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Based on interview and lack of documented evidence that the facility maintained a list of contracted services, it could not be determined if all services were adequately provided in a safe and effective manner.

The facility failed to produce a list of contracted services, which was requested during survey from 4/19 to 4/23/2010. Therefore, contracted services could not be evaluated.

Based on document reviews and interviews, it was determined that the facility did not conduct timely, thorough, and complete investigations of patient grievances. Furthermore, complainants were not provided with a written notification of the outcome of the facility's findings.

Either or both were found in 8 of 12 complaints reviewed, complaints #s 10-26, 10-29, 10-31, 10-38, 10-39, 10-43, 10-54, and 10-66.

Findings include:

1. On April 22, 2010 at 11:30 AM, during a review of grievances pertaining to the quality of care provided to patients at the facility and staff attitudes towards patients, it was noted that there was no documented evidence that an investigation was done for complaints # 10-26, and 10-31. Complaint # 10-26 was received on 2/5/10 and was closed that day without evidence that the complaint was investigated.

2. In complaints #10-66, and 10-39 the results of substance abuse were not documented in the investigations. A similar finding was noted for complaint #10-29.

3. In 3 of 12 complaints (10-38, 10-54 and 10-43), there were no written responses provided to the complainants.

These findings were verified by Staff #1 at that time.

Based on observations and staff interviews, a registered nurse did not supervise and evaluate the nursing care for each patient.

Findings include:

1. On 4/19/10 at 12:47 PM, an observation of the Medical Surgical Room 620 revealed that a multi dose opened 1000cc Normal Saline solution was on the patient's bedside table. The bottle was not labeled with the time and date of opening. Staff # 25 witnessed and validated this observation.
2. On 4/19/10 at 3:05 PM an observation of Medical Surgical Unit Rooms 513 and 515 revealed that the patients were on intravenous infusions (IV) of fluids. Although the IV lines had red colored IV labels affixed to them, the staff had not completed the information on the labels to include the date and time hung. This observation was witnessed by Staff #25 and #7. The labelling requirement was validated by a review of the facility's policy, Nursing Procedure # 4-8, "Central Venous Catheter, Maintenance Of", which stated in procedure step 9, Labeling:
a. IV solution- Label solution container with IV LABEL (date, time, and 2 hour increments)
b. IV Tubing - Label with time, nurse's initial and date to be changed.
This finding was discussed and verified with Staff #37 at the time of observation.

3. During an observation on 4/19/2010-4/20/2010 in ICU/CCU/PCU, throughout all three units, there were no dates, times, and initials written on IV bags; including Piggy back IV and Tube Feeding bags. Also, there was no start date/time or stop date/time noted on a urinary indwelling catheter.

For example: MR #8 was receiving IV therapy with D5 / 1/2NS. The IV was not labeled when it was started or when to stop (date/time). It also was not initialed by the nurse.

This finding was discussed and verified with Staff #37.

Based on observation and staff interviews, the hospital did not ensure that nursing staff develops and maintains current nursing care plans for each patient. This was evident in 2 of 43 medical records reviewed. MR #23 and #39.

Findings include:

1. Patient MR #23, 83 years old, was admitted on 4/19/10 from a Home for Adults, status post fall with a previous history of Lumbar disc surgery. On admission, Physical Therapy evaluated the patient on 4/20/10 to require minimum assistance of one person for bed mobility. The patient is a moderate risk for skin impairment, according to a Braden score of 14, documented on the "Admission Profile" on 4/19/10.

A review of the "Daily Assessment Form" of 4/19/10, 4/20/10 and 4/21/10 did not indicate the patient to be in need of assistance for bed mobility or at risk for skin impairment for any shift. There was no care plan relating to prevention of skin impairment.

A facility document, "THE FOUR P's RULE" was reviewed on 4/20/10. It revealed that the patient was in bed (indicated by the letter "B" in the section marked for position) from 3:00 PM to 11:00 AM the next day.
The document did not reflect if the patient was assisted by staff for bed mobility and positioning. There was no indication that the patient was positioned.

On 4/21/10 at 11:55 AM, Staff #40 stated that the patient' s needs are prioritized in the Kardex. However, the option to turn and position the patient was not checked off on the Kardex.

2. A review of MR #39 on 4/21/10, revealed that the patient was admitted on 1/29/10 to the Critical Care Unit. The Critical Care Flow Sheet" on 1/29/10, 1/30/10 and 1/31/10 indicates that the patient requires assistance of staff with turning and positioning every 2 hours. Review of the medical record revealed that there was no evidence that staff turned and positioned the patient.

At 2:00 PM on 4/21/10, Staff #40 stated that "THE FOUR P's RULE" form was not used at the time the patient was admitted.

Based on medical record review on 4/19/2010 - 4/23/2010, it was determined that the facility did not ensure that all orders are dated, timed, and authenticated promptly by the ordering practitioner. This was found in 7 of 19 medical records. (MR #s 7, 9, 11, 13, 14, 18 and 36)

Findings include:

1. Review of medical records during observations on 4/19/2010-4/23/2010 at The Turning Point Detox Unit, for MR #7, revealed the Comprehensive Psychosocial Assessment on 4/14/2010 was signed and dated by the patient, but clinical staff did not sign and date.
This patient's History and Physical was dictated on 4/14/2010. It was signed by the MD but the PA did not sign it.

2. During an observation round and review of medical records of the ICU on 4/20/2010, a review of MR #9 on 4/19/2010 revealed that the Anesthesia Progress Notes did not include the time written; Neurosurgery progress note did not indicate the time; a physician order to "repeat non-contrast of head CT today," did not indicate the time; physician order for pre-op was signed, but no time was indicated.

