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Based on observations, staff interviews, and review of procedures it was determined the facility did not comply with requirements for the protection and promotion of patients' rights as required.


Findings Include:


The facility failed to meet the Condition of Participation for Patient Rights due to non-compliance with requirement as follows:


The facility failed to implement an effective surveillance system for the protection of infants and young children on pediatric units in order to minimize the potential risk for harm or abduction. In addition, ineffective monitoring of exit and access (from unlocked Endoscopy suite) to the pediatric unit within the facility was identified.


Cross refer to specific citations noted under Patient Rights, 482.13 (c) (2), TAG # A 144.

Based on review of records, observation and interview it was determined that the hospital failed to meet its responsibilities to provide food and dietetic services to patients in a safe and therapeutic manner. The following are repeat citations from the previous survey of 11/8/13.

Repeat Findings include:

The following observations were noted during a tour of the kitchen conducted on 11/3/14 at approximately 11:00 AM

1- The hospital failed to maintain required temperatures of foods. (Cross reference to A 620)
2- The hospital failed to sanitize pots and pans in an appropriate manner. (Cross reference to A 620)
3- The hospital failed to maintain a sanitary environment in an area where clean items were being stored. (See Cross reference A 620)
4- The hospital failed to maintain equipment that was not in use in a sanitary manner. (Cross reference to A 620)
5- The hospital failed to label foods, which creates a need for staff to open the food items more often than necessary (e.g. to identify), which can promote food contamination. (Cross reference to A 620)
6- A food service employee was observed cleaning the table counter with a pink rag. This employee proceeded to clean the food slicer with the same pink rag. The Food Service Director was informed of the observation. During the observation the Clinical Nutrition Manager stopped the employee from further cleaning of the slicer with the same rag. (This is not a repeat citation, but an improper practice and a potential contamination danger.)

Based on observations, staff interviews, review of policies and procedures, infection control, and quality assurance documentation, it was determined that the facility failed to provide a sanitary environment to minimize the possibility of contamination and transfer of infection.


Findings include:


Pervasive Infection Control violations were noted in the hospital. Specific reference is made to the failure of the Infection Control Officer to monitor all areas of the hospital including hand washing, food storage, handling and preparation of food, housekeeping and maintenance, and maintenance of the facility's ventilation system in providing appropriate air flows in critical care/non-patient areas.


Furthermore, the issue of improper ventilation in terms of the incorrect air flow in the facility is a REPEAT DEFICIENCY from the Federal Survey of 11/08/13.


Cross-refer to findings noted under Tags A 620 and A 749.

Based on observation, staff interviews, and review of procedures it was determined the facility facility failed to have an effective surveillance system in place for protection of infants and children in the pediatric unit.

Findings include:


1. During the tour of the Pediatric Unit on the 4th Floor on 11/05/14 at 11:05 AM, it was revealed that the facility used an electronic tag system manufactured by "McRoberts (Ex-Prosec)" to augment safety and tracking of pediatric patients on the 4th Floor.


This system operates by connecting an electronic transponder tag to a plastic band, and this device is then attached around the ankle/wrist of the pediatric patient. This device is linked electronically to a computer tracking system which locks the door of the unit and stairwell D when the device worn by an infant/child approaches the proximity of the exit or stairwell doors of the unit. The device also elicits a visual and audible electronic alarm if the exit door or stairwell is kept ajar when an infant/child wearing the device approaches within the proximity of these areas.
In addition, when an infant/child wearing the attached transponder tag is present in the pediatric floor elevator cab, the elevator will fail to operate unless an employee enters a security code on a keypad present inside all the elevator cabs.


The Vice President of the Support Services (VPSS), Director of Security (DS), and the nursing staff were interviewed on 11/5/14 at 11:05 AM regarding the effect on the security system when a device band is cut.


The VPSS, DS, and the nursing staff stated that if the transponder tag is cut or becomes loose and falls off the child's wrist/ankle, the system will not trigger any alarm, notification, or result in locking of doors from the unit.


