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Based on observation, interview and record review it was determined that the hospital failed to ensure that patients' rights were protected.

Findings include:

The facility failed to ensure that it has an effective grievance process which included prompt resolution of all grievances that the facility received. Reference is made to A-119.

The facility failed to ensure that all staff who apply restraint are appropriately trained. Security Officers who assist in the application of physical restraints have no evidence of training. Reference is made to A-194.

The facility failed to correct the loopable hazards in the inpatient psychiatric units. Reference is made to A-701.
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Based on record review and interviews, it was determined that the hospital's Governing Body failed to ensure that the QAPI (Quality Assurance Performance Improvement) program reflects the complexity of the hospital's organization and services.

Findings include:

1. Review of Quality Assurance documents found that there was no evidence of scheduled reporting of QA activities to the Board of Trustees QA committee. Cross reference is made to A-309.

2. There was no documented evidence of presentation of any QA reports to the Governing Body since June 2014. Cross reference is made to A-309.

3. There was no documented evidence that the governing body requested QAPI reports. Cross reference is made to A-309.
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Based on review of records, observation and interview it was determined that the hospital failed to meet its responsibilities to provide food and dietetic services to patients in a safe and therapeutic manner.

Findings include:

1. The hospital failed to keep refrigerated foods at a safe temperature. Cross refer to A-620

2. The hospital failed to maintain a temperature logs. Cross reference to A-620

2 The hospital Food and Nutrition department failed to have a policy that references food labeling. Cross reference to A 0620

3. The hospital failed to perform Nutritional screens for 100% of the in-patient psychiatric patients. Cross reference to A-0621

4. The hospital failed to provided temperature log for the pantry refrigerator in the Intensive Care Unit (ICU). Cross reference to A 0620

5. The hospital failed to sanitize pots and pans and other items. Cross reference to A-0749

Based on record review, interviews and observation it was determined that the hospital failed to formulate and implement an effective infection control program that meets the needs of patients.

Findings include:

1. Staff was observed cleaning a glucometer in an unsafe manner. Cross reference is made to TAG A-0749

2. The staff provided inconsistent information to the survey staff related to the cleaning of glucometers. Cross reference to A-0749

3. The Infection Control program failed to conduct adequate surveillance and correction of deficient practices found in the kitchen. Cross reference to A-0630

4. The Infection Control department failed to formulate and implement an effective plan to correct and monitor the potential for patient harm where a leak in the roof over the ceiling of Operating Room (OR) #2 resulted in a growth of a gram negative bacteria in that OR.
Cross refer to A- 0749

5. The hospital failed to properly clean ceilings in isolation rooms in the Emergency Department, in the Intensive Care Units, and in Medical - Surgical units.
Cross refer to TAG A- 0749
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Based on observations and staff interview, the hospital failed to comply with the New York State Department of Health (NYSDOH) licensure requirements and agreement as set forth by the state agency. Specifically, the hospital was observed to be operating a 5 bed Extended Telemetry unit in a location which was not approved by NYSDOH for inpatient care.

Findings include:

Review of the hospital's patient census on 07/25/14 at approximately 10:00 AM revealed that the hospital had 5 admitted patients in the "Medsurg CL area" (medical surgical cardiac catherization lab) since 07/24/14. Interview of the Director of Quality Management at approximately 10:30AM, revealed that the hospital converted a closed Cardiac Catherization Lab area into a patient care area to accommodate overflow of patients in the Emergency Department.

During the tour of the Cardiac Catherization Lab at approximately 11:00 AM, it was observed that this area had been converted into an extended telemetry unit for observation of 5 admitted patients in need of cardiorespiratory monitoring.

Upon interview of the Chief Nursing Officer on 07/25/14 at approximately 12:00 noon, it was revealed that the unit was put into operation the previous day due to the fact that the hospital did not have an adequate number of functioning telemetry (cardiac monitoring) boxes. The surveyors noted that these patients admitted to this "Meds CL area" were connected to portable monitors. Further interviews with the Director of Biomedical Service revealed that 5 out of the 17 telemetry boxes used in the telemetry section on the second floor of the hospital were under repair since the beginning of July 2014.

Observation of care in the Extended Telemetry room on 07/25/14 at approximately 11:30 AM revealed a portable monitor in the 5th patient bay that was noted to be placed on a chair by the bedside. This patient care area did not have a patient bathroom in close proximity. It was observed that patients were escorted by a patient care technician to a bathroom in the Emergency Department,when requested.

Further interviews with the Director of Quality Management on 7/25/14 revealed that the QA (Quality Assurance) department was not aware of the existence of this Extended Telemetry unit.
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Based on document review and staff interview, it was evident that the hospital failed to formulate and implement a policy and procedure to evaluate the efficiency of the services provided to the facility through contracted services. The hospital did not provide evidence of review of the conduct and efficacy of contracted services.

Findings include:

Review of the Performance evaluation conducted for an acute dialysis management company on 7/25/14 at 10:00 AM found an entry that stated "Timely repair of equipment,including portable water treatment and plumbing fittings" was one of the (1) seven(7) criteria used in determining the vendor's performance level. The surveyor requested, but the hospital did not provide documented evidence of audits conducted on equipment repair and maintenance. No schedule of inspection for these inspections was provided.

Review of the Maintenance logs of dialysis machines revealed that this vendor company did not implement the Preventative Maintenance Program for the dialysis machines according to manufacturer's guidelines. Refer to Tag 724 . Upon interview of staff from the vendor company and the hospital on 07/25/14 at approximately 10:45 AM, it was revealed that the vendor company did not provide the hospital with the Preventative Maintenance and repair reports.

Review of facility policies and procedures on 7/28/14 found no evidence of a policy to ensure that all services provided under contract are subject to departmental or governing body review.

At interview with the Director of Quality Management on 7/31/14 it was stated that there is no policy in effect to ensure systematic and ongoing assessment of the conduct of contracted services in the facility. Furthermore, it was stated that there is no evidence of any formal reviews of any of the contracted services in the facility. Review of managerial job titles and duties found no reference to who in the department has accountability to measure the performance of services rendered to the hospital under contractual agreements.

The hospital has contractual agreements with over 120 vendors, excluding LLP s (Limited Liability Partnerships) and PC's (Professional Corporations) and any academic and clinical affiliations. Review of the contract with a private security firm to provide licensed security guards for the facility found no evidence of audits or evaluations of the the contract.