3. During observation and review of medical records in PCU on 4/20/2010, 11:40 AM, MR #11 revealed that the MD did not sign the patient's History/Physical on 4/17/2010 on admission. A consultation for CHF was not signed by the MD.

4. During observation and medical record review on 4/21/2010 on the 4th floor Rehabilitation unit, review of MR #13 revealed that the Emergency Psychiatric consultation on 3/12/2010 was not signed by MD.

5. Medical record review on 4/23/2010 in the Turning Point Detox Unit revealed that MR #14 was admitted on 4/6/2010. The patient's Hx and Physical was dictated on 4/7/2010, but the attending MD did not sign off.

6. For MR #18, the Emergency Provider Record, alcohol/drug dependence evaluation (ED evaluation) on 4/17/2010 was not signed by the MD.

7. During medical record review on 5th floor, Spellman on 4/23/2010, MR #36, admitted on 4/7/2010, revealed that the Emergency provider record (Psych Disorder/Suicide Attempt/Overdose) did not have a date and time.

Based on medical records reviews and staff interviews, the facility did not ensure that verbal orders are authenticated within 48 hours by the physician. This was evident in 3 of 43 medical records reviewed. MR #'s 39, 36, and 22.

Findings include:

1. A review of MR #39 on 4/21/10 at 2:00 PM revealed that for the following dates and times, telephone orders were not signed by the physicians:
a. On 4/13/10 at 0530 a telephone order was written for "Lyrica 50mgs BID, OK to give 5 AM dose today."
b. On 4/15/10 at 1400 a telephone order that the patient was "stable for discharge" was written.
c. On 4/17/10 at 1523 a telephone order was written for "CT Pelvis and L Spine Stat. S/P fall c/o coccyx and L hip pain."
d. On 4/17/10 at 1830 a telephone order for "PSA level in AM" was written.

2. Similarly, a review of MR #36 on 4/21/10 at 3:00 PM revealed that telephone orders were not authenticated by the physicians.
a. On 4/13/10 at 2320 a telephone order was written to "Discontinue IV fluids. Change IV Haldol to 2.5mgs IM q6h prn."
b. On 4/16/10 at 1400 a telephone order was written "Hold Lovenox morning of procedure (Cisternogram Tuesday). No ASA at this time."

3. During observation and review of medical records on CCU on 4/23/2010, MR #22 revealed that the following three telephone orders on 4/21/2010 were not signed by MD:
a. at 1600 for "HGB and HCT Q 4hour x 3 after post H & H is done".
b. at 1700 for "call MD if the patient's temperature >101 during blood transfusion".
c. at 1715 for "PCA - Morphine 1 mg every 6" 10mg maximum".

Based on medical record reviews and staff interviews, the hospital did not ensure that the medical records document all information necessary to monitor the patient's condition. This was evident for 1 of 3 records reviewed on the Mental Health Unit. MR #36

Findings include:

During review of MR #36 on 4/23/2010 on Spellman, 5th floor Mental Health Unit, it was revealed that the patient received Thorazine 200mg (2 tabs), and Ativan 2mg p.o. PRN, at 7:12 AM on 4/19/2010. According to the policy and procedures for patients receiving these medications, vital signs are to be monitored and recorded in nurse progress notes, as well as the reason for administration of the medication. However there was no documentation evident in the nurse progress notes that these requirements
were followed. This was verified by Staff #37 and 42.

Findings include:

1. On 4/19/10 at 11:55 AM to 12:45 PM, during observation of the environment on the 6th floor Medical Surgical Unit, accompanied by Staff #25, the following expired items were found in the medication room, and utility and storage rooms:
a. 46 purple Vacutainer specimen bottles with expiration date of 12/09.
b. 1 Prolene 3.0 suture set with an expiration date of 1/09.
c. 3 Chromic Gut 2.0 sutures with expiration date of 7/09.
d. 1 Chloraprep with an expiration date of 07/09.
e. 1 BD Spinal needle with the expiration date of 03/08.
f. 1 bottle of multi-dose Heparin 1000 USP 10mls was noted opened with no date of opening on the bottle.
g. 1 Lantus Insulin bottle was opened and in the medication refrigerator without a date of opening on the bottle.
h. 1 bottle of opened Humolog Insulin was observed also in the refrigerator without a date.
i. In the storage drawer were found 1 BD Threaded lock canula with the expiration date of 3/10; 1 Urine specimen collection kit for Chlamydia with expiration date of 8/31/09; 1 Endo Cervical specimen collection and handling test tube with the expiration date of 1/31/10 and (1)
7.0 Nasopharyngeal airway with the expiration date of 9/09.
j. 1 bottle of rubbing Alcohol with the expiration date of 2/10 was found in the dirty utility room. Also found in the dirty utility room was a pair of sterile gloves in package.
k. A bottle of opened Normal Saline with no opening date was found in Room 620.

2. On 4/19/10 at 12:15 PM to 3:15 PM, during observation of the environment on the 5th floor Medical Surgical Unit, accompanied by Staff #25, the following expired items were found in the medication room, and utility and storage rooms:
a. 1 Contiplex Touchy Continuous Nerve Block Set with expiration date of 10/09.
b. 1 BD Getting Started Home Kit for diabetes with expiration date of 9/08.
c. 4 BD Getting Started Home Kit for diabetes with expiration date of 9/09.
d. 1 Dual port feeding tube with flow through stylet with expiration date of 2010/03.
e. 1 Air eliminator spike pump set with expiration date of 04/09
f. 1 Stat lock catheter secure device with expiration date of 06/09.
g. 2 Culture swabs with expiration date of 10/09.
h. 50 purple Vacutainers with expiration date of 12/09.
i. The emergency box was opened and inside were found: 1 purple Vacutainer bottle with expiration date of 12/09; and (2) two 0.9 sodium chloride 5mls syringes with expiration date of 08/2009.

