HospitalInspections.org

Based on document review and interview it was evident that the facility did not implement a governing body structure that was separate and distinct from any other health care facility.

Findings include:

Review of governing body minutes and table of organization of the hospital found that meetings of the governing body of the hospital and Rutland Nursing Home are held concurrently in the same location and that some board members of the hospital are also on the Rutland Board. The Roberts Rules of Order are in effect for these meetings and a quorum must be reached.

At interview with hospital administrative staff on 1/11/12 it was reported that the hospital board is integrated with the Rutland Board in that the nursing home is hospital based and that they have interests in common.

Review of contracts and facility organization finds that the critical services ( dietary, medical staff, personnel, security, infection control ) were in common with both entities. In many policies the names of both the hospital and the nursing home are noted at the preface.

Furthermore, review of the operating certificate of the hospital found that 8 acute pediatric beds were approved. However, these 8 beds were found in the Rutland Nursing Home and that while nursing staff was provided by the nursing home, medical care was provided by hospital staff. Review of NYSDOH documents from 1982 found that this change was deemed to be temporary.
.

Based on review of documents and interview there was no evidence that the facility evaluated contractual services as an entity.

Findings include:

Review of contracts for a sample of such services on 1/12/12 did not find assesment of the total effectiveness of the services provided. The facility assessed each person under contract as though they were employees with no overall assessment of the service.
At interview with the medical director on 1/12/12 it was stated the contracts are evaluated however, this evidence was not provided at the survey.
.

Based on review of the facility 's Patient Relations Log & patients files for 2011, Patient Complaint/Grievance Policy and staff interview, it was determined that although the facility has a grievance process it was not responding to patients ' /patient's representatives grievances in a timely and consistently manner.

Findings include:

Review of Patient Relations /Customer Department documents on 1/10/12 noted that the facility received grievances from the patient in MR # 3 (log # 11-001 A & 11-001 B) on 1/6/2011 pertinent to physician care and Ancillary Services. It was noted that the grievance was referred to the Departments of Medicine and Ambulatory. The responses were due in the Patient Relations Department on 1/11/2011. It was noted that the Department of Medicine completed the investigation on 2/10/11. The Department of Patient Relations/Customer received a response from the Ambulatory Services on 3/01/11. The response to the patient on the resolution was dated 4/18/2011 over 30 days after the facility completed its investigation and three months after the grievances were received.

In MR # 4, (log # 11-023A & 11-023B), the patient's representative filed a grievance to the facility on 3/4/2011 regarding discharge and medical care issues. The grievance was referred to the Department of Medicine and the Department of Social Work for an investigation. It was noted that Department of Social Work completed the investigation on 3/15/11. It was noted that there were two responses from the Department of Medicine dated 3/14/11 & 4/13/11 located in the file. The Department of Medicine investigation date of 3/14/11 indicated that the patient received appropriate care. The second response dated 4/13/2011 indicated " unable to ascertain which resident was involved with the care of the patient ". It was noted that it took the Department of Medicine over 30 days after it received the grievance to respond that it was " unable to ascertain which resident was involved with the patient's care ". The resolution of the grievance to the patient was dated 4/25/2011.

On 4/1/2011, the Patient Relations/ Customer Department received grievances from the patient in MR # 5 (log # 11-42 A & 11-042 B) regarding nursing care and medical care. It was noted that the Department of Nursing completed the investigation on 4/4/11 & Department of Medicine completed the investigation on 4/13/11. It was noted that the last response to the patient regarding the resolution of the grievance was dated 9/9/11. This response indicated that the investigation was on going. There was no documentation in the file why it was taking so long to complete the resolution for this grievance.