During the tour of the Pediatric Unit on 11/05/14 it was observed that employees must swipe an identification card at the entrance doors to gain access to the unit, but that no identification card is needed to exit through these portals. Therefore, the main egress door exits were unrestricted and it was also noted at this time that exits were not continuously monitored by camera and/or staff.


At this time, it was concluded a potential risk existed for child/infant abduction because if the security band is removed or cut, the security system would not alert staff of a possible abduction from tampering or removal of the device. In addition to the failure to alarm upon potential removal of the device, it was also observed that unrestricted egress from the unlocked unit doors and the lack of consistent monitoring of the cameras or activity at entrances/egress points by staff represented a continuing high risk for elopement.


During interviews with the Nurse Manager and nurses present on the floor on 11/05/14 they stated cameras are present in all 7 rooms in the unit. The cameras are displayed on a monitor near the nurse's station. There are usually 2 nurses present in the unit during each shift. The cameras in room #29 and #41 were found to be not working. It was noted that room #29 is the first room located upon entry from the doors at the main entrance, but it is not in direct visual field of the nurse's station.


Inspection of the electronic infant protection system on 11/05/14 found it did not properly operate in 1 of 3 instances during system testing conducted on the pediatric unit between 11:15 AM to 12:00 PM.


The Director of Security requested the pediatric nurse to activate a tag/transponder so that it may be tested for the effectiveness of the system. Tag #F17557 was activated for the test and tied around the wrist of the Director of Security.


When this tag was brought in close proximity to the exit door from the unit and Stairwell D, both doors failed to lock instantaneously. Both doors remained unlocked and could be opened when the Director of Security stood at the doors with the activated tag. A delay of at least 10 seconds was observed until the door locked when tag #F17557 was tested. The Director of Security did not specify a minimum time lapse for the door lock to engage when a transponder comes into the vicinity/field of the doors. However, he acknowledged that the doors should have locked immediately when the transponder #F17557 came within the direct vicinity of the doors.


2. On 11/05/14 at 2:30 PM, another tour of the 4th floor Pediatric Unit was conducted.

At that time it was noted that there are other doors from the pediatric unit leading to the Ambulatory Center/Endoscopy suite and Labor & Delivery unit. The doors required swiping of an employee card. The nursing staff stated that the doors are closed/locked and can only be accessed by an employee. During the observation the doors were tested and locked. They were opened utilizing an employee swipe card.

During the follow-up tour of 11/6/14 at 4:40 PM, it was also brought to the surveyors attention that although the door to the ASC/Endoscopy unit is restricted leading from the Pediatric unit, this door is unlocked and "unrestricted" when entering from the ASC/Endoscopy unit into the pediatric unit. Therefore, anyone could enter the pediatric unit through this ASC/Endoscopy unit door without swiping an employee card and can potentially leave with a child without a band via the main exit of the pediatric unit without causing any alarm, notification, or staff alert that an infant/child has been abducted.

The ASC/Endoscopy unit is open from approximately 6:00 AM to 7:00 PM and the entrance to the ASC/Endoscopy unit is unrestricted.

On 11/05/14 at 2:30 PM at the nurse's station only one nurse was observed working on a patient chart. At interview, this nurse acknowledged that the nurses do not continuously monitor the cameras in the patient rooms.


On 11/6/14 at 10:45 AM, the Vice President of Support Services (VPSS) and Director of Security (DS) stated that the camera in room #29 had been fixed. The VPSS and DS stated the facility is looking into the possibility of securing the unit by either upgrading the infant/child security system to include the skin contact feature or have the pediatric unit have a secured exit by locking the unit.


The facility provided a policy and procedure titled "Infant and Child Security Policy #AD-01-51-Effective date 01/13", however this policy did not describe in detail or include a policy and procedure to be followed for preventive maintenance of the infant protection system and all its components, including the device tags/transponders.


On 11/6/14 at 10:45 AM , the Director of Security (DS) provided the surveyor with a service ticket for the preventive maintenance of the system dated 04/14/14. The DS was requested to provide previous preventive maintenance on the system. The DS stated at that time that there were no other reports available. It was noted that this report did not include any preventive maintenance of the tags/transponders.


