HospitalInspections.org

Based on findings from document reviews, observations and interviews, the Governing Body has failed to ensure the hospital is in compliance with all Conditions of Participation for the Medicare Program. Specifically, it has not ensured that staff are accurately identifying and effectively complying with patients' advance directives (an Immediate Jeopardy situation was identified and removed during this survey), that up-to-date policies and procedures (P&Ps) guide the care being provided at this hospital, that utilization review activities at the hospital are being conducted in accordance with requirements, and that patients are being provided complete information concerning patients' rights. See the findings in Tags A063, A115, A117, A132, A652 and A654.

Based on findings from document reviews, observations and interviews, in 2 of 12 medical records reviewed, the patients' desires for no resuscitation in the event of cardiopulmonary arrest were not acted upon. The Immediate Jeopardy identified in this situation was removed before the survey was completed. Various policies and procedures addressing patients' rights, including advance directives, were outdated, incomplete, not immediately available to hospital staff caring for patients, and/or were lacking. In both the inpatient and outpatient settings, not all patients were being provided the patients' rights information required by the New York State Department of Health. See the findings in Tags A063, A117 and A132.

Based on findings from document reviews and interviews, the hospital lacks a current UR plan and a UR committee, and members of the medical staff are not involved in utilization reviews of services provided.

Findings include:

-- Per review of the hospital document titled "Utilization Management / Discharge Planning Manual," last revised 7/11/95, it defined and described the hospital's plan for review of the utilization of its facilities through the Multidisciplinary Committee (MDC). It noted the MDC addresses under and over utilization of hospital services relative to medical necessity, inefficient scheduling of resources and cost effectiveness.

-- Per interview of the UR Coordinator on 12/03/12 at 1:15 pm, the above referenced document does not describe the hospital's current UR program. Currently, the UR Coordinator refers any questions from his/her utilization review activities to the hospital Administrator or Associate Administrator. The UR Coordinator attends and reports directly to the Quality Improvement Committee, not the MDC described in the above referenced Utilization Management manual.

-- See Tag A654.

Based on findings from document review and interview, the hospital failed to have up to date policies and procedures (P&Ps) directing patient care and lacked some P&Ps altogether. Findings include:-- On 12/04/12 at 12:30 pm when a surveyor requested the hospital policy & procedure (P&P) titled "Advance Directives," the MedSurgical/Pediatric unit staff obtained it from the hospital intranet. This P&P had a last revised date of 1/2007. Two hours later hospital administrative staff provided the surveyor a copy of a different "Advance Directive" policy - that P&P was last revised 9/2012.

-- During interview of the Director of Quality Improvement on 12/04/12 at 03:45 pm, he/she could not explain why the unit staff did not have access to the latest revision of the policy.

-- Further, review of both Advance Directives P&Ps revealed they each lacked information specifying what procedures to follow when a patient requests DNR (Do Not Resuscitate) status, and how to identify any patient's DNR status while on or off the nursing units.

--During interview of the Patient Registration and Accounting Supervisor on 12/04/12 at 9:45 am, he/she stated that patients are provided patients' rights information in the booklet titled "Your Rights as a Hospital Patient in New York State (at) Edward John Noble Hospital" during registration, but acknowledged there was no P&P addressing this process.
-- During interview on 12/04/12 at 11:15 am, the Utilization Review Coordinator, who was currently performing discharge planning activities (since 11/30/12), indicated not knowing if there were P&Ps addressing discharge planning. During interview on 12/04/12 at 1:00 pm, the Nurse Educator did not know if there were discharge planning P&Ps and could not locate any such P&Ps on the nursing unit. -- During interview on 12/04/12 at 9:40 am, the Infection Control Practitioner (ICP) indicated many of the infection control P&Ps are available on the hospital intranet. However, during follow up interview on 12/04/12 at 1:00 pm with the Nurse Educator, when he/she attempted to obtain a P&P regarding isolation precautions on the nursing unit, the only P&P available from the intranet regarded preventing transmission of DROs (Drug Resistant Organisms). -- During interview on 12/04/12 at 1:30 pm, the Director of Quality Improvement acknowledged having the most up to date infection control and discharge planning P&Ps in his/her office and was planning to place them on the intranet as soon as he/she could. -- During a tour of the Edwards Health Center (EHC) and interview on 12/03/12 at 10:30 am, the Administrative Assistant (AA) who oversees the hospital's extension clinics confirmed that EHC's P&P manual contains multiple P&Ps that had not been reviewed or revised within the past 2 years. Examples include the following P&Ps:

Urine Chem Strip10 Testing, dated 11/30/02; and
Urine HCG Test, last revised 6/2007.

