HospitalInspections.org

Based on observation, interview and document review, the governing body does not carry out the functions required to effectively conduct the operations of the hospital.

Findings include:

Observation and interview revealed the chief executive officer failed to be responsible for managing the entire facility; specifically, the CEO was unaware of pathology procedures related to collection and storage of tissue specimens located in the Pathology Laboratory, and had not contracted with the pathologist to perform pathology services in the laboratory.
Cross refer to Tag A057.

Observation, interview and document review revealed the hospital does not provide proper management of Regulated Medical Waste every 30 days as required by Part 70 of NYCRR, due to lack of payment to the contracted waste hauler.
Cross refer to Tag A713.

Document review and interview revealed the hospital has not ensured an approved maintenance program for the fire alarm and fire suppression system in accordance with NFPA requirements is in place, as evidenced for the last two quarters of 2011. Review on 1/23/12 at 2:00 PM of the facility's "Quick Reference Fire Alarm and Suppression System Testing/Maintenance Log" revealed the service contractor had not been to the facility since 6/15/11. Prior to that date, the contractor had been onsite quarterly reviewing components of the system to ensure the complete review was conducted annually. Interview with Staff #15 revealed the company has not been maintaining the system due to lack of payment from the hospital.

NYSDOH Hospital Program staff received a telephone call from a public utility company employee on 1/23/12 to inform the DOH that the hospital had received a utility shut-off notice with an impending date of 2/16/12. The hospital would not commit to a payment plan. This was the second shut-off notice the hospital had received from this utility company in a five month period.

Based on observation and interview, the chief executive officer (CEO) failed to be responsible for managing the entire facility; specifically, the CEO was unaware of pathology procedures related to collection and storage of tissue specimens located in the pathology laboratory, and had not contracted with the pathologist to perform pathology services in the laboratory.

Findings include:

Observation during facility tour on 1/24/12 at 11:30 AM revealed numerous containers of tissue specimens stored on top of a laboratory fume hood. Interview with Staff #16 revealed Staff #17, a pathologist, occasionally obtains specimens from funeral homes and brings them to the hospital for examination conducted in the hospital's former pathology lab. The hospital currently has no pathology program. The specimen containers are labeled with name and date. Interview also revealed that the specimens are maintained until a time when a lawyer informs the pathologist they can be discarded. The specimens are then packaged for Regulated Medical Waste collection.

Interview on 1/25/12 at 9:00 AM with the CEO, Staff #2, revealed the facility does not have a contract with Staff #17 to perform pathology services in the laboratory. Staff #17 is, however, contracted as the laboratory's Medical Director. Staff #2 stated she was unaware that this service was being conducted in the facility's laboratory, and reiterated that she did not know Staff #17 was conducting pathology services at the facility.

Based on medical record review and interview, the hospital does not ensure patients are provided information regarding their Federal and State patients' rights for 5 of 5 clinic patients. (Patients #28-32)

Findings include:

Medical record review on 1/23/12 and 1/24/12 for Patients #28-32 revealed no evidence any of the patients received a copy of their patients' rights.

This finding was verified with Staff #1 on 1/25/12.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 2/11/08.

Based on document review, medical record review and interview, the facility has not implemented a process to appraise and evaluate demonstrated competence of all medical staff, as evidenced for 5 of 5 medical staff members. (Staff #4-8)

Findings include:

Review on 1/25/12 of the medical staff bylaws (last revised 1/11) revealed the following:
- Practitioner Specific Files: A separate file entitled Performance Improvement file shall be maintained in the medical staff office, containing only quality issues and kept confidential. This file shall contain accurate statistical data reflecting practice patterns, peer reviews, mortality reviews and adverse reviews by departments regarding complaints, events or occurrences. This information shall be summarized every two years by the chief of the appropriate department concurrently with recredentialing activities.
- Clinical privileges: Periodic re-determination of clinical privileges and the increase or curtailment of same shall be based upon the direct observation of care provided, review of the records of patients treated in this or other hospitals and review of the records of the medical staff, which document the evaluation of the member's participation in the delivery of medical care.

