HospitalInspections.org

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Based on observations, document review and staff interview during the Federal Recertification Survey, it was determined that the facility failed to meet the Condition of Participation for Infection Control. This was evident by the facility's failure to follow Infection Control Standards.

Findings:

The facility failed to ensure that the staff maintained standard Infection Control Practices while obtaining a patient's blood sugar levels.
(See Tag A 748)

The facility failed to ensure that the staff followed the facility's Policy and Procedure when performing glucose monitoring.
(See Tag A 748)

The facility failed to ensure that there was documentation of staff education and competency on the use of the glucometer.
(See Tag A 748)

The facility failed to ensure the development of a complete Policy and Procedure addressing the use of the glucometer.
(See Tag A 748)

The facility failed to ensure that each employee had an annual Mantoux Skin Test.
(See Tag A 749)

The facility failed to ensure that the facility staff followed Standard Infection Control Guidelines.
(See Tag A 749)
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Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure the patients' right to privacy including the patients' location in the hospital. This was evident in two (2) of two (2) units with telemetry monitors.

Findings:

During a tour on the 4 North Unit on 07/15/14 at approximately 10:00AM, the telemetry monitors were observed hanging on the walls of the main hallway with more than twenty (20) patients' full names (last and first names) in view of anyone on the Unit.

This observation was made in the presence of Staff #28.

During a tour of the MICU (Medical Intensive Care Unit) on 07/15/14 at approximately 1:50PM, the telemetry monitors were observed hanging on the wall behind the Nursing Station facing out into the main hallway with more than ten (10) patients' full names in view of anyone standing at the Nursing Station desk.

This observation was made in the presence of Staff #28.
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Based on record review and interview during the Federal Recertification Survey, it was determined that the facility failed to ensure that Orders for pre-surgical tests were authenticated by the Attending Physician in two (2) out of two (2) records reviewed (Patients #18 and #19).

Findings:

The Physician's Order Form for Patients #18 and #19 lacked a Physician's signature "to certify that I have ordered the above tests as indicated". The form also states in the section for the Physician's signature "must be signed by Attending Physician".

Staff #32 confirmed that the Physician's authentication for the pre-admission tests was needed to initiate the Orders.

An interview on 7/15/14 in the morning with Staff #33 revealed that the Orders were carried out by the Physician's Assistant without the signature of the Attending as required.

This information was reviewed with Staff #32 on 07/15/14 at 11:25AM.
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Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that all ceiling, door and wall finishes in the hospital building were maintained in good repair.

Findings:

(a) On 07/14/14 at 10:31AM, two (2) stained ceiling tiles were found in an On-Call Room on the 6th Floor of the Hoag Pavilion.

(b) On 07/15/14 at 3:42PM, two (2) stained ceiling tiles were found in an office on the 4th Floor of the Potter Pavilion.

Concurrent interviews were conducted with the facility's Vice President of Engineering & Facilities.

42 CFR 482.41(a)

10NYCRR, 405.24(a)(1)
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Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that accessible facilities were designed and maintained in accordance with Federal, State and Local Laws, Regulations and Guidelines.

Findings:

(a) On 07/15/14 at 10:38AM, a tactile room identification sign for a unisex accessible Toilet Room on a 1st Floor Main Building corridor (near the entrance to the Chapel) was found to have been improperly installed directly on the door to this room. Accessible signage is required to be installed on the wall adjacent to the latch side of the door.

(b) On 07/15/14 at 11:00AM, a tactile room identification sign for a unisex accessible Toilet Room on a 1st Floor Main Building Pediatric Emergency Department patient Toilet Room was found to have been improperly installed directly on the door to this room. Accessible signage is required to be installed on the wall adjacent to the latch side of the door.

Concurrent interviews were conducted with the facility's Vice President of Engineering & Facilities.

