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.

Based on record review and interview the hospital failed to ensure that hemodialysis treatments provided to patients by a contractor were in accordance with acceptable standards of practice.

Findings are:

On 10/3/16 at approximately 10:30 AM, while conducting interviews of registered nurse staff regarding dialysis treatments, 2 of 4 nurses (Staff C and D) interviewed stated that technicians from the contract dialysis service change central line dressings on dialysis patients. Nursing staff B stated on interview, on 10/3/16 at approximately 11:15 AM, that technicians from the contract dialysis service administered the intravenous heparin bolus to patients who are undergoing dialysis treatment. (See A405)

On 10/3/16 at approximately 10:50 AM review of the medical record of patient #1, indicated he received hemodialysis treatments on 9/27/16, 9/30/16, and 10/3/16. The hemodialysis treatment sheets in the patient's medical record showed the administration of the bolus doses of heparin administered to patient #1 was recorded on the treatment sheet by the contract dialysis staff, a licensed practical nurse (LPN). (See A405)

Review of the facility policy "Dialysis - Peritoneal and Hemodialysis" (Revision Date: 10/15) indicates that registered nurse staff are to draw the heparin into the syringe for administration to the patient and change patients' central line dressings. Staff A confirmed on interview, on 10/3/2016 at approximately 2:00 PM, that per hospital policy, contract staff are not supposed to administer heparin or change central line dressings. (See A405)

Though LPNs who practice in the outpatient chronic dialysis setting are permitted to care for patients undergoing dialysis treatment via a central line, the New York State Education Department Practice Guidelines, entitled "The Practice of IV Therapy by Licensed Practical Nurses (LPNs) in Acute Care Settings" (1/31/2013), indicates that when practicing in Acute Care Hospitals, LPNs may not change central venous line dressings, draw blood from a central venous line or administer intravenous drugs and solutions to patients via a central venous line.

Staff A verified on interview that contract dialysis staff who performed dialysis treatments at this hospital consisted of two LPNs and one dialysis technician. (See A405)
Based on record review and interview, for 1 of 42 medical records reviewed during the survey, it was found that contract dialysis technician staff administered intravenous heparin to a patient who was undergoing acute dialysis treatments at this facility on 9/27/16, 9/30/16, and 10/3/16. This does not conform with facility policy, nor New York State Education Department Practice Guidelines.

Findings - See A083.
Based on observation and interview, the hospital did not maintain the physical plant in a manner to ensure the safety and wellbeing of patients.

Findings are:

During the facility tour, the following items were observed:

a) It was noted on 10/3/2016 at 11:00AM that the floor drain outside the storage room in the kitchen was grease laden and that there were drain flies present in the area of the drain. Also, drain flies were present in the area of the automatic dishwasher.
b) It was noted on 10/3/2016 at 11:30AM that the floor in the kitchen, behind the steam kettles, stove and griddle were soiled with built up grease and dried up food debris.
c) It was noted on 10/3/2016 at11:40AM that there was a hot water line leaking above the carts of clean linen in the clean linen receiving area.

These findings were confirmed by Staff I at the time of observation.

On review of 7 generator inspection and preventive maintenance checklists for the sub-basement generator, dated 3/12/2015- 8/3/2016, the contracted inspector recommended that the batteries be replaced, due to their age being over 3 years. On review of the generator inspection and preventive maintenance checklists for the K-wing generator, dated 3/12/2015 it is noted that "batteries will be due in Dec. 2015." Reports of 2/11/2016, 5/9/2016, and 8/1/2016 all recommend that the batteries be replaced due to age. The facility was not able to provide evidence to indicate that these reports have been reviewed or acted on by the facility.

It was noted an 10/4/2016 at 11:30 AM that operating room #5 had damage to the sheetrock at the bottom of one wall and a hole in the flooring where it meets the wall. There were areas of the walls that were spackled, but not painted. There were several holes in the walls where wall mounted equipment had been removed.

When Staff M and N were asked about the condition of the other operating rooms, they indicated that the other rooms had similar types of damage to the floors and walls.
Based on observation and interview the facility failed to maintain patient equipment and supplies.


During tour of the labor and delivery unit on 10/4/16 at 11:00 AM, infant warmers in room 214 and the nursery were observed to be ready for use. Both warmers had clipboards attached with a daily equipment checklist. Neither checklist had been completed for 10/1-10/4/16.

In the nursery 4 commercially prepared, prefilled oxygen humidifiers were located with supplies. All 4 humidifiers had expiration dates of 2013.

At the time of the tour, Staff H stated unit staff were responsible for daily equipment checks and maintaining supplies for the unit.
Based on interview the facility did not maintain records that demonstrate they have achieved required levels of relative humidity in anesthetizing locations.

Findings are:

During tour of the labor and delivery unit on 10/3/2016 at 2:15 PM, the temperature and humidity logs for the cesarean section operating room were requested for review. Staff H stated that they have not kept these logs since April 2016, because they were being kept by the Engineering Department.

During interview on 10/4/2016 at 9:15 AM when asked to review the temperature and humidity logs for the cesarean section operating room, Staff I said that the Engineering Department did not keep the logs.
Based on observation and interview, facility staff failed to adhere to infection control policies.


On 10/03/16, at 10:30 AM during an interview with patient #3, it was noted that the patient had an intravenous insertion site in the antecubital area of his left arm. Half of the intravenous site dressing was visibly soiled. Staff F noted that the intravenous insertion site had a soiled dressing over it. Staff F stated that it was facility policy to change any dressing that was visibly soiled.

On 10/04/16, at 1:15 PM, during an observation of nursing care, nursing staff G was performing tracheostomy care. At the end of the care, the nurse, who was wearing gloves, placed a clean 4 x 4 tracheostomy split gauze sponge around the patient #2's tracheostomy tube. The nurse then walked across the room, touched the ventilator and also touched the monitor screen, which was displaying the patient's vital signs. This was done without removing the soiled gloves.