3. On 4/20/10 at 10:05 AM to 11:30 AM, during observation of the environment of the Chemistry, Histology, Microbiology, and Cytology Lab floor, and accompanied by Staff #24 and the department staff, the following expired items were noted as listed below:
Chemistry Lab at 10:05 AM
a. 1 purple, and 2 red Vacutainer test tubes with expiration dates of 2/10.
b. 1 red and 1 purple Vacutainer test tubes with expiration dates of 1/10.
c. 1 purple Vacutainer test tube with expiration date of 3/10.
d. 1 bottle of 1000 cc of opened sterile water dated 3/10/10
e. 1 bottle of 1000 cc of opened sterile water dated 10/09

Blood Lab at 10:40 AM
Cleaning supplies were noted under the sink. Included among the cleaning supplies was a bottle of Glycerol and a bottle of Normal saline. Staff #35 validated the findings.

Histology Lab 11:10 AM
a. Cleaning supplies in large amount and various types were noted under the sink. Staff #16 validated the findings and cleaned out the area under the sink.

Microbiology Lab at 11:20 AM
a. A bottle of opened .45 Normal Saline 1000cc covered by a dispensette with a date of opening of 6/30/08.
b. A bottle of opened .45 Normal Saline 1000cc covered by a dispensette with the bottle opened on 3/2/10.
c. A bottle of opened distilled water opened on 4/8/10.
d. A bottle of opened Normal Saline with opening date of 4/8/10.
Staff #17 validated all the findings within the area.

4. On 4/20/10 at 11:40 AM during observation of the Dialysis Unit, validated by Staff #24 and #19, the following were noted:
a. A bottle of 1% Lidocaine10mg/ml with opening date of 2/4/10 was found in the storage drawer.
b. 1 container of Residual Peroxide test strips with expiration date of 01/10 was noted among the storage of supplies.
c. Dialysis machine #3 was not in working condition.
d. Dialysis machine #4 being used to dialyze a patient at 11:40 AM was not able to automatically deliver the intermittent dose of Heparin. Staff #19 said she did not know why she elected to use machine #4 since it was not functioning well.

5. On 4/20/10 at 2:00 PM during environmental observation of the Radiology department and accompanied by Staff #24 and #21, the following items were observed in different locations within the department:
a. Oxygen tubing connected to O2 pipeline in the wall in radiology room. The tubing open end was not covered.
b. 90 expired insulin syringes with expiration date of 08/08 were found in a box in the storage room.

c. Stereotactic/Breast Biopsy Room - Findings at 3:00 PM.
i. One bottle of Alcohol with expiration date of 2/10.
ii. Eight Prolene 4.0 Stitch with expiration date of 01/09.
iii. One Providone swab with expiration date of 01/10.
iv. Four Opsite dressings with expiration date of 08/06.
v. 30 Prolene 2.0 Stitch with expiration date of 7/09.

6. On 4/21/10 at 10:10 AM to 11:15 AM, an observation of the Hyperbaric and Wound Center was performed. Staff #24 and #22 validated the findings noted in the storage cabinet:
a. 2 Iodosorb Cadexomer Iodine Gel dressings with expiration date of 03/10.
b. 1 Kendal Iodoform packing strip dressing with expiration date of 3/10.
c. 1 Promogran Wound Management dressing 28cm with expiration date of 11/09.
d. 1 Personal antimicrobial skin cleanser with expiration date of 08/09.
e. 2 Prisma wound management dressings opened on 4/20/10 and 4/14/10. It was confirmed on 4/22/10 at 3:05 PM by Staff #24 and #22 that the dressings, once opened, should have been discarded.

7. On 4/23/10 at 11:25 AM to 12:05 PM an observation of the 243 North Road Extension Clinic was performed. Staff #1, 26, and 27 validated the findings noted at the facility:
a. Cleaning and sanitizing items were stored under the sink in the main treatment room, including 3 bottles of hand sanitizers.
b. A container of hand sanitizers with expiration date of Jan. 06 was noted on the counter in the main treatment room.
c. A tube of Solsite Wound Gel with expiration date of 1/08 was also on the counter in the treatment room.
d. A container of Alcare Antiseptic Hand Rub with expiration date of Dec. 09 was found on the counter by the hand washing sink

8. During observation of CCU on 4/19/2010, three Discofix 4-way Stopcocks were found with expiration date of 5/2009.

9. During observation in Cardiac Catheterization and Interventional Radiology on 4/19/2010, the following items were found:

a. In the Cardiac Catherization Lab, two IABP (Intra Aortic Balloon Pump) machines had expired tags as of 11/09/2009.
b. In the Interventional Radiology room, the BiPAP plus machine inspection tag indicated that the next inspection due date was 11/2009. This was verified by Staff #38 and #39.
c. One Povidine-Iodine Swabstick was found expired as of 7/2009.
d. Three BD vacutainers, blue top, had expiration dates of 11/2009.
e. Three BD vacutainers, red top, had expiration dates of 2/2010.
These findings were verified by Staff # 37.

10. During observations of the ICU, CCU, and PCU clean utility room on 4/20/2010, the following items were found:
a. Three SAF-Gels (Hydrating dermal Wound Dressing with Alginate) expired on 2/2010.
b. Two Bone Marrow "1" type Aspiration Trays with Safety Components expired on 1/2010.
c. Two Cranial Access Kits expired on 3/2009 and 2/2010.
d. Two Micro Ventricular Bolt Pr.- temperature monitoring kits expired on 1/2009.

