HospitalInspections.org

Based upon observation, record review (privileging files, policies and procedures, Medical Staff Bylaws, committee minutes) and interviews, the Condition of Participation for Governing Body is not met.

Findings include:
In reference to contracted company # 1, it was reported in the media that confidential medical , personnel, vendor and contractor records from this facility dating back 20 years were stolen from an unlocked and unattended van on 12/23/10 in New York City. It was reported in the media that the Health and Hospital Corporation (HHC) has begun notifying 1.7 million people affected by the theft.

Documents submitted by the facility on 5/2/11 indicated that during this period the facility was contracted with company #1 for transporting confidential health information.

The HIPPA Security Officer & Network Department Chief were interviewed on 5/4/11 who reported that on 12/23/10 a theft of confidential health information back up tapes occurred while a truck from company #1 was left unlocked and unattended in New York City. Company #1 was responsible for transporting confidential health information to a secured location in New Jersey. The staff interviewed reported that the contract with this company was terminated on 2/11/11.

The facility was unable to provide documents to indicate that company #1 was assessed and monitored for the services provided.

Based on interview with the hospital CEO on 5/5/11 at 11:00 AM, and review of the meeting minutes of New York City Health and Hospital Corporation (HHC) Board of Directors it was determined that North Central Bronx Hospital (NCBH) did not have a Governing Body that carries out the functions required under the Medicare Hospital Conditions of Participation (COP).

Findings include:
On interview with the CEO, on 5/5/11, it was noted that the HHC Board of Directors was "the Governing Body of the hospital" and that as of 5/26/11 there would be quarterly meetings with senior staff specific to NCBH. Upon reading the meeting minutes for March 2011 HHC Board of Directors meetings, it was noted that NCBH was not the focus of the meeting but other HHC facilities were. Based upon review of the meeting minutes, the business of the HHC was conducted, but not the business and Governing Body functions required under the Medicare Hospital COP NCBH.

Additionally, the facility's failure to have an effective governing body responsible for the conduct of the hospital as an institution by findings found at :
482.12 ( see findings at tag A 043, A 077, A 083 & A 084)
482.21 (see findings at tag A 264)
482.24 ( see findings at tag A 438, A 450, A 466 & A 467)

Based on interview conducted it was determined that the facility failed to have a plan prepared as required.

Findings include:

Based on interview of facility staff conducted on 5/6/11 at 12:45pm the facility failed to maintain financial committee meeting minutes to indicate regularly scheduled meetings and representatives in attendance.

Based on review of documents and staff interviewed it was determined that the governing body did not ensure that a contractor of services furnishes services that permit the hospital to comply with all applicable conditions of participation.

Findings include:

Based on review of documents and staff interviews on 5/4/11 it was determined that the facility ' s governing body did not provide adequate evaluation and monitoring of the contracted service responsible for the transportation and storage of back up tapes containing confidential health information for 1.75 million patients and staff. Specifically, on 12/23/10 a theft of confidential health information back up tapes occurred while a GRM truck was left unlocked and unattended in New York City. GRM was responsible for transporting confidential health information to a secured location in New Jersey. No documentation was provided as to how the contracted service was being monitored.

Based on document review and staff interviews, it was determined that the facility failed to monitor and evaluate the quality of its contracted services and therefore did not ensure that each non clinical-contracted service is provided in a safe and effective manner.

Findings include:

Review of documents and interviews with staff on 5/4/11, 5/5/11 and 5/6/11, it was determined that the hospital did not have a formal mechanism to evaluate the quality of each non-clinical contracted service provided. Specifically the facility failed to perform a documented quality evaluation for the following non-clinical contracts reviewed. There is no evidence that data was collected to assess the performance of 5 of 12 contracts reviewed. (Companies #1, #2, #3, #4 and #5)

There was no documented evidence of the specific criteria utilized by the facility to assess the individual performance of each of these contracted services.


The listing of all the hospital non-clinical contracts were reviewed on 5/6/11, the list contained 144 contracts, of these 66 were corporate issued by New York City Health and Hospital Corporation (HHC), 56 were North Central Bronx Hospital contracts and 22 were state contracts.

Interview with the Associate Director of Regulatory Affairs and Associate Executive Director Logistics and Support Service on 5/6/11, found that all of the facility's corporate contracts are monitored by the corporation (HHC). The Associate Executive Director Logistics & Support Services stated that the corporation (HHC) does evaluate the quality of service provided by each contracted services, however he was not able to provide documented evidence that this was done. There was no evidence that the hospital developed its own independent indicators to evaluate the service provided by theses contracted companies.


Review of the 2010 Quality Assurance Performance Improvement Minutes found no evidence of evaluation of the aforementioned contracts.

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 # 1 the patient presented to the Emergency Department on 2/20/11 for Shortness of Breath and Chest Pain. EKG was done. Two EKG's performed on 2/20/11 at 15:48:12 and 15:48:44, noted to have both patients' MR #1 and MR # 2 name, medical record number, and date of birth on the EKG sheets without indication of an error.




