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 | April 8, 2016 |
| VIOLATION: PHARMACY ADMINISTRATION | Tag No: A0491 | |
| Based on observation, document review and interview, the facility did not ensure medication refrigerators are used only for the storage of medications. Storing medications with other supplies or food can increase the potential for contamination. Findings include: Review of Policy, " Medication Storage- Refrigerator/Freezer " , #020.0327 last reviewed 4/2014 revealed, ... " The storage of food and other non-medication items in medication storage refrigerators and freezers is prohibited. Food and other non-medication items must be stored in separate refrigerators and freezers. " ..... Observation of the Adult Rehab Unit medication preparation area on 4/7/16 at 1:00pm revealed a pitcher of water in a refrigerator labeled for medication only. The refrigerator contained 1 syringe of .5 ml influenza and 1 vial Tubersol 1ml/10 tests PPD. Interview with Staff #42 on 4/7/16 confirmed the above finding. |
||
| VIOLATION: UNUSABLE DRUGS NOT USED | Tag No: A0505 | |
| Based on observation and document review, the facility did not ensure expired medications were removed from the Emergency Department pediatric emergency cart. Having expired medications available for use has the potential to result in a patient receiving an expired medication. Findings include: Review of Policy, " Non-Conforming Product " #MM.060 last reviewed 2/2016 revealed according to policy " Process " , ...., " A. Any employee inspects products (either in stock or upon receipt) to assure product is appropriate for use (e.g., it is what was ordered, it is not damaged or expired, it is an approved substitute). If not, product should be segregated as " Not for use " and notify department supervisor. " Observation of the Emergency Department pediatric emergency cart on 4/4/16 at 2:20pm revealed 8.4% Sodium Bicarbonate Injection USP 50meq, expiration 4/1/16. Interview with Staff #8 on 4/4/16 confirmed the above finding. |
||
| VIOLATION: DISPOSAL OF TRASH | Tag No: A0713 | |
| Based on observation, interview and policy review, the facility does not ensure biohazardous waste, specifically sharps containers, are properly secured and stored. Failure to properly secure sharps containers can place patients, staff and visitors at risk of injury and/or infection. Findings include: Review of policy, Needle BOX Handling, SOP EVS 603 last revised 2/2016 revealed according to " Equipment " , ....., " 3. Sharps disposal containers may also be mounted on a cart (e.g., on crash cart, anesthesia cart, or as a large container on a wheeled stand such as in surgery or dialysis). Free standing containers may be in a base (sometimes described as a " dog dish " ); such containers should be in locations restricted to authorized staff, as regulations require used sharps be kept secure from patient/visitor tampering. " Observation in the outpatient Hand Center on 4/7/16 at 3:35pm revealed an unsecured tabletop sharps container in a patient care area. Observation in the outpatient Lab Department located in the Health Services building on 4/8/16 at 9:00am revealed two large unsecured floor sharps containers in a two patient treatment room. Interview with Staff #8 on 4/7/16 confirmed the above finding. |
||
| VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE | Tag No: A0724 | |
| Based on observation, interview and document review, the facility did not follow the manufacturer's recommendations for the maintenance of the Gastrointestinal endoscopes and colonoscopes. Findings include: Observation during the tour on 4/5/16 at 10:00am revealed oxygen is used as a drying agent for the scopes in the clean processing room. Interview with Staff # 46 revealed oxygen has always been used in drying the lumens of the scopes. Review of the facility ' s Policy and Procedure titled "Reprocessing Endoscopes (Custom Ultrasonic) 2 Bays" last revised 1/2016 revealed step #44 " blow out with compressed air supplied by an E tank. Review of the Olympus Evis Exera instructions, Reprocessing Manual on 4/6/16 Chapter 5.7 note, "These guidelines also recommend drying endoscope channels with compressed filtered air at each reprocessing procedures and with alcohol at the end of the day". Interview with Staff #46 on 4/6/16 confirmed the above finding. Based on observation and interview, the facility did not maintain the HVAC (Heating Ventilation and Air Conditioning) system to ensure required air pressure relationships for restrooms and storerooms. Findings include: Observation during the tour on 4/5/16 at 11:30am revealed the Clean Supply storage room of the