Patient Relations/Customer Department received grievances from the patient in MR # 6 (log # 11-165 A & 11- 165 B) on 11/30/11 regarding the nursing care and physician care rendered in the facility ' s Emergency Department. It was noted that the case was referred to Department of Nursing and Department of Medicine. It was noted that the responses were due on 12/5/2011. It was noted that Department of Nursing completed the investigation on 12/19/2011 and Patient Relations/Customer Department received Nursing response on 12/20/11. The department of Medicine investigation was not located in the patient ' s file. There was no documentation that Patient Relations Staff follow-up with the Department of Medicine nor the reason why this was not necessary. This patient's grievance file, dated 1/10/11, was over a month pass due to the to Patient Relations Department. However, there was no documentation if any staff was tracking this delay.

There were similar findings of delay in grievances responses for the patients in MR # 7 (log 11-032 A) and MR # 8 (log # 11-119 A),

The facility's Patient Complaint/Grievance policy was reviewed on 1/10/12.
This policy indicated " If a complaint/grievance is received by the Department of Patient/Customer Relations it will forward a copy to all affected departments requesting the investigation within 5 days ". It was noted that this policy did not address how grievances that did not come into the facility directly to Patient/ Customer Department is handled. It was also noted that the policy did not address what happens when the departments were referred and did not investigate the grievance within 5 days.

It was noted that this policy indicated that Patient Representatives will meet monthly as the grievance committee to review prior month's complaints/grievances.
The Grievance Minutes and staff attendance for the past 12 months were requested but the facility was unable to produce these minutes. Therefore, it could not be determined if the facility was following its Patient Complaint/Grievance Policy.

The Director and Assistant Director of Department of Patient/Customer Relations were interviewed on 1/9/12 at 10:41. They stated that the Governor Body designed the Grievance Committee to oversee the hospital's grievance/complaint process. The Grievance Committee consists of Patient/Customer Relations Department staff. There are three staff members, the director, assistant director and one patient representative. The Director of Patient/Customer Relations reported that the Grievance Committee meets monthly. However, there was no attendance sheets or monthly minutes.
.

Based on medical record review and Patient Grievance files, it was determined that the facility did not consistently ensure that all patient/patient representative right to participating the in development and implementation of patient's discharge plan.

Findings include:

Review of MR # 9 on 1/9/12 noted that this 80 year old married patient was admitted from Bishop Henry Nursing Home on 12/23/11. Medical history included Glaucoma Hypoxemia s/p CVAs admitted diagnosis acute, Respiratory Failure. The initial Discharge Planning assessment dated 12/27/2011 indicated that prior to admission to the nursing home the patient resided at home with hospice care. The Social Worker noted that the patient had a DNR in place but his wife wanted to revoke it. On 1/4/12 at 2:37PM SW ( social work) noted "spoke with patient's grandson, he stated family wanted patient to return to nursing home for more rehab following discharge ". It was noted that there was a discussion with the grandson on 1/6/12 and 1/9/12. There was no documentation why the facility was taking directions from the patient ' s grandson and not the patient ' s wife or the reason why this was not necessary.

Review of the Patient Relations file for the patient in MR # 8 on 1/10/12 noted that this paraplegic patient filed a grievance with the facility on 9/1/11. This patient alleged that the social worker was telling everyone around her that she was being discharged including her daughter and her home attendant but not her. The patient noted that the social worker made her felt like she did not exist.

MR documentation: " SW note dated 8/29/2011 at 4:35PM, patient is for discharge as of 8/29. SW spoke to CABs. Patient's aide will meet her at the hospital at 11:00AM. SW will arrange transportation for patient and her daughter was in agreement. The patient was discharged on 8/30/11. The patient was not incapacitated and she did not inform the hospital staff that she had designated her daughter to make decision on her behalf. Therefore, the facility was required to make discharge plan with the patient. There was no documentation that there was a follow-up with the patient on the day of discharge with the discharge information
.

Based on review of medical records, unit tour and patient interview, it was determined that the facility did not consistently ensure that each patient/patient's representative right to make informed decision regarding the patient ' s care requirement.