Further, the AA confirmed EHC does not have P&Ps addressing the limited blood draws performed at EHC or the cleaning of the glucometer between patients.-- During interview on 12/03/12 at 2:45 pm, the Director of Dietary Services (DDS) confirmed that multiple dietary P&Ps had not been reviewed or revised within the past 2 years. Examples include the following P&Ps:

Nutrition Screening & Assessment, last revised 6/2005;
Between Meal Nourishments, last revised 6/2005; and
Nutritional Services, last revised 2/2010.

Additionally, the DDS was not aware of a P&P for purchasing food and supplies.-- During interview on 12/04/12 at 9:00 am, Emergency Department (ED) registered nurse (RN) #1 and ED/Telemetry licensed practical nurse (LPN) #1 each confirmed that multiple ED P&Ps had not been reviewed or revised within the past 2 years. Examples include the following P&Ps:

Medical Screening Exam, last revised 9/2002;
Discharge Planning from the Emergency Department, last revised 5/2005;
Assessment/Reassessments, last reviewed 9/2002;
Charge Structure, last revised 5/2005; and
Dispensing Medications from the ED, last revised 2/2010.

Additionally, ED RN #1 and LPN #1 were unable to locate a P&P addressing what to do when a patient leaves without being seen or against medical advice.

-- During interview on 12/04/12 at 12:15 pm with the Charge Nurse of the Medical/Surgical/Pediatric and Swing Bed Unit (SBU) and the Nurse Educator at 12:25 pm, they acknowledged that multiple SBU P&Ps had not been reviewed or revised within the past 2 years. Examples include the following P&Ps:

Restraints, last revised 5/2008;
Skin Lesion Prevention Care & Monitoring, last revised 10/2008; and
Swing Bed Services, last revised 12/2009.

Additionally, each was unable to locate any P&Ps for any of the following concerning SBU patients:

Medical Records;
Discharge;
Transfer; and
Married Couples. --Per review of the P&P titled "Medication Administration," last reviewed 8/2009, it did not address the staff's current practice of using electronic bedside scanning procedures to ensure correct medication administrations.

--During interview on 12/04/12 at 8:45 am, the Pharmacy Director verified the medication administration P&P did not address the current procedures for bedside medication verification, and also acknowledged that the hospital did not have a P&P that addresses the process for patients using their medications brought in from home.

Based on document reviews and interviews, the hospital did not ensure that 8 of 11 patients were informed about their Patent's Rights, informed consent for treatment was obtained for two (2) patients, and signed Medicare notices were obtained for 7 of 8 patients. Additionally, the hospital did not include state specific requirements in its Patient's Rights booklet.

Findings include:

-- During review of patient MRs, it was noted that the hospital consent form titled "Consent To General Medical Surgical Treatment" (hereafter referred to as the general consent form), last revised 6/1998, contains a check box to indicate when a patient has been provided the patients' rights booklet " Your Rights as a Hospital Patient."

Review of Patients A through F's medical records (MRs) revealed that each lacked documentation on the general consent form indicating the patient was provided the Patients' Rights booklet.

During interview on 12/03/12 at 3:30 pm, the Nurse Educator acknowledged the findings above.

-- Per review of Patient K's MR (a one day surgery patient) on 12/03/12 at 1:25 pm, the general consent form was not signed.

Per review of Patient L's MR (a one day surgery patient) on 12/03/12 at 1:27 pm, the general consent form could not be found.

During interview on 12/03/12 at 1:30 pm, Registered Nurse (RN) #2 acknowledged these findings.