As a result of the above findings, an IMMEDIATE JEOPARDY was declared on 11/06/14 at approximately 2:45 PM. The hospital, in their response to this situation, stated that they had decided to assign a security officer 24 hours, 7 days each week in the pediatric unit (this monitoring was started from 11:00AM on 11/6/14). The assigned officers are responsible for monitoring the main exit from the unit, the entrance/exit from the Ambulatory Surgery/Endoscopy Unit, stairwell D, and entrance/exit to the Labor and Delivery unit.


3. On 11/6/14 at 4:40 PM, a follow-up tour of the Pediatric Floor was conducted to observe the presence of the security staff on the unit. A security staff was on duty at the newly established post. The Security guard's position did allow for visualization of all fields and points of entry and egress.

In reviewing the computer monitor for all the cameras in the 7 rooms, it was noted that room #29's camera was repaired, however, the camera for room #41 was not repaired.

During interview with the Nurse Manager, she stated that the unit did not utilize the camera in room #41 since adults are placed in that room. At that time she reported to the surveyor that a 46 year old patient was admitted to room # 41 on the pediatric unit from the Ambulatory Surgery Center. It was revealed that adult patients are at times housed on the pediatric unit in a room adjacent to where infants and children are housed.

The immediacy of this immediate jeopardy situation was abated at 5:00 PM on November 6, 2014 when the hospital provided, in writing, an interim corrective action plan, and policies to ensure the safety of the patients on the unit. The interim measures accepted by the Department of Health to abate the immediate jeopardy situation on 11/6/2014 included: (1) Round the clock posting of security officers in the infant and pediatric inpatient area; (2) New procedures for monitoring of entrance; and (3) Training for nursing and security staff in new monitoring procedures that require increased awareness of unit activity. The implementation of these interventions was evidenced by review of the schedule for assignment of round the clock hospital security staff and direct observation that a security officer was stationed at the pediatric unit entrance/exit on 11/6/2014 at 4:40 p.m. Additionally, the training for nursing staff in the new procedures for increased monitoring of activity on infant and pediatric units was verified on 11/6/2014.

On November 7, 2014 at 5:00 PM the administrative staff provided follow-up documentation of interim short term measures to correct the immediate jeopardy situation, as well as a proposed long-term plan to improve the electronic infant and pediatric security system.


Short term measures that were verified included 24 hour round the clock direct visual monitoring by security staff of the all pediatric entrance and corridors leading from the pediatric unit.


The long term measures proposed to correct the situation includes: (1) A plan to upgrade the current infant abduction system to the skin sensitive type within three months; (2) A plan to upgrade the current infant abduction system to include an alarm if the tag / transponder is removed from the patient; (3) validation that the system when activated will lock down all exit doors and elevators on or near the unit; and (4) the feasibility of locking all egress points from the pediatric unit from both sides.


The additional actions taken by the hospital on 11/07/14 (by providing the schedule of the Security officers and ensuring 24/7 coverage along with the proposals from the vendors for upgrading the infant protection system or locking the pediatric unit), resulted in the abatement of the immediate jeopardy condition at 5:00 PM on November 7, 2014.


These findings were verified with the Vice President of Support Services, Director of Engineering and Director of Security at the time of the observations.

Based on tour and staff interview, it was determined the hospital failed to ensure that medical records are properly stored in a secure location.

Findings include:

A tour of the outpatient Rehabilitation Center located at 700 White Plains Road was conducted on 11/6/14 at approximately 9:45 AM. The Vice President of Patient Services and the Director of the Rehabilitation Center were present during the tour. At interview with the Director of Rehab on 11/5/14 at approximately 10:00AM stated that current medical records within two years are stored in 5 desk drawers. These desks drawers were observed unlocked and not secured from unauthorized access at all times.

Based on observation and staff interview the Food Service Director did not ensure that the daily operation of the Food Service Department is maintained in a sanitary manner.