16790

Based on medical record review, tour of unit and staff interview, the facilty did not ensure that all patient have a accurate and complete medical record. This deficiency was noted in three of thirteen records reviewed ( #5, #4 & #8)

Findings include:
During tour of unit 9B (Medical/Surgery unit) it was noted that the patient in MR #5 was discharged on 5/2/11 but the patient left the unit prior to surveyor arrival on the unit. Therefore, the patient could not be interviewed.
Review of MR # 5 noted that this 69 year old patient with history of HTN, HL went to the ER on 4/24/11 with presenting symptoms of rash over his body and he was admitted. It was noted that a copy of the IM (Important Message from Medicare) form located in the record was not signed by the patient. It was noted that a notation on the form indicated that a copy will be sent to the patient's home. There was no documentation why this was not given to the patient prior to discharge. There was no documentation that the information listed on the form was discussed with the patient.
-It was noted that a copy of a completed Discharge notice given to all Non-Medicare Patient form dated 5/2/11 was located on the chart. However, the record indicated that the patient was insured by Medicare.
-The staff interviewed reported that Patients' Rights documents are given to patients in the Emergency Department (ED). This staff was unable to explain why Patients' Rights were not reinforced with the patients in the unit.

During the tour of unit - 10 B (Critical care unit) MR # 4 was reviewed. It was noted that it was documented that the patient was unable to sign acknowledging that he received a copy of the New York City Health and Hospital Corporation Private Notice. It was noted that the patient ' s personal representative signed this form. There was no documentation why the patient ' s personal representative was not given An Important Message From Medicare About Your Rights (IM) form. The patient signed the form on 5/2/11 on the day of the survey. However, there was no documented evidence that a copy of this form was given to the patient, as required.

Review of MR #8 ( a closed record) on 5/5/11 noted that a copy of the Discharge Notice form dated 3/16/11 did not include the patient ' s name , attending physician ' s name, medical record and the discharge date, as required.

Based on medical record review, tour of the unit and staff interviews, it was determined that the facility did not consistently ensure that all patients' medical records were legible and complete. This deficiency was noted in two of thirteen records reviewed ( #3, # 4)

Findings include:

During the unit tour of 12A ( Geriatric psych unit) on 5/2/11, MR # 3 was reviewed. It was noted that this patient, 65 year old male with past medical history of HTN, DM, Bipolar, went to the Emergency Department (ED) on 4/14/11 by ambulance. The patient was medically cleared in the Emergency Department (ED) for high glucose and he was involuntary admitted to the psych unit on 4/15/11. The Weekly Treatment Plan Review for Week #1 form dated 4/26/11 was reviewed. It was noted that the individual members of the team did not sign the follow-up treatment plan. In addition, the responsibility of each member of the team was not noted on this form
-It was noted that on 4/28/11 the patient was converted from involuntary to voluntary status. It was noted that on 4/28/11 the patient submitted a 72 -hours discharge notice and his status was converted to Involuntary Status on 4/29/11. It was noted that a Notice for application for court authorization to retain the patient form dated 4/29/11 was located in the record. - There was no documentation that there was a discussion with the patient regarding the reason why he could not be discharged as requested or documented why this was not necessary.
The medical staff interviewed stated that the patient was given a copy of his rights and informed about the court hearing and the patient knew why he could not be discharged. This staff acknowledged that the discussion with the patient regarding his request for discharge was not documented.
The staff interviewed reported that the patient was waiting for a court hearing for retention. According to this staff, the patient was still psychotic and not stable for discharge. There was no documentation in the medical record why since the patient ' s medical condition was not safe for discharge why he was allowed to sign the voluntary papers.

During the tour of unit 10 B (Critical care unit) noted that the patient in MR # 4 was on 1:1 observation. Upon review, it was noted that this patient a 72 year old male went to the ED on 4/30/11 after he took an over dose of multiple drugs and he was admitted. It was noted that the Management-Course/Procedures in ED section of the ED record was blank. It was noted that there was a section on the record for the provider ' s and the attending to print their names this was not completed. The attending signature was illegible.

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 ( #7, #8) .

Findings include:
Review of MR #7 noted that on 2/28/11 at 1433 a rapid HIV pre & post test was done. A copy of the consent for this test was not located in the medical record reviewed.

Review of MR #8 noted that a copy of Prenatal and Obstetrical Services form located in the record which was dated 3/16/11 at 12:20 was incomplete as it did not document the name of the doctor or certified midwife who was going to provided this service.

Based on record review, it was determined that the facilty did not consistently ensure that all necessary and required patient information was documented in the medical record. This deficiency was noted in two of seven applicable medical records reviewed (#6 & #7).