-- Per review of Medicare Patients A, B, D, F, G, I, and J's MRs on 12/03/12, each MR lacked a signed and dated initial "Important Message from Medicare About Your Rights" (IM) notice within 2 days of admission. The IM notice advises patients and/or their representative about discharge appeal rights. In instances where patients were unable to sign, there was no evidence that the IM notice was provided to the patients' authorized representatives.

During interview with the Nurse Educator and the Charge Nurse of the Medical/Surgical/Pediatric unit on 12/03/12 at 3:30 pm, neither were familiar with the IM form and its requirements. They were unable to explain why the IM forms had not been given to and signed by patients within the required timeframe.

-- The New York State Department of Health regulation at Title 10NYCRR 405.7 (c) requires hospitals to utilize specified Patients' Rights information for patients.

The hospital's "Your Rights as a Hospital Patient in New York State (at) Edward John Noble Hospital of Gouverneur, NY" booklet was incomplete as it did not contain the following information published in the New York State Department of Health booklet titled "Your Rights as a Hospital Patient in New York State," dated 6/2010:

* Steps to Appeal Your Discharge (starting on page 17 in the Department of Health's booklet).

* Deciding about Health Care: A Guide for Patients and Families (starting on page 19 in the Department of Health's booklet).

Based on findings from document reviews, observations and interviews, in 2 of 12 medical records (MRs), the hospital's process for determining and complying with patients' advance directives, such as a desire to not be resuscitated, was not safe or effective. This resulted in identification of Immediate Jeopardy which was removed prior to the completion of the survey. Also, the hospital's policy and procedure (P & P) regarding advance directives was not up to date or complete, and outpatients were not being provided information about advance directives.

Findings include:

-- Review of Patient A's MR on 12/03/12 about 3:00 pm revealed the following information:
Patient A, alert and oriented, was admitted on 12/01/12 with diagnoses of congestive heart failure, rule out myocardial infarction. The Consent to General Medical and Surgical Treatment form (hereafter referred to as "the general consent form"), which contained Patient A's witnessed signature and was dated and timed 12/01/12 at 1:15 pm, did not have any information checked under the Advance Directive section.

On the Nursing Admission form "Patient request DNR" (Do Not Resuscitate status) was entered at 12/01/12 at 4:05 pm under the Advance Directive section.

The 24hr Summary - MedSurg/Pediatrics form printed on 12/03/12 at 6:00 am and present in the MR indicated the patient had an advance directive. However, the section to indicate "DNR" was blank.

The copy of Patient A's Health Care Proxy form (dated 1/28/05) in the MR indicated the following under the Optional Instructions section: "Nothing is to be done. Just let me die if there isn't a chance of ever recovering, etc."

A copy of Patient A's Living Will (dated 01/28/05) in the MR specifically indicated she did not want cardiac resuscitation or mechanical respiration.

However, Patient A's MR lacked physician documentation discussing the patient's advance directive and lacked a physician order for DNR status.

During interviews with the Nurse Educator and the Medical Staff Coordinator (MSC) on 12/03/12 at 3:45 pm, they verified that Patient A was not currently on DNR status. At 4:00 pm the MSC returned from the Medical Records Department with a copy of a previous DNR order for Patient A that was dated 03/23/09. Registered Nurse (RN) #3 discussed the Full Code (full resuscitation) versus DNR status with Patient A who confirmed the desire to be DNR. RN #1 then contacted the physician and obtained a verbal order for DNR status at 4:10 pm.

-- Follow up review of Patient A's MR on 12/04/12 at 10:00 am revealed that Patient A's 24hr Summary - MedSurg/Pediatrics form, printed 4 hours earlier at 6:00 am, still only indicated the patient had an advance directive and continued to lack indication the patient wished DNR status. Also, Patient A's MR was still not marked with a black circle on the outside to indicate to staff the patient was a DNR. (During interviews of the Nurse Educator and the Charge Nurse of the Medical/Surgical/Pediatrics (MSP) unit on 12/03/12 at 2:30 pm, they had each indicated that placement of a black circle on a patient's MR was one of the hospital's mechanisms for informing staff that a patient was on DNR status).

