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Based on review of medical records, hospital documents, and staff interviews, it was determined that the governing body did not ensure that its medical staff provided quality of care that met acceptable standards of practice. MR #s 13 and 14.

Findings include:

1. The patient MR #13 was admitted on 6/9/11 for a complaint of shortness of breath and was admitted to the telemetry floor with the diagnosis of COPD exacerbation, Atrial Fibrillation and Cellulitis.
a. On 6/12/11 at 0645, the physician ordered Ativan 2mgs IM Now. The reason for the order was not included, rendering the order incomplete. However, the nurse acted on the order and administered the medication to the patient and recorded the administration of the drug in the Medication Administration Record (MAR) without including the specific time of administration.
b. Similarly, the same patient was given Ativan 1mg IV x 1 Now by a telephone order from the physician on 6/12/11 at 1330.

2. The patient MR #14 was admitted on 6/13/11 to a medical floor with the diagnosis of Failure to Thrive and Dementia. On admission his home medication regimen included Risperdone 1 mg orally once daily and Gabapentine 300mgs daily at bedtime for post herpetic neuralgia. On admission, the admitting physician noted that the patient was not compliant with his prescribed medications and was decompensating as evidenced by signs
of increased dementia. The physician orders included Risperdone 1 mg orally twice daily and Haldol 5mgs IM PRN for agitation without specifying how often this was to be administered to the patient, creating an incomplete order. The admission orders also included Gabapentine 300mgs daily at bedtime.

It is pertinent to note that an order to give Haldol 5mgs IM Q12H PRN as given by the physician on 6/14/11 at 0049 over the telephone to the nurse for the patient, for whom this drug is not part of his home medication regimen, constitutes an order for a chemical restraint.

On 6/16/11 at 0900, a nurse documented on the MAR that Ativan 2 mgs orally x 1 dose had been administered to the patient. This was given without an order from the physician. On 6/16/11 at 1105, in addition to the already administered Ativan 2mgs PO at 0900, a telephone order was given by the physician to administer Ativan 2mgs orally x 1 and Percocet 5/325mgstab orally x 1. At 1145 on 6/16/11, a telephone order was received to give Narcan 0.4 mgs IV to the patient to reverse the cumulative effects of the drugs given to the patient.

3. A review of the facility policy "Restraint & Seclusion", initiated 01/99 and revised 3/2011, revealed that it states in 2.10.b): "Chemical restraints are NOT approved for Behavioral Health Restraints". Therefore, since the facility's policy did not recognize the use of chemical restraints as appropriate for Behavioral Health Restraints, it did not provide guidance to staff regarding restraint techniques required for safe use of chemical restraints. The facility also failed to educate staff on the criteria to follow in monitoring patients who receive chemical restraints.

Based on medical record review, the facility did not ensure that the order for chemical restraints was not written as standing order or on an as needed basis (PRN).
This is evident in 1 of 30 medical records reviewed. MR #14

The patient MR #14 was admitted on 6/13/11 to a medical floor with the diagnosis of Failure to TBased on review of medical records, hospital documents, and staff interviews, it was determined that the governing body did not ensure that its medical staff provided quality of care that met acceptable standards of practice. MR #s 13 and 14.

Findings include:

1. The patient MR #13 was admitted on 6/9/11 for a complaint of shortness of breath and was admitted to the telemetry floor with the diagnosis of COPD exacerbation, Atrial Fibrillation and Cellulitis.
a. On 6/12/11 at 0645, the physician ordered Ativan 2mgs IM Now. The reason for the order was not included, rendering the order incomplete. However, the nurse acted on the order and administered the medication to the patient and recorded the administration of the drug in the Medication Administration Record (MAR) without including the specific time of administration.
b. Similarly, the same patient was given Ativan 1mg IV x 1 Now by a telephone order from the physician on 6/12/11 at 1330.

2. The patient MR #14 was admitted on 6/13/11 to a medical floor with the diagnosis of Failure to Thrive and Dementia. On admission his home medication regimen included Risperdone 1 mg orally once daily and Gabapentine 300mgs daily at bedtime for post herpetic neuralgia. On admission, the admitting physician noted that the patient was not compliant with his prescribed medications and was decompensating as evidenced by signs
of increased dementia. The physician orders included Risperdone 1 mg orally twice daily and Haldol 5mgs IM PRN for agitation without specifying how often this was to be administered to the patient, creating an incomplete order. The admission orders also included Gabapentine 300mgs daily at bedtime.

It is pertinent to note that an order to give Haldol 5mgs IM Q12H PRN as given by the physician on 6/14/11 at 0049 over the telephone to the nurse for the patient, for whom this drug is not part of his home medication regimen, constitutes an order for a chemical restraint.

On 6/16/11 at 0900, a nurse documented on the MAR that Ativan 2 mgs orally x 1 dose had been administered to the patient. This was given without an order from the physician. On 6/16/11 at 1105, in addition to the already administered Ativan 2mgs PO at 0900, a telephone order was given by the physician to administer Ativan 2mgs orally x 1 and Percocet 5/325mgstab orally x 1. At 1145 on 6/16/11, a telephone order was received to give Narcan 0.4 mgs IV to the patient to reverse the cumulative effects of the drugs given to the patient.