Based on observation and review of the dietary policy and procedure manual, it was determined that the facility did not provide dietary and food services according to the current standards of practice.

Findings include:

1. During observation and inspection of the kitchen and food service areas conducted on 4/19/10 through 4/23/10 and review of the dietary policies and procedures manual, the following items were noted:

a. On 4/19/10 and 4/23/10, all handwashing sinks in the kitchen and cafeteria failed to have valves that can be operated without the use of hands.

b. On 4/19/10 and 4/23/10, artificial lighting fixtures located over, by or within food storage, preparation, service or display areas throughout the kitchen and cafeteria, were observed not to be protected to prevent broken glass from falling into food or onto food-contact surfaces. Furthermore, artificial light sources were not being properly maintained to provide adequate lighting in food preparation areas.

c. On 4/19/10, two cutting boards observed were noted to have excessive wear and were not easily cleanable.

d. On 4/19/10, clean pans being stored on shelves were observed stacked and wet and not properly air-dried.

e. On 4/19/10, cooked beef roasts, dated 10/16/09, were observed being stored in the freezer. Review of the Dietary Policy and Procedure Manual failed to find a policy to address the storage and timeframes of unused, potentially hazardous food stored in the freezer.

f. On 4/19/10 and 4/23/10, at least two sinks used for food preparation or food service were observed in the kitchen and cafeteria without strainers.

g. On 4/19/10 at approximately 11:00AM, chemical test strips were not available to test the adequacy of the sanitizing solutions used in the kitchen and pot washing area. Therefore, there was no method available to assure that adequate chemical concentrations were achieved to provide for proper sanitation for pot washing, and for counter tops, etc.

h. On 4/19/10 and 4/23/10, garbage containers throughout the kitchen and cafeteria were observed uncovered when not in use.

i. On 4/19/10, at least two fire extinguishers in the kitchen were observed that were not Class K.

j. On 4/19/10, the hood above the gas steamer and kettles was observed to not have the Ansul Fire system installed, as required.

k. On 4/23/10, the wallpaper behind the ice machine in the cafeteria was observed in need of repair.

l. On 4/23/10, the portable fan observed in the cafeteria was dusty.

2. Review of the Food and Nutritional Services Department Policy and Procedure Manual revealed that the last review and/or approval by the Vice President of Support Services (Staff #35) and the Director of Food Services (Staff #4) were dated January 2008. All policies and procedures must be reviewed at least bi-annually.

3. "Food and Nutrition Services Policy No. B051, Subject: Safety in food preparation, handling procedures for pork, poultry, lamb and beef " stated that for "Storage": "If product is more than 6 pounds it must be cut into pieces of 6 pounds or less." "Cover, label and date. refrigerate for up to 5 days at 41 degrees or less." On 4/19/10, cooked beef roasts were observed weighing more than 8 pounds, dated 10/16/09, being stored in the kitchen freezer.

4. There was no evidence available that nutritional analysis of the menus was conducted to ensure that the meals provided to the patients meet the current national standards for the recommended dietary allowances, as well as conform to the therapeutic diet requirements.

Based on observation, it was determined that the facility did not maintain a safe, sanitary and comfortable environment to ensure that the safety and well-being of patients are not compromised.

Findings include:

1. During survey of the patient floors between 04/19/10 and 04/23/10 between 10:30 AM to 3:00 PM, it was noted that the heating units in patient rooms (including but not limited to room #521, #522, #523 & #518 on 5th floor-Cooke), exhibited an accumulation of dirt and dust around the floor perimeters of the heating/air-conditioning units beneath their edges. Also, the grills/heating elements of some heating/air-conditioning units in patient rooms exhibited an accumulation of dust, dirt, excessive lint and garbage. It was also noted that the grab bar in patient bathroom of room #621 had blood stains and tape stuck on it.
Thick accumulation of dust and dirt was also found on the corners of the carpet outside patient rooms (such as the Seclusion room) on 5th floor-Spellman, Mental Health Unit.

All findings were verified with Staff #2 and Staff #34 at the time of observation.

2. During the survey it was noted that the exhaust vents and heating radiators of the bathrooms in patient rooms were dirty with thick layers of dust accumulation. Examples, including but not limited to, are: PACU bathroom, PCU/ICU bathroom, and patient room bathrooms on 5th and 6th floor-Cooke. Also on 04/19/10 at 3:00 PM, it was noted that the ventilation exhausts of the Cysto room #1 and room #2 were very dirty. This situation leads to environmental contamination.

Findings were verified with Staff #2 and Staff #34 at the time of observation.

3. During the survey between 04/19/10 and 04/23/10, it was observed that several patient and visitor bathrooms on different floors of both hospital campuses, and bathrooms in outpatient areas, did not have the appropriate emergency nursing call bell pull cords as required by AIA 7.32.G2. The emergency pull cords were either short in length, were tied up to a grab bar, or were bunched together. This practice does not provide easy access for patient's safety. Also it was noted that the emergency call bell cords were covered with an accumulation of dirt. Examples include but are not limited to:
a. The emergency nursing call bell cords were very short in patient corridor bathrooms on the 3rd and 6th floor-Cooke, and in patient bathrooms of room #619 and room #324, and thus were not providing easy access to a patient who might collapse on floor.
b. Some emergency nursing call bell cords in patient bathrooms on 6th and 5th floor-Cooke were noted tied around the grab bar, thus not providing easy access to a patient who might collapse on floor.
c. No emergency nursing call bell was provided in the bathroom used by patients inside the locker room near the entrance to the OR core.