Subsequently, during interview on 12/04/12 at 10:00 am, the Charge Nurse of the MSP unit placed a black circle on the outside of Patient A's MR.

-- Per review of the hospital policy titled "Advance Directive," last revised 1/2007, obtained from the intranet on 12/04/12 by MSP unit staff and identified as the only P & P on this topic, it did not contain directions specifying 1) what procedures to follow when a patient requests DNR status, and 2) how to identify patients on DNR status.

-- Review of Patient G's MR on 12/03/12 about 1:30 pm revealed the following information:
Patient G, with history of dementia, was admitted with sepsis of unknown origin. The general consent form, which contained a witnessed signature by Patient G's spouse and was dated and timed 12/01/12 at 5:15 pm, indicated that Patient G was DNR status; "Copy on File" was also checked on the general consent form. However, the 24hr Summary - MedSurg/Pediatrics form printed on 12/03/12 at 6:00 am indicated the patient did not have any advance directives, and the section to indicate "Patient Request DNR" was blank. The Advance Directive section on the Face Sheet in Patient G's MR indicated "NO," the patient did not have advance directives.

Further, Patient G's MR lacked physician documentation discussing the patient's advance directive and lacked a physician order for DNR status.

Per interview of the Charge Nurse of the MSP on 12/03/12 at 1:50 pm, he/she had spoken to Patient G's spouse at the time of admission and requested copies of advance directives but was not aware that the general consent form indicated the patient was a DNR. Immediately (during this interview) the Charge Nurse contacted Patient G's spouse about the patient's advance directives. Within the hour Patient G's spouse provided a completed Health Care Proxy (HCP) form (dated 12/12/08) that revealed the spouse was the HCP. At the request of the spouse, a physician order was obtained and Patient G was placed on DNR status at 2:50 pm.


-- On 12/04/12 at 4:45 pm the hospital's administrative staff were verbally notified of the Immediate Jeopardy findings described above. The hospital staff immediately initiated corrective actions to eliminate repeat lapses in correctly identifying and complying with patients' advance directives, i.e., Nursing Supervisor #1was assigned responsibility to review all new admissions to ensure patients' advance directives were accurately addressed. At the same time, over the course of the next 16 hours, administrative staff updated the hospital P&P addressing advance directives, educated all hospital staff in any way associated with patient care about the updated P&P, and initiated a monitoring mechanism to evaluate the effectiveness of the corrective actions taken.

On 12/05/12, beginning at 10:30 am DOH survey staff began reviewing the hospital's new Advance Directives P&P and the related training/ education activities regarding the new advance directives P&P (including plans for education of staff that were not currently scheduled to work). Twenty (20) staff, 2 patients and 2 family members were interviewed. Medical records were reviewed for corresponding accuracy of advance directives information. Identification bracelets for patients who were DNR status were observed, verifying they contained an orange dot to communicate the patient's DNR status to all (in accordance with the new procedures for identifying such status no matter the location of the patient in the hospital). At 3:00 pm the Immediate Jeopardy was deemed removed.

-- Regarding attention to advance directives in the outpatient setting:

During interview on 12/03/12 at 10:00 am, licensed practical nurse (LPN) #2, the LPN who manages the Edwards Health Center extension clinic site, revealed that information addressing advance directives was not being given to adult patients during their initial visit to the clinic. Also, 2 of 3 adult MRs (Patient P and Q) reviewed lacked documentation indicating the patients were asked about whether or not they had executed a HCP, or indicating the patients provided written or oral advance instructions about treatment to facility staff responsible for their care [as required by New York State Department of Health regulations at 10 NYCRR 400.21(d)(2)]. These findings were acknowledged by the LPN at the time.

Based on findings from observations, document review and interviews, nursing staff are dispensing intraveneous (IV) antibiotic medications stocked on the nursing unit, absent the direct supervision of a pharmacist.

