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.

JOHN T MATHER MEMORIAL HOSPITAL OF PORT JEFFERSON 75 NORTH COUNTRY ROAD PORT JEFFERSON, NY 11777 April 1, 2016
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
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Based on observation and interview, the staff did not perform hand hygiene after handling a patient specimen or removing gloves.

This lapse in Infection Control Technique may have placed patients at increased risk for Hospital-Acquired Infections.

Findings:

During an observation on 03/30/16 at 3:18PM Staff C (Nurse Practitioner) was observed handling a filled urine specimen container with gloved hands. After labeling and bagging the specimen container, Staff C proceeded to the pneumatic tube delivery system with gloved hands, opened the door, inserted the specimen container into the delivery cartridge, closed the door, entered the delivery destination code on the key pad and sent the specimen to the Laboratory.

With gloves still on, Staff C walked into the Nursing Station, removed her gloves, disposed of them in the waste basket and pulled up a chair to sit at the computer station, without performing hand hygiene after glove removal.

This observation was discussed with Staff G (Nurse Manager) on 03/30/16 at 3:20PM. Staff G stated that the Policy, and the expectation for the staff, is to perform hand hygiene after glove removal.

The Policy titled "Hand Hygiene" last revised June 2015 states "Hands must be cleaned before and after every patient encounter...Decontaminate hands...after contact with body fluids or excretions...[and] after removing gloves to maintain low levels of bacteria on hands..."
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VIOLATION: INTEGRATION OF EMERGENCY SERVICES Tag No: A1103
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on document review and staff interview, the Social Work Department did not develop a Policy to provide intervention to patients identified as having a Positive Alcohol Screening Questionnaire "Audit C" Score who are screened and discharged in the emergency room after hours (8:00PM until 8:00AM), in one (1) of thirteen (13) Medical Records.

This lack of a Policy results in patients identified with potential Alcohol Abuse not receiving appropriate intervention or community referrals.

Findings:

Review of Patient #12's Medical Record identified the following information: this [AGE]-year-old (MDS) dated [DATE] with complaints of Chronic Back and Wrist Pain. The Physician Assistant documented that the patient had a Past Medical History of Alcoholism. The Nurse documented a Positive (Total Score = 11) Alcohol Screening Questionnaire (Audit-C) in the "ED Nurse's Note" on 03/27/16 at 7:55PM but there is no documented intervention or follow up addressing the Positive screening.

Patient #12's Medical Record identified this patient again presented to the emergency room with complaints of Back Pain on 03/27/16 at 7:23 PM. The Physician's Assistant documented at 7:31PM that the patient had a Past Medical History of Alcohol Dependency and Alcohol Abuse. The Nurse documented a Positive (Total Score = 6) Alcohol Screening Questionnaire (Audit-C) in the "ED Nurse's Note" on 03/27/16 at 7:55PM but there is no documented intervention or follow up.

During an interview on 04/01/16 at 10:30AM the "Interim Director of Social Services" (Staff H) explained that a Positive Alcohol Screening Questionnaire "Audit C" Screen (Total Score of three {3} for women and four {4} for men) identified by the Nurse in the Electronic Medical Record automatically goes into the Social Worker's Assessment and the Social Worker must address the notification or they cannot complete the screen. "There is a Medical Social Worker covering the emergency room from 8:00AM to 12:00PM, then a designated Social Worker assigned to the emergency room from 12:00PM to 8:00PM. The Social Worker gets the electronic prompt to see the patient to provide a brief intervention regarding their alcohol use and offers a list of referrals but this does not happen after 8:00PM. The prompt will disappear when the patient is discharged and comes off the Patient Tracker."
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VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on document review, observation and interview, the emergency room Staff did not:

(a) Follow the facility's Policy for Pain Assessment, Reassessment and Timely Intervention in seven (7) of thirteen (13) Medical Records reviewed. This lack of Assessments and Intervention resulted in the patients' pain not being controlled.

(b) Document Nursing Assessments or complete Nursing Notes, in three (3) of thirteen (13) Medical Records as required by facility Policy. This lack of documentation makes it difficult to determine if appropriate Nursing Care is being provided to patients treated in the emergency room .

(c) Follow the facility's Policy for specimen labeling. This lapse in Policy may have placed patients at an increased risk for potential specimen mislabeling and improper treatment.