Findings were verified with Staff #2 and Staff #34 at the time of observation.

4. During survey of the patient floors between 04/19/10 and 04/23/10 between 10:30 AM to 3:00 PM in the handicap accessible patient bathrooms (including but not limited to those on floors 6, 5 and 4-Cooke), it was noted that:
a. the drain pipes underneath the handwashing sink were not protected/insulated to prevent patient leg contact against hot water pipes. (ADA 4.24.6);
b. the door hardware was the knob shape and not the handle/lever type so that pinching, grabbing or twisting of wrist as per code ADA 4.13.9, does not occur;
c. the mirror in patient handicap accessible bathroom in Same day Surgery unit (observed on 04/23/10 at 12:15 PM), was mounted such that the bottom edge of the reflecting surface was more than 40 inches above the floor and thus was not in compliance with ADA 4.19.6; and
d. for same handicap accessible bathroom in Same Day Surgery Unit, no protective sleeve was found under the sink to cover the hot water pipes.

5. During the survey of the facility from 04/19/10 to 04/23/10, it was noted that many medicine/specimen and pantry refrigerators had ice/frost build up/accumulation which indicated that they had not been defrosted. Furthermore, the gaskets of such refrigerators and blanket warmers were noted dirty or broken. Examples, including but not limited to, are:
a. Medication refrigerator in the Med/Surg medication room (6th floor-Cooke) was noted to have heavy built up of ice/frost in the refrigerator and the gasket was found broken. Frost buildup increases the amount of energy needed to keep the motor running and may put more load on the engine which in turn decreases the efficiency of the unit. If the unit is 'non-frost', then this build up indicates the possibility that the heater element has failed. Therefore, ice/frost build up is a sign that the unit is not being maintained and cleaned frequently to avoid contamination or infection control issues.
b. Refrigerator in the kitchen in Sleep Center (3rd floor-Spellman) had heavy ice/frost built up in the refrigerator section.
c. Medication refrigerator in the Same Day Surgery medication room (2nd floor-Spellman) was noted to have torn gasket.
d. Lab refrigerator storing control acetone had heavy ice build up and torn gasket.
e. Blanket warmer in the sterile core of the OR was noted to have dusty gaskets with lint and greenish accumulation in between the ridges.

All findings were verified with Staff #2 and Staff #34.

6. During the survey from 04/19/10 to 04/23/10 from 10:30 AM to 4:00 PM, it was noted that 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.
Examples, including but not limited to, are:
a. The soap dispensers installed above the scrub sinks in the sterile core of the OR were noted to be dusty.
b. The machine/equipment used to make address/identification badges for the patients in the sterilization core was noted dirty, and had residue of sticky tape and some tape stuck on it.
c. The anesthesia cart, Bair hugger machine and its wires in Cysto room #1, were noted dirty with dust and dirt.
d. The blood glucose test kits on 5th and 6th floor-Cooke were noted dusty and dirty on the inside. The kits had open cotton swaps and gauzes used to wipe blood during the test and therefore they were coming in contact with the dust particles.
e. The buckets used for rinsing 'Endo Ebu' endoscopes in the Endoscopy suite, were noted to have broken handles and to be dirty with dust. The bucket used for holding the Cidex and then the scopes was noted to have thick greenish precipitates/residues around the edges .
f. The Hydrocollator machine in the Rehab department (4th floor-Cooke) was noted to have dirty inclusions floating in the water and the bottom of the equipment exhibited black patches which could not be verified as precipitates/dirt or just the disrepair of the bottom metal surface.
g. The code cart on 2nd floor-Cooke PCU had a dusty, dirty bottom drawer, and the suction cup was dirty with dust around its edges.
h. Use of sticky tape was found in many places around the facility. Tapes were found stuck on stretchers, refrigerators ( such as Lab refrigerator used for Acetone control, chairs ( such as in 5th floor-Cooke patient lounge), on glucose meters on patient floors ( used to label or identify the meter) and other places. If tape and its sticky residues are not cleaned properly, they are a means of cross-contamination.
i. The ultrasonic cleaner in the decontamination room of the Central Sterile suite, was found in disrepair with broken gasket and accumulation of rusty fluid around its perimeters.

All findings were verified with Staff #2 and Staff #34.

7. During the survey, it was noted that the water cooler/ice dispenser unit on different patient areas/floors such as PACU and Med/Surg unit (6th floor-Cook) had greenish residue (most probably hard water residue) around the end of the water dispensing pipes.
Similarly, mostly all taps on the scrub sink in the sterile core of the OR, had similar precipitation/corrosion around their edges. Furthermore, the scrub sink outside OR #5 in the core, had brownish/orange sticky material around its perimeter.

All findings were verified with Staff #2 and Staff #34 at the time of observation.

8. During the survey between 04/19/10 to 04/23/10, 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. Locker room and storage in the OR suite (outside the sterile core/OR rooms) had a stained ceiling tile.
b. Brown stained tiles were noted in the corridor across the radiology reception area.
c. It was noted that one ceiling tile was stained (around sprinkler head) outside OR #1 in the sterile core.
d. Medical records room had 2 stained ceiling tiles.
e. On 04/21/10 at 11:15 AM, during the above ceiling inspection of the fire wall above double door (4th floor-Spellman by Dialysis room), it was noted that a suspicious black growth was covering about 20-25 inches of the wall. It was also noted that the tiles beneath were stained.