3. A review of the facility policy "Restraint & Seclusion", initiated 01/99 and revised 3/2011, revealed that it states in 2.10.b): "Chemical restraints are NOT approved for Behavioral Health Restraints". Therefore, since the facility's policy did not recognize the use of chemical restraints as appropriate for Behavioral Health Restraints, it did not provide guidance to staff regarding restraint techniques required for safe use of chemical restraints. The facility also failed to educate staff on the criteria to follow in monitoring patients who receive chemical restraints.


hrive and Dementia. On admission his home medication regimen included Risperdone 1 mg orally once daily and Gabapentine 300mgs daily at bedtime for post herpetic neuralgia. On admission, the admitting physician noted that the patient was not compliant with his prescribed medications and was decompensating by showing signs of increased dementia. The physician orders included Risperdone 1 mg orally twice daily and Haldol 5mgs IM PRN for agitation without specifying how often this was to be administered to the patient.
The order was clarified in a telephone order on 6/14/11 at 0049 when the physician ordered that Haldol 5mgs IM Q12H PRN be given to the patient. This order constitutes an order for a chemical restraint written as a PRN order as this was not a part of the patient's home medication regimen.

Based on facility policy and procedure reviews, medical records reviews, and staff interviews, the facility did not ensure that that staff was trained in the safe implementation of chemical restraints on the patients. This is evident in 1 of 30 medical records reviewed, MR #14.

Findings include:

The facility failed to train/ educate staff on the criteria to follow in monitoring patients who receive chemical restraints.

During interview with Staff #6 on 6/21/11 at 3:15PM, it was revealed that facility staff had only a vague knowledge of the use of Chemical Restraints and the requirements for assessments, monitoring of vital signs, review of care plans, medication regimen reviews, staff debriefing and 1:1 physicians assessments of the patients within 1 hour of the use of chemical restraints had not been brought to staff attention and staff had not received training about chemical restraints use.

Based on observations, the facility did not ensure that the patients were observed and that staff completed the observation form " Turning and Skin Care Record " in a timely manner. Similarly, staff did not position patients who required repositioning in accordance with facility policy. This is evident in 5 of 30 medical records reviewed, MR # 18, 19, 23, 26 and 27.

Findings include:

1. The patient MR #18 was admitted on 6/17/11. On admission, the patient presented with a stage IV pressure ulcer on the sacrum which, upon assessment done on 6/17/11, measured 5.0 x 4.7 x 1.1, and the bone was visible. On 6/21/11 at 2:10 PM, the patient was observed in Room 352 lying in bed. Staff # 5 and 6 witnessed the observation that the record of repositioning " Turning and Skin Care Record " for the patient was left blank from 7AM until the time of observation at 2:10 PM.
A review of the patient's medical record revealed that the Braden score done on 6/20/11 classified the patient as a high risk for pressure ulcer development at a score of 10-12 which requires frequent turning and repositioning. There was also no previous documentation of the patient being repositioned frequently from admission until the time of observation as there were no Turning and Skin Care Record forms in the medical record.
2. Similarly, the patient MR # 23 was admitted on 6/14/11 with a Braden score of 13- 14 and was classified as moderate risk for the development of pressure sore. The patient also had a stage II pressure ulcer on the coccyx measuring 1cm x 0.3cm. The patient was observed on 6/21/11 at 3:35PM lying in bed on her back. This observation was witnessed by Staff # 5 and 6.

A review of the patient's medical record revealed that the facility failed to document that the patient was repositioned every 2 hours to prevent worsening condition of the patient's ulcer as the form, Turning and Skin Care Record, was not documented from 6/14/11 until the time of observation.

3. The patient MR #27 was admitted on 6/17/11 with a Braden score 13-14 and was classified as requiring measures to prevent skin breakdown, including repositioning. On 6/21/11 at 3:45PM, the patient was observed. This observation was witnessed by Staff # 5 and 6. Medical record review revealed that repositioning records, Turning and Skin Care Record, were not maintained on the patient from admission. According to the body diagram documented on the patient on admission and on 6/18/11, the patient had 2 noted areas of bruises on the dorsal part of the body that were blanchable. On 6/19/11 and 6/20/11, the sacral area was non blanchable, and purplish, respectively. The facility failed to put measures in place to prevent the patient's skin condition from becoming worse.
4. On 6/22/11 at 12:30 PM, the patient MR#26 was observed, and this observation was witnessed by Staff # 5 and Staff # 6. Review of the position record, Turning and Skin Care Record, revealed that it was left blank from 7AM till the time of observation. The patient had Braden scores of 10 on 6/15/11, 12 on 6/16/11 and 13 on 6/13/11. On 6/21/11, the Braden score was erroneously calculated to be 19 without any changes in the patient's mobility status. A review of the medical record revealed that there was only one partially (7AM -7PM) completed position record on an unknown date in the patient's medical record. By 6/21/11, the body diagram showed that the patient had an erythematous area on the sacral area. The facility failed to apply preventive measures including repositioning to prevent the patient's skin from being damaged.
5. Finally, the patient MR #19 was observed on 6/21/11 at 3:05PM lying on her back, and this observation was witnessed by Staffs # 5, 6 and 11. At admission of the patient on 6/7/11, the patient's Braden score was 9 and the patient had one ulcer staged differently by the nurses to be a stage III or IV pressure ulcer on the coccyx. It was noted that a repositioning record, Turning and Skin Care Record, was not documented on the patient.