Findings include:

--Per observation on the Medical/Surgical/ Pediatrics (MSP) unit on 12/03/12 at 9:15 am, IV minibags of the following antibiotics were stored on a shelf in the medication room: ceftriaxone, ciprofloxacin, metronidazole, zithromycin and cefazolin. They lacked labeling with any patient names.

-- Per review of the hospital policy titled "Medication Area Inspections," last reviewed 10/2012, it indicated that "Medications that are bulk supply are labeled patient specific."

-- During interview on 12/03/12 at 9:15 am with the Charge Nurse of MSP, after a physician's order is received and verified for one of the IV antibiotics (named above) that is stored in the medication room, nursing staff generates the medication label for the antibiotic, selects the minibag from the shelf, affixes a label to the bag and administers the antibiotic to the patient. He/She also confirmed that the pharmacist is not involved in the selection of the medication.

-- During interview on 12/04/12 at 8:45 am, the Director of Pharmacy (DP) acknowledged that the labeling of patient medications was the responsibility of a pharmacist. Additionally, the DP indicated that bulk supplies of antibiotics should not be stored in the nursing unit's medication room and had them removed.

Based on findings from observations and interviews, medications and medication injection supplies were stored in an unsecured area.

Findings include:

-- Per observations during a tour of the Edwards Health Center (EHC) on 12/03/12 at 9:45 am, the following medications and injectable supplies were observed in an unsecured closet in the public hallway: 6 boxes of Novafin 32 gauge tip disposable needles (10 tips per box); 1 box of 100 insulin syringes; 1 bottle Lantus insulin 100 units; > 50 tablets of furosemide 40 mg; > 20 tablets of Glipizlie 10 mg; 10 bottles containing 6 tabs each of Vimova 500 mg/2 mg; and 4 packs of Budesonide Inhaler Suspension 0.5 mg/2 mg.

-- During the observations, the Administrative Assistant for the EHC and LPN #1 accompanying the surveyor acknowledged the above findings.

Based on findings from observations, interviews and document reviews, it was identified that (1) drugs which were outdated, or opened but not labeled with date opened, were available for patient use, (2) medications for oral ingestion were inappropriately stored next to topical ointments, and (3) the hospital did not ensure pharmacy inspections of nursing medication rooms/areas were performed at least monthly.

Findings regarding (1) above include:

-- Per observations on 12/03/12 at 9:45 am, the emergency cart on the Medical/Surgical/Pediatric (MSP) unit contained five vials of adenosine 6 mg/2 ml and 2 vials of furosemide 100 mg/10 ml with expiration dates of 10/2012.

-- Per observations on 12/03/12 at 10:15 am, the medication room on the MSP unit contained 8 minibags of Zosyn 4.5 grams in 100 ml normal saline with an expiration date of 11/26/12 and one multidose vial of Novolin insulin labeled with an open date of 10/30/12 (greater than 28 days earlier).

The Nurse Educator was present during these observations and acknowledged the above findings.

-- Per observations during a tour of the Edwards Health Center (EHC) on 12/03/12 at 9:45 am, the medication room contained the following medications which where opened, undated and available for patient use: 20 cc lidocaine 1% 10 mg/ml bottle, 20 cc sodium chloride 1 mg/ml bottle, and 5 ml Tubersol (PPD) bottle.

The EHC Administrative Assistant and LPN #1 were present during these observations and acknowledged the findings.

Findings regarding (2) above include:

-- Per observation during the tour of the Edwards Health Center (EHC) on 12/03/12 at 9:45 am, 10 tabs of the oral medication metroprolol (50 mg) were stored in the same basket as > 20 individual topical triple antibiotic ointment packets.

The EHC Administrative Assistant and LPN #1 were present during this observation and acknowledged the above finding.

Findings regarding (3) above include:

--Per review of the hospital policy titled "Medication Area Inspections," last reviewed 10/2012, it indicated that the Director of Pharmacy or their designee conducts monthly inspections of medication areas in the adult and pediatric patient care unit (MSP unit), operating and recovery rooms (OR), labor and delivery (OB), intensive care unit (ICU), emergency department (ED) and outpatient clinics, and noted that medications that expire by the end of the next calendar month are removed from the medication areas.