The facility was unable to provide a comprehensive list of contractual services.
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Based on staff interviews, and review of the facility's Complaint Log, Patients' Grievance files, Patient Grievance Committee (Quality Council Sub-Committee) Meetings, Grievance Committee Meetings, Patient Relations Departmental Agenda and Patient Grievance and Investigation Process Policy, it was determined that the facility failed to ensure that it has an effective grievance process which includes the prompt resolution of all grievances that the facility received. Specifically, twelve (12) of the twenty (20) patients' grievance files reviewed, lacked timely written responses (File #2, #3, #4, #5, #6, #7, #8, #9 #10, #11 & #12).
Findings include:
During an interview with staff #27 on 7/23/14 at 11:00 AM, it was stated that the facility has a Grievance Committee and that this committee met in May of 2013, May of 2014 and June of 2014. There was no schedule of how frequent these meetings are conducted and what is the staff composition of such meetings. The June 2014 meeting's minutes were not available for review.
Staff #7 was interviewed on 7/23/14. This staff stated that the Board of Trustees delegated the Grievance Committee, a sub-committee of the Quality Council, on May 7, 2013 and May 1, 2014, to resolve patient grievances.
Grievance file #3 was reviewed on 7/23/14. The Patient Case Report form was dated 2/13/14. It was noted that this was a written complaint from a patient who was seen in the facility's Ambulatory Care Department. The patient felt that she was billed for care after she was verbally abused by the provider. It was noted that the clinic administrator's response was dated 2/13/14. As of the review on 7/23/14, there was no evidence that the complainant was provided a written response on the outcome of the investigation.
Grievance file #5 was reviewed on 7/23/14. The Patient Case Report form was dated 5/29/14. It was noted that the facility received a verbal grievance on the behalf of the patient's aunt. The patient was seen in the facility's Psych ED on 5/22/14. According to the complaint, this patient was attacked by another patient while in the psychiatric emergency department. It was noted that a copy of the written response on the outcome of the investigation was not located in the file.
Thr Patient Grievance and Investigation Process policy Number R1-02, revised October 12, 2013, was reviewed on 7/23/14. It was noted that, in this policy, the facility indicated that if it is unable to complete the investigation within 7 days, a letter will be sent to the complainant requesting more time.
The Grievance policy also documented that "a written response to the grievance with the results of the investigation will be sent to the complainant within 30 days."
The Patient Grievance Committee (Quality Council Committee) Meeting minutes dated May 22, 2014 were reviewed on 7/23/14. It was noted in these minutes that the facility's Grievance Committee failed to identify and discuss issues related to patients/patient's representative's grievances such as untimely responses and the content of the responses. Furthermore there was no quality improvement interventions to investigate why there is such a protracted response time to complaints and grievances. The committee did not discuss how complaints regarding clinical issues can be managed in a more efficient manner where interviews of providers and expert review of records are indicated.
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Based on staff interview, record review, incident report and policy, it was determined the facility failed to formulate and implement an escalation policy for staff conducting a 1 to 1 observation. This was evident for one of one patient reviewed (Patient #21).
Findings include:
Review of policy and procedures on 7/25/14, identified that the Hospital failed to have an Escalation policy to address how staff who are assigned to 1 to 1 observation of patients or any other level of increased supervision of patients who for any reason feel unsafe may communicate this without abandoning patients.
The facility's Patient Notification Event, dated 06/17/14, was reviewed on 7/25/14. It was noted that the Patient #21 eloped (left the facility unknown to staff) from the facility on 6/17/14. It was noted that the patient, 32 year old male, was admitted to the psychiatric unit on 6/10/14. The patient was transferred to a medical unit on 6/15/14 and he eloped on 6/17 /14.
The physician's progress notes dated 6/17/2014 timed at 05:05 indicated that the patient was "transferred from the psych floor for altered mental status s? Seizure??Syncope after code 77. The patient was placed on one to one observation for elopement. I was informed by nurse that the patient became violent at about 3:00 AM this morning and was breaking cardiac monitors. Security was called to curtail the patient. Patient was said to have run out through the east building. RN informed police and patient was located at home by the family." Code 77 represents a Rapid Response Team needed.
Nursing documentation dated 6/17/14 at 17:21 (5:21 PM) documented, "the charge nurse heard patient yelling and loud banging sound coming from the room. Upon investigation the patient was banging on the portable cardiac monitor with his hands. When asked by staff, what was wrong, the patient stated that, he told her that he asked the PCT (patient care technician) her name and she refused. He further stated that he does not want her in the home,(room) and he was leaving. The charge nurse interviewed the PCT who stated that the patient was sexually preoccupied and she became uncomfortable and she leave the room."

The facility's lack of Escalation policy and procedure addressing how staff, who are assigned to 1 to 1 observation of patients or any other level of increased supervision of patients who for any reason feel unsafe, may communicate this without abandoning patients was discussed with staff # 7 on 7/25/14.

Based on staff interviews and review of employee documents, it was determined that the facility failed to ensure that all security staff are trained in the application of restraints. This was evident on 30 of 30 Security officers reviewed.
Findings include:
The Director of Security was interviewed on 7/24/14. It was reported that security officers are called to assist the clinical staff in the application of restraints, which sometimes include physical holds.
Review of 30 of 30 of the security officers files (including training files) on 7/24/14 included CPI (non violent crisis intervention program). The syllabus of CPI (non violent crisis intervention program) was reviewed and it was noted that the training does not include the application of restraints or implementation of any assistance of staff such as "physical holds."
Review of facility policy and procedure titled, Restraints, on 7/24/14 failed to identify Security's role in the Restraint process.
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Based on staff interview, documents reviewed and hospital policy, it was determined that the facility failed to assure that its Quality Assurance (QA) Program identified all problems to prevent and manage a patient eloping from the facility. This was evident in 1 of 1 patients reviewed. (Patient #21)
Findings include:
Risk management reports submitted for review on 7/25/14, indicated that the case regarding the patient elopement from 2 west on 6/17/14, was discussed in the Risk management Occurrence Meeting on June 25, 2014.
A Risk Management Occurrence Meeting dated June 25, 2014 documented, that on 6/10/14, a 32 year old male was brought by ambulance because the patient was abusive, inappropriate aggressive and threatening at home. Upon arrival to the Emergency Department (ED), he required pharmaceutical intervention with Haldol 5 milligrams (mg) , Ativan 2 mg and Benadryl 50 mg. The patient was diagnosed as psychotic and admitted to 9 east for in-patient psychiatry on 6/10/14. On 6/13/14, the patient was eager to leave the hospital, but continued to display bizarre behavior. On 6/15/14, the patient was found unresponsive in the bathroom. Code 77 (Rapid Response Team) was activated and the patient was transferred to 2 West, a medical unit. On 6/15/14, the patient was placed on 1:1 observation for confusion and elopement risks, exhibiting mild confusion, poor judgment and insight. On 6/16/14 he remained on 1:1 observation for "high fall risk", according to the medical progress notes. On 6/17/14, the PCT (patient care technician) assigned to 1:1, reported that patient became sexually preoccupied and she became uncomfortable and left the room. The patient's behavior escalated becoming increasingly angrier yelling at the nursing staff and attacking a monitor. Security was called to intervene, but the patient exited the unit via the stairs, before security arrived. The patient knocked the sliding doors off the tracks as he exited the East building doors. The patient was later found at home by Police. He was brought back to the hospital where he was readmitted.
The Risk Management Weekly Incident Review meetings of June 2014, documented that the Standard of Practice was not met. In addition, it acknowledged that the facility failed to follow its elopement policy and take corrective action. It was noted that the plan was to be implemented immediately. However, there was no follow-up action to ensure that the actions were implemented. It was noted that the proposed action did not include re-in-servicing/re-educating the staff on the facility's elopement policy. Additionally, there was no evidence that all staff was educated on the new de-escalation techniques.
The Plan was for nursing to advise the Risk Management Incident Review committee as to what if any actions were implemented with the PCT. There was no evidence that this action was taken as the necessary documentation was not provided to this surveyor. There was no evidence that the staff was re-inserviced on the facility's one to one monitoring. There was no evidence that the necessary steps were taken to ensure that all staff assigned to do one to one monitoring for patients with aggressive behavior were properly trained.
The facility's plan stated that 1:1 observation should be performed by the staff of the same gender. However, the policy failed to address the the facility's plan when same sex staff is not avaiable.
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Based on review of documents and interviews, it was determined that the hospital's Governing Body failed to ensure that the facility maintains an ongoing program for quality improvement to improve the quality of patient care and safety.
Specifically, the Governing Body failed to maintain overall responsibility for the Performance Improvement Program as specified in the "Hospital-Wide Performance Improvement Plan, 2014."