Findings include:
During the tour of B 2, a surgical/medical unit, on 1/9/2012 at 11:45 AM an attempt was made to interview the patient in room B 229 A. It was noted that this patient only spoke " Creole ".
Review of MR # 10 on 1/9/2012 at approximately 2:30 PM noted that this 77 year old patient was admitted to the facility on 12/30/11. Medical history included liver disease. It was noted that the patient was alert and oriented x 3. The Multidisciplinary Patient and Education record form dated 12/31/11 identified language barrier; language Creole/French.

Five consent forms located in the medical record were reviewed:

1. The consent form indicated that the patient consented for CT scan of the abdomen with IV contrast as witnessed by a staff member certifying that the patient signed the form on 12/30/11. The patient did not date the form. This form was written in English. It was noted that although there was a section on the form for an interpreter, no interpreter was used. There was no documentation why this none English speaking patient did not have an interpreter to explain this diagnostic test or the reason why this was not necessary.

2. This consent form indicated that the patient consented for Paracentesis which was witnessed by staff member on 12/31/11 verifying that the patient signed the form. This form was written in English and no interpreter was used to fully explaining the procedure to the patient. There was no documentation why an interpreter was not necessary.

3. This consent form indicated that the patient's daughter consented to
"laparoscopy/laparotomy/possible colostomy/possible ostomy ".
There was no documentation why the patient's daughter was consenting for the procedure instead of the patient. There was no documentation in the medical record that the patient designated his daughter to make decisions for him.
It was noted that this procedure required anesthesia. It was noted that the physician providing anesthesia and the one performing the procedure signed certifying that the risks and benefits were explained to the patient's daughter. There was no documentation that the risks and benefits for procedure and anesthesia were not explained to the patient or the reason why this was not necessary.
It was unclear what type of proposed anesthesia the patient's daughter consented for as no anesthesia was checked off on this form.

Anesthesia pre-anesthesia notes dated 1/3/12 at 5:40: "the anesthesia noted patient scheduled for colostomy tomorrow possible lap. all risk benefit anesthesia explained and discussed with the daughter all questions answered agree with plan consent signed by daughter". There was no documentation why anesthesia was not explained to the patient.
The consent forms for Liver biopsy by Interventional Radiology and CT scan of Abdomen & Pelvis with Intravenous Contrast dated 1/9/12 noted that the patient signed using an interpreter.
.

Based on record review, review of incident reports and interview, it was determined that the facility did not ensure that the staff was appropriately educated regarding the implementation of DNI ( do not intubate ) orders.

There was no policy and procedure to govern staff duties in response to action to be taken where a patient who is intubated who has a DNI in place, and has an unplanned extubation.

Review of incident reports finds that the facility maintains a record of unplanned extubations. This includes a rapid response team. At interview with the nursing staff on the vent unit on 1/11/12 it was stated that where there is a DNI in effect a patient who was accidently extubated would not be re-intubated. Upon further interview, it was stated that such an incident would generate a rapid response team.

At interview with the pulmonologist on 1/12/12 and the Vice President of Nursing it was stated that each case of unplanned extubation would be considered separately and a consult with the family would be made. The surveyor noted that deferring such action pending family notification would result in a delay that could have an adverse effect on the patient.
.

Base on review of medical record and unit tour, it was determined that the facility did not consistently ensure all patients the right to receive care and adequate monitoring in a safe setting.

Findings include:
During tour of the unit B 2 , on 1/9/12 B 2 at approximately at 11: 50AM and on 1/9/12 at approximately 2:30 PM, it was observed that the two patients in RM 228 were on 2:1 monitoring .

The staff accompanied on the tour stated that the patients in MR # 525097 & MR # 483782 were placed on 1:1 observation today (1/9/12).