It is important to find the cause of the stained ceiling tiles because, if ceiling tiles are not replaced and stay humid/wet, they may harbor growth of mold/fungi and contribute to environmental contaminants. Also, the ceiling tile stains need to be investigated for potential leaks above, as they 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.

All findings were verified with Staff #2 and Staff #34 at the time of observation.

9. During the survey from 04/29/10 to 04/23/10, it was noted that the facility did not ensure that the physical plant was kept in good repair to ensure a sanitary environment. Examples include:
a. The guard wall in front of OR #3 was noted missing and revealing the dirty, sticky structure underneath.
b. Room #509 (5th floor-Cooke) had a big hole in the wall behind the bed/stretcher.
c. The wall outside OR #7, OR #3 and OR #2 in sterile core had a big hole. Furthermore, it was noted that many other areas/patches of the wall in this sterile core were in massive disrepair.
d. It was noted that in the disinfecting room of the Endoscopy suite, there was a wall with a hole exposing a steam pipe. This situation not only compromises the clean environment required for a disinfecting room housing the sterilizers, but it also facilitates pest infestation.
e. In the ventilator storage room (Respiratory unit, 3rd floor-Throne) it was noted that a patch in the ceiling was open revealing a pipe.
f. It was noted that in the gym area of the inpatient PT/OT unit (4th floor-Cooke), a formerly used toilet room was being used as a storage room for walkers and various other equipment. It was observed that where the water was capped off (by the toilet bowl area) there was a big hole with a towel inserted inside it.
g. All drains in the mechanical room of 1 Cooke, were noted open with no strainers to prevent entry of rodents. It is to be noted that this room is near the Central Sterile Supply room.
h. The cart washer in the Central Sterile Supply room was missing a portion of metal plate on the floor and thus exposing a gap/hole. This gap/hole leads to a small room on the side of the cart washer which as per facility is used as a mechanical/repair room for the sterilizer/cart washer. This small room was also found to be extremely dirty and in disrepair.
i. In the Central Sterile Supply room another mechanical room behind the autoclave was noted. This mechanical room was noted to be dirty, with some elements of the steam pipes disintegrating and accumulating on the floor. Furthermore, towels were found thrown on the floor and some near the drains.

All findings were verified with Staff #2 and Staff #34 at the time of observation.

10. During the survey of the facility, it was noted that the facility did not ensure the provision of a safe environment to prevent safety hazards for patients. Examples include;
a. It was noted that wooden exercise stairs/steps (used for rehabilitation for patients) in the patient lounge of Orthopedic unit (5th floor-Cooke) had splinters.
b. The electrical sockets in the corridors of Mental Health unit (5th floor-Spellman) could not be verified for tamper-proof status.
c. It was noted that the Occupational Therapy room on the 4th floor-Cooke, had its door open and sharp objects such as knife, fork and other items were stored in the unsecured open area of the room. This corridor is open to public access.
d. The metal parallel bars in the gym of PT/OT (4th floor-Cooke) had protruding rivets, one of the end cover caps (for the sharp metal ends) was missing, and one end of the bar was covered with blue tape. During exercise the protruding rivets may pose harm or injury to the patient's palm.

All findings were verified with Staff #2 and Staff #34 at the time of observation.

11. During the survey of Orthopedic/Trauma unit (5th floor-Cooke) on 04/21/10 12:15 PM, it was noted that when a nurse call was elicited from a patient room, it did not register in the medication room, clean utility room, soiled utility room and other areas as per AIA 7.32.G1. Furthermore, it was noted that this multi-corridor unit did not have any intersectional corridor lights, as required by the same code mentioned above.

It is to be noted that the unit is arranged such that there is only one one nurses's station from which some of the patient rooms and the emergency dome lights in the unit may be viewed. There is a long corridor behind the station that has patient rooms that cannot be seen from this nurse's station from any angle. The presence of a nursing call bell console at the nurse's station, emergency dome lights at the patient room door, secondary signals in the ancillary rooms, and multi-corridor lights, are multiple essential layers through which a facility may ensure that prompt help to the patient is available when requested. Staff #7 agreed that apart from the one nursing call bell console present in the nurse's station, there was no way to ensure prompt response to the patients in the rooms that cannot be seen from the nurse's station.

Findings were verified with Staff #2 and Staff #34 at the time of observation.

12. The following findings were observed on 4/23/10 at two hospital outpatient extension clinics:
a. An observation made on 4/23/2010 at 12 noon at the Center for Communication Disorders site, 115 Delafield Street, revealed that the Group Room #4 is adjacent to the Electrical Room. The door to the Electrical Room opens into Group Room #4 and does not have a lockable door handle. The door can be opened from inside Group Room #4, creating a safety hazard.

b. An observation in the Balance Testing Room made during this time, revealed that the foam mat for patients to sit on has torn and open corner edges, making it pervious, such as to prevent proper cleaning.

c. An observation made on 4/23/2010 at 11:30 AM at The Therapy Connection site, 243 North Road, revealed that foam bolsters in the gym had torn covers, making them pervious, such as to prevent proper cleaning.

Based on observations, record reviews and staff interviews, it was determined that the facility did not meet the applicable provisions of the Life Safety Code, NFPA 101, 2000 edition.

Findings include:

During the survey of the facility from 12/08/09 to 12/11/09, Life Safety Code deficiencies were noted in multiple areas of the Code requirements and were cited under the following Fire/Life Safety Code tags:

· K-18 (Corridor doors not kept free of impediments);
· K-29 (All hazardous areas not safeguarded by one hour construction or self-closures/positive latching);
· K-30 (Gift shop not protected from the corridor as hazardous area);
· K-52 (No sensitivity report for the smoke detectors);
· K-56 (All sprinkler heads not kept free of foreign material);
· K-64 (Portable fire extinguishers installed above the required 5 feet/60 inches height);
· K-77 (Medical gases not maintained as per NFPA 99);
· K-104 (Penetrations in smoke/fire barrier not completely sealed/protected);
· K-130 (Portable oxygen cylinders not protected from combustibles);
· K-160 (Fire fighter recall not installed on all patient-serving existing elevators).