Findings:

Review of documents and interviews were conducted on 7/28/14 and 7/29/14 and findings are as follows:

The Quality Council QA Committee Minutes dated January 23, 2014, February 24, 2014, March 20, 2014 and April 17, 2014 documents monitoring activities for Clinical and Administrative/Ancillary Departments, but there is no documented evidence of quarterly reporting to the Board of Trustees Quality of Care Committee.

The designation of responsibility to the Board of Trustees for the implementation and maintenance of the Performance Improvement Plan is outlined in The Hospital-Wide Performance Improvement Plan 2014, which states; The Board of Trustees maintains overall responsibility for the implementation and maintenance for the Performance Improvement (PI) Plan and delegates this responsibility to the President/Chief Executive Officer.

At interview on 7/29/14 at 12:40 PM, Staff # 7, Director of Quality Management stated, there have been no presentation of reports to the Governing Body since June 2014.

An interview was conducted on 7/29/14 at 2:10 PM with Staff # 7 and Staff #18 who also acknowledged that there have been no presentation of reports to the Governing Body since June 2014. They stated that two Board Meetings of the new board were held, however, no documentation of the Board Meetings were available to be provided to the surveyors. Specifically, reporting from the Quality Council could not be validated.
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Based on review of medical record, staff interviews and review of the facility's policies and procedures, it was determined that the facility failed to ensure the implementation of physician orders. Specifically, the nursing staff failed to assess, obtain physician orders, implement a nursing care plan and treat skin impairment for two of three patients reviewed. (Patient #1 and #2).

Findings:
Review of the patient #1's medical record on 7/23/14 and 7/25/14 documented
that Patient #1 was a 84 year old (y/o) male, admitted to the facility on 1/25/14 with diagnosis: AMS (Altered Mental Status), R/O (Rule Out) Pneumonia, Sepsis: PMH of HTN (Hypertension), Seizures, Alzheimer, CRF (Chronic Renal Failure).
The Registered Nurse's (RN) Admission Initial Assessment was completed on 1/25/14 and the Braden Risk Assessment was administered. The Initial Skin Assessment revealed an actual skin impairment, identified as a Pressure Ulcer, Unstageable, Black Eschar ( blackened skin evidencing tissue destruction due to alteration in circulation ) 4.5 centimeter (cm.) X 4.5 centimeter (cm.) on Left Heel. Treatment with Aqualcel Foam was initiated by the nurse on 1/27/14, approximately 48 hours after the initial assessment which is not consistent with the policy that states treatment should be initiated upon identification of actual pressure ulcers.

The Braden Risk Assessment (a tool used it identify potential or actual skin impairment) identified the patient as being high risk for the development of pressure ulcer and the Nursing Care plan for "At Risk for Impaired Skin Integrity/Pressure Ulcer Development" should be initiated, as stated in the "Skin and Tissue Integrity" Policy. However, the documentation to validate initiation of the nursing care plan could not be located in the Electronic Medical Chart (EMC) by Staff #9. Review of the printed EMC presented to the surveyor for the period 1/28/14 to 7/24/14, revealed interventions for "Alteration in skin integrity" were initiated by the nurse on 4/21/14.

The Physician Order for wound care to the Left Heel was documented on 6/15/14 as follows: "Aquacel Foam wound Dressing Left Heel Daily." However, this order was obtained approximately five (5) months after treatment was initiated and was not in compliance with the policy, which states, the nurse upon identifying actual pressure ulcers should "initiate treatment/obtain doctor's order for treatment following the Wound Protocol Selection Guide."

Additionally, documentation 7/18/14 to 7/23/14 showed that wound care to the Left Heel was not provided daily as per physician order.

Hospital Acquired Pressure Ulcers were documented to the: right (Rt) heel, left (Lt) Elbow, Lt Posterior Shoulder and Rt Lateral Shin and wound care was initiated by the RN. There was one physician order, "Aquacel Foam wound Dressing Behind Shoulder Q12," documented on 3/9/14 and there are no physician orders for the wound care documented by the RN to the other pressure ulcers.

Additionally, there is no documented evidence of the provision of wound care to the shoulder Q12 hours (every 12 hours) from 3/9/14 to 3/17/14.

All Pressure ulcer assessment parameters were not documented at time of dressing change and/or daily, as specified in the "Skin and Tissue Integrity." Policy. This was noted in the Wound Assessment documentation 1/27/14 to 3/17/14 and 7/18/14 to 7/23/14.

Weekly measurements and progress of every pressure ulcer was not documented by the RN on Wednesdays, as per policy.

Patient #2: 68 year old (y/o) female was admitted to the facility 7/14/14 for Femoral Bypass Graft; H/O (history of) HTN (Hypertension), PVD (Peripheral Vascular Disease), CAD (Coronary Artery Disease).

The Admission Initial Assessment completed on 7/14/14 by the RN revealed; Wound, Lt Lower Extremity, Skin Graft, Dry and Intact. The RN provision of treatment and care is not in compliance with the physician order and facility's policy, as evidenced by:

(a) Each skin impairment to the Lt Lower Extremity was not documented as a separate occurrence in the Wound Assessment.