A review of the patient ' s medical record revealed that since admission, the facility did not document the frequency of repositioning the patient on the form Turning and Skin Care Record, and did not ensure that the patient was positioned in a way to prevent the patient from lying on the coccyx area to avoid further injury to the ulcer on the back.

A review of the facility policy "Skin Assessment & Pressure Ulcer Prevention", revised 2/17/10, revealed that it states in policy statement # 2.0 c: " Institute measures to minimize risk factors that cause skin breakdown". The facility failed to institute the measure of repositioning the patient to prevent skin breakdown. The policy also states in 3.6 a: " Turn patient at least every 2 hours when in bed ... ... "

On 6/23/11 at 12:10PM -12:40PM, the above findings were discussed with Staff # 16 and the lack of documentation on repositioning of the patient was brought to her attention.

Based on medical record review, the facility did not ensure that a medication was administered to a patient only on the order of a physician or other licensed independent practitioner who is responsible for the care of the patient. This is evident in 1 of 30 medical records reviewed, MR #14.

Findings include:

The patient MR #14 was given Ativan 2 mgs orally x 1 dose on 6/16/11 at 0900. There was no written or telephone order from the physician before the nurse administered this oral dose of Ativan to the patient.

Based on findings in the locations of the facility on dates and times cited, the following
were observed and the observations were witnessed by Staff # 5 and 6:

Findings include:

1. Radiology.
a. At 12:30PM on 6/20/11, the Emergency cart located within the department was notedwith 4 expired Provent Blood Gas syringes. The expiration dates were 04/2010.
b. At 12:35PM, expired Hypodermic Needle safety devices with the expiration dates of 02/2011 for 1 device and 03/2011 for 2 devices, were found in room CT01.
2. Laboratory.
A container of water in a pipette-like container was noted in use in the department. Staff #18 confirmed that this was not a closed system. The container was not labeled with the time and date the water was put in the container. Staff # 18 also stated that the water in the container does come in contact with specimens collected from patients for testing.
3. Pharmacy.
a. Noted in storage were 8 containers of expired 5% Dextrose and 225 Na Cl. 1000cc. The IV solutions had expired on 4/1/11. Staff # 19 stated that the facility no longer uses the solutions and they should have been discarded and not kept with the stock of supplies.
b. A stock of 24 5% Dextrose with 9% NS with the expiration date of 12/2010 was
found at 3:35 PM among the stock of IV solutions in the department.

Based on observation, staff interview, and review of the dietary policy and procedures, the facility failed to provide dietary and food services according to the current standards of practice.

Findings include:

During observation and inspection of the kitchen, cafeteria, and food service areas conducted on 6/21/11 through 6/24/11, staff interview, and review of the dietary policies and procedures manual, the following items were noted:

1. During the tours of the dietary areas on 6/21/11, clean trays were observed on an open rack next to the garbage containers, creating a possibility of cross contamination.

2. During the tour of the kitchen on 6/21/11, the food preparation sinks did not have an indirect drain.

3. During the tour of the kitchen on 6/21/11 and 6/24/11, dented cans were observed in the storeroom.

4. During the tour of the kitchen on 6/24/11, the door of the Janitor's closet was observed not to be self-closing.

5. During the tour of the kitchen on 6/24/11, the area behind the cooking equipment was noted to be extremely dusty and soiled.

Based on observations, staff interviews and document reviews, it was determined that the facility failed to maintain a safe, sanitary and comfortable environment to ensure that the safety and well-being of patients are not compromised.

Findings include:

1. During observations of the patient floors/areas in the facility from 06/20/11 to 06/24/11 between 10:30 AM to 4:00 PM, it was noted that the grills/heating elements of some heating/air-conditioning units in patient rooms/corridors (such as rooms on the 2nd and 3rd floors) exhibited accumulation of dirt and dust in the grills and around the floor perimeters beneath their edges.

All findings were verified with Staff #21 and Staff #24 at the time of observation.

2. During the survey from 06/20/11 to 06/24/11 between 10:30 AM to 4:00 PM, it was noted that the facility did not ensure that the environment around the premises and the equipment used were maintained in a sanitary condition, and free of dust and dirt to prevent transmission of infection and contamination. Furthermore, the facility did not ensure that the physical plant was kept in good repair to ensure a sanitary environment.

Examples, including but not limited to, are:
a. The perimeters of the wall inside patient rooms on 2nd and 3rd floor and the corners around the door were noted very dirty and dusty. Some examples are room #s 373, 318, 320, 319, 206 and others. Also some of the patient bathrooms in these rooms exhibited very dirty diffuser links of the vents.
b. In rooms such as room #210 and #206, it was noted that there was hair, dirt and dust around the legs of the chair kept for visitors in the patient room.
c. It was noted in the control/Staff room in the Radiology department (providing support to 4-5 x-ray rooms) that the perimeters of the room were very dusty and dirty and there was accumulation of excessive dust and dirt behind fax machines and under tables. Furthermore, a room identified as 'Dark room' was noted having very dusty and dirty floors.
d. The underneath surface of various OR tables/stretchers were noted dusty.
e. The corners of the Central Sterile Supply room were noted dusty and some had cob-webs. Furthermore, there was a dirty vent above the steam sterilizer.
f. The floors and edges of the Main Clean linen room were noted dusty and dirty.
g. Bronchoscopy supply room was dusty.
h. The Morgue was noted dirty and dusty. Furthermore, the vents were noted accumulated with thick black layer of dirt and dust.
g. Some Wooden doors, such as the door of Ultrasound room in the Main Radiology department and some patient rooms on floors, were noted to have splinters.

