRSA ... and resistant gram-negative organisms ... Patients infected by the same microorganisms may share a room. When a private room is not available, place the patient in a room with a patient(s) with the same organisms..."

Observations during a tour of the facility's 3 North Unit on 04/02/19 at 11:00AM identified that Patient #6 was on Contact Precautions for gram-negative infections. This patient was housed in a semi-private room [two {2} patient beds with a shared bathroom] with Patient #14, who was status post-surgical procedure and free of infections.

Review of Patient #6's Medical Record identified that this patient (MDS) dated [DATE] with purulent drainage from a leg abscess and a wound culture was obtained. On 03/29/19 Patient #6 was admitted into the semi-private room where Patient #14 was already housed. The culture results were called to the Nurse on 03/31/19 and resulted positive for Methicillin Resistant Staphylococcus Aureus (MRSA), Morganella Morganii and Klebsiella (all three {3} are gram-negative opportunistic bacteria and potentially harmful pathogens).

Review of Patient #14's Medical Record revealed that this Diabetic patient had been admitted on [DATE] and required surgery. The Physician Note dated 03/29/19 stated that Patient #14 did not require Isolation Precautions, had no history for MRSA, and had no risk of exposure prior to admission. Patient #14 underwent a toe amputation on 03/30/19, one (1) day after Patient #6 had been admitted as his roommate. Patient #14 continued to be housed in the same room as Patient #6. There was no documented evidence of patient education on the use of Contact Precautions relative to the room he shared.

During interview of Staff E (Nurse Manager) at the time of the observation, when asked why Patient #6 and Patient #14 were housed together, Staff E reported that Patient #6 did not ambulate and couldn't get up to use the restroom. Therefore, he could be cohorted with other patients. Staff E also indicated that the Unit has a capacity to hold twenty-four (24) beds.

Review of the Bed Census at the time of observation was twenty-one (21). Further review of the Unit's Bed Census Logs from 03/28/19 to 04/02/19, revealed there were unoccupied beds available on this Unit for all the above dates, and that the unit's Patient Census never exceeded bed capacity during that time.

A review of the Physician Order for Activity Level dated 03/29/19 revealed that both patients could ambulate with assistance. This finding was confirmed upon interview of both Patients #6 and #14 at the time of observation, who reported that they did ambulate to the shared bathroom.

These observations and findings were made in the presence of Staff D (Senior Administrative Director of Patient Care Services) and Staff E, who confirmed these findings.
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VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on Medical Record review, document review and interview, the facility staff did not ensure that pertinent patient information for follow up and treatment was provided to the Sub-Acute Rehabilitation facility at the time of discharge, in one (1) of three (3) Medical Records reviewed.

This failure may have placed patients at risk for inappropriate post-hospital care and/or readmission.

Findings include:

The facility Policy and Procedure titled "Discharge Planning" last revised 03/16/17 contained the following statements: "The objectives of the discharge planning process are: to ensure communication regrading ongoing plan of care is sent to the next provider of care and primary care provider ... if the patient is being transferred to ... sub-acute rehabilitation, applicable documents such as a discharge plan or transfer summary are sent with the patient at the time of discharge ... a summary of care record must include ... goals and instructions ... current problem list..."

Review of Patient #3's Medical Record identified the following information:

The Advance Practice Nurse (APN) Consultation Note dated 10/09/18 at 2:22PM stated that Patient #3 was "bedbound, incontinent of urine and stool ... with increased moisture in intertriginous folds ... [had] hypopigmentation noted along rectal-anal [area]. Blanchable [DIAGNOSES REDACTED] and bogginess of left heel ... Severe incontinence/moisture related dermatitis ... sacral fold with open ulceration measuring 2.5cm x 1.5cm x 0.2cm [with] ... irregular boarders, 40% pink dermis with yellow translucent fibrin film, and 60% area of darkened dermis ... At 11 o'clock, 1cm away from peri-wound skin, there is an area of denuded epidermis (excoriation) measuring 1cm x 1.5cm x 0.2cm ... Right medial heel Suspected Deep Tissue Injury (SDTI) complicated by [DIAGNOSES REDACTED]% well demarcated purple maroon discoloration. Irregular boarders. No drainage. Peri-wound skin with hyperpigmentation and bogginess." This APN Consult Note also recommended treatments and interventions for the identified skin impairments.

The Adult Discharge Note and the Patient Review Instrument (PRI) for Patient #3, both dated 10/10/18, lacked documented evidence that Patient #3's skin impairments or skin treatment recommendations, were communicated to the Sub-Acute Rehabilitation facility at the time of discharge on 10/11/18.

These findings were confirmed by Staff D (Senior Administrative Director of Patient Care Services) at the time of the observation.