Endoscopy suite had no ventilation. This regulation requires clean patient care supplies to be stored in a positive pressure room. Observation during the tour on 4/4/16 at 2:50pm revealed no exhaust in the staff restroom or soiled workroom of the Rehabilitation Department on the fourth floor. These areas are required to be of negative pressure to the corridor. Interview with Staff # 43 on 4/4/16 and 4/5/16 verified the above findings. Based on observation, document review and interview, the facility did not ensure that expired supplies were removed from patient care areas. Not removing expired supplies increases the liklihood that an expired product will be used during patient care. Findings include: Review of Policy " Code Team " # NS.340 last revised 11/2013 revealed, " The pharmacy department shall be responsible for the appropriate security and integrity of code cart and pediatric code cart contents. " ..... Review of Policy, " Non-Conforming Product " #MM.060 last reviewed 2/2016 revealed according to policy " Process " , ...., " A. Any employee inspects products (either in stock or upon receipt) to assure product is appropriate for use (e.g., it is what was ordered, it is not damaged or expired, it is an approved substitute). If not, product should be segregated as " Not for use " and notify department supervisor. " Observation of the pediatric emergency cart, located in the Emergency Department, on 4-4-16 at 2:20pm revealed the following expired supplies: Pediatric emergency system Broselow/Hinkle intubation module expiration 10/2015 Pediatric emergency system Broneslow/Hinkle introsseus module expiration 2/2016 - 2 boxes Interview with Staff#7 on 4/4/16 at 2:30pm confirmed the above finding. Observation in the Emergency Department supply room on 4/4/16 at 2:45pm revealed BD microtainers, 50 tubes, expiration 3/16 Interview with Staff #8 on 4/4/16 confirmed the above finding. Observation in the outpatient Occupational Therapy/Physical Therapy/Speech Therapy Department on 4/7/16 at 9:00am revealed 2 Empi Carbon FM electrodes for Transcutaneous Electrical Nerve Stimulation, Neuro Muscular Electrical Stimulation, and Functional Electrical Stimulation with expiration dates of 6/2014 and 9/2014. Interview with Staff #29 on 4/7/16 confirmed the above finding. Observation in the outpatient lab department supply room on 4/8/16 at 9:00am revealed 78 vacutainers with an expiration date of 2/2016. Interview with Staff #8 on 4/8/16 confirmed the above finding. |
||
| VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS | Tag No: A0117 | |
| Based on observation, interview and policy review, the hospital did not ensure that the patient representative was informed of the pediatric patient's rights in accordance with hospital policy and Title 10 New York Codes, Rules and Regulations. Findings include: Review of policy " Patient Rights " , #LE.050 last reviewed 4/2015 revealed according to " Distribution of Patients ' Rights Information " , ...., " The pediatric patient and parent bill of rights is posted in every designated pediatric room. Observation of the Emergency Department on 4/6/16 at 9:00am revealed the Parent's Bill of Rights was not posted. Interview with Staff #8 on 4/6/16 confirmed the above finding. Review of medical records for pediatric Patient #35 and 36 on 4/6/16 at 9:20am revealed no documentation to indicate the Parent's Bill of Rights was provided to the parent. Interview with Staff #37 on 4/6/16 at 9:20am confirmed the above finding. |
||
| VIOLATION: MEDICAL STAFF PERIODIC APPRAISALS | Tag No: A0340 | |
| Based on credential file review, document review and interview, the facility did not ensure peer review information was included in the reappointment process for 3 of 5 providers (Staff # 54, 57 and 58). Findings include: Review of Medical Staff By-Laws(undated) on 4/7/16 revealed: Subsection B: Verification of Information...The Vice President/Medical Affairs shall...verify ...on each reappointment application form...information deemed pertinent to the reappointment process. This shall include information regarding the staff appointee's ongoing professional practice evaluation, any focused professional practice evaluation...If there is insufficient clinical/peer review data available, a peer recommendation will be obtained. Review of credential files for Staff #54, 57 and 58 revealed no documentation to indicate an ongoing evaluation of professional practice was conducted or that the information obtained from an evaluation was utilized during the reappointment process or that a peer recommendation was obtained. Interview with Staff #41 on 4/7/16 verified the above finding. |
||