Findings include:

A tour of the hospital's kitchen was conducted on 11/3/14 at approximately 11:00 AM. The surveyor was accompanied by the Food Service Director and Clinical Nutrition Manager. The Food and Nutrition Department is managed by a contractor. Examples of issues observed, during the tour included, but are not limited to, the following:

A. Unsanitary Environment/ Food Safety

1-The temperature of the food warmer was observed to be 120 degree Fahrenheit. On opening the food warmer it was found packed with racks of aluminum pans containing food. The surveyor asked the Food Service Director how long was the food in this warmer. The Food Service Director did not know when the food was placed in the food warmer. The temperature of this food warmer was in the danger zone (40-140 degree Fahrenheit). A review of the kitchen "hot holding warmer temperature log" revealed that the temperature of the warmer should be between 140 and 185 degree Fahrenheit. Based on this criteria, the food was being held in a warmer that did not meet the standard for food safety. The internal temperature of the hot food in the aluminum pan was not monitored by the kitchen staff nor did the Food Service Director provide a directive to the staff for this procedure to be done.

2- Some containers in the kitchen refrigerator and freezer were labeled with a date of when they were packaged, and some were not labeled. The labeled containers did not contain the name of the food that was stored nor did the labels contain the expiration dates of the food. Some examples of the foods that were stored are grilled chicken, grilled vegetables, etc. The Food Service Director informed the surveyor that he would let the staff know that the labeling was not being done properly.

3- The window screen behind the pot washing area was covered with black dust. The window sill had multiple items: a dusty radio, 4 strainers, 2 food racks and a soup pot. This window sill was dusty and grimy. The window screen and window sill is directly behind the counter where clean equipment are placed in the pot washing area.

4- The metal counter in the pot washing area, below the window, had a large stack of clear food container lids stacked one on top of the other. The metal counter where the lids were located was dusty and had dried water stains.

5- Approximately 50 sheet pans were observed on a rack next to the pot washing area. The rack is located in an area of high foot traffic, as employees were observed walking back and forth to the opposite side of the kitchen. The racks of sheet pans were inspected and multiple sheet pans were wet. Wet pans promote rust and creates an unsanitary environment for cooking.

6-Food racks in the freezer and refrigerators were dirty. There were dried food stains throughout the racks where food was placed.

7-Paper and plastic wrapping were observed on the floor in the freezer. The Director of Food Service informed the surveyor that the freezer would be swept by the end of the day. The amount of debris observed in the freezer created a potentially hazardous environment for staff entering and exiting the freezer.

8-The microwave was dirty. Dried food was stuck to the roof, floor and the side of the microwave.

9- The floor model Hobart mixer had dried food attached to the area where the whisk would be connected. This mixer was not cleaned which could create a food safety hazard.

10- The hot food preparation table contained 3 drawers. One drawer was observed to have approximately one inch of water which was yellow in color. The drawer also contained an oven mitt, miscellaneous kitchen utensils and a saran wrapped package. The second drawer contained miscellaneous kitchen utensils and water. The third drawer was dirty with stains and food debris. The Food Service Director informed the surveyor he does not know how the water got into the drawers.

11- The walk-in refrigerator's light bulb in the vegetable box was not working and the fan motor was very dirty.

12- The milk box and the dessert refrigerator had no thermometer.

Based on observations, staff interviews and document reviews, it was determined the infection control officer was not effective in her role to ensure that patients receive care in a sanitary and clean environment to prevent and minimize the risks of infections and cross contamination.

Findings include:

1. The facility failed to ensure that all members of its staff followed proper infection control techniques. This was noted in operating room #1 (OR) on November 4, 2014. The circulating nurse in OR #1 was observed on November 4, 2014 at 11:30 AM when she was conducting her duties in this capacity. She was noted to be cleaning the operative site (the patient's hand) with a gloved hand. When she completed this procedure, she discarded the glove and cleaning products, and without sanitizing her hands proceeded to open and discard the outer portions of clean and sterile packages. She then assisted with covering the patient after which she moved 2 stools closer to the operating table with her bare hands.

Without sanitizing her hands she participated in the patient's timeout and she again moved one of the stools with her bare hands. She then opened a sterile towel near the sterile field, discarded more packaging in a garbage container which she opened with her bare hands. Still without sanitizing her bare hands she documented in the patient's medical record, lifted the garbage container again with her bare hands to discard garbage (covering of packages), before she sanitized her hands.

