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 JOSEPH'S HOSPITAL, INC | 555 ST JOSEPH'S BLVD ELMIRA, NY 14902 | Jan. 14, 2011 |
| VIOLATION: LICENSURE OF PERSONNEL | Tag No: A0023 | |
| Based on document review and interview, the facility does not ensure that the health status of personnel is assessed annually as required by New York State Title 10 regulation 405.3(b)(11), which requires the reassessment of the health status of all personnel as frequently as necessary, but no less than annually, to ensure that personnel are free from health impairments which pose potential risk to patients or personnel or which may interfere with the performance of duties, for 8 of 12 staff who had been working at the facility for over one year. (Staff #1, 8, 11, 12, 14, 15, 17 and 19) Findings include: Personnel file review on 1/12/11 and 1/13/11 for Staff #1, 8, 11, 12 and 14-21, who had been working at the facility since 2009 or before, revealed that the files for Staff #1, 8, 11, 12, 14, 15 and 19 did not contain evidence of health status reassessment since 2009. The file for Staff #17 did not contain evidence of health status reassessment since the pre-employment physical examination in 2007. This finding was verified with Staff #27 on 1/13/11 at 2:30 PM. Based on interview and document review, the facility does not ensure that personnel have annual training on infection control and fire safety as required by hospital policy and New York State Title 10 regulations 405.3(b)(4), which requires implementation of a written plan for inservice training, and 405.24(b)(3), which requires that personnel shall be trained in emergency procedures and all duties in the master fire plan, for 4 of 14 staff. (Staff #1, 12, 14 and 21) Findings include: During interview on 1/11/11, Staff #1 stated that all staff complete annual mandatory inservicing training, which among its topics includes inservices such as fire safety and infection control. Review of the hospital form used to document staff completion of the annual Mandatory In-services revealed 18 topics, which include infection control and fire safety. Personnel file review on 1/12/11 and 1/13/11 for Staff #1, 8 and 11-22 revealed that the files for Staff #1, 12, 14 and 21 did not contain evidence of training in infection control or fire safety since 2009. This finding was verified with Staff #27 on 1/13/11 at 2:30 PM. |
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| VIOLATION: CONTENT OF RECORD - OTHER INFORMATION | Tag No: A0467 | |
| Based on interview and medical record review, the facility does not ensure that all information regarding the patient's status is recorded for 4 of 25 patients. (Patients #15-17 and 33) Findings include: During interview on 1/12/11, Staff #10 indicated that Hourly Patient Rounding sheets should be completed on all patients. -Medical record review on 1/11/11 revealed: ---Patient #15: No Hourly Patient Rounding sheets for 1/10/11. ---Patient #16: Incomplete Hourly Patient Rounding sheets for 1/9/11 and 1/10/11. ---Patient #17: Incomplete Hourly Patient Rounding sheets for 1/10/11. -Medical record review on 1/13/11 for Patient #33 revealed incomplete Hourly Rounding Sheets for 1/25/10 and 1/26/10. -These findings were verified with Staff #1 on 1/14/11. |
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| VIOLATION: MEDICAL RECORD SERVICES | Tag No: A0450 | |
| Based on policy review, medical record review and interview, the facility does not ensure that all patient record entries are complete for 2 of 3 records at the Southport Internal Medicine site. (Patients #28 and 29) Findings include: Review on 1/20/11 of Nursing Service Policy I-1-E "Nursing Documentation in Patient Chart" (revised 6/2010) revealed that all medical records must be dated and timed and signed with "... at least the first initial of the first name, last name and the initials of your professional status after each entry". Medical record review on 1/13/11 for Southport Internal Medicine patients revealed: --Patient #28: Entries for 6/21/10 and 6/28/10 were not timed and the person responsible for the medical record entries was not identified. --Patient #29: Entries for 3/10/10 and 8/30/10 were not timed and the person responsible for the medical record entries was not identified. These findings were verified with Staff #1 on 1/13/11. |