However, review of the unit medication area inspection forms revealed that inspections of the medication rooms for the MSP, OR, ICU and OB had not been completed since 9/2012, the ED had not been inspected since 2/2012 and the outpatient clinics since 8/2012.

During interview with the Director of Pharmacy on 12/04/12 at 8:45 am, the above findings were acknowledged.

Based on findings from observation and interview, the Director of Food Services did not ensure safe food handling practices relative to food temperature monitoring and storage.

Findings include:

-- The following was observed during a tour of the hospital's kitchen on 12/03/12 at 1:30 pm:

The freezer contained a quart of cut strawberries in a plastic container with a lid, stored in the same bin as raw ground beef (the strawberries were immediately disposed).

The prep area contained two 13 gallon bins of flour and sugar, each bin had a soiled top. The flour bin was stored adjacent to an open full trash container.

During the tour, the accompanying Director of Food Services acknowledged the above findings.

-- Per review of the cooking temperature log on 12/04/12 at 11:40 am, no initial cooking temperatures were registered to confirm the critical control point of foods, i.e., that required temperatures are reached during the cooking of particular types of food.

During interview with the cook on 12/04/12 at 11:40 am, he/she confirmed that initial cooking temperatures are not taken.

This practice does not ensure the hospital is following standardized food safety guidelines relative to reaching required temperatures during the cooking of food.

Based on findings from document review and interviews, the hospital did not have a Utilization Review (UR)Committee and members of the medical staff were not involved in UR activities.

Findings include:

-- Per interview of the UR Coordinator on 12/03/12 at 1:15 pm, a UR Committee has not met in 2012.

-- Per review of the hospital's list of medical staff committee assignments in 2011-2012, a UR Committee was not included in physician assigned committees.

-- Per review of the Medical Staff Committee meeting minutes from January 2011 through September 2012, there was no information about UR activities.

-- During interview on 12/03/12 at 4:40 pm, the Director of Quality Improvement acknowledged that the hospital does not have a functioning UR Committee and that the UR Coordinator gathers data and reports directly to the Quality Improvement Committee on a quarterly basis.

Based on findings from interviews and document review, the fuel supply for the emergency generator which powers vital service areas in the older part of the hospital is insufficient to maintain those services in the event of an extended power interruption.

Findings include:

-- During interview with the Director of Facilities and the Maintenance Technician on 12/04/12 at 11:15am, they stated the following:

* A 350kw emergency generator supplies backup power to the older part of the existing hospital and the attached 40 bed, Kinney Nursing Home

* The hospital services (departments) that rely on this generator include: three Operating Rooms, Emergency Department, Central Sterilization Suite, Obstetrics/Maternity Unit, Outpatient Surgery, Kitchen, Administrative offices, etc.

* The emergency generator fuel supply is 250 gallons, which is estimated to provide about 8 hours of power for the emergency generator.

-- Also, during inteview with the Director of Facilities and the hospital Chief Executive Officer on 12/05/12 at 3:45 pm, they acknowledged the hospital did not have a written agreement with a fuel supply company guaranteeing a fuel supply source in the event of a power outage extending beyond 8 hours.

Based on findings from observation, document review and interviews, the hospital did not ensure that all generally accepted infection control measures relative to isolation precautions and storage of clean/sterile patient care supplies were implemented and followed.

Findings include:

--The CDC document titled "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings," contains the following statements: "...when Contact Precautions are used (i.e., to prevent transmission of an infectious agent that is not interrupted by Standard Precautions alone and that is associated with environmental contamination), donning of both gown and gloves upon room entry is indicated to address unintentional contact with contaminated environmental surfaces...Donning PPE (Personal Protective Equipment) upon room entry and discarding before exiting the patient room is done to contain pathogens."