The facility's policy titled "Hand washing and Hand Antisepsis in Healthcare Settings", which was last reviewed in April 2014, states "Decontaminate hands after removing gloves." The policy also states staff should decontaminate hands after "contact with inanimate objects that are likely to be contaminated, if hands are not visible soiled." The circulating nurse did not follow this policy on multiple occasions during the observations noted above.

These findings were discussed with the Nurse Manager of the operating suite when the findings were observed.




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2 (a). During the tour of the facility from 11/03/14 to 11/05/14 between 10:30 AM and 4:00 PM, following areas were observed exhibiting wrong air flow/pressure:

i. The Clean Utility room across from room #542 on the 5th floor exhibited negative air pressure instead of the required positive air pressure.

ii. The Clean Utility room across from room #540 on the 5th floor exhibited neutral air pressure instead of the required positive air pressure.

iii. The sub-sterile room of Cysto 4/Room #2 in the Surgical suite exhibited neutral air pressure instead of the required positive air pressure.

iv. The sterile supply room across from room # 214 in the Surgical suite exhibited negative air pressure instead of the required positive air pressure.

v. The Microbiology Lab in the 2nd floor exhibited positive air pressure instead of the required negative air pressure.

vi. The Soiled Utility room in the Critical Care Unit on the 3rd floor exhibited positive air pressure instead of the required negative air pressure.

vii. The Medication room in the Critical Care Unit on the 3rd floor exhibited negative air pressure instead of the required positive air pressure.

viii. The Janitor Closet of the Oncology Unit on 4th floor exhibited positive air pressure instead of the required negative air pressure.

ix. The Biohazard room on the 2nd floor exhibited positive air pressure instead of the required negative air pressure.

x. The Clean Linen room/ Laundry in the basement exhibited strong negative air pressure instead of the required positive air pressure.

xi. In the morning of 11/04/14 at about 11:00 AM, it was observed that the Decontamination room/Sterile Processing area was positive to the Clean Central Sterile Supplying/processing area. Therefore the air from the dirty area was flowing into the clean sterile area.

THE ISSUE OF "WRONG AIR PRESSURE / FLOWS" (and in particular the Central Sterile Processing area along with clean utility room across from room #542) IS A REPEAT DEFICIENCY FROM THE FEDERAL SURVEY OF 11/08/13.

During the observation of wrong air flow/pressures in the above 11 examples from 11/03/14 to 11/05/14 between 10:30 AM and 4:00 PM, Director of Engineering (DOE) did not explain or provide reason for the rooms not being in compliance.


The DOE stated that the facility has hired an outside vendor who is responsible for doing a bi-annual air-balancing test, however, the DOE acknowledged that there was no mechanism in place to ensure that once the air-balancing is done that the facility would perform any kind of preventive maintenance or continuous follow-up to ensure that the rooms are providing the correct air-pressure.

(b) During the observation of the Triage room in the Emergency Department on 11/04/14 at 12:00 PM, it was observed that the triage room does not have negative air pressure, which is needed to ensure that the patients and staff are safe from a possible air-borne infection.

American Institute of Architects (AIA) 1996-97 section 7.9.D3 states that:"The triage area requires special consideration. As the point of entry and assessment for patients with undiagnosed diseases.

Above findings were verified with Vice President of Support Services, Director of Engineering and Director of Infection Control during the times of observations.


3. During the tour of the Central Clean Sterile Processing room on 11/04/14 at 11:00 AM, the document review for sterilization records revealed that the facility is not performing the 48 hour Biological Indicator test.

The Director of Sterilization Services stated that the facility is utilizing "3 M Attest (Trademark) 1292 Rapid Readout Biological Indicators" and thus are not required to perform 48 hour Biological Indicator test.

Centers for Disease Control in their "Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008" states that:
"A rapid-readout biological indicator detects the presence of enzymes of G. stearothermophilus by reading a fluorescent product produced by the enzymatic breakdown of a nonfluorescent substrate.
The rapid-readout biological indicator is a dual indicator system as it also detects acid metabolites produced during growth of the G. stearothermophilus spores. This system is different from the indicator system consisting of an enzyme system of bacterial origin without spores."
As per the manufacturer, 'in the use of rapid-readout biological indicators (3M Attest 1292) the studies and data collected indicates that most growth visual positives were detected by fluorescence within 3 hours of incubation and by the visual pH color within 48 hours of incubation.