(a) Findings:
Review of Patient #2's Medical Record identified the following information: this [AGE]-year-old presented to the Emergency Department (ED) at 2:54PM on 10/10/15 with complaints of Low Back Pain. The patient was triaged by the Physician's Assistant as a Triage Acuity Level 4 (four), but there was no Pain Scale Assessment documented at triage. The ED Nurse's Note documented the patient's vital signs at 3:03PM, but there was no Initial Pain Scale Assessment documented by the Nurse.

The Nurse then documented a Pain Scale Assessment of 9 (nine) out of 10 (ten) at 6:50PM, almost 4 (four) hours later, but there were no documented interventions provided to the patient. The patient then left the emergency room without being seen by a Physician at 7:00PM.

Review of Patient #12's Medical Record identified the following information: this [AGE]-year-old presented to the Emergency Department (ED) at 7:48PM on 03/16/16 with complaints of Chronic Back and Wrist Pain. The patient was triaged by the Physician's Assistant as a Triage Acuity Level 4 (four), but there was no Pain Scale Assessment documented at triage. The ED Nurse' Note documented the patient's vital signs at 11:07PM, but there was no Initial Pain Scale Assessment documented by the Nurse.

This lack of documentation was confirmed during the onsite record review with Staff B on 03/30/16 and with Staff E on 03/31/16.

The same lack of documentation regarding an Initial Pain Scale Assessment was found in the Medical Record for Patient #11.

The facility' Policy and Procedure titled "Guidelines for Triage / Patient Classification of ED Patients" last revised November 2015, stated the following: "The Triage Assessment may include, but is not limited to, the following: Pain Assessment". And "Severe pain is determined by clinical observation and/or by the patient rating of greater than 7 (seven) on a 0-10 (zero to ten) Pain Scale".

The Policy titled "Pain Management - Assessment and Treatment Modalities" last revised November 2015 states "...all patients will be assessed for the presence / absence of pain and to determine their individual comfort function goal as part of the Admission Assessment". And "Pain Scales will be utilized according to developmental needs and cognitive ability".

Review of Patient #10's Medical Record identified the following: This [AGE]-year-old with a Past Medical History of Irritable Bowel Syndrome (IBS) and Asthma, (MDS) dated [DATE] at 11:54PM with a complaint of Rectal Bleeding. Patient #10 was assigned a Triage Acuity Level 3 (three). Patient #10's initial vital signs were assessed on 04/01/16 at 12:00AM and her initial pain level was assessed one (1) hour and twenty-one (21) minutes later at 1:21AM. Patient #10 complained of 10/10 (ten out of ten) abdominal pain, with a comfort goal of 0 (zero). Patient was given intravenous (IV) pain medication on 04/01/16 at 1:21AM. At 1:37AM Patient #10's pain level was 4/10 (four out of ten). No further pain interventions or assessments were documented for three (3) and one-half () hours.

At 5:06AM Patient #10's pain level was 8/10 (eight out of ten). The patient was given 2 (two) tablets of Norco 325mg-5mg at 5:06AM. Twelve (12) minutes later, at 5:18AM, Patient #10's pain level was re-assessed as unchanged, 8/10 (eight out of ten). Upon Medical Record review at 10:30AM, no further Pain Interventions or Pain Assessments were found. This was confirmed with Staff E (Nurse Educator) and F (Assistant Nurse Educator).

Per interview with Staff Members E and F on 04/01/16 at 10:35AM, the staff are expected to assess pain level initially with vital signs, and then re-assess within an hour of medication administration for pain.

The patient was discharged at approximately 12:00PM without any further Pain Assessments documented. This was verified with Staff Members G and I.

The Policy titled "Pain Management - Assessment and Treatment Modalities" last revised October 2013 states "...Reassessment of pain following medication administration for intermittent pain will be completed within one (1) hour of intervention. The pain score will be assessed and recorded at this time and should then be evaluated in relation to the comfort function goal..."

Review of Patient #8's Medical Record identified the following: This non-verbal [AGE]-year-old with a Past Medical History (PMH) of Huntington's Disease and Dementia, was brought in by ambulance to the Emergency Department (ED) on 03/31/16 at 11:44AM, with a non-functioning urinary catheter. Patient #8 was assigned a Triage Acuity Level 3 (three) and her initial vital signs were documented at 11:56AM. No Initial Pain Assessment was documented.