Based on observation and staff interview, it was determined that the facility did not ensure that pressure monitor gauges outside the isolation room and dialysis machine room were maintained and handled to ensure an acceptable level of safety.

Findings include;

1. On 04/21/10 at 11:45 AM, during the observation of the Orthopedic/Trauma Unit (5th floor-Cooke) it was noted that the pressure gauge outside isolation room #514 was fluctuating between a green and red light. As per Staff #7, the room had a patient who required air-borne isolation/negative air pressure. Staff #2 stated that when the pressure gauge reads green light it means the room has negative pressure, whereas red light means the room is not on negative air pressure.

A simple tissue test was done by Staff #2 to see the air flow and negative air pressure was verified. However, Staff #7 was not aware of the fluctuating light and Staff #2 was unaware regarding the reason why the light was fluctuating between red and green.

2. On 04/21/10 at 4:00 PM, during survey of the Dialysis unit (4th floor-Spellman), it was noted that a patient was receiving treatment on Station #3. The conductivity of the machine was reading 14.6. Staff #19 was asked to show the theoretical conductivity (TCD) of the machine, which indicates the parameters of the actual conductivity to be given to the patient. The TCD for the dialysate prescription of 3K 2.5 Ca and 140 Sodium was reading as 13.9 and the alarm range for the high and low conductivity was set at 13.8 to 14.8.

As per the Fresenius manual, the alarm range for the conductivity of the dialysate being given to the patient is set by default, +/- 0.5 of the TCD. With this manufacture's requirement the alarm range should have been 13.4 to 14.4. Thus the patient at the time of survey was receiving dialysate at a higher conductivity.

Staff #19 was not aware of the significance of TCD and was asked for a policy and procedure regarding the different dialysate concentrations given in the facility/dialysis unit and the acceptable range. Staff #19 stated that she did not have any policy.

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 the survey of the facility from 04/19/10 to 04/23/10 from 10:30 AM to 4:00 PM, it was noted that:
a. The doors of OR #1, OR #5, and OR #6 were not completely shut/positively latched during operative procedures (being conducted in the above rooms at the time of survey) to ensure that the ORs maintain their positive air pressure and that cross contamination from the corridor does not take place.

b. One of the ventilation exhausts in OR #7 (installed on the lower end of the wall) was blocked/obstructed by various equipment, such as supply carts, stools, and other items. Such blockage compromises the air exchange to take place effectively.

c. During survey it was noted that a procedure was being performed in Endoscopy room #2, and the door connecting the Endo #1 and Endo #2 rooms, was open. No procedure was being conducted in Endoscopy room #1; however, such an arrangement not only compromises the per hour air exchange of the rooms, but also contributes to cross contamination.

2. During the survey of the facility from 04/19/10 to 04/23/10, it was noted that most of the toilet/bathroom doors were kept open in the facility. This practice compromises the per hour air-exchange of the toilet as required by AIA, Table 2.

Based on observations and interview, it was determined that the facility failed to implement an effective infection control environment consistent with recognized infection control practices to prevent cross-contamination by keeping clean supplies separate from dirty areas and ensuring that all patient care equipment are in good repair to prevent infections.

Findings include:

1. Clean supplies were stored below a handwashing sink. During a tour of the ED on April 20, 2010 at 10:18 AM, a pitcher, blanket, 2 rolls of hand towels, a cup, and an empty hand sanitizer container were among other items being stored below the handwashing sink in the storage room. Storing clean supplies under the sink increases the risks of contamination from the drain pipe. This finding was verified by Staff #24 at that time.

2. Clean supplies were stored near handwashing sinks in the ED. Several sinks in the ED had clean supplies within approximately 3"-5" of handwashing sinks. These findings included but were not limited to room #17 where clean gloves and orthopedic supplies for casting were stored next to the handwashing sink. In the decontamination area, supplies such as face masks and gloves were near the handwashing sink at 10:20 AM that morning. This facilitates splashing of dirty/contaminated water onto clean items which are to be used for patient care.

3. In the Brinn unit, there were 11 bags with patients' clothing and other belongings stored in the medication room where medications are stored and dispensed. This poses a risk for cross-contamination.

4. There was a missing ceiling tile in room #3 in the ED at 10:21 AM on April 20, 2010. This open area poses a risk for infection. All findings in the ED were verified by Staff #24 at those times.

5. On April 21, 2010 at 12:20 PM, the Coblator II equipment noted to be due for inspection on 11/08 was seen in OR #3, a clean area which was prepared for a surgical procedure. This finding was verified by the OR Manager at that time who stated that the equipment had been borrowed from the ambulatory surgical unit to be used whenever it is needed in the main OR. She further stated that all equipment borrowed from that unit is checked when taken from that unit. However, at 2:00 PM that day, the engineering staff stated after inspecting the equipment, that the equipment had not been obtained from the ambulatory surgical unit but had been borrowed from an outside facility.

6. Observed on 4/22/10 at 11:30 AM, the Uroview equipment in Cystoscopy room #2 had an inspection sticker indicating an inspection was due on 11/09. This finding was verified by the OR Manager who stated that she was certain that the machine had been tested recently, maybe a month or 2 ago.