All findings were verified with Staff #21, Staff #24 and other unit staffs at the time of observation.

3. During the survey of the facility from 06/20/11 to 06/24/11 between 10:30 AM to 4:00 PM, it was observed that several ceiling tiles on different floors of the hospital showed signs of old leaks. Examples include, but are not limited to:
a. One ceiling tile was stained in the Main clean linen storage room.
b. One ceiling tile stained in the Endoscopy room #2.
c.Two ceiling tiles were noted stained in the Chemistry Laboratory.
d. One ceiling tile was noted stained in room #459 in the maternity unit.
e. One ceiling tile was noted stained in room #306 and 309.

All findings were verified with Staff #21 and Staff #21 at the time of observation.

NOTE: If ceiling tiles are not replaced and stay humid/wet, they may harbor the growth of mold/fungi and contribute to environmental contaminants. Also, stained ceiling tiles need to be investigated for potential leaks above, as it may be an indication of a problem with the plumbing/sprinkler system or of insufficient insulation around the steam pipes supplying heating to the facility.

4. During the survey on 06/21/11 at 11:30 AM, it was determined that the facility failed to ensure that the facility's environment remains free from accident hazards to the staff and patients. The facility did not ensure that the temperature of hot running water at the hand wash sink in the Emergency Department used by the staff, was maintained at acceptable levels [not to exceed 110 degrees Fahrenheit (F)] to prevent potential burns. Hot water temperature of 119*F was noted in a sink outside room #20.

Findings were verified by Staff #21.

5. The kitchen and dietary area were not maintained to ensure an acceptable level of safety and quality for the patients and staff.
See A 620.

Based on observations, record reviews and staff interviews, it was determined that the facility failed to meet the applicable provisions of the Life Safety Code, NFPA 101, 2000 edition.

The findings include:

During the survey of the facility from June 20-24, 2011, Life Safety Code deficiencies were noted in multiple areas of the Code requirements and were cited under the following Fire/Life Safety Code K-Tags:

K-12 (Structural elements not completely protected /fire proof);
K-18 (Doors in the smoke barrier not kept free of impediments for easy closure in case of fire)
K-29 (Hazard area not protected with self-closing devices);
K-34 (Guard rails of the stairs had gaps more than 4 inches);
K-38 (Means of egress not kept free of impediments);
K-50 (Fire drill not performed under varying conditions);
K-62 (Sprinkler heads not kept clean of foreign material);
K-64 (Portable fire extinguishers not installed at height less than 5 ft);
K-73 (Artificial plants not flame retardant);
K-75 (Soiled linen containers greater than 32 gallon not protected in a rated enclosure)
K-77 (Medical gases not maintained in reliable condition);
K-130 (Electrical receptacles in patient care areas not tested and Storage of Oxygen Cylinder not as per code);
K-145 (Type I EES system not distributed into three branches);
K-147 (Electrical wiring not done as per NFPA 70)
K-160 (Elevators not equipped with fire fighter recall system)

Based on observations made during the survey tour, it was determined that the facility did not ensure that all facilities/areas and equipment were maintained in such a way to ensure an acceptable level of safety and quality for both patients and staff.

Findings include:

1. Equipment was not inspected according to facility's policy. Observation of the Plum Pump on 6/20/11 at 12:35 PM in the ED Core II revealed that it was due for inspection on 3/11. This observation was verified by Staff #2 at that time.

2. Observation on 6/21/11 at 11:21 AM in the delivery room of the Labor and Delivery Room revealed the Bear Hugger was due for inspection on 8/10. This was witnessed by Staff #19 at that time.

3. Observation in the Delivery Room at 11:35 AM on 6/21/11 revealed a section of the anesthesia machine to regulate gases was taped and in need of repair. This was witnessed by Staff #19 at that time.

4. Observations of the rehabilitation counseling room #1 at the Bridge Back Rehabilitation Center revealed the light fixtures were not in working condition on 6/22/11 at 11:36 AM. This was witnessed by Staff #20 at the time.

5. Cabinets and 2 drawers were missing doors and drawers and were in need of repair on 6/22/11 at 12:18 PM. These findings were witnessed by Staff #20 at that time.

6. On 6/22/11 at 12:25 PM at the Bridge Back Rehabilitation Center, observations of the maintenance closet revealed the light fixture was not in a working condition. This was witnessed by Staff #20 at the time.

7. On 6/21/11 at approximately 11:00 AM through 1:00PM, the recorded temperatures of the two blanket warmers located in the surgical suite area were 163?F and 152?F, respectively. Review of the Hospital's Policy entitled "Storage of Heated Blankets", which was revised on 8/20/10, stated: "Keep temperature at or below 130?F (54?C)" in the blanket warmer cabinet.