Review of MR # 11 on 1/9/12 at approximately 3:00 PM noted that this 72 year old patient was admitted to the facility on 12/26/11. On 1/9/12 at 1:46 am, the nurse noted
"patient with confusion. Patient placed on 1:1 observation this am after the patient verbalized I want to kill myself if I don't get my depression medication ". The nurse noted patient was seen by surgical staff and ordered 1:1 observation.
It was noted that on 1/9/12 the resident surgery note indicated that this morning the patient expressed depressive thoughts of suicidal ideation. Patient was placed on 1:1 watch.
Review of physician's order # 244 noted the order description was 1 to1 observation until 08:45, 01/10/12. The reason for the 1:1 order was because the patient was a danger to self.

Review of MR # 12 noted that this 82 year old patient was admitted to the facility on 1/6/12 . It was noted that the patient was admitted with altered mental status and hip pain. On 1/9/12, the social worker assessment indicated that the patient was confused for two days. Review of physician's order noted that this patient was on 1 to 1 observation on 1/9/2012 at 07:30 AM.

These patients required 1:1 observation but were placed on 2:1 observation instead.
.

Based on medical record review and observation, it was determined that the facility did not consistently ensure that all patients received appropriate nursing monitoring according to physician's orders. This deficiency was noted in two medical records (MR # 11 & MR # 12).

During a tour of the unit B 2, on 1/9/12 B 2 at approximately at 11:50AM and again on 1/9/12 at approximately 2:30PM, it was observed that the two patients in MR # 11 & MR # 12 were on 2:1 observation.

Review of MR # 11 on 1/9/12 at approximately 3:00 PM noted that on 1/9/12 at 1:46AM, the nurse noted "patient with confusion. Patient placed on 1:1 observation this am after the patient verbalized I want to kill myself if I don't get my depression medication".
Review of physician's order (order # 244) noted that the patient was to be placed on 1 to 1 observation until 08:45, 01/10/12.

Review of MR #12 noted that, on 1/9/12 at 7:30AM, the physician ordered (order #34) 1 to 1 observation until 07:30, 01/10/12.
.

Based on medical record review it was determined that the facility did not
maintain a medical record for each patient that was accurately written and properly filed.

Findings include:
Review of MR # 13 noted that all information in this medical record did not pertain to this patient . There was information for another patient including the other patient's D.O. B, past medical history and reason for coming to the Emergency Department ( ED).
.

Based on medical record reviewed, it was determined that the facility did not consistently ensure that inform consent was properly executed. This deficiency was noted in two of seven applicable medical record reviewed.

Findings include:
Review of four consents forms signed by the patient and the patient's daughter in MR # 10 (on 12/30/11, 12/31/11, 1/3/12 and two on 1/9/12) noted that the patient or the patient's legal representative did not date and time the informed consent forms signed by the patient or the patient's legal representative.
It was noted that an interpreter was used on 1/9/12. This individual did not print his/her name as required on the form
.

Based on record review ( pharmacy interventions ) and interview it was evident that the pharmacy maintained a record of cases where the computerized system warned the provider that the dosage or route may not be correct.

Findings include:

Review of records of medication errors found that the "near misses" classified as
"interventions" were not included under medication errors. There was no evidence that these "interventions" were included as "near misses" to be discussed as a subject of performance improvement.
.

Based on interview and review of medical records, it was determined that pharmacy failed to implement the facility's policies and procedures to ensure timely delivery of drugs to patients. This finding was noted in two of eight medical records reviewed.

Findings include:

MR #1 is a 78 years-old patient admitted on 1/6/12 with multiple medical conditions including diabetes, coronary artery disease, status post stent, congestive heart failure, atrial fibrillation on Coumadin. Cardiology progress note at 1245 on 1/9/12 noted patient had intermittent A-fib with rapid ventricular response, and heart rate 100bpm. A medication order was written at 1251 for Amiodarone 400mg PO " Now and Routine " every eight hours x 4 days. The patient received Amiodarone 400mg at 1440, an hour fifty minutes after the order was entered into the system. The medication order was verified by pharmacy at 1400. At interview with the patient ' s nurse he stated that the "Now" order was omitted because the patient was due for a routine dose at 1400.