(b) The treatment type to the left (Lt) Lower Extremity Ulceration is not documented by the RN 7/14/14 through 7/20/14.

(c) Surgical Intervention; Excision Lt Infected Prosthetic Femoral Tibial Anterior Bypass Graft (removal of infected artificial femoral and tibial vascular bypass graft located along front of left leg) is documented in the EMR (electronic medical record), 7/17/14. There is no documentation that the nurse obtained doctors order to treat this incision and intervention is not documented in the Wound Assessment record.

(d) Physician order was documented on 7/14/14 as follows: Aquacel Foam Wound Dressing, left (Lt) Lower Thigh Daily and Versiva XC Dressing, Lt Lower Leg Daily. There is no documentation that these orders were implemented for daily wound care, and specifically, to which sites.
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Based on observation, staff interview and review of dietary policy and procedures, the Food Service Director did not ensure that the daily operation of the food service department is maintain in a sanitary manner.
Findings include:
A tour of the hospital kitchen was conducted on 7/23/14 at approximately 10:30 AM. The surveyor was accompanied by the Food Service Director and Director of Operations. The Food and Nutrition Department is managed by a contractor. Examples of issues observed, included, but are not limited to, the following:
A. Unsanitary Environment/ Food Safety
A refrigerator located next to the food warmer had a temperature of 58 degrees Fahrenheit on the thermometer attached to the refrigerator. When staff #1 was informed that this temperature was out of range the surveyor was told that the temperature they record is not from the outside thermometer but the thermometer inside the refrigerator. The inside thermometer recorded a temperature of 80 degrees Fahrenheit . The pans of food were removed from the refrigerator.
The food warmer did not have a thermometer log to ensure that food temperature were not in the danger zone( 41 to 140 degrees Fahrenheit.)
Labeling of foods in the refrigerator was not consistent.
During an interview with staff #1 , it was asked what was the department policy on dating food. Staff #1 stated that foods were disposed of after three days from the date on the label. The surveyor was told that the date on the food item is the date when the food expires.
Review of the department policy and procedure manual showed that the department did not have a policy on food labeling. Food items in the refrigerator had dates on them but it was uncertain if the food date was when the item was prepared/open or the date it expired.
The labels on the food in the refrigerator did not identify the food item. Examples: Open bag of frozen omelet, a dish containing a white creamy substance later identified as " vanilla yogurt ".
The Dairy refrigerator did not have an operating light bulb.
The buffalo chopper and the meat slicer which were not in use were uncovered and had evidence of failure to clean.
On either the cart or the refrigerator that warned employees that it was not in use.
An uncovered weight scale under a counter was observed to be dirty and laden with dust.
The microwave in the kitchen had evidence of lack of cleaning.
A shelf with seven plastic containers of spices , bottles of oil and vinegar had no label with expiration date.
Ceiling tiles had evidence of inadequate cleaning in that the color of those tiles was amber, which was not the original color.
There were large spaces between tiles over the steamer. These spacer can harbor insects.
Large bins containing sugar and brown rice were unlabeled.
Metal rack belonging to the oven was on the floor with evidence of dry grease on it.
Hand wash sink was full of dirty water. Staff #2 informed the surveyor it was broken. There was no signage that warned staff not to use that sink.
The sheet pans and other pots and pan in the pot washing area had evidence of grease on them.
Backsplash behind the steamers had water films.
Floor Hobart mixer had evidence of dry food located where the attachment is placed on the mixer.
The two ovens had evidence of dry grease in them.
There was an oven that was not working but observed to have used rags, and cups inside it. Further, a container with soup base and a large steel container with melted butter were found on the rack inside the oven.
The floors and pipes adjacent to the stoves had evidence of inadequate maintenance.
A tour of the ICU unit and third floor was conducted on 7/25/14 at 10:00 AM. The head nurses of both units (Staff #9 and Staff #16) accompanied the surveyors. It was observed on both floor pantry refrigerators that the refrigerator temperature log sheets noted the danger zone as 46 degrees Fahrenheit and above. The refrigerator log form on both units noted temperatures above 40 degrees Fahrenheit for their pantry refrigerators. The National standard with food refrigerator temperature is 40 degrees Fahrenheit and below.
Upon review of the temperature log form: it was found that the form used to record food refrigerator temperature on the units was actually a form used to record the temperature of refrigerators containing vaccines. This form was distributed by the "Immunization Action Coalition".
The temperature log form used for food refrigerator was the wrong form. In addition, the refrigerator in the ICU was clean and contained one apple juice container. The third floor refrigerator was found to be dirty with brown stains on the door and shelf. It also contained a carton of milk with a label. The label had the name of a patient and room number. The use of this form placed patient's foods brought from home and hospital nourishments at risk due to the use of an erroneous temperature log.
A review of the Emergency Preparedness Manual was done on 7/23/14 at approximately 12:00PM. The surveyor was provided with two (2) manuals. When the surveyor asked which manual was their Emergency Department Manual, he responded that both these manuals were found in the department. They were uncertain which manual the Command Center had for its copy. One of the manual had a three day menu. This menu was generic and would be provided to all patients. Portions of food was not listed. There was no pureed menu. A list of equipment and paper goods were also absent in the manual. The amount of water to be provided to patients and staff on the unit was also missing. There were no mention of the availability of enteral feedings. There was no diagram as to the location of foods in the kitchen. There was no distribution list by unit for all meals.
The Food Director was interviewed on 7/23/14 at 3 PM concerning the Food Service Performance Improvement Program. The Food Service Director stated, that the division of food service of the department did not have a performance improvement program.
There was no evidence of a Food Service performance improvement program. The Clinical Nutrition Manager was interviewed concerning the clinical nutrition performance improvement program. She stated that the clinical nutrition division of the Food and Nutrition department does have a quality assurance program with indicators however the annual plan that would have been submitted to the quality assurance committee was absent.
It was observed that the hospital menus were not posted in the kitchen.
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Based on staff interview and policy and procedure, it was determined that the Dietitian did not ensure that all patients receive a nutrition screen to identify patient at risk for malnutrition. Specifically, the Hospital failed to perform a Nutritonal screen for patients on the inpatient psychiatric units. This was evident for 60 of 60 psychiatric patients.

Findings include:
During an interview on 7/24/14 at approximately 1:00 PM, the Clinical Nutrition Manager informed the surveyor that the patients in the Psychiatric Units, do not receive a Nutrition screen (by nursing).
The Hospital policy titled; Screening/Comprehensive Assessment documented that all patients would be screened by nursing.
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Based on staff interview, review of hospital's menus and physician diet prescription formulary, it was determined that the Hospital failed to accurately transcribe physician diet orders.