8. At the Bridge Back Rehab Center on 6/22/11 at 11:36 AM, observations in front of the receptionist area revealed that one of the light fixtures was not working. This finding was verified by Staff #20 at the time.


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9.(a) On 06/22/11 at 12:30 PM, during the survey of the Ambulatory Day Surgery (ADS), it was noted that when a nurse call bell was tested from a patient bay/ room, it did not register in the medication room, clean utility room, soiled utility room and other areas as required by AIA 7.32.G1.

The findings were verified with Staff #24 at the time of the observation.

(b) Furthermore, On 06/24/11 at 12 00 PM, during survey of the Dialysis unit, it was noted that when a call bell was tested from a patient bay, it did not elicit audible alarm at the nurse's station or at the bay where it originated.

10. On 06/24/11at 12:45 PM during the survey of Dialysis unit, Staff #28 was asked to perform Total Chlorine and Chloramine test. Staff #28 did not perform the test as per policy since she did not time the test as required by facility's policy. Furthermore, Staff #28 stated she does not have a watch and counts the time in her head. The Chief Technician of the unit showed her that there was a phone with clock to time the test.

11. During the survey of Ambulatory Day Surgery on 06/22/11, it was noted that room #172 had two beds in the room and on the wall there was only one oxygen outlet and two suctions. As per AIA 1996-97 Table 5, such rooms require one oxygen station outlet per bed. Therefore, to have two beds in this room, two oxygen outlets are required which was not present.

Based on observation, it was determined that the facility did not ensure that proper ventilation was provided and monitored in patient care and other areas of the building.

Findings include:

1. During observations of the ORs on 06/21/11 at 2:00 PM, Staff #21 was interviewed regarding how the temperature, humidity and air pressure are monitored. Staff #21 stated that the engineering department was responsible for central monitoring and no monitoring was done in the OR itself before or during an operation.
Staff # 21 also stated that Engineering staff is responsible to check on the computer and notify the surgical department if any discrepancies occur. However as per observation and interview with Staff #21, it was noted that in minor procedure room, the air flow was negative and when Staff #21 checked on the computer no information was shown regarding this malfunction.

Furthermore, the sub-sterile room of this OR was positive to the OR instead of negative.

2. During the survey of the OR suite on 06/21/11 at 215 PM, it was noted that one of the ventilation exhausts in OR #5 (installed on the lower end of the wall) was blocked/obstructed by equipment. Such blockage compromises the air exchanges.

3. During the survey from 06/20/11 to 06/24/11 between 11:00 AM to 4:00 PM, it was noted that non-patient areas that may contribute to infection control/contamination did not have the required ventilation/air-pressure as per AIA 1996-97 Table 2.
Examples include, but are not limited to, the following:
a) Main Decontamination room in Central Sterile area was noted neutral instead of negative.
b)Soiled Utility Room near the Emergency Department had positive air blowing into the non-sterile area.
c) House-keeping closet in the Ambulatory Day Surgery was neutral instead of negative.
d)Main Laboratory was neutral instead of negative.
e) Soiled Utility Room of Maternity suite was positive instead of negative.
f) Janitor Closet in the Pain Management extension clinic was neutral instead of negative.

4. On 06/21/11 at 11:30 AM during the tour of the Emergency Department, it was noted that the Isolation Room #20 did not exhibit negative pressure as required. Finding was verified with Staff #21.

Based on observations, interviews, and reviews of policies, it was determined that the facility's infection control officer failed to ensure that steps were taken to prevent cross-contamination and the spread of infections to facility's patients and staff, including development of a system to identify protocols for staff infection control practices and for labeling of biological supplies.

A. Soiled Rooms/ Supplies/ Equipment

Findings include:

1. During tours of the Bridge Back Alcohol Rehabilitation and Methadone Clinics conducted on 6/22/11 at 11:35 AM several chairs (>6) were noted to be stained, this poses a risk for contamination and infection. This finding was witnessed by Staff #20 at the time.

2. Observations of the ceiling in front of the receptionist area at the Bridge Back Rehabilitation Clinic on 6/22/11 at 11:40 AM revealed there were cobwebs with a trapped dead insect. These findings were witnessed by Staff #20 at the time.

3. At least 2 pieces of clothing were noted to be stored in a drawer in the pantry at the Bridge Back Rehabilitation Clinic on 6/22/11 at 12:08 PM. These findings were witnessed by Staff #20 at the time.

4. A white residue/powdery substance was observed in the cabinets located in the Pantry at the Bridge Back Rehabilitation Center on 6/22/11 at 12:20 PM. This finding was witnessed by Staff #20 at the time.

5. The refrigerator in the pantry at the Bridge Back Rehabilitation Center was noted to be dirty. The refrigerator was noted to be stocked with supplies of milk, juices, condiments, fresh fruit and other food items. This finding was noted by Staff #20 at the time.

6. Observations of the front of the receptionist area on 6/22/11 at 11:38 AM at the Bridge Back Rehab Center revealed the carpet was stained and in need of cleaning. This finding was witnessed by Staff #20 at the time.

7. The television stand in the Breakout Group room in the Bridge Back Rehabilitation Center was noted to be in need of cleaning on 6/22/11 at 11:45 AM. This finding was witnessed by Staff #20 at the time.