The review of the Department of Pharmacy policy and procedure titled Verification Times for Stat, Now, and Routine orders noted that "Stat" medication orders must be entered/verified within 25 minutes upon receipt of medication orders. " Now and Routine " medication orders must be entered/verified within 60 minutes upon receipt of the medications order. Routine medication orders must be entered/verified within 120 minutes upon receipt of the medication order.

A similar finding regarding pharmacy failure in the implementation of verification times was noted in MR #2. An order for Ambien 5mg PO Stat was entered on 01/09/12 at 2319. The medication was given at 0421 at 1/10/12. The verification of the Stat order by pharmacy was not within 25 minutes upon receipt of the medication order. Ambien was verified at 0404 on 01/10/12 almost five hours later.
.

Based on staff interview and review of records, it was determined that the director of the food and dietetic services failed to take responsibility for the daily management of the dietary services.

Findings include:

1. During observation, inspection tour of the kitchen on 1/9/12, and review of tray line temperature logs, the following was noted.

(a) On 1/9/12 during lunch meal service, it was observed that the temperature of short order food served on the tray line was not taken prior to service. Review of tray line temperature taken for October, 2011, November, 2011 and December 2011 noted that short order food on the tray line daily was not reflected in the log and no evidence was provided that the temperature was taken for these three months.

(b) During tour of the kosher kitchen on 1/9/12, the temperature of the food just served for lunch was requested. The Rabbi in the kitchen stated that he just came on duty and was not the one who took the lunch temperature. When asked if he takes the temperature of the food served at dinner meal service his answer was no. During lunch tray line service in the main kitchen 4 wrapped kosher food packages for patients on unit M3, K1, B4, and B3 was observed sitting on the unit tray carts. It was noted that these units were not currently been served. The temperature log for the kosher food service was requested by surveyor for review on 1/9/11 at approximately 11:30 AM. This was not provided to surveyor during the surveyor to review during the survey that ended on 1/13/12.

The food service director failed to ensure that food temperatures were taken prior to service for short order food on the tray line and food served to kosher patients to minimize the risk of food borne illness.

2. Based on staff interview and review of records, it was noted that the food service director failed to implement a Quality Assurance Performance Improvement (QAPI) program that review activities of all aspects of the food and dietetic services. Rutland Nursing Home resident satisfaction with food services survey for March 28, 2011 was provided as the hospital food service department QAPI.
.

Based on interviews and the review of medical records it was determined that the nutritional needs of patients are not met in accordance with dietary practices. The deficiency was noted in one of twelve applicable records.

Findings include:

MR # 2 is a 27-year-old male with past medical history of paraplegia, status post Gun Shot Wound and a stage IV sacral decubitus ulcer. The patient was admitted on 12/29/11 for inpatient rehabilitation. The initial nutrition assessment on 12/30/11 revealed the patient had muscle loss, was underweight and severely compromised nutritionally with BMI 15.57, admission weight 99 pounds, and albumin 1.4. The patient in the past had refused nutritional supplement and preferred regular food. Based on a calculated Ideal Body Weight of 148 pounds, the Dietician estimated a 1575 calorie diet which was below the nutritional needs of the patient.

The nutritionist recommendation was to continue diet and Megace and encourage PO intake. The Megace was ordered on 12/29/11 and discontinued 12/30/11due to patient's refusal to take the medication. At interview with the patient's nurse on 1/10/12, she stated the patient's appetite remained poor, eats 50% of meal and has a preference for food from outside vendors. There was no continuous review and evaluation of the adequacy and appropriateness of the patient ' s care plan. There was no revision of the original care plan and no indication that patient food preferences were provided to meet the patient's basic nutritional needs.
.