During interview on 03/31/16 at 2:30PM, Staff Members F and G indicated that non-verbal patients should have their pain assessed based on the Geriatric Guidelines. They added that staff should document this as "Assume Pain Present" [APP] in the Medical Record. Staff Members F and G demonstrated where in the Electronic Documentation System this notation should have been made. No Non-Verbal Pain Assessment documentation was found.

The Policy titled "Pain Management - Assessment and Treatment Modalities" last revised October 2013 stated "...when the patient is unable to self-report [pain] because of cognitive impairment, the American Geriatric Society Guidelines algorithm will be used to assess for pain. The Nurse will Assume Pain Present (APP) based on this Guideline to provide pain control measures..."

The same incorrect documentation regarding an Initial Pain Assessment was found in the Medical Records for Patients #3 and #5.

(b) Findings:
Review of Patient #3's Medical Record identified the following information: this [AGE]-year-old female (MDS) dated [DATE] at 9:52AM with complaints of Abdominal Pain and Bloating for two (2) weeks. The patient had a Past Medical History of Gastritis. The patient was triaged by the Physician's Assistant, then examined by the emergency room Physicians. The patient had an intravenous placed, underwent an abdominal x-ray and received oral medication but the Medical Record lacks all Nursing documentation. There is no Nursing "ED Nurse's Note" and no "ED Assessment and Care" Notes.

This lack of documentation was confirmed during the onsite record review with Staff B on 03/30/16 and with Staff E on 03/31/16.

The same lack of Nursing documentation regarding the Nursing "ED Nurse's Note" and the "ED Assessment and Care" Notes was found in the Medical Record reviews for Patient #11 during an emergency room visit on 03/21/16 and for Patient #12 during an emergency room visit on 03/25/16.

This missing documentation was also confirmed during review of the Medical Records with Staff E on 03/31/16.

The facility's Policy and Procedure titled "Nursing Process Policy" last revised July 2015 states the following: "The Emergency Department (ED) RN (Registered Nurse) will complete a Nursing Assessment on all patients in the ED utilizing the ED Nursing documentation in Sunrise".

The facility's Policy and Procedure titled "Charting - Nursing Documentation" last revised July 2016 states "Patient care will be documented by the Nurse a minimum of once per twelve (12) hour period" and "The Emergency Department will document patient care of ED patients in the EMR (Electronic Medical Record)".

(c) Findings:
During an observation on 03/30/16 at 3:18PM Staff C (Nurse Practitioner) was observed handling a filled urine specimen container at the Nursing Station. Staff C walked out of a Patient Area to the Main Treatment Area Nursing Station, placed the filled specimen container wrapped in a paper towel on the Nursing Station counter, and proceeded to label and bag the specimen container.

This observation was discussed with Staff G at 3:20PM. Staff G stated "That is not our Policy. The Policy is for the staff to label the specimens at the patient's bedside so they can use patient identifiers to prevent errors in labeling."

The Policy titled "Specimen Collection and Disposition" last revised February 2016 states "All specimens are labeled at the bedside or at the point of care to assure accuracy".
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VIOLATION: SUPERVISION OF EMERGENCY SERVICES Tag No: A1111
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Based on interview and document review, the Medical Staff did not designate a Supervising Physician nor have established criteria delineating the qualifications a Medical Staff Member must possess to supervise the provision of Emergency Care Services.

This failure may lead to a non-qualified Medical Staff Member supervising Emergency Care Services.

Findings:

The facility's Medical Staff Bylaws dated 05/05/15 did not contain established criteria such as the necessary education, experience or specialized training, delineating the qualifications a Medical Staff Member must possess in order to be granted Privileges for the supervision of Emergency Care Services.

During an interview on 03/31/16 at 11:30AM Staff J (ED Medical Director) stated "We do not have a designated Supervising Physician". When asked if there were specific criteria delineating the qualifications a Medical Staff Member must possess in order to supervise Emergency Care Services, Staff J responded "No, we do not have specific criteria for supervision in the ED" [Emergency Department]. This was confirmed with Staff K (Director of Nursing Emergency Services).