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| VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION | Tag No: A0168 | |
| Based on policy review, medical record review and interview, the facility does not ensure that all patient restraints are ordered appropriately for 2 of 2 patients for whom restraints were used. (Patients #14 and 31) Findings include: Review on 1/11/11 of Emergency and Special Procedures Policy Oy-114K "Protective Restraint of Patients" (dated 8/30/10) revealed that "Level One" patient restraints must be ordered by a licensed independent practitioner (LIP) and "...re-ordered every 24 hours with the need for restraint stated". Medical record review on 1/11/11 for Patient #14 revealed: --The Restraint Observation Flow Sheet documented that the patient was restrained on 1/3/11 between 12 midnight and 10:30 PM without an LIP's order. On 1/6/11, the patient was restrained between 10:30 AM and 10:00 PM without an LIP's order. On 1/7/11, the patient was restrained between 12 midnight and 11:00 PM without an LIP's order. --The Protective Restraint Order Form dated 1/8/11 showed no documentation of the "time for restraint" (duration). Medical record review on 1/13/11 for Patient #31 revealed: --The Protective Restraint Order Form dated 2/8/10 showed no documentation of the "reason for the restraint". --The Protective Restraint Order Form dated 2/9/10 showed no documentation of the "time for restraint". These findings were verified with Staff #1 on 1/14/11. |
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| VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION | Tag No: A0175 | |
| Based on policy review, medical record review and interview, the facility does not ensure that all restrained patients are monitored every 30 minutes for 1 of 2 patients for whom restraints were used. (Patient #14) Findings include: Review on 1/11/11 of Emergency and Special Procedures Policy Oy-114K "Protective Restraint of Patients" (dated 8/30/10) revealed that patients in "Level One" restraints must have a "Patient assessment and documentation... by the nurse every 30 minutes while the patient is restrained". Medical record review on 1/11/11 for Patient #14 revealed that the Restraint Observation Flow Sheet showed documentation on 1/3/11 that the patient was restrained between 12 midnight and 10:30 PM, but 30 minute assessments were not documented between 12 midnight and 7:00 AM. On 1/8/11, the patient was restrained between 12:30 AM and 11:00 PM, but 30 minute assessments were not documented between 7:00 AM and 2:00 PM and between 5:10 PM and 9:15 PM. These findings were verified with Staff #1 on 1/14/11. |
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| VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES | Tag No: A0749 | |
| Based on observation and interview, the facility does not ensure that staff wear appropriate personal protective equipment (PPE) when performing the reprocessing of the endoscopes. (Staff #28) Findings include: Review on 1/11/11 of the package insert for the high level disinfectant Metricide (2.6% Glutaraldehyde) revealed that precautions must be exercised when using this solution. The insert indicated that the following PPE must be utilized: ---Protective gloves (butyl rubber, nitrile rubber, polyethylene or double gloved latex); ---Eye protection; ---Face masks; and ---Liquid proof gowns. During observation on 1/11/11 of Staff #28 performing the cleaning/disinfection of dirty endoscopes, it was noted that the only PPE that she wore was a pair of latex gloves. During interview on 1/11/11, Staff #28 and 32 indicated that they were not aware of this manufacturer requirement. |
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| VIOLATION: VENTILATION, LIGHT, TEMPERATURE CONTROLS | Tag No: A0726 | |