Based on observation, document review, and staff interview it was determined that the facility did not maintain the hospital environment in such a manner that the safety and well-being of patients are assured.
Findings include:

Emergency Department (ED):

1. During a tour of the ED on the morning of 1/9/2012, the door of the isolation room # 11 was not closing properly and needed adjustment to maintain the negative air pressure of the room.

2. The ceiling tiles of the bathroom # 136 of the ED were noted to be missing and the wall above the ceiling tiles was observed to be broken and the insulation was observed to be exposed.

3. The surface of the ice machine and the interior of its chutes (ice chute and water chute) of the pantry room were observed to be dirty.

4. The corner walls outside the X ray room of the ED was broken and had a gap in that wall of approximately 4 inches long and 2 inches wide.

5. The supply room # 125 was observed to have missing ceiling tiles and other ceiling tiles were stained.

Psychiatric Unit:

During a tour of the Psychiatric unit on the afternoon of 1/9/2012, the followings were observed:
1. The strike plate of the seclusion room was observed to be loose and one of its two screws was missing.

2. The storage room in the shower corridor was missing 2 ceiling tiles and a third tile was stained.

3. The relaxation lounge, room #3313 had two electric outlets that were not tamper resistant.

4. The reading room was observed to have six metal protrusions (6) that seemed to be used to hang a picture frame that was removed. These metal protrusions posed a risk of self or other harm and /or injury in the psychiatric unit.

5. The patient's bathroom # 310 of the Psychiatric room was noted to be dirty, had stool on the floor and had a very bad odor.

The Coronary Cardiac Care Unit (CCU):
1. The smoke door at the back of the CCU was observed to have a gap of 1/2 to 1 inch between its two leaves which permits the flow of smoke between the smoke compartments.

The Surgery and Vascular Lap Department:
During a tour of the vascular surgery unit on the morning of 1/11/2012 the following findings were identified:
1. Some ceiling tiles were missing in the telecom room # 4440, another ceiling tile was broken and had a hole of approximately 2 x 3 inches in size. Also, there were signs of a water leak on the side of the window of that room.

2. The exam rooms # 1 and # 2 of the vascular surgery department were observed to have piles of linen and gowns on the window's ledge and on top of a counter next to the hand washing sink. Also, those two rooms had linen hampers full of soiled linen and gowns.

3. The storage room of the vascular surgery department housed hundreds of boxes. This usage of the room creates a fire hazard since that room was not sprinklered and did not have one hour fire rated walls.
.

Based on interview and observation it was evident that the infection control program did not implement a policy to govern what type of items can be stored in a reprocessing room.

Findings include;

On tour of the endoscopy unit on 1/12/12 it was noted that there was a large cart with a tarp over it that contained clean supplies for use other than reprocessing in the reprocessing unit. There was minimal distance from the machines, contaminated scopes and sink. The air flow was neutral, which is not in compliance with air flow for this type of room .

During interview with OR management on 1/12/12 it was stated that the tarp over the cart prevented any contamination.
.

Based on medical records review, it was determined that the facility did not consistently ensure that all patients identified as likely to suffer adverse health consequences without adequate discharge planning that these patients have complete assessments for a proper evaluation. This findings was noted in three of fifteen applicable medical records reviewed (MR# s, #14, #15, #16 )

Findings include:
Review of MR # 14 on 1/11/12 noted that this 70 year old patient with past medical history include Parkinson's dementia, and prostate cancer was admitted to the facility on 10/20/11. The initial discharge plan assessment dated 10/25/11 indicated that the patient lived with his sister at home. He also received visits from VNS. The discharge plan was for him to return home with family. The patient was discharged on 10/28/11. There was no documentation when the
patient ' s home care service was reinstated. The date and time the home care services was implemented was not documentation. There was no final SW discharge note.

On 10/28/11, the attending noted that the patient was scheduled to be discharge today because yesterday's discharge was postponed for a rehab evaluation. The physician noted that the patient was not a candidate for acute rehab. The discharge reassessment did not include that the team was considering acute rehabilitation for this patient. There was no documentation that sub-acute rehab was explored or why this was not necessary. The discharge planning assessment did not include if returning to the previous environment was still appropriate and safe for this patient.