42 CFR 482.41(c)

10NYCRR, 711.2(c), Design standards for the disabled. The Americans with Disabilities Act of 1990 (ADA) extends comprehensive civil rights protection to persons with disabilities. Health care facilities must comply with the ADA and the Regulations which implement it. Title 28 of the Code of Federal Regulations, Public Health Parts 35, Non-Discrimination on the Basis of Disability in State and Local Government Services, and Part 36, Non-Discrimination on the Basis of Disability by Public Accommodations and in Commercial Facilities, including Appendix A, "Standard for Accessible Design", 2004 Edition. 28 CFR Part 36 ADA Standards for Accessible Design: 703.4.
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Based on observations and staff interview during the Federal Rectification Survey, the facility failed maintain an environment which was safe and sanitary. This was evident on several observations during the survey.

Findings:

On 07/14/14 at 11:05AM, an observation of the Dirty Utility Room in the Surgical Area found that there were ten (10) empty reusable sharps containers stored on a rack.

Interview with Staff #25 on 07/14/14 revealed that these empty sharps containers are stored in the Surgical Dirty Utility Room and are then transferred to the floor as needed.

Staff Members #6, #8 and #18 were also present during the tour and witnessed the sharps containers in the Surgical Dirty Utility Room.

During a tour of the Endoscopy Suites on 07/15/14 at 11:00AM, a Procedure Room, which had just been cleaned by the Hospitality Staff, was found to have tubing still connected to the CO2 (Carbon Dioxide) outlet and a flush bottle, which is used to cleanse the camera lens while scoping the patient, was still left in the room and not removed as required.

An interview was conducted with Staff #21 on 07/15/14 at 11:15AM who advised that they are responsible for cleaning the room post procedure. The staff member stated that they had completed cleaning the room and that they were aware that these items should have been removed from the room during the cleaning process.

The facility's Environmental Cleaning Policy dated 06/14 states that all items pertaining to the patient are removed from the room before the next patient is brought in. The "Post Procedure Cleaning" lists to remove all pieces of trash from floor before mopping and that prior to mopping the floor, the room should be inspected to ensure that all cleaning was completed.

The yellow environmental sign was in front of this Procedure Room on 07/15/14 at 11:00AM indicating that this room was just mopped.

During a tour of the SICU (Surgical Intensive Care Unit) on 07/16/14 at approximately 10:30AM, three (3) commodes were observed stacked in a hallway bathroom. The Surveyor asked Staff #29 "Are the commodes clean?" She replied "Yes". The staff member also stated that this bathroom is used by patients.

This observation was made in the presence of Staff #28.

A Unit tour on 07/16/14 at 11:05AM with Staff Members #11 and #15 revealed that bagged patients' belongings were stored on the floor in a Medication Room.

Staff #11 stated that the floor was mopped daily. Staff #15 stated that the patients' belongings should not be stored on the floor.
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On 07/16/14 at 3:20PM, the wrist blades on a hand wash sink in Exam Room 6 on the 4th Floor Pediatric Hematology Outpatient Unit located at the 120 Mineola Boulevard, Mineola, New York Institute for Care Multi-Specialty Care Extension Clinic were found to only be approximately two (2) inches long.

10NYCRR, 711.2(b)(7) Guidelines for Design and Construction of Health Care Facilities, 2010 Edition 3.1-7.2.2.8 (4) (a) (ii).

Concurrent interviews were conducted with the facility's Vice President of Engineering & Facilities.

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Based on documentation, interviews and observations during the Federal Recertification Survey, the facility failed to develop and implement Policies to ensure the use of the glucometer which follow the standards of Infection Control as evidenced by: (a) the staffs' failure to maintain standard Infection Control Practices while obtaining a patient's blood sugar levels in four (4) out of nine (9) observations (Patients #26, #52 and two {2} observations on Patient #3), (b) the staffs' failure to follow the facility's Policy and Procedure when performing glucose monitoring in six (6) out of eight (8) observations (Patients #26, #52, #53, #54 and two {2} observations on Patient #3), (c) the facility's failure to ensure that there was documentation of staff education and competency in the use of the glucometer in two (2) out of six (6) Personnel Records (Staff Members #1 and #13), and (d) the facility's failure to develop a complete Policy and Procedure addressing the use of the glucometer.

Findings:

(a) During an observation of a blood glucose monitoring on 07/14/14 at approximately 11:20AM, Staff #2 was observed performing a blood glucose on Patient #3. When Staff #2 needed to repeat the test for confirmation of a low blood sugar, the staff member entered the glucometer strip container without changing their soiled gloves.