8. Soiled labels and adhesive were noted on the drawers in the pantry at the Bridge Back Rehabilitation Center on 6/22/11 at 12:20 PM. This finding was witnessed by Staff #20 at that time.

9. A cautery machine in Operating Room (OR) #2 had dirty adhesive tape attached to it on 6/21/11 at 3:00 PM. This finding was witnessed by Staff #21.

10. A tourniquet in OR #2 on 6/21/11 at 3:04 PM was noted to have residual soiled adhesive. This finding was witnessed by Staff #21 at that time.

11. A container of clean diaper wipes was noted to be stored at the baby-washing sink in the nursery on 6/21/11 at 11:38 AM. This finding was witnessed by Staff #19 at the time.

12. The baby warmer in the nursery was observed to have soiled adhesive on 6/21/11 at 11:40 AM. This finding was witnessed by Staff #19 at the time.

13. An uncovered Yankauer suction catheter which was attached to a suction canister was observed at the bedside in Room #452 on the maternity unit on 6/21/11 at 11:05 AM. This finding was noted by Staff #19 at the time of observation.

14. The Bovie machine in the L & D operating room was noted to have soiled adhesive on 6/21/11 at 11:24 AM. Staff #19, who witnessed the finding at the time, stated it's the facility's policy for equipment to be cleaned after each use.

15. A used 1 ml syringe was observed on the top of the anesthesia cart in the L & D operating room on 6/21/11 at approximately 11:26 AM. This finding was verified by Staff #19 at the time.

16. The top of a storage cart in Core II in the ED was noted to have an accumulation of dirt at 12:55 PM on 6/20/11. The cart is used to store intravenous fluids, saline flushes, blood tubes and other clean and sterile supplies. This finding was witnessed by Staff #2 at that time.

17. Observed in a sink in the clean utility (storage) room in the ED, were 2 airways on 6/20/11 at 12:20 PM. This finding was verified by Staff #2 at the time.

18. Stored in the Decontamination Room in the ED on 6/20/11 at 12:40 PM were 1 Reeve Board, 1 long board, a large closed yellow bin and a large black closed bag. These findings were verified by Staff #2 at the time.

19. Both refrigerators at the Pain Management Center was noted to be dirty on June 23, 2011 at 11:25 AM. Stored in these refrigerators were containers of Yoghurt, sandwiches, juice, several bottles of water, soda, and a thirty-two ounce opened container of orange juice, etc. This was witnessed by Staff #1 at the time of observations.

20. The vacuum machine at the Pain Management Center had soiled adhesive on June 23, 2011 at 11:18 AM. This was witnessed by Staff #3 at the time.

21. During the survey of the facility from 06/20/11 to 06/24/11 between 10:30 AM to 4:00 PM, it was noted that rooms identified as janitorial/housekeeping closets throughout the facility had an abundant amount of clean supplies (such as toilet rolls, paper towels and other such clean supplies). This finding was verified with Staff #21, Staff #24 and other unit staffs present during survey.







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B. No System to Identify Protocols for Staff Infection Control Practices and Biological Supplies Labeling

Radiology
1. At 11:55PM on 6/20/11, an opened O2 tubing was noted hanging on the Oxygen outlet in Room #3 without a cover.
2. 2 opened O2 tubings were found in a drawer, also in Room #3.
3. At 12:05PM on 6/20/11, an opened Yankauer suction catheter connected to the suction canister on the wall was noted without a cover in Room #4.
4. At 12:30PM on 6/20/11, the Emergency cart located within the department was noted with 4 expired Provent Blood Gas syringes. The expiration dates were 04/2010.
5. An opened suction tubing was also found in the same Emergency cart.
6. At 12:35PM expired Hypodermic Needle safety devises with the expiration dates of 02/2011 for 1 device and 03/2011 for 2 devices were found in Room CT01.

Dialysis Unit
1. A suction tubing, opened and without a cover was noted on the suction canister at 12:45PM.
2. Staff # 7 was noted taking a pair of gloves from the glove box on the wall and then sanitizing her hand at the dialyzing machine before donning the pair of gloves she had obtained from the supply box on the wall.

Laboratory
A container of water in a pipette like container was noted in use in the department. Staff #18 confirmed that this was not a closed system. The container was not labeled with the time and date the water was put in the container. Staff #18 also stated that the water in the container comes in contact with specimens collected from patients for testing.

Pharmacy
1. A 500cc of Aminosyn IV fluids opened and without the outer wrapping on the IV solution was noted at 3:10 PM on 6/20/11 and kept in storage. Staff #19 stated that this was not a good practice.
2. Also noted in storage were 8 containers of expired 5% Dextrose and 225 Na Cl. 1000cc. The IV solutions had expired on 4/1/11. Staff #19 stated that the facility no longer uses the solutions and they should have been discarded and not kept with the stock of supplies.
3. A stock of 24 5% Dextrose with 9% NS with the expiration date of 12/2010 was found at 3:35 PM among the stock of IV solutions in the department.