7. Staff #10, the OR circulating nurse, was observed on 4/22/10 at 11:24 AM picking up garbage from the floor in OR #6 during a surgical procedure, (Left Shoulder Arthroscopic Repair). She then proceeded to adjust and reposition the screen of a video equipment monitor located above the lower end of the operating room table before washing her hands.

8. During survey of the main Laboratory (1st floor- Spellman) on 04/23/10 at 12:15 PM, it was noted that:
a. An abundant amount of used agar plates (having microbiological colonies) were being stored with clean supplies in the storage room.
b. A housekeeping/janitorial bucket was found stored in the clean supply storage room.
c. Two biohazard containers filled with blood specimen test tubes, were found stored among the clean supplies in the storage.

9. During survey of the Central Sterile Supply (1st floor-Cooke) on 04/20/10 at 2:30 PM, it was noted that:

a. The ceiling tiles in the Central Sterile Supply were not tightly fixed in their grooves, thus exposing the structure above. As per AIA 7.28.B8, ceiling in sterile processing room should contain minimum number of fissures, open joints, or crevices that minimize retention or passage of dust particles.

It was also noted that the ceiling tiles were extremely dirty, dusty and had various kind of stains. Clean linens stored in open shelf were found stored beneath the dusty ceiling tiles. Findings were verified at the time of observation, with Staff #2 and Staff #34.

On 04/21/10 at 10:30 AM, Staff #3 provided the surveyor with a policy #40 'Cleaning Central Service'. The policy instructed to 'High dust all vents, light fixtures and ceilings 1x a week and as needed'. Another line instructed to 'Spot clean walls, doors and partition as needed'.

b. During survey it was observed that there is a mechanical room (in-between the decontamination room and clean room) that is housing a portion (back side) of the two sterilizers that open on the clean side. At the time of survey, door of the mechanical room opening into the decontamination/dirty room was found open and the mechanical room was found dirty with fabric/towel/cloth and garbage all around the room. It was further noted that the sterilizers are installed as so that there is a wide gap between the wall and the edges of the sterilizers. This gap creates a passage for air exchange between the clean (processing) and dirty (decontamination) side.

c. During survey of the decontamination room, it was noted that one staff came into the decontamination room/dirty side from the clean side and then went back to the clean side without taking any measures or precaution. Staff #33 also noted the activity of the particular staff. Staff #33 was interviewed regarding what is correct procedure/flow from dirty to clean area. Staff #33 stated that once a person comes into the dirty side they cannot return directly to the clean side without changing their attire.

All findings were verified with Staff #2 and Staff #34 at the time of survey.

10. On 04/22/10 at 11:15 AM during the survey of Dialysis Unit (4th floor-Spellman), it was noted that Staff #29 was not wearing any gloves and was moving between three patient stations while touching computer screens, drawing Heparin, and touching the dialyzer. Finding was verified with Staff #30 at the time of survey.

11. Clean supplies such as tissue rolls for the toilets, paper towels and other supplies were found stored in the soiled utility room of the Cardiac Cath lab. Similarly, clean supplies (exercise equipment, exercise pulleys and others) were found stored in the toilet of the Occupational therapy room of the inpatient Rehab Unit.

12. On 04/19/10 at 3:00 PM, during the observation of the Surgery unit/Operating Room (2nd floor-Cooke), it was noted that saline bags were hanging to be drained on the faucets of 4 different scrub sinks.

All findings were verified with Staff #2, Staff #34 and Staff #10 at the time of survey.

13. On 4/19/10 at 12:45 PM during observation of the medical surgical unit #6, Staff #12 was observed wearing a pair of gloves coming out of a patient room and walking with the gloved hands to another patient's room. Staff #8 and 25 witnessed this observation. During an interview, Staff #12 stated that she did not use the gloves on the patient in the previous room.

14. During environmental observation of the facility between 4/19/10 to 4/23/10, several multi-dose biological items were found with expired dates after they were opened in various locations of the facility. In some instances, the Staff were not clear about when a multi-dose item should be discarded. SEE A505.

15. On 4/20/10 at 1:15 PM, Staff #19 was observed while performing a catheter dressing change procedure in the Dialysis unit. It was observed that Staff #19:
a. Kept a supply of face masks in the pocket of her gown.
b. Did not wipe down the television as part of the station wipe down procedure at the conclusion of the treatment.
c. Did not remove the gloves she used to apply the dressing on the catheter site and used the same soiled gloves to remove face mask from the patient's face.
Staff #24 witnessed the findings.

16. An observation made on 4/19/10 at 12 noon in the Pharmacy revealed that an Emergency Room crash cart replacement box was found to be on the floor instead of on the shelf. The technician indicated she would wipe it down before placing it back.

Based on record review and interview, the hospital Quality Assurance Performance Improvement program is not structured to measure, analyze and track quality indicators for all services of the facility.

Findings include:

1. A review of Board Quality Committee minutes from July 31, 2009 to March 29, 2010 revealed that the current responsibilities of the Quality Council Board include reviewing core measures where thresholds are established, but not all indicators for all services are reviewed by the Quality Council. They are reviewed by the individual Board Quality Council Committees, and not all issues are forwarded to the Quality Council to be evaluated, analyzed and reviewed to determine what action was taken and if follow-up is needed.

Examples of some of the areas in which this was evident include: physical environment; mental health; safety; medication events; falls; and patient complaints.

2. Interview with Staff #1 on 4/21 and 4/22/2010 at 3:00 PM, revealed that the current QAPI program incorporates selected Dashboard items. Individual performance committees for all services meet and discuss items from the Dashboard. The structure will be changed to incorporate all areas of the hospital.