During an observation of a blood glucose monitoring on 07/14/14 at approximately 11:20AM, Staff #2 after performing a blood glucose on Patient #3, was observed placing the used glucometer into the tote box without cleaning it. Staff #2 then removed the glucometer, wiped it with a Sani-Wipe, and before cleaning the inside the tote box, placed the cleaned glucometer in the tote box.

This was observed in the presence of Staff Members #22 and #27.

During a blood glucose monitoring observation on 07/15/14 at approximately 2:35PM, Staff #5 was observed answering their cell phone immediately after performing hand hygiene and donning gloves. Without removing their gloves, performing hand hygiene and donning gloves, the staff member proceeded to perform a finger stick on Patient #26.

On 07/15/14 at approximately 2:40PM, after performing a blood glucose, Staff #5 was observed placing the used glucometer and tote box onto Patient #26's bedside table and wheeling the bedside table into the hallway to perform documentation. Staff #5 then wheeled the tray table back into Patient #26's room.

On 07/15/14 at approximately 2:45PM, after performing a blood glucose, Staff #5 was observed placing the used glucometer into the docking station and the dirty tote box on the desk by the docking station without wiping the equipment with Sani-Wipes.

This was observed in the presence of Staff #23.

During an observation of a blood glucose monitoring on 07/15/15 at approximately 11:45AM, Staff #4 was observed proceeding to the next patient room without cleaning the glucometer and tote box that had been on Patient #52's bedside table.

Staff #24 interrupted Staff #4 and reminded Staff #4 "What are you supposed to do between patients?" Staff #4 wiped the glucometer and the inside of the tote box and proceeded to the next patient's room without cleaning the outside of the tote box.

Staff #4 was then reminded to clean the outside of the tote box by the Surveyor and Staff #24. At that time Staff #4 continued to the next patient's room, placed the uncleaned tote box on the counter and cleaned it.

This was observed in the presence of Staff #24.

(b) During a blood glucose monitoring observation on 07/14/14 at approximately 11:20AM, Staff #2 was observed cleaning the table surface with a Sani-Wipe and placing the glucometer equipment and documentation book on the table. Without removing their gloves, performing hand hygiene and donning gloves as per facility Policy, Staff #2 performed a finger stick on Patient #3

During a blood glucose monitoring observation on 07/14/14 at approximately 11:40AM, Staff #1 was observed cleaning the table surface with a Sani-Wipe and placing the glucometer equipment and documentation book on the table. Without removing their gloves, performing hand hygiene and donning gloves as per Policy, Staff #1 performed a finger stick on Patient #3.

Patient #53 was admitted to the facility on 07/01/14 with diagnoses that included Foot Cellulitis and Diabetes. A Physician's Order dated 07/01/14 at 6:12AM documented finger stick with Novolog Insulin correction subcutaneous three (3) times daily before meals.

During a blood glucose monitoring observation on 07/14/14 at 12:00PM, Staff #13 was observed obtaining a blood sample on test strip, then placing the glucometer on the clean tote box which was open while waiting for the patient's blood sugar reading. After the patient's blood sugar reading was displayed, the staff member placed the glucometer back in the tote box without cleaning it and closed the tote box. The staff member was overheard saying that they had to clean the glucometer while still in the patient's room.

After removing their gloves and performing hand hygiene, Staff #13 took the tote box, without cleaning it, out of the patient's room. The staff member proceeded to the Medication Room where they placed the tote box, without cleaning it, on the counter. The staff member removed the glucometer from the tote box and without cleaning it, placed the glucometer in the docking station.

Staff #13 stated that they should have cleaned the glucometer before placing it in the docking station.

Review of the Policy titled "Blood Glucose Monitoring: Roche Accu-Check Inform II Blood Glucose Monitoring System" dated 11/13, documents on Page 1 of 17 that the device should be cleaned and disinfected with the hospital approved germicidal disinfectant (PDI: Super Sani-Cloth Germicidal Disposable Wipe) after each use to prevent carry-over of blood and infectious agents.

On 07/14/14 at 12:00PM Staff #15 confirmed these findings.