Therefore, by not having a 48 hour reading for pH (which is acid metabolites) the Biological Indicator results are not comprehensive.
The manufacture recommends to incubate the positive control and sterilized Attest (Trademark) 1292 Rapid Readout Biological Indicators for 3 hours. The final fluorescent negative biological indicator reading is to be made at 3 hours.
Furthermore, the processed biological indicator and the positive control may also be further incubated at 60°C for a visual pH color change. The biological indicators are examined for early detection of positive results (media turns yellow) at convenient time intervals such as 12, 18 and 24 hours. The final negative reading (media remains purple) for a visual pH color change is made at 48 hours. The positive control should show a yellow color change of the growth media within 48 hours.
The appearance of a yellow color in the processed indicator demonstrates bacterial growth and a sterilization process failure. No color change (i.e. media remains purple) indicates an adequate sterilization process. A final negative result is made after 48 hours of incubation. The positive control indicator should show a color change from purple to yellow for the processed indicator results to be valid.

Above findings were verified with Director of Sterilization Services and Director of Infection Control.


4. On 11/07/14 at 12:00 PM, the Director of Engineering (DOE) was interviewed regarding how the humidity and temperature in the Operating Rooms are maintained. The DOE stated that the humidity and temperature is monitored through a computerized system and if the value falls from the national standard and facility policy range of 68 *F to 73*F, then an alarm condition is indicated on the computer. Also in the operating rooms there are wall mounted monitors that the surgical staff looks at and informs engineering if something is read as out of range.

A record for the month of October 2014 was requested to verify the value of temperature and humidity maintained in the surgical suite.

During review of the documents on 11/07/14 at 2:00 PM it was noted that for OR #1 from 7:00 AM on 10/12/14 to 9:00 AM on 10/13/14 the temperature range was between 63*F to 67*F.

There was no documentation, reasoning or corrective action for the temperature being out of range for that particular full day.

Findings were verified Director of Engineering during the time of observation.

5(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 11/04/14 at 12:00 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 room exit sliding door.

Similar issue was noted in other air-borne isolation rooms present in the facility such as on the Med/Surge and other nursing units where air-borne isolations rooms are present.

(b). On 11/03/14 at 3:00 PM during the tour of the Post Operating Recovery area in the 2nd floor, it was observed that the isolation room did not comply 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.

6. On 11/04/04 at 11:30 AM, during the tour of the Central Sterilization Decontamination area it was noted that the room is also used for the endoscope processing. The decontamination room did not contain any handwash sink.

As per AIA 1996-97 section 9.9.B2 a freestanding handwashing fixture is required.

7. During the tour of the Clean Linen room/Laundry in the basement conducted on 11/4/14 at 11:45 AM, following issues were noted:
i. The room was very dirty and dusty. There was thick layer of dust accumulation on pipes, ducts, vents and perimeter all around the room.

ii. The clean linens were stored in such a way that they were directly under the dust laden ducts and vents. Some linens were leaning against dusty pipes. These linen are used by patients in all patient care areas in the facility.

iii. The room did not have any drop ceiling to prevent cross contamination from the dust to the clean linen. As per AIA 1996-97 section 7.28.B7 "In dietary areas and in other areas where dust fallout may present a problem, provide suspended ceiling".

iv. The laundry room had Vinyl composition tile (VCT) floor covering only half of floor of the room and the other unfinished half of the room's floor had cracks and dips. Some areas of the floor appeared worn out. There were areas on the unfinished floor that had water standing. The cracks and cervices of the unfinished floor had dust and dirt. As per AIA 1996-97 section 7.28.B4 "Floor materials shall be easily cleanable and appropriately wear-resistant for the location".