| Based on observation, document review and interview, the facility does not ensure that the humidity in 7 of 7 operating rooms is within facility-established parameters. (Rooms 1 - 7) Findings include: During facility tour on 1/12/11, it was observed that the mechanical exhaust in operating rooms 3 and 4 was not operational. During interview, Staff #42 indicated that these exhaust vents had worked in the past, but were not operational at this time. Review on 1/12/11 of the Daily Temperature Log, which included daily humidity readings, revealed that the facility-established parameters for the humidity level was 50-60%. The log indicated that the humidity was not within facility-established parameters for the following days: June 2010: ---OR 1: 1 of 21 days ---OR 2: 17 of 21 days ---OR 3: 2 of 21 days ---OR 4: 6 of 21 days ---OR 5: 1 of 21 days ---OR 6: 2 of 21 days ---OR 7: 5 of 21 days July 2010: ---OR 1: 5 of 21 days ---OR 2: 3 of 21 days ---OR 3: 3 of 21 days ---OR 4: 4 of 21 days ---OR 5: 5 of 21 days ---OR 6: 3 of 21 days ---OR 7: 7 of 21 days August 2010: ---OR 1: 9 of 22 days ---OR 2: 6 of 22 days ---OR 3: 4 of 22 days ---OR 4: 4 of 22 days ---OR 5: 5 of 22 days ---OR 6: 10 of 22 days ---OR 7: 12 of 22 days September 2010: ---OR 1: 8 of 21 days ---OR 2: 14 of 21 days ---OR 3: 7 of 21 days ---OR 4: 7 of 21 days ---OR 5: 9 of 21 days ---OR 6: 7 of 21 days ---OR 7: 12 of 21 days October 2010: ---OR 1: 15 of 21 days ---OR 2: 19 of 21 days ---OR 3: 17 of 21 days ---OR 4: 18 of 21 days ---OR 5: 18 of 21 days ---OR 6: 16 of 21 days ---OR 7: 16 of 21 days November 2010: ---OR 1: 20 of 20 days ---OR 2: 20 of 20 days ---OR 3: 20 of 20 days ---OR 4: 20 of 20 days ---OR 5: 20 of 20 days ---OR 6: 19 of 20 days ---OR 7: 20 of 20 days December 2010: ---OR 1: 20 of 21 days ---OR 2: 20 of 21 days ---OR 3: 6 of 21 days ---OR 4: 20 of 20 days ---OR 5: 19 of 20 days ---OR 6: 21 of 21 days ---OR 7: 20 of 21 days An interview with Staff #7 on 1/12/11 revealed that the gauges in each operating room required recalibration. Documentation was not provided to verify that a manual humidity was obtained for these rooms prior to being utilized. Documentation was also not provided to verify that the maintenance department had been notified that the humidity readings were consistently outside of the facility-established parameters. These findings were verified with Staff #2 and 42 on 1/12/11. |
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| VIOLATION: DISPOSAL OF TRASH | Tag No: A0713 | |
| Based on observation and interview, the facility does not ensure the security of sharps containers. Findings include: Observation on 1/12/11 at 1:30 PM of the clean utility room on the ambulatory surgery unit (E2) revealed a small sharps container with a lid that was accessible on top of the code cart. The sharps container contained the following partially used medication vials: --2 vials of Diphenhydramine 50mg/1ml --2 vials of Meperidine 50mg/1ml --6 vials of Dexamethasone Sodium Phosphate 4 mg/1ml --1 vial of Famotidine 20mg/2ml When the small sharps container was tipped upside down, the partially-filled vials of medication were easily retrieved. This finding was verified with Staff #3 on 1/12/11. Based on observation and interview, the facility does not ensure that 2 of 2 full sharps containers, in the phlebotomy room at the Southport Internal Medicine site, are removed when full. Findings include: During tour of the Southport Internal Medicine site on 1/13/11, it was observed that two full sharps containers were present in the phlebotomy room. Holders for the sharps containers were not present in the phlebotomy room to ensure the security of the containers. During interview, Staff #50 indicated that hospital staff had not been present to retrieve and dispose of the full containers. |
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| VIOLATION: UNUSABLE DRUGS NOT USED | Tag No: A0505 | |