During a blood glucose monitoring observation on 07/14/14 at approximately 2:35PM, Staff #5 did not clean the table surface with a Sani-Wipe before placing the glucometer equipment and documentation book on the table as per Policy. The staff member then performed a finger stick on Patient #26.

During a blood glucose monitoring observation on 07/15/14 at approximately 11:35AM, Staff #4 did not clean the table surface with a Sani-Wipe before placing the glucometer equipment and documentation book on the table as per Policy. The staff member then performed a finger stick on Patient #52.

Review of the facility Policy titled "Blood Glucose Monitoring: Roche Accu-Check Inform II Blood Glucose Monitoring System" dated 11/13, documented in Section C "Patient Test Procedure" #2 instructions to clean the surface designated for the equipment with Sani-Wipes, for staff to remove gloves and perform hand hygiene before placing the equipment on the surface, and then perform hand hygiene and don gloves again before proceeding to the patient to perform the finger stick.

During observation of a blood glucose monitoring on 07/15/15 at approximately 11:35AM, Staff #4 did not wash their hands prior to donning gloves to perform a blood glucose on Patient #52.

Review of the Policy titled "Blood Glucose Monitoring: Roche Accu-Check Inform II Blood Glucose Monitoring System" dated 11/13, revealed in Section C "Patient Test Procedure" #2 revealed staff instructions to perform hand hygiene and don gloves.

During a blood glucose monitoring observation on 07/15/14 at approximately 2:35PM, after being instructed by Staff #23 to wash their hands and change their gloves after answering their cell phone, Staff #5 was observed cleaning the glucometer with a Sani-Wipe. Without removing their gloves, performing hand hygiene and donning gloves, the staff member performed a finger stick on Patient #26.

During an interview with Staff #4 on 07/15/14 at approximately 11:20AM, the Surveyor asked "When are the insides of the tote boxes cleaned"? The staff member replied "Whenever they need it".

Review of the facility Policy titled "Blood Glucose Monitoring: Roche Accu-Check Inform II Blood Glucose Monitoring System" dated 11/13, revealed in Section J "Cleaning the ACCU-CHEK Inform II Meter/Base Unit/Accessory Tote" that the tote should be cleaned on the inside and out with Sani-Wipes daily when quality control tests are performed.

During the tour of the Emergency Department (ED) on 07/17/13 at 11:15AM, Staff #10 was observed performing documentation at a Work Station on Wheels (WOW) in the Ambulance Triage Area.

Patient #54 was observed arriving accompanied by Emergency Medical Personnel into the facility ED on 07/17/14 at 11:15AM with a chief complaint of Syncope and diagnoses that included Colon Cancer and Diabetes.

Staff #10 was observed performing a physical assessment of Patient #54, taking vital signs and then returning to the WOW to document the recording.

At 11:20AM Staff #10 was observed assessing Patient #54's blood glucose levels. Staff #10 did not wash his hands prior to donning gloves to perform the blood glucose on Patient #54.

The RN walked to the tote box which was open and laying on a mobile table and picked up the Roche Accu-Chek Inform II device (glucometer) while leaving the tote box behind on the table. The Registered Nurse (RN) removed the glucometer from the tote box and failed to clean the glucometer with a Sani-Wipe as per facility Policy. The RN placed the glucometer on the patient's stretcher alongside the patient's lower extremities and did not utilize a clean table surface to place the glucometer equipment on as per facility Policy. The RN was observed to puncture the patient's finger with a lancet and obtain the patient's blood. The RN entered the glucometer strip container without changing their gloves.

The RN attached a test strip to the glucometer device and applied the patient's blood to the strip. After the patient's blood sugar reading was displayed, the RN placed the glucometer back in the tote box without cleaning the used glucometer or the tote box as per facility Policy.

The RN then removed their gloves and performed hand washing (for the first time since the observation began at 11:15AM) and resumed documentation at the WOW at 11:25AM.

This was observed in the presence of Staff #30 who stated "Yes, I saw that too and I will speak with this Nurse about what was done wrong".

(c) Review of Staff Member #1's and #13's Personnel Education and Training Records for staff who perform blood glucose monitoring lacked evidence of the Roche ACCU-CHEK Inform II Blood Glucose Monitoring System education and competencies.