Findings include:
1. Menus were reviewed with staff # 17, Clinical Nutrition Manager. It was determined that the Physicians' diet orders were abbreviated on menus and did not match the physician prescribed diet orders. The menu must correspond with the prescribed diet.
Examples of diet order abbreviations on menus were:
a) Diabetic Renal Dialysis (Diet order)
DIRENLDIAL (Abbreviation on menu)
b) 80 Gram (gm) Protein-2 gm Sodium P80NA2GM (Abbreviation on menu)
c) High Fiber
HIFIB (Abbreviation on menu)
d) Regular Vegetarian LAOV-V (Abbreviation on menu)
e) Low Oxalate Diet LOWOX (Abbreviation on menu)
f) Diabetic 2500 calories
DB25 (Abbreviation on menu)

2. Diets listed on physician diet formulary failed to contain the amount of nutrient provided on diet.
Examples of these findings are:
a) High Calorie High Protein- there was no amount of calories or protein listed on the physician diet formulary, patient ' s menu or consistency in nutrient analysis.
b) High Fiber- the amount of fiber was not listed on the physician diet formulary, patient's menu or in the nutrient analysis.
c) Low Cholesterol or Low Cholesterol-Low Fat- there was no amount of fat or cholesterol listed on the physician diet formulary, patient's menu or consistency in nutrient analysis,
d) No Added Salt- there was no amount of sodium listed on the physician diet formulary, patient's menu or consistency in nutrient analysis.
e) Renal - there is no protein amount listed in physician diet formulary, patient's menu or consistency in nutrient analysis.

3. There were no age specific diets for Pediatric patients. The dietary department had one diet titled, "Pediatric" which addressed the adolescent population needs in food items and food portions. There was no documented evidence that the infant, toddler or school age child was provided the food and food portion required by the age group. In addition, there was no nutrient analysis available to substantiate that these age groups met the nutritional needs required for their age group.
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Based on observation, staff interview and review of diet formulary, it was determined that the facility failed to ensure that current diet manuals are used as a guidance for ordering and educating patients on their prescribed diets.

Findings are:
1 The hospital failed to follow the Pediatric Diet Manual. There was no evidence that age specific needs were met with the hospital generic menu.
2 In reviewing the nutrient analysis of the hospital master menu and hospital physician diet formulary, it was determined that the Nutrition Care Manual for Adults was not used as a reference since diets such as BRAT (Banana, Rice, Applesauce and Toast) and Bland included in the diet formulary had been deleted from the diet manual. Special approval for these diets from the hospital Nutrition Committee was not available.
3 Diet reference from the diet manual was not evident in the physician diet formulary. The amount of the diet restriction was absent in the diet formulary and the patient menu.
4 The adult care diet manual references the "Consistent Carbohydrate Diet" as the new diabetic diet that substitutes grams of carbohydrates per day for calories per day. The hospital has been following the old caloric diabetic diet instead of the consistent carbohydrate diet. There was no evidence that the caloric diabetic diet was approved by the nutrition committee to substitute for the consistent carbohydrate diet. An addendum to the diet manual was not in place.
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19043

Based on observation and staff interviews, the facility failed to maintain the physical plant in a manner to ensure an environment of patient safety.

Findings include:

During the tour of the emergency department on 07/23/14 at approximately 10:30 AM, the following were noted:

The nurse call bell system in the isolation room did not have a nurse call bell.

The patient bathroom in the hallway opposite to the exam room did not have a nurse call system.

Psych ER
Three (3) regular sprinkler heads were observed in the waiting area of this unit and the cover was missing on one of them.

Dental Clinic
The facility did not have tamper resistant electrical outlets in the waiting area of the dental clinic. This waiting area was being used by both adult and pediatric patients.

During the tour of 9 East and 8 West on 07/24/14 at approximately 2:00 PM, the following were observed:

The handwashing sinks in the patient bathrooms in rooms 901-911 were observed to be protruding and were about 4 feet high from the ground. These sinks have the potential of becoming a looping hazard.

Similar handwashing sinks were observed in patient rooms on 8 West.

A flat top surface mounted bathroom tissue dispenser was observed in all patient bathrooms on the 9th and 8th floor .This type of tissue dispenser is capable of becoming a looping hazard in a psychiatric unit.

The door handles on doors of rooms 901-911 were of the type that had the potential of becoming a looping hazard

The hinges on patient closets in rooms 901-911 were of the pivot type and had potential of becoming a looping hazard.

Two public phones were observed to be installed in the hallway on the 9th and 8th floors. These phones had long metallic cords which potentially could be used as a weapon and also created a potential looping hazard.

Thermostats with hard metallic cover were noted to be installed in room 901B at a height of at least 7 feet from the floor. This arrangement was noted on the 8th floor also. These boxed thermostats had a flat surface on the top, and therefore were a potential for creating ligatures.

A corner at the side of room 801A was not readily visible from the hallway and there was no mechanism for monitoring in this corner. This corner could potentially be used by psychiatric patients to hide and harm someone while entering the room from behind.

The two day rooms on 9E had a television set enclosed in a wooden box and was observed to be installed at approximately 8 feet from ground. These devices were observed to be potential for looping hazards.

Shower curtains were observed in shower rooms on the 8th and 9th floor were of the non-breathable type, that could potentially be used for suffocation by patient with suicidal tendencies.

Sprinkler heads on three psych units (9E, 9W and 8W) were not concealed.

This is a repeat deficiency from the Recertification survey of 9/13/12.



Also, the wall behind the patient's bed #211 was observed to have two (2) holes of approximately 6 inches in diameter. It was also observed that the wall was broken on the side of the patient's bed. The wall was broken along a strip of 4 inches wide from the ceiling to floor on the side of the bed. The interior mesh used in the construction of wall was exposed.

Upon interview of the head nurse on the unit on 7/24/14 at 11:00AM, stated that the wall kept breaking down in spite of being repaired multiple times. The room was observed to be in use by a patient.

In addition, review of the Executive Committee meetings revealed that the roof over the operating suite leaked during the heavy rains in April and May 2014.

The Director of nursing for peri-operative services and the Director of Facilities upon interview on 7/24/14 at 11:00 AM , stated that the outer wall of Operating Room #2 and Operating Room #3 were damaged due to entry of water through the roof. The facility repaired the outer wall of the operating rooms, but did not take actions to repair the roof immediately.
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Based on review of documents and staff interview, the facility failed to ensure that an established program for Preventive Maintenance (PM) of the dialysis machines used in the treatment of patients at the hospital was implemented in accordance with the manufacturer's guidelines and acceptable standard of practice. This was evident on 8 of 8 dialysis machines in the facility.