| Based on observation and interview, the facility does not ensure that all outdated and expired drugs and biologicals are not available for patient use. Findings include: -Inspection of the locked ICU Emergency Cart on 1/10/11 revealed the following expired items: (2) 500 ml 0.9% Normal Saline Bags expired 9/2010 and (1) 500 ml 0.9% Normal Saline Bag expired 12/2010. -This finding was verified with Staff #10 on 1/10/11. -Inspection of the locked Unit D2 Emergency Cart on 1/11/11 revealed (1) Central Venous Catheter Kit that had expired 11/2010. -This finding was verified with Staff #34 on 1/11/11. -Tour of the Endoscopy Unit on 1/11/11 revealed 16 Endo Vive Mini Button Care Kits that had expired between 4/2008 and 5/2010. -These findings were verified with Staff #2 on 1/14/11. -Tour of the Emergency Department on 1/12/11 revealed the following: 2 expired Med-Tox Blood Alcohol Kits: (1) expired 2/2001 and (1) expired 2/2001. The Latex Allergy Box contained (5) Esteem Polysoprene Surgical Gloves expired 2/2006 and (2) Protective 20 gauge IV Insert needles expired 2/2009. -These findings were verified with Staff #52 on 1/12/11. -Inspection of the Radiology Special Procedures Room locked narcotic box on 1/12/11 revealed the following expired items: (1) Sterile Water vial expired 2/2010; (1) Naloxone Hydrochloride 1 mg/1 ml vial expired 9/2010; (1) Flumazenil 0.5 mg/5 ml vial expired 10/2010 and (1) Morphine 10 mg/ ml vial expired 10/2010. -These findings were verified with Staff #3 on 1/12/11. Based on interview and observation, the facility does not ensure that all drugs and biologicals are dated and timed when opened. Findings include: Interview with Staff #1 on 1/12/11 revealed that all medications and bottles should be dated and timed when opened. Tour of the Emergency Department on 1/12/11 revealed the following undated, untimed items in a cupboard in the Nurses' Station: normal saline, hydrogen peroxide, Gastrografin and rubbing alcohol. These findings were verified with Staff #1 on 1/12/11. Based on interview and observation, the facility does not ensure that all patient care items are labeled, dated and timed when opened. Findings include: Interview with Staff #2 on 1/11/11 revealed that all patient care items should be labeled, dated and timed when opened. Tour of Patient #17's room on 1/11/11 revealed undated and untimed IV tubing, opened normal saline, an opened bulb syringe set-up, and a cup of vinegar that was unlabeled, untimed and undated. This finding was verified with Staff #2 on 1/11/11. |
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| VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS | Tag No: A0117 | |
| Based on interview and medical record review, a copy of patient's rights is not provided to outpatients and emergency services patients as required by this regulation, and by New York State Title 10 regulation 405.7(a)(2) specifically for outpatients and emergency service patients, for 7 of 7 patients. (Patients #10, 21-23 and 28-30) Findings include: -Interview with Staff #1 on 1/12/11 revealed that a copy of patient's rights is not provided to outpatients and emergency services patients. -Medical record review on 1/12/11 for emergency services Patients #10 and 21-13 did not reveal evidence that they received a copy of patient's rights. -Medical record review on 1/13/11 for Southport Internal Medicine Patients #28-30 did not reveal evidence that they received a copy of patient's rights. |
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| VIOLATION: PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS | Tag No: A0147 | |
| Based on observation and interview, the facility does not ensure confidentiality of all patient medical records at the Southport Internal Medicine site. Findings include: Tour of the Southport Internal Medicine site on 1/13/11 revealed the following: --At 8:45 AM, 4 medical records were observed on a table in the employee break room. --At 8:55 AM, 11 white trash bags and one box containing medical records were observed in an unlocked, unused office. Staff #49 stated that the medical records were being kept there while waiting to be shredded. --At 9:00 AM, 12 boxes containing medical records for discharged or transferred patients were observed in an unlocked storage room. These findings were verified with Staff #49 on 1/13/11. |
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| VIOLATION: ORDERS DATED AND SIGNED | Tag No: A0454 | |