During an interview with Staff #25 on 07/15/14 at 3:15PM, the staff member stated in 11/13 a new glucometer, the Roche Accu-Chek Inform II Blood Glucose Monitoring System, was implemented house-wide. The staff received education and had documented competencies for the new equipment. Staff #25 agreed that Staff Members #1's and #13's Personnel Files lacked documented evidence that they received education and had documented competencies for the new equipment.

Review of the Competency Based Performance Form for the "Roche ACCU-CHEK Inform II Blood Glucose Monitoring System" revealed the Competency Form failed to include having the staff demonstrate the proper cleaning procedure for the following:

(1) Cleaning the surface of the tote box

(2) Cleaning the inside and outside of the tote box and

(3) Cleaning the inside and outside of the ACCU-CHEK Inform II Base Unit.

On 07/15/14 at 2:10PM Staff #25 confirmed the above finding.

(d) Review of the Policy titled "Blood Glucose Monitoring: Roche ACCU-CHEK Inform II Blood Glucose Monitoring System" dated 11/13, documented after performing the blood glucose monitoring, the staff will remove gloves, perform hand hygiene, and exit the patient's room with the equipment (monitor and tote box). The Policy does not include the location where the monitor and tote box should be cleaned and the procedural steps.

For Isolation patients the Policy incorrectly documents to clean the monitor and tote box outside the patient's room. The Policy does not include the location where the monitor and tote should be cleaned and the procedural steps.

An interview with Staff Members #25 and #19 on 07/15/14 at 2:30PM revealed the staff are expected to clean the equipment outside the patients' rooms. There are wipes outside each patient's room in the hallway. Staff #19 stated "the ideal way to clean the equipment is in the patient's room, then exit. But not all patient rooms have wipes in them." Staff Members #25 and #19 acknowledged that it is physically impossible to carry the monitor and tote box outside the patient's room, obtain a wipe and clean the equipment in the hallway. Staff #19 stated "The Policy needs to be looked at".
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28670

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Based on observations, interviews, review of Personnel Files and other documents during the Federal Recertification Survey, it was determined that the facility failed to systemically control infections and communicable diseases by failing to ensure that: (a) each employee has an annual Mantoux Skin Test and an annual comprehensive Tuberculosis Screening Questionnaire, these findings were evident in six (6) of eleven (11) Employee Health Files (Employees #6, #7, #8, #16, #17 and #33), and (b) the facility staff followed Standard Infection Control Guidelines. This was evident in various observations made during the survey.

Findings:

(a) The Personnel File for Staff #6 lacked documentation of PPD (Purified Protein Derivative) placement in 2013. The Annual Health Assessment documents a PPD was last placed on 08/21/12.

The Personnel File for Staff #7, which was reviewed on 07/15/14 in the afternoon, lacked documentation that a PPD was placed in 2012, 2013 or 2014. The Annual Health Assessment documents a PPD was last placed and read on 11/01/11.

The Personnel File for Staff #8 lacked documentation of PPD placement in 2013. The Annual Health Assessment documented a PPD was last placed on 08/21/12

Similar findings were found in the Personnel Files for Staff Members #16, #17 and #33.

Review of the Employee Orientation Program Policy titled "Employee Health Guidelines", which was reviewed on 07/15/14 in the afternoon, documented that an Annual Health Assessment should be obtained from all employees and an annual Tuberculosis Skin Test is required for all personnel that have a negative PPD response.

Review of the Employee Health Policy titled "Tuberculosis Screening" last revised 04/13, documented that all employees must be offered Tuberculin testing at the time of pre-placement examination, all health care workers with a negative reading will have a second PPD placed approximately one (1) to two (2) weeks after the first to establish a valid baseline. The Policy further notes that all personnel will have an annual Health Assessment and an annual Tuberculosis Skin Test should be given to all personnel.

On 07/15/14 at 2:30PM during interview, Staff #31 stated "I agree these are out of compliance".



28670

(b) During a medication administration observation on 07/14/14 at approximately 11:30AM, Staff #1 did not wash their hands prior to donning gloves to administer medication to Patient #3.

This was observed in the presence of Staff Members #22 and #27.