Findings include:

Review of the Preventive Maintenance (PM) for dialysis machines on 7/25/14 performed in 2013 revealed that, Dialysis Machine #1 underwent an annual PM on 12/11/13. A comment "no meter" was noted to be documented for the field "3.16-check volt hi lo detect", in the field "3.26-Check internal blood pressure module"and in the field "Check Electrical leakage" on the manufacturer's PM check list. Interview of the Chief Dialysis Technician on 07/28/14 regarding the comment"no meter" on the PM checklist revealed that the equipment technician did not have a meter to check the hi-lo volt, the internal blood pressure module and the electrical leakage and therefore these tasks were not done.


Dialysis Machine #5 - Review of the completed "Maintenance Checklist for six (6) month" dated 06/05/2013 revealed that the equipment technician did not perform maintenance check on the Internal BP (Blood Pressure) module. A comment "no meter" was noted to be documented on the checklist against the area "check Colin module- (complete Internal BP Module-Routine Maintenance check list).

Dialysis Machine #2- Review of the completed "Maintenance Checklist for six (6) month" dated 06/24/2013 revealed that the equipment technician did not perform maintenance check on the Internal BP (Blood Pressure) module. A comment "no meter" was noted to be documented on the checklist against the area "check Colin module- (complete Internal BP Module-Routine Maintenance check list).


This practice was noted in all the completed Preventative Maintenance checklist (both Annual and six(6) month) on all the 8 machines for the year 2013.

The facility performed a complete Annual Preventative Maintenance checks on 2 out of 8 dialysis machines (machine #4 and machine #6) on 1/07/14 and 12/31/13 respectively.

Therefore, there is no documented evidence to indicate that the facility at a later date conducted maintenance checks, to ensure optimum functioning, on the hi lo volt and internal Blood Pressure module of the remaining 6 dialysis machines.

During an interview with the Chief Dialysis Technician on 07/29/14 at approximately 11:00 AM, it was stated that the equipment technician assigned to perform the maintenance checks on the dialysis machines did not have a electrical analyzer to perform the checks. The facility did not have an analyzer on site. It was stated by the Chief Dialysis Technician that the equipment technicians are expected to bring one from another facility to perform maintenance checks on the dialysis machines in this unit.

Therefore, review of the documentation on the checklists and the interview of the Chief Dialysis technician confirmed that the equipment technician/s did not perform all the required checks as specified by the manufacturer.

In addition,the dialysis unit staff failed to provide record of the Preventative Maintenance checks conducted on the electrical analyzer used in the facility to conduct Preventative Maintenance checks on machine #4 and machine #6 on 1/07/14 and 12/31/13 respectively.
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Based on observations and staff interview, it was determined that the Hospital failed to monitor and implement Infection Control practices related to the environmental design of the facility to prevent the potential for cross contamination and spread of infections. Specifically, the Hospital failed to ensure that proper sanitary environment is maintained in the Operating Rooms and failed to disinfect Blood Glucose monitors between patient use.

Findings include:

The ceiling tiles in the Isolation Room(s) in the Emergency Department, Intensive Care Unit (ICU), Medical Surgical Units on 2 East, 3 East, and 2 West, were observed to be acoustical and non-cleanable.

The ceiling tiles over the twelve (12) ICU beds on 2 East were also observed to be of acoustical and the non-cleanable/washable type.

The isolation room on 2 West was observed to have positive airflow, instead of negative airflow as required.

The Decontamination room for the ventilators in the Respiratory department located on the 5th Floor did not have a dedicated exhaust and therefore the air pressure was not negative.

During the tour of the Laboratory, it was observed that the staff did not have a separate handwashing sink to wash hands in the Tuberculosis testing room. This room also did not have negative air flow.

During the tour of the Central Sterile Department on 07/24/14 at approximately 3:00 PM, it was noted that the Clean Sterilization Room did not have positive air pressure.

During tour of Hospital Kitchen on 07/23/14 at 1:50 PM it was observed that the dietary staff were not utilizing all the three compartments of the Pot Washing sink to clean the Pots and Pans. An employee was observed scrubbing the pots with soap and then dipping them into the sanitizer without rinsing the soap. This is not the standard of practice for the cleaning and sanitization process.

Additionally, cleaned pots and pans were observed to be drying on a metal cart (placed next to the sanitizing compartment of the pot washing sink) that was covered with dust and debris.

Review of the Environmental Surveillance test results of 05/20/14 revealed that three culture tests were conducted at the leak site outside of OR #2. The results for all three cultures (5/19/14, 5/16/14 and 5/20/14) were positive for Acinobacter Baumannil-a gram negative bacteria.

During interviews with the Director of Infection Control and the Assistant Director of Infection Control on 07/29/14 at approximately 3:00 PM it was stated that the hospital did not conduct repeat/follow-up surveillance culture tests.

Further interviews of Assistant Director of Infection Control from the Infection Control Department stated that the cultures were conducted while the wall surface of OR #2 was wet.

During the tour of the Operating Suite on 07/24/14 at approximately 10:00 AM, it was noted that OR #2 was prepared and ready for patient use. However, the necessary repairs to the leaking roof were not done.


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During an observation on 7/24/14 at 11:44am, Staff #1 removed the glucometer (Blood Glucose Meter) from the docking station. After completing the scanning process to enter the patient identifier into the glucometer, the staff performed hand washing and used a paper towel to dry her hands. The staff picked up the glucometer and wiped the exterior with the paper towel that was in her hands. Staff attempted to walk towards the patient with the glucometer and was stopped by the surveyor.

When asked by the surveyor what is the protocol for cleaning the glucometer between patient use, Staff #1 stated the glucometer should be wiped off with a rag with soap and water. "The machine does not touch the patient and you should not use any liquid that may seep in and mess up the machine".

Staff # 2, the Assistant Head Nurse of the unit was interviewed and directed the surveyor to a notice posted on the front of the glucometer case with instructions to "use only the Alcohol Prep (70% Isopropyl Alcohol) to clean off the glucometer in between patients." Staff #2 stated this instruction was given to the employees by a lab technician a few months ago. Staff #1 stated she was not given these instructions.

During an interview with Staff #3, it was stated that the glucometer should be cleaned with soap and water. This statement was found in the facility's policy titled, "Point-of-Care Testing" The policy documented that, "daily cleanse the exterior surface of monitor with mild soap and water. Do not use Alcohol swabs to clean monitor surface."

The written instructions to use only Alcohol Prep to clean the glucometer was noted on 50% of the glucometer storage cases. These instructions were noted on the 6 inpatient units toured on 7/23 to 7/25/14: 2nd Floor Medical Surgical Unit, ICU, 4th Floor Pediatric, 6W, 8W and 9E.

Interviews with staff #1, #2, #3, #4, #5, and #6 revealed inconsistent responses to the method used to clean glucometers between patient use.