8. During the tour of the facility 11/03/14 to 11/07/14 from 10:30 AM to 4:00 PM, following infection control/cross contamination issues were observed in the facility:

i. In the Critical Care Unit on the 3rd floor, housekeeping carts were noted stored in the soiled utility room instead of being stored in a dedicated housekeeping closet. It is to be noted that housekeeping closet and mops are considered dirtier than the soiled utility room and as per AIA 1997-97 there needs to be two separate rooms.

ii. During the tour of the Infusion Center it was observed that the inside fold of the handrest for patient chairs/recliners were dirty with accumulation of food and sticky residues.

iii. The wall of room #310 was noted having brownish stains by the bedside,

iv. In the Laboratory the Director of Laboratory was interviewed at the time of observation regarding how the disposal of urine samples take place. She stated that facility utilizes a regular sink in the lab to dispose off urine. It was noted that the sinks are not clinical sinks that may be used for this purpose.

This lab did not have any soiled utility room and the sink utilized for disposing the urine is in the middle of the working area. Such arrangement may lead to environmental contamination.


All above findings were verified with Director of Infection Control and Vice President of Support Services at the time of observations.

Based on medical records reviews and staff interviews, it was determined the governing body failed to ensure that the anesthesiologists provided adequate care when patients received anesthesia. Specifically, the patients end tidal carbon dioxide (ETCO2) assessments and respiratory rates did not indicate the numerical values. This was found in 4 of 5 medical records reviewed of patients that had received monitored anesthesia care (MAC). This was found for patients #1, #2, #4 and #11.

Findings include:

1. The anesthesiologists documented the ETCO2 assessment as "+" value and the respiratory rates as "SV" instead of documenting the findings with a numerical value. A review of patient #1's medical record on November 5, 2014 revealed this is an eighty-one year old patient who presented to the facility for a Release of right Carpal Tunnel and Right Third Trigger Finger Release under MAC that day. The patient had a previous medical history of Atrial Fibrillation (irregular heart beat), Diabetes Mellitus (high blood sugar), Hypertension (high blood pressure), and End Stage Renal Disease (kidney failure) which was managed with hemodialysis.

At the onset of the procedure at 9:50 AM that morning, the patient's blood pressure (B/P) was 185/68 and the respiratory rate was "SV". During the procedure the patient was given Labetalol 10 milligrams (mg) intravenously (IV), Propofol 30 mg IV and Fentanyl 50 micrograms (mcg) IV. The patient required administration of oxygen 3 Liters per minute via a nasal cannula and vital signs were monitored at 5 minute intervals. The ETCO2 was documented as "+" on 3 occasions as were the respiratory rates which were documented as "SV" on 3 occasions.

2. Patient #2 is a seventy-eight year old patient who presented to the facility on November 3, 2014 for a Right Inguinal Hernia Repair with a mesh placement that day under MAC. The patient had a previous medical history of Sleep Apnea and a history of smoking.

The patient was given Midazolam 2 mg, Fentanyl 100 mcg and Propofol 120 mg IV during the procedure. The ETCO2 was documented as "detected with nasal prongs" even though on 1 occasion the oxygen saturation was 94% (normal range 96-100)while he received 5 Liters of oxygen per minute via a nasal cannula. The assessments were incomplete as the anesthesiologist failed to record any numerical value of the patient's ETCO2 and respiratory rates.

3. For patient #4 who was given Fentanyl 100 mcg, Propofol 400 mg and Midazolam 2 mgs IV during a hemorrhoidectomy which was performed under MAC on November 3, 2014, the ETCO2 was documented as a "+."

4. In patient #11's medical record the patient was bradycardic (heart rate less than 60 beats per minute) during a Sigmoidoscopy, Hemorrhoidectomy and Examination under Anesthesia, procedures which were performed under MAC on November 3, 2014. The patient was at a high risk for having a complication given his previous medical history of bradycardia, Coronary Artery Disease, Paroxysmal Atrial Fibrillation (sudden recurrence or intensification of an abnormal heart rhythm), Ischemic Heart Disease (when the heart muscle receives insufficient blood flow), Obesity, Hypertension, Sleep Apnea and Skin Cancer. The ETCO2 was documented as "+."

During an interview conducted on November 4, 2014 at 12:05 PM, Staff #4, an anesthesiologist, stated that anesthesiologists were not required to document the ETCO2 values when patients received MAC because the values are not accurate.