Findings include:

Review of MR # 6 on 5/3/11 at 3:45 PM noted that this 49 year old patient went to the ED (Emergency Department) on 2/9/11. The chief complaint was asthma attack. This patient was admitted on 2/9/11 and discharged on 2/10/11. Review of the Emergency Department Record noted that the patient was triaged on 2/9/2011 at 1534; category level 2. The triage nurse notation " Interventions: " albuterol / Atrovent nebulizer started " . The date and time that this intervention was initiated was not documented.
-The provider ' s Management-Course/Procedures in the ED section of the record was reviewed. The provider noted patient with severe shortness of breath initially given albuterol/Atrovent x 3. The physician ' s orders were reviewed. There was no evidence that that there was an order for Albuterol/Atrovent while the patient was in the ED.

- It was noted that on 2/9/2011 at 2025 there was a physician ' s order for Influenza A & B Ag, Rapid; the result for this culture was not located in the record.

Review of MR #7 on 5/5/11 at 9:45 AM noted that this 52 year old male with history of HTN and anemia went to the facility ' s ED on 2/28/11 with chief complaint of swollen left foot and pain. The patient was admitted to surgical services with diagnosis of cellulites. On 3/3/11 at 1456, the attending noted " patient has septic arthritis he also has elevated sugar with a slightly elevated creatinine & HgAlc of 6.7 will involve medicine to make recommendations for this elevated blood sugar " . Although there was a new MD order for Regular Insulin dated 03/04/11 at 1229, medical physician ' s evaluation/recommendation was not located in the record.

Based on documents reviewed, staff interview and unit tour, it was determined that the facility did not administer the Quality Assurance (QA) Program to assure that all problems concerning patient care and services were identified and properly monitored for its effectiveness.

Findings include:
During the tour of the medical record department on 5/3/11 at 1:50 PM , the Director of Health Information Management was interviewed. This staff member reported that all patients request for medical records or documents from their medical records that have to be mailed are completed by the contracted staff located in the department.
-A list of patients requesting copies of their medical records for the months of March 2011 and April 2011 were requested and these documents were reviewed. It was noted that requests for medical records/information were placed in three categories: continued care, attorney ' s request and patient ' s requests.

In reviewing patients' requests for the month of March 2011, it was noted that 54 patients requested copies of their medical records/documents. It was also noted that six of the patients who made requests on 3/21/2011 the status were listed as logged; the logged in date was 3/21/2011; the same as the request date. There was no further information noted. This document was printed on 5/3/2011, way over two months. Similar medical records/documents requested on 3/16/2011 (one request) , 3/22/2011 ( one request), 3/25/2011 ( one request) , 3/31/2011 ( one request).
One patient ' s request dated 3/8/2011 status indicated that the request was in progress. This was dated 3/8/2011. However, this list was printed 5/3/2011.
According to the facility ' s policy, the facility should respond to the patient ' s request within 10 days.

In reviewing the documents submitted on 5/3/11 at 3:00 PM, it was noted that the patients' names listed on the March 2011 list were not duplicated in the April 2011 list. This surveyor was unable to determine when the patients actually received the requested documents.

The Department of Medical Record submitted a document on 5/4/11 under (Protected Health Information) PHI and Information Technology (IT) reports from Apr-10 - Mar-11. This surveyor was informed that this was the QA for the correspondence. This document did not address the issues mentioned above.
In addition, this document did not differentiate between Patients requests, Attorney ' s request or Continued Care requests.

The facility ' s Hospital Wide QAPI minutes were requested.
The facility submitted minutes for Network Leadership Hospital Performance Improvement Committee minutes October 21, 2010, November 18, 2010, December 16, 2011, January 2011, February 17, 2011, March 17, 2011, & April 21, 2011. In addition, Breakthrough Executive Steering Performance Improvement Committee Minutes,
August 2010, October 5, 2010, October 26, 2010, November 23, 2010, February 16, 2011& March 22, 2011.
- The issues identified regarding patients' requests were not identified or discussed in these minutes.
- Although the media coverage incident of confidential records lost by the vendor on 12/23/10, this was not discussed until the facility ' s Network Leadership Hospital Performance Improvement Committee minutes in February 17, 2011. It was also noted that there was no further follow-up discussion in subsequent meetings.

In the Breakthrough Executive Steering Performance Improvement Committee dated February 16, 2011, it was discussed that " electronic medical record (EMR) is undergoing a conversion to a new version. There are many items that are monitored by this committee and there is concern as to the cue that has been created. These needs to be discussed with IT as to what items ranks highest and need attention sooner rather than later " .

- The Director of Health Information Management ( HIM )was interviewed on 5/3/11 for clarification. This staff suggested that the surveyor should discuss this information with IT (Information Technology).
-During an interview with Network Chief Information Technology and HIPPA Security Officer on 5/4/11, surveyors were informed that there was no Director of Information Technology located at North Central Bronx.
The minutes discussed in Breakthrough Executive Steering Performance Improvement Committee dated February 16, 2011, was discussed with the Network Chief Information Technologist .This staff had no knowledge of this information.
The surveyor was later informed by staff that this should have been addressed with the staff actually doing the work.

In addition, it was determined that the facility did not develop a Hospital Wide Quality Assurance Program to address all of the problems concerning patient care and services as the finding under 482.24 ( tags A 438, A 450, A 466 & A 467) were not identified .