The Operator's Manual for the Blood Glucose Monitoring Meter recommends cleaning the exterior surface of the monitor daily and to " follow your facility's policies and procedures for infection control, which may require more cleaning. "

During an interview on 7/25/14 at approximately 3:00PM, Staff #8, was presented the facility's policy on cleaning the exterior surface of the monitor with soap and water. Staff#8 stated that her knowledge of infection prevention is to use Sani-wipe disinfecting for equipment touching the patients and also to follow the manufacturer's recommendation for specific device. In response to the written instruction to use alcohol preps, Staff #8 stated she was not aware of this instruction regarding the glucometer.

Review of the policy titled," Point-of-Care Testing," section 7: Performing the Patient Test revealed: infection control measures related to cleaning and disinfecting the glucometer and use of Personal Protective Equipment are not included in the policy.
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Based on the review of medical record review and hospital policy, it was determined that the facility failed to ensure that all patients identified as needing discharge planning, had timely and appropriate discharge planning evaluation. This was evident in five of seven applicable medical records reviewed (#23, #24, #25, #27, and #28).
Findings include:
MR #23 was reviewed on 7/31/14. It was noted that the patient, a 69 year old legally blind went to the facility on 7/8/14 with chief complaint of right ileocecal (small and large intestinal) mass on 7/8/14. The patient was admitted and underwent excision of lesion in ileocecal area. The patient was discharged on 7/16/14.
It was noted that the general nursing admission assessment, dated 7/9/14, identified the patient as needing discharge planning and the patient was referred to social services on 7/9/14. The initial discharge planning evaluation was dated 7/15/14, a week after the referral was made and on the day before discharge.
It was noted that the patient had a Physiatrist (rehabilitation physician) consultation on 7/15/14 12:52 PM. The physiatrist recommended acute rehabilitation specifically 3 hours of therapy 5 to 6 days/weeks.
On 7/15/14 1640 (4:40 PM) the social worker (SW) noted "spoke with patient at bedside with assistance of a Spanish interpreter. SW informed patient about sub-acute placement and the benefits of physical therapy (PT). Patient agreed to placement. However after speaking with the granddaughter, SW was informed that earlier patient told her family that she wanted home PT. SW informed surgery MD that home care services will needed to be resumed and that a referral will be made to . . . for nursing and home PT."
On 7/16/14 at 1427 (2:27 PM) a notation in the Social Services notes documented that "SW contacted the patient's granddaughter to inform her that the patient's services have been resumed and that Visiting Nurse Service will provide skilled nursing and home PT." The discharge planning assessment did not include the reason for the skilled nurse services. The assessment did not include the patient's prior home care services and hours and if it was adequate to fit the patient's current needs.
MR #24 was reviewed on 7/31/14. It was noted that the patient, 67 year old male was sent to the emergency department (ED) from the outpatient clinic to be evaluated for elevated temperature on 6/2/14. The patient was admitted for cellulitis (skin infection) and to rule out osteomyelitis.
The discharge planning evaluation was dated on 6/6/14, the day of discharge. The SW noted that the patient was ambulatory with a walker. The SW noted "we discussed sub-acute rehab but the patient was not interested. He prefers to go home". This discharge assessment indicated that the patient was independent in ADLs (activities of daily living) and that the patient received nursing care for wound dressing and home attendant services. The SW noted that the patient would receive physical therapy at home. The assessment did not include the reasons and the benefits to the patient if the patient was placed in a sub-acute vs discharge to home.
MR #25 was reviewed on 7/31/14. It was noted that the patient, 97 year old female who presented in the ED ( Emergency Department ) on 6/30/14 accompanied by her niece. The presenting complaint was shortness of breath and dry cough.
The patient was admitted on 7/1/14. It was noted on 7/5/14 that the physician indicated that the patient was medically ready for possible discharge on Monday, and he advised the social worker to discuss with relatives the discharge plan and to have HHA (home health aide) reestablished.
The discharge planning evaluation dated 7/7/14 at 1214 PM was reviewed. It was noted that the discharge planning evaluation was completed on 7/7/14, the day of discharge. On 7/7/14 at 1214 PM, the social worker noted that she was informed that patient is medically ready for discharge today. There was no indication that the discharge planner had a discussion with the patient's representative to address the patient's discharge needs prior to 7/7/14. The social worker noted that "per chart review patient has dementia". SW noted that she attempted to reach patient's niece. It was noted that this contact was on 7/7/14 at 1558 (3:58 PM), the day of discharge. It was noted that the social worker spoke to the niece who informed her that the patient has private home care services. The SW noted that transportation was arranged for discharge to home on 7/7/14 at 4:30 PM. It was noted that as an inpatient, the patient was on one to one motioning. The discharge planning assessment did not include if the patient had adequate home care services prior to discharge, as the assessment did not include how many hours of home care services were provided. There was no coordination as to why the patient's need to be on 1 to 1 observation in the hospital could be safely discontinued when the patient was at home.
Policy title Discharge Planning- Policy number CRM-011 effective date July 2014 was reviewed on 7/31/14. It was noted that this policy did not include the time frame the initial discharge screening and discharge planning evaluation will be completed.
Similar finding noted for patients in MR #27 & #28 who did not have timely discharge planning evaluations.

Discharge planning requirement including timely assessments and appropriate discharge planning evaluations was discussed with staff # 29 on 7/31/14.

Based on patient and staff interviews, review of medical record and hospital's policy, it was determined that the facility failed to ensure that all patients' discharge plan were reassessed when necessary for appropriateness of the discharge plan. This was evident in one of three applicable medical records reviewed (#22).

Findings include

Staff #26 was interviewed on 7/28/14 and stated that the Patient #22 was discussed in interdisciplinary rounds and she was informed that the patient was scheduled for discharge today, 7/28/14. Staff #26 stated that the patient's discharge plan was to reinstate his home care services. Staff #1 stated, she just learned from the patient's sister that his C-pap (Continuous positive air way pressure) machine was not working and the patient cannot be discharged without a working machine. She stated that the physician was notified.

The patient in MR #22 was interviewed. The patient stated that he has been ready to be discharged since Friday. The patient also stated that the social worker did not discuss the discharge plan with him. The patient stated that prior to admission, he had 4 (four) hour's home care services and he would like to have this service increased.

MR #22 was reviewed on 7/28/14. It was noted that the patient, 65 year old male was brought to the facility's emergency department (ED) by ambulance on 7/18/2014. The chief complaint was weakness/fatigue. The patient was triaged on 7/18/14 2050 (7:50 PM) and the patient was admitted on 7/19/2014 at 0019. The admission diagnosis was acute was coronary syndrome (sudden cardiac decompensation). It was noted that a Emergency Deparment nurse documented that the patient disclosed an incident of falling at home a few weeks ago and he showed healed bruised on left knee. The record indicated that the patient was evaluated by physiatrist on 7/19/14. It was noted that the physiatrist indicated that patient would benefit from rehabilitation in a Cardiac gym, once medically cleared.