3 East, 2 Broadway and 2 West Units
1. On 6/21/11 at 2:07 PM, the patient in Room 353 was noted receiving IV fluid. The IV line was not identified with the date to change the line.
2. A grey colored recliner with torn upholstery was noted in Room 276A at 3:35 PM on 6/21/11.
3. At 2:07 PM on 6/21/11 an uncovered nasal cannula was noted hanging on the Oxygen outlet in Room 350A.
4. At 11:45 AM on 6/22/11, an uncovered nasal cannula was noted hanging on the Oxygen outlet in Room 206A.
5. At 12:45 PM on 6/22/11, the patient in Room 216A was noted receiving IV fluids. The IV line was not identified with the date to change the line.

Hyperbaric Department
At 12:50 PM Staff #14 stated that the hyperbaric chambers are cleaned after each use and inspected daily for functionality, but a log of routine cleaning of the chambers were never maintained in the department as a practice.


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C. Building Structure/ Rooms/ Fixtures

1. On 06/20/11 at 3:00 PM, during survey of the Central Sterile Supply room, it was noted that the ceiling tiles in the room were porous/had holes that may retain dirt (they were not monolithic) and thus were not as per AIA 7.28.B8. Such porous ceiling tiles compromise thorough cleaning of the ceiling which is required to keep the environment of Central Sterile as clean/sterile as possible.

2.a. As per AIA 7.9.D22, at least one airborne infection isolation room should be provided complying with the requirements of Section 7.2 in the emergency department. Section 7.2.C4 states that 'air borne infection isolation room shall have self-closing devices on all room exit doors'. During the survey of the Emergency Department on 06/21/11 at 12:30 PM, it was noted that the facility has two rooms designated to be isolation rooms but they did not comply with all requirements of Section 7.2. The isolation rooms did not have self-closure or self-closure mechanism installed at the exit sliding door.

2.b. As per AIA 7.2C1, at least one isolation room is required for the nursing/surgical unit (and more may be required as per the infection control committee). The facility has med/surg unit/beds on the second floor and third floor. As per interview with Staff #21, any room may be converted to negative isolation pressure room by putting in a portable HEPA filter. Also the facility has designated one room on each floor as an isolation room.

However, on 06/23/11 at 12:00 PM during observation of 3rd floor Med/Surg Broadway, it was noted that none of the rooms complied with all requirements of Section 7.2 for isolation room (such as self-closure at the door). The ceiling tiles were porous and were of such material that they would not minimize the retention of dirt as required by 7.28.B8 and would not be thoroughly washable/cleanable.

3. On 06/20/11 at 3:00 PM, during survey of the Central Supply Room it was noted that there was an open pass through window space about 2ft x 2ft( with no window panels/pane closing it off) between the Clean and Dirty side. This arrangement my contribute to cross contamination and in-effective air-balancing in both rooms.

4. On 06/22/11 at 11:45 AM, during the tour of the Endoscope processing room, it was noted that the room had carpet on the floor that is made of impervious material and will not allow thorough cleaning in case of a spill.

Based on review of medical records and hospital policy, there is no documented evidence in the Intraoperative Record to show that the operative/procedural site was marked by the surgeon prior to the incision. (Medical Record #21 and #22).

1. The preprinted Intraoperative Record forms in the surgical medical records do not contain documented evidence to state that the operative/procedural site was marked by the surgeon prior to the incision for the patients Medical Record #21 and #22, as per the standard of practice and hospital policy.

2. Review of the hospital policy entitled, "Time Out Policy/Universal Protocol" states that the "Marking the Operative/Procedural Site" includes "All sites involving laterality and/or paired organs, multiple structures or multiple levels."

Based on medical record reviews and staff interviews, it was determined the facility failed to ensure that a physician completed history and physical examinations or updated examinations of its patients that received surgical procedures at 1 of its offsite locations in 3 of 3 medical records reviewed at that center. This was found in MR #s 1, 2 and 3.

Findings include:

1. Physical examinations were not completed prior to patients undergoing surgical procedures.
MR # 2, this eighty-nine year old patient, according to the nursing assessment, had undergone Bypass surgery in 1998 and Stent placement in 1992. The patient was admitted to a hospital in March 2011 for bowel impaction and had a Total Hip Replacement in April 2011. The patient had right hand numbness, twoTransient Ischemic Attacks, a stroke with mild impairment and had balance issues. The patient had fallen the day before the procedure and had sustained abrasions on the nose and forehead.

The physician carried out a Right Lumbosacral Transforaminal Epidural Steroid Injection of 40 mgs of Kenalog on June 22, 2011 without the benefit of a complete physical examination and a clearance from a cardiologist. The latter requirement would be a necessary and recommended practice given the patient's multiple medical comrbidities. This finding was witnessed by Staff #3 on June 23, 2011 at 11:45 AM when the chart was reviewed.

2. MR #1, this seventy year old patient's physical examination was not reviewed prior to surgery. The patient had a physical examination on June 16, 2011, which showed the patient had a history of Hypertension and according to the nurse's notes and was allergic to Codeine. The patient had been taking medications that included Crestor, Amlodipine, Besylate and Advil. The physician noted that the patient had a "fifteen month history of back pain which was primarily on the left but occasionally on the right side which averaged at 9/10 and that it had been interfering with the patient's activities of daily living such as walking, bending and picking up things." On 6/22/11 the patient was given Versed 5 mgs IV which is a narcotic, prior to undergoing the Lumbar Epidural Steroid Injection without a re-assessment the day of the procedure. This finding was also verified by Staff #2 on June 23, 2011 at 11:50 AM.