However, the hospital's policy and procedure (P&P) (the only P & P available to staff on the nursing unit) titled "Measures for Preventing Patient to Patient Transmission of Drug Resistant Organisms," last reviewed 5/2009, stated the following: "Wear a gloves / gown when entering room if: ...You anticipate that your clothing will have substantial contact with the patient...or with environment surfaces or equipment in the room ... "

--Per observations on 12/03/12 at 3:30 pm, an isolation sign indicating that gown and gloves needed to be worn for room entrance was located inside room 127 on the wall. Gowns and gloves were available inside the room on a bedside table. Registered Nurse #3 was noted entering room 127, not wearing an isolation gown or gloves and pushing a medication cart; he/she administered an intravenous flush to the patient.

During interview at the time, RN #3 indicated he/she was not aware that the patient was on isolation.

--Per observations on 12/03/12 at 3:40 pm, Nursing Assistant #1 was noted entering room 127 without a gown and pushing a vital sign cart; he/she obtained vital signs from the patient. Items on the vital sign cart were not disinfected after patient use.

-- Per observations on 12/03/12 at 3:30 pm, an isolation sign indicating that gown and gloves needed to be worn for room entrance was located on the door of room 143. The Director of Respiratory Therapy was noted with the patient in room 143 not wearing an isolation gown.

During interview on 12/03/12 at 3:35 pm, the Director of Respiratory Therapy stated that use of a gown was not required as it depends on what is being done but gloves are always used.

Findings include:

-- Per observations of the Central Sterilization Suite on 12/04/12 at 12:10 pm, the doorway was open, lacking a door - this provided a direct connection between the soiled/decontamination room and the clean processing room where sterilization of instruments is conducted.

Separation between these dirty and clean areas is required for infection control purposes.

-- Per observations in the soiled / decontamination room on 12/04/12 at 12:10pm, a large shelving unit contained the following:

* Three blue packages of instruments. The items were sterilized as tape strip indicators had turned black.

* Approximately twelve clear wrapped packages of sterilized scissors and clamps, labeled for the EJ Noble extension clinics.

A sign above these items on the shelf stated: "Clean materials - Processed - Sterile - Outgoing."

During interview with the Central Sterile Services Supervisor on 12/04/12 at 2:40 pm, the clean and sterile supplies in storage for delivery to the extension clinics have been stored in the decontamination room for years. When asked about the potential cross- contamination issue, the Supervisor acknowledged it was an infection control concern and agreed to remove supplies, re-sterilize all, and implement a new clean storage location for these items.

-- Per observations during a tour of the Edwards Health Center on 12/04/12 at 10:00 am, the room used for blood draws contained multiple boxes of sterile syringes to be used for injection of medications and vaccines.

During the tour, the accompanying staff Nurse Educator acknowledged this finding.

Based on findings from observation, document review and interview, in 2 of 2 surgical procedures observed, surgical services staff did not perform pre-procedure time outs in accordance with generally accepted standards of practice. Also, the hospital's policy & procedure (P&P) for time outs did not include all generally accepted standards of practice.

Findings include:

--Per observation on 12/03/12 at 11:00 am, Patient K was in the operating room (OR). Immediately prior to the start of Patient K's colonoscopy procedure, a time out was performed by OR staff. However, all the team members did not cease what they were doing to fully participate in the timeout as Anesthesiologist #1 continued to administer medication to the patient.

--Per observation on 12/03/12 at 12:00 pm, Patient L was in the operating room. Immediately prior to the start of Patient L's laproscopic cholecystectomy, a time out was performed by OR staff. However, all the team members did not cease what they were doing to fully participate in the timeout as Surgeon #1, with the assistance of the certified surgical technician, continued drying his/her hands and applying sterile gloves.

--During interview on 12/03/12 at 1:45 pm, Anesthesiologist #1 indicated he/she fully participates in the time out even if he/she is involved in an activity at the same time.

--Per review of the hospital P&P titled "Surgical Site Identification," last reviewed 2/2012, while it indicated that a time out must occur immediately before the start of a procedure, it did not require that all work cease during the time out to allow all members of the team to focus on the time out, as required by the New York State Surgical and Invasive Procedure Protocol for Hospitals, Diagnostic and Treatment Centers, Ambulatory Surgery Centers and Individual Practitioners (NYSSIPP), dated 9/2006.