| Based on policy review, medical record review and interview, the facility has not ensured that telephone orders are authenticated by a practitioner for 3 of 25 patients. (Patients #11, 14 and 17) Findings include: Review on 1/13/11 of Nursing Service Policy I-1-J "Transcription of Orders by Physicians, Physicians' Assistants and Nurse Practitioners and Certified Registered Nurse Anesthetists" (revised 6/2010) revealed that "All telephone orders are to be countersigned by a physician as soon as possible or within 48 hours". Medical record review on 1/11/11 revealed the following orders were not authenticated by a practitioner as of the date of the review: --Patient #11: Two telephone orders written by a nurse on 12/30/10, one at "2030" for Morphine, and one at "0130" to "hold IV antibiotics and nitro paste and to let pt. (patient) have ice chips". --Patient #14: Two telephone orders written by a nurse on 1/1/11, one at "1530" for Morphine, and one at "0500" to "do CT of abdomen in am, (change) Morphine prn and adm (administer ) Morphine IV now". Three telephone orders written by a nurse on 1/2/11, one at "1620" to "give 2 amps of bicarb, Diprovan IV and hourly CVP readings", one at "1620" for soft wrist restraints, and one at "1950" for ventilator settings. Two telephone orders written by a nurse on 1/3/11, one at "2010" for a normal saline bolus, and one at "2245" to increase the rate of (IV) normal saline. --Patient #17: Two telephone orders written by a nurse, one on 12/17/10 at "2045" to "mix vinegar with sterile water and apply to buttocks", and one on 12/19/10 at "0300" to renew Morphine. These findings were verified with Staff #1 on 1/14/11. |
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| VIOLATION: CONTENT OF RECORD | Tag No: A0458 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility has not ensured that all patients have a medical history and physical documented no more that 30 days prior to or 24 hours after admission or registration for 2 of 25 patients. (Patients #1 and 11) Findings include: Medical record review on 1/10/11 for Patient #1 revealed that the patient was admitted on [DATE]. There was no evidence of a history and physical in the record as of the date of the review. Medical record review on 1/11/11 for Patient #11 revealed that the patient was admitted on [DATE]. There was no evidence of a history and physical in the record as of the date of the review. These findings were verified with Staff #1 on 1/14/11. |
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| VIOLATION: SECURE STORAGE | Tag No: A0502 | |
| Based on interview, document review and observation, the facility does not ensure that all drugs and biologicals are kept in a secured area, both at the main site and the Southport Internal Medicine site. Findings include: -Interview with Staff #40 on 1/12/11 revealed that the emergency cart lock on Unit E2 should be checked daily in order to ensure the integrity of its contents. -Review on 1/12/11 of the Unit E2 Emergency Drug Cart Inventory Audit Record for January 2011 revealed that the cart lock was not checked for 1 of 7 days the unit was open. -This finding was verified with Staff #40 on 1/12/11. -Interview with Staff #52 on 1/12/11 revealed that the emergency cart locks in the Emergency Department should be checked every shift (3 shifts per day) in order to ensure the integrity of its contents. -Review on 1/12/11 of the Emergency Department Pediatric Emergency Drug Cart Inventory Audit Record revealed that for December 2010 the cart lock was not checked every shift for 25 of 31 days, including 4 full days, and for January 2011 the cart lock was not checked every shift for 11 of 11 days, including 1 full day. -Review on 1/12/11 of the Emergency Department Adult Emergency Drug Cart Inventory Audit Record revealed that for November 2010 the cart lock was not checked every shift for 17 of 30 days; for December 2010 the cart lock was not checked for 22 of 31 days, including 2 full days; and for January 2011 the cart lock was not checked for 9 of 11 days, including 1 full day. -These findings were verified with Staff #52 on 1/12/11. Tour on 1/13/11 of the Southport Internal Medicine site revealed an open box containing 20 prescription pads in an unsecured room used for items awaiting shredding. This finding was verified with Staff #20 on 1/13/11. |
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