3. A similar finding was noted in MR #3.

4. None of the physician's orders were signed by the physician. These orders included orders for the Versed 5mg IV stat, IVF of 500cc of Lactated Ringers @ KVO and the order to discharge the patients.

Based on review of policies and job descriptions, and interviews, the facility's Emergency Department's initial "quick registration" process was performed by an untrained and unqualified staff member.

Findings include:

1. Staff #27 was observed sitting in front of a computer at the entrance of the first triage room on June 20, 1011 at 11:48 AM. During an interview with Staff #27 on June 20, 11 at 11:50 AM, she stated that once a patient arrives to the ED, she asks them for their name, address, if the patient is new to the facility and date of birth. This is considered a quick registration. Staff #27 also stated she asks the patient for their complaint or reason for visiting the ED. This information is entered into the computer which is then reviewed by the triage nurse.

2. Review of the job description entitled, "Patient Access Registration Representative" (Staff #27), states that the job responsibilities includes the following:
- "Gathers and records complete and accurate demographic and financial information to register all patient into the hospital information system, per established electronic billing requirements."
- "Ensures necessary consent forms are signed and properly maintained."
- "Educates the patient regarding copay/deductible responsibilities at or prior to the point of service, reviews Patient Bill of Rights, HIPAA, Advanced Directives, NYS Your Rights as a Hospital Patient and interprets department and Hospital policies and procedures."
- "Initiates the pre-administration/pre-registration process by interviewing patients and preparing the necessary documentation in advance of patient arrival."

There is no mention in the job description that the job responsibilities includes asking and documenting the patient's chief complaint.

3. Review of the hospital policy regarding Orientation and Training states that "Upon hire: Mini Orientation is processed
a. The employee is to review the mandatories and complete written test
b. Test is graded by manager then reviewed with employee."

Review of the personnel record for Staff #27 revealed that as of 6/20/11, Staff #27 did not complete the hospital's mandatory inservice training courses, which includes fire and safety, patients' rights, infection control, advanced directives, etc.

Based on facility document reviews and staff interviews, the hospital did not measure, analyze, and track quality indicators and other aspects of performance that assess processes of care, hospital services, and operations. This is evident in 1 patient care related department of the facility, Radiology.

Findings include:

On 6/23/11 and 6/24/11 the facility QAPI program data were reviewed with Staff #4 and 17, and it was stated that the responsibility of measuring, analyzing, and tracking quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital services, and operations, were assigned to the different Vice Presidents of the different Departments and Programs.
Staff #4 also stated on 6/23/11 at 3:30PM that since the responsibility was given to the Vice Presidents, she was not aware of departments who were not collecting and analyzing data. Staff #4 then submitted a list " titled B----& Kingston QAPI Department Reporting Schedule " . Staff # 4 also stated that the dashboards for the departments were in the computer and hard copies were not available for review. On 6/24/11 at 11AM, Staff #4 submitted for review the dashboards for the Departments and Programs.

It was revealed that since February/March 2010, the Radiology Department had stopped measuring, analyzing, and tracking quality indicators, including review of adverse patient events. Indicators for which the department had stopped collecting and analyzing data include, but are not limited to, the following:
1) Compliance with MRI screening tools; 2) Case review discrepancies for Nighthawk Radiologist; 3) Contrast related events # reactions; 4) Percent (%) of patients' cancelled; and 5) Patient satisfaction.
A review of the facility ' s " Quality and Performance Improvement Risk Management Plan 2010-2011 " states in the last sentence on page 3 under the topic Performance Improvement Objectives: " Ensure that necessary PI information is communicated effectively and in a timely manner to the Leadership, Medical Executive Committees, and the Governing body. " The facility failed to ensure that the Radiology Department was compliant with this objective.

2Based on medical record review and staff interviews, the facility did not ensure that drugs are administered in accordance with the orders of the practitioner responsible for the patient's care, and with accepted standards of practice. This is evident in 1 of 30 medical records reviewed, MR #20

Findings include:

The patient MR #20 was admitted on 6/18/2011 with the chief complaint of bilateral lower leg pain and swelling. According to the consult note of 6/18/11, the assessment plan by the physician included providing the patient with pain medication. According to the MAR, the patient was ordered to have pain relieving medications of Acetaminophen-Hydrocodone (Norco) 1 tablet orally Q6H PRN Pain and Morphine Sulfate 2mgs IV Q4H PRN Pain.

On 6/21/11 at 2:45PM witnessed by Staff # 5 and 6, the patient complained of severe pain and reported that she was not getting her pain medication as ordered. A review of the
patient's medical record revealed that the patient was medicated for pain at 0950 on 6/21/11 with the medication Acetaminophen-Hydrocodone (Norco) 1 tablet orally Q6H PRN, and was not given the Morphine Sulfate 2mgs IV Q4H PRN Pain.

Further review of the medical record revealed that a pain assessment had not been performed on the patient and there was no variance note to indicate that the patient was medicated for pain. During interview, Staff #11 stated that the nurse assigned to the patient had floated back to an affiliated facility before completing the assignment.

Therefore, the facility failed to ensure that the nurse medicated the patient as ordered, and that she documented the patient's level of pain as required on the facility form "Today's Comfort Goals", which was noted blank.