Review of MR # 15 on 1/11/12 noted that this 32 year old female was admitted on 10/142011. It was documented that the patient was in the acute rehab for one week . While in the rehab, the patient's blood pressure dropped and she was transferred to the hospital. The SW noted that the patient did not wish to return to acute rehab. The discharge plan was for the patient to return home with family. The discharge evaluation did not include if the patient no longer required acute rehabilitation. In addition, the assessment did not include if this was a safe and appropriate discharge plan for this patient.

Review of MR # 16 on 1/12/12 noted that this 44 year old patient with history of cellulites legs was admitted on 10/13/11. The initial discharge planning assessment dated 10/15/11 indicated that prior to admission the patient had home care services. In this assessment, the SW noted that the patient stated that she would like a home attendant upon discharge. She stated that prior to hospitalization she was receiving wound home care services. The SW concluded that the patient needed a referral for home care services. The SW also documented that the patient also expressed that would like to be referred for in-patient rehab.

This patient was discharged to home on 10/17/11. It was noted that the patient request for an in-patient rehab service at discharge was not addressed in the discharge plan assessment. The discharge evaluation did not include the reason why discharge to home with services was still an appropriate discharge plan for this patient. It was noted that the date that the referral to home care agency was made was not documented. It was noted that the date and time the home care agency would be reinstated was not documented.
.

Based on record review, it was determined that the facility was not consistently re-assessed patient ' s discharge plan.

Findings include:
Review of MR # 17 on 1/11/12 noted that this 61 year old patient was admitted to the facility on 9/19/2011 with a colostomy. It was noted that the initial discharge plan dated 9/19/11 indicated that the expectations was for the patient to return to his former residence. The patient did not have an initial discharge planning evaluation because on the Assessment section of the Social Work Assessment form the worker wrote "screen-out". This patient was discharged to Resort Nursing home on 10/7/11.

On 10/07/11 at 10:31 AM, the discharge planner noted "plan for patient is to return to Resort NH upon discharge. Patient not entirely happy that he needs to return to Resort. However, no other SNFs are accepting patient". A discharge reassessment was not done. The reasons why this patient was reluctant to return nursing was not documented. The facilities that rejected and the reasons for the rejections were not documented.
.

Based on medical record review, it was determined that the facility did not consistently give the patient's/patient's representative a choice to select home care services as required. This finding was noted in two of seven applicable medical records reviewed (# 12 & # 18)

Findings include:
MR # 12 was reviewed on 1/9/12 at approximately 3:15 PM. It was noted that this 82 year old patient with medical history includes HTN and anemia and admitted on 1/6/2011. The patient was admitted with diagnosis of change in mental status. The patient was confused and alert x 2. The chart indicated that the patient lived with his wife but the facility was unable to contact the wife. Review of the initial discharge plan noted that the SW documented that the patient was referred to VNS for visiting nurse and possible home health aide service. The referral was made before the SW had a discussion with the patient's representative regarding the discharge plan.


Review of MR # 18 on 1/10/11 noted that this 57 year old male was admitted to the facility on 10/16/11 with diagnosis of Diabetes Mellitus. The initial discharge planning assessment date 10/18/11 was reviewed. The SW noted " may need services upon discharge such as VN for wound care". The facility "Chose One" form dated 10/18/11 at 11:00 AM indicated that the patient requested no specific home care agency and agreed to be referred to VNSNY. There was no documentation that there was a discussion with the patient that he had the right to choose a home care agency. There was no documentation that the patient was given a list of home care agency to choose from.
.

Based on review of medical and pertinent records, it was noted that the hospital does not consistently notify the Organ Procurement Organization (OPO) of every death in the hospital. As evidence in 3 of 7 applicable records reviewed.