The discharge planning evaluation for this patient was reviewed. It was noted that the patient was admitted on 7/19/14. It was noted that the nursing admitting assessment did not identify the patient as needing discharge planning so the patient was not referred to social services by nursing. It was noted that the initial discharge plan evaluation was dated 7/23/14 at 14:30 (2:30 PM). The social worker (SW) indicated that she was unable to provide a complete discharge assessment as the patient appeared confused and unable to answer any questions.

On 7/25/14 at 1504, the SW noted "SW was informed by MD patient has worsening renal functioning". SW was informed by MD that patient has home care services that need to be reinstated prior to discharge. SW spoke with patient at bedside, patient "was alert and has some confusion . . . patient stated that he lives with his sister and has home care services." SW received a call from the Agency, who was informed that a discharge summary will be needed to be faxed once the patient is medically stable for discharge. It was noted that the discharge planning assessment did not include if prior home care services information was obtained from the home care agency.

On 7/28/14 at 1151 AM, "SW noted informed in interdisciplinary team rounds that patient is medically stable for discharge today. Spoke to patient at bedside to discuss discharge plans patient alert and confused. SW informed patient that he is up for discharge today and was informed that his C-pap (continuous positive airway pressure) machine needs to be serviced. The patient stated that he called the number on the machine and was informed that the vendor was out of business. SW contacted the Agency and was informed that the patient's c-pap machine needed to be replaced or serviced prior to patient coming home."

The SW noted that the patient receives home care services 6 days/4 hrs and the agency was informed that the services will need to be reinstated.

It was noted that it was not until the day of discharge that pertinent discharge information was obtained. It was noted that the acute rehabilitation recommended by Physiatrist on 7/19/14 was not mentioned in the assessment. In addition, the patient fell at home prior to admission. The discharge planning assessment did not include if the current home care service was still adequate for the patient. It was noted that the patient was confused at times as an inpatient. It was noted that the patient resided with his sister, but there was no input from the family on the patient's baseline at home. The level of supervision at home required for this patient was not included in the discharge planning evaluation. There was no mention as to who assists the patient when the home care service was not in place or present beyond the 4 hours per day.

An addendum 07/28/14 at 1635 (4:35 PM) was written by the SW, "the patient will need a new bipap machine and in order for the patient receive a new machine the patient will need a new sleep study. SW noted that the home care agency will follow up the patient in the community to get a new bipap machine. MD stated that she will make an appointment for patient to follow up with sleep study in the community".

The policy titled, Discharge Planning, number CRM -011 effective date July 2014 was reviewed on 7/31/14. It was noted that this policy did not include when a patients' discharge plans will be reassessed.
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Based on record review, and interview, it was determined that the hospital failed to consistently and adequately discuss with the patient or the patient's representative and to include in the discharge plan a list of HHAs (Home Health Assistance Agencies) or SNFs (skilled nursing facilities) that are available to the patient, that are participating in the Medicare program, and that serve the geographic area as defined by the HHA in which the patient resides in the geographic area requested by the patient. This was evident for 4 of 6 discharge records reviewed (MR#s 26, #27 , #28, and #29).

Findings include:
MR #26 was reviewed on 7/31/14. It was noted that the patient, 93 year with history of hypertension, chronic constipation, was admitted on 5/13/14 for acute renal failure. The patient was discharged on 5/27/14 to an acute rehabilitation facility.
The social services notes dated 5/21/14 at 1222 (12:22 PM) were reviewed. The social worker (SW) noted "patient was referred to (an agency) requesting authorization for acute rehab. PRI (patient review instrument) was sent to the following SNFs (skilled nursing facility): . . . Patients NOK (next of kin) was informed. She was also informed that ..... is not in network".
It was noted that although the discharge planner sent PRI (patient review instrument) to four SNFs, there was no documentation that the patient/patient's representative was given a list from which the patient/patient's representatives made a selection in order of preference. It was noted that prior to admission the patient resided at home.

MR # 27 was reviewed on 7/31/14. It was noted that the patient, an 83 year old patient was brought to the facility's Emergency Department on 6/10/14 after a fall. The patient was admitted due to right hip fracture and she underwent right hip open reduction internal fixation on 6/13/14.
On 6/13/14 at 1622 (4:22 PM), SW Social Workers note recorded "unable to speak to patient at bedside as patient was very drowsy. Patent stated that she had home care services 7 (seven days) a week." SW left voice mail for the patient's daughter.
On 6/17/14 at 11:43 AM, SW noted "informed by MD that the recommendation is for acute rehab as recommended by PT." SW faxed referral to a hospital based rehabilitation. SW placed call to patient's family friend to discuss discharge plans. SW informed family friend that a voice mail was left for the patient's daughter. On 6/17/14 1443 (2:43 PM) SW noted that the patient was accepted to go to a SNF.
On 6/17/14 at 1517 (3:17 PM) SW noted that he/she spoke with patient at bedside to discuss discharge plans. "Patient was made aware that the recommendation is for acute rehab. Patient stated that she agreed with the discharge plan." It was noted that the discharge plans were made prior to discussion with the patient. The patient was not given a choice on acute rehabilitation placement.

MR #28 was reviewed on 7/31/14. It was noted that the patient was 70 year old patient with history of diabetes, hypertension and left hip replacement in 2011. The patient was admitted on 7/6/14. The chief complaint was leg pain. The patient was admitted due to fracture of right tibia/fibula and renal failure.
The patient underwent ORIF (open reduction and internal fixation). The discharge summary indicated that the patient was discharged on 7/11/14 ,to an acute care facility. The physician's progress note dated 7/11/14 1800 (6:00 PM) indicated that the patient was medically stable and that the plan is to transfer the patient to acute rehab at a hospital based rehabilitation center

The list of choice of SNFs or HHAs must be presented to patients for whom home health care or post-hospital extended care services was discussed with staff # 29 on 7/31/14

Based on staff interview, review of hospital master menus and nutrient analysis of menus, it was determined the Food and Nutrition Department failed to ensure that physician prescribed diets met the therapeutic nutritional needs of patients. This finding was noted in 68 of 93 diets.

Findings include:
A review of hospital master menus and nutrient analysis of menus was conducted on 7/23/14 at approximately 2:00 PM. The hospital has a two week cycle menu and a diet formulary consisting of approximately 93 different diets available to the physician for diet ordering.
Listed below are the findings identified in the menus and the nutrient analysis of prescribed diets:
1. The hospital failed to have a nutrient analysis for 68 therapeutic diets. A nutrient analysis validates that a diet meets the needs of the national nutrient standards and it also validates that the diet meets the diet restriction(s) ordered by the physician.
2. The High Fiber diet nutrient analysis failed to have the column for fiber.
3. The hospital Master menus failed to have the portions for each food to be provided on the tray.
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