Review of the facility Policy titled "Medication Administration" dated 06/14 lacks instructions to perform hand hygiene prior to the administration of medications.

On 07/14/14 at 11:30AM during a medication administration observation, Staff #14 was observed using the hand sanitizer dispenser which broke apart and onto the floor. Staff #14 retrieved the broken piece of equipment from the floor and placed it on top of the medication cart. Without performing hand hygiene and cleaning the medication cart, the staff member continued to dispense medication.

Staff #14 acknowledged they placed the broken piece of equipment from the floor on top of the medication cart. Staff #15 confirmed this finding.

During a medication administration observation on 07/15/14 at approximately 10:50AM, Staff #3 performed hand hygiene and without donning gloves as per Policy accessed Patient #14's Peripherally Inserted Central Catheter.

Review of the facility Policy titled "Accessing a Central Venous Catheter" dated 04/14, instructed in Procedure Step #2 to "Don Gloves" prior to patient central line access.

Patient #23 is a 55-year-old male who was admitted to the facility on 07/11/14 for Chest Pain. The patient ' s medical history also included Acute Urinary Retention.

A Physician ' s Order dated 07/15/14 at 10:13PM documented Foley catheter to bedside drainage for Acute Urinary Retention.

Observation of Patient #23 was conducted on 07/15/14 at approximately 2:00PM. The patient was observed in bed, no distress noted. Patient #23's Foley catheter was observed positioned on bed but the bottom end of the Foley bag was resting on the floor.

Review of the Policy titled "Indwelling Urinary Catheter and Drainage Bags: Care, Maintenance and Removal" dated 06/14, documented in the General Information Section the "collecting bag must not touch the floor".

On 07/11/14 at 2:20PM Staff #15 confirmed these findings.

This observation was made in the presence of Staff #28.



33919

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Based on staff interviews and review of Medical Records during the Federal Recertification Survey, it was determined that the facility failed to provide timely nutritional assessment to ensure that patients' nutritional needs were met. This finding was noted in five (5) of seven (7) records reviewed (Patients #20, #22, #28, #29 and #54).

Findings:

Review of the Medical Record for Patient #29 on 07/15/14 noted that this 70-year-old patient with past medical history of Hypertension, End Stage Renal Disease (ESRD) on Hemodialysis, Diabetes and Coronary Artery Disease (CAD). The patient was admitted to the facility on 07/9/14 with the diagnosis of Pancreatitis.

The Admission Assessment and Initial Screening Record done on 07/9/14 failed to identify any nutritional triggers and no nutritional referral was made.

The patient was determined to be at high nutritional risk six (6) days after admission and a Limited Nutrition Assessment was performed on 07/13/14.

A Comprehensive Assessment was done six (6) days after admission by a Registered Dietitian.

Review of the Medical Record for Patient #20 on 07/15/14 noted that this 72-year-old patient had a past medical history of Insulin Dependent Diabetes (IDDM), Hypertension, Chronic Renal Insufficiency (CRI) s/p multiple amputations and Coronary Artery Disease (CAD). The patient was admitted to the facility on 07/4/14 with the diagnosis of Cellulitis of the Leg.

The Admission Assessment and Initial Screening Record done on 07/4/14 failed to identify any nutritional triggers and no nutritional referral was made.

The patient was determined to be at high nutritional risk three (3) days after admission and a Limited Nutrition Assessment of her was performed on 07/07/14.

A Comprehensive Assessment was done six (6) days after admission by a Registered Dietitian.

Similar findings of delayed Nutritional Assessments were noted for Patients #22, #28 and #54.

The facility's policy titled "Assessment Referrals" stated that all patients shall receive an Initial Nutrition Screening by Nursing within twenty-four (24) hours of admission by Nursing Staff, utilizing pre-established criteria on the Admission Assessment and Initial Screening Record. It states that if a patient receives a total score greater than one (1) upon this initial screening, a referral will be entered online via computer by the Nurse, Clerical Support or Patient Care Assistant (PCA). Upon receiving this referral from Nursing the Dietitian / Diet Technician will follow-up with a Nutrition Assessment.

These findings were confirmed with Staff #26.
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