Findings include:

Review of MR# 4 on 1/10/12 noted that the patient expired on 10/6/11, but there was no notification form in the medical record indicating that the hospital notified the OPO of the patient's death. Similar findings were seen in the following medical records; MR # 5, MR # 6 and MR # 7.
.

Based on review of documents and interview, it was evident that the hospital failed to formulate and implement a policy and procedure regarding site marking, verification for laterality, and time out that ensured that incidents in this area would not occur.

Findings include:

Review of Administrative Policy titled "Verification, site marking and time out" in the Administrative Manual section "Universal protocol" Policy # UP - 1A, 1B and 1C Section F- titled "Site Marking Exemptions" found a reference for exemption where the primary pathology itself is plainly visible, for example, a single laceration. The policy did not refer to who would be responsible for implementing this waiver. It did not address issues where a
"pathology " such as a large hernia was present but it was on the contralateral side of an incarcerated hernia that required repair.

At interview with the OR nursing administrator on 1/12/12 it was stated that she was unaware of this "policy" and that she would look to evidence of laterality in all cases which would include site marking.

At interview with the Surgical Director on 1/12/12 it was stated that this exclusion was in effect. When the facility was advised of this issue, both administrators took the action of immediately stopping this exclusion and stated that the new universal protocol policies would not allow for this waiver.
.

Based on review of computer records and interview it was evident that the facility did not ensure that all types of medication errors ( including near misses ) are subject to QA review.

Findings include:

Review of documents on 1/11/12 found that the pharmacy has a system where the medication dispensing system includes a warning system that advises the medical staff of a possible error in dosage or administration. This was called an " intervention ". This information was not entered as a Class A medication error because these errors were prevented by the system instead of a pharmacist.
.

Based on staff interview and review of records, it was determined that the facility does not have a policy in place to ensure the security and confidentiality of electronic patient records.

Findings include:

On 1/12/12 during interview with the director of hospital information management (HIM) the policy and procedure for electronic medical record was requested. The director presented only the policy and procedure titled "Late Entries to Electronic Medical Record". The facility did not present any other policy for electronic patients record.
.

Based on medical record review, it was determined that the facility did not consistently give the patient's/patient's representative a choice to select skilled nursing facility as required. This finding was noted in two of six applicable
medical records reviewed. MRs (#19, #20)

Findings include:
Review of MR # 19 on 1/12/12 noted that 90 year old with medical history of CVA, COPD, Afib, HTN and speech impaired was admitted to the facility on 12/08/11. Prior to admission, the patient resided in a private home with home care services. It was noted that the initial discharge plan was to nursing home. It was documented that the patient's son was the community contact. There was no documentation that the discharge process was fully explained to the patient's representative. There was no documentation that the patient's son was given a list of skilled nursing facility for the family member to chose form prior to discharge.
The facility's "Choose One" dated 1/3/12 at 3:30 PM indicted that the patient was unable to participate in discharge planning, and the next of kin has chosen a referral to River Manor. This documentation did not indicate that the patient's representative was given a list of skilled nursing from which to chose from based on patient's insurance. The names given were not documented. The date this information was provided to the patient's representative was not documented. The patient was discharged to River Manor NH on 1/4/12.

Review of MR# 20 on 1/11/12 noted that this 58 year old male who had previously suffered a stroke and was very confused was admitted to the facility on 12/26/11 with cellulites scrotal. Prior to admission the patient was living at home with home attendant services. The initial discharge planning assessment dated 12/27/11 indicated that the patient's sister was requesting placement in a SNF. The Social Worker noted (SW) that the patient's sister was given names of facilities in her area. The names given were not documented. The SW noted "she will advise us tomorrow of her facility choices". On 12/28/2011, SW noted family contacted this worker this AM and gave us a list of five facilities where they would like to have PRI and screen. The list of names given by the family member and preference was not documented. The patient was discharged on 1/5/12 to Ruby Weston NH.