Review on 1/23/12 of the credential files for Staff #4-8 revealed no evidence of peer review or evaluations.

Interview on 1/23/12 at 3:36 PM, and 1/24/12 at 1:55 PM, with Staff #1 revealed the bylaws were revised in 2011 and a new peer review system has been developed. It is currently being completed on all midlevel practitioners in the detox and rehabilitation units. Prior to this, reviews were only done for "occurrences".

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 2/11/08.

Based on document review and medical record review, medical staff was not accountable for quality of care provided to Patient #15 as evidenced by lack of assessment related to seizure activity/precautions.

Findings include:

Review on 1/25/11 of the medical bylaws, Article 2- section 2 "Progress Notes" (last revised 1/11), revealed pertinent progress notes will be recorded at the time of observation. Whenever possible, each of the patient's clinical problems should be clearly identified in the progress notes and correlated with specific orders as well as results of tests and treatment.

Medical record review on 1/25/12 for Patient #15 revealed the following:

- Nursing progress note dated 11/14/11 at 2100 revealed the roommate notified the nurse that something was wrong with Patient #15. Patient #15 was found lying on the bed, stiffened with his eyes opened and fixed. He was unresponsive for 30-45 seconds. Afterward, Patient #15 denied previous seizure activity. A physician was notified and gave orders for seizure precautions. No evidence was found to indicate Patient #15 was examined by a physician following the seizure activity.
- Physician orders dated 11/14/11 through 11/16/11 revealed no evidence of an order for seizure precautions.
- The detox unit medicine notes dated 11/14/11 to 11/16/11 revealed no evidence of seizure activity or that seizure precautions were implemented. The "abnormal findings" section was blank for all three assessments.
- The discharge summary dated 11/29/11 indicated no history of withdrawal or seizures. No evidence was found of documentation that Patient #15 experienced a seizure while hospitalized.

Based on medical record review, nursing staff did not evaluate/monitor the care needs of Patient #15 as evident by inconsistent documentation related to seizure activity/precautions.

Findings include:

Medical record review on 1/25/12 for Patient #15 revealed the following:
- Nursing progress note dated 11/14/11 at 2100 revealed the room mate notified the nurse that something was wrong with Patient #15. Patient #15 was found lying on the bed, stiffened with his eyes opened and fixed. He was unresponsive for 30-45 seconds. Afterward, Patient #15 denied previous seizure activity. A physician was notified and gave orders for seizure precautions.
- Physician orders dated 11/14/11 through 11/16/11 revealed no evidence of an order for seizure precautions.
- The detox nursing flowsheets dated 11/14/11-11/15/11 revealed the mental status/neurological section indicated no seizure activity occuring. On 11/15/11 at 1930 seizure precautions were checked as "Yes". The nursing diagnosis section dated 11/14/11 at 1600 indicated a new onset withdrawal seizure, and on 11/15/11 at 1930 the issue was "still relevant".
- No other evidence of documentation/assessment related to seizure precautions was found in the record.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 2/11/08.

Based on policy and procedure review and observation, the facility does not ensure outdated drugs and biologicals are not available for patient use.

Findings include:

Review on 1/25/12 of policy "Expired Medications" (last revised 8/10) revealed on a monthly basis, the onsite pharmacist will remove all medications that expire the following month.

Review on 1/25/12 of policy "Dating of Open Sterile Containers" (last revised 8/10) revealed all sterile items for parenteral use will be labeled with the date, time and initials of the person opening the container. Multidose vials with preservative will be discarded 28 days after opening and must be labeled with the date, time and initials of person opening.

Observation during facility tour on 1/23/12 revealed the following:
- At 9:45 AM in the rehabilitation unit:
-3 500 ml 5% dextrose IV bags located in the medication cabinet, expired 7/11.
-1 50 ml 0.9% sodium chloride bag located in the medication cabinet, expired 2/11.
-2 20 ml 2% lidocaine located in the medication cabinet, expired 8/1/11.
-2 20 ml 2% lidocaine located in the medication cabinet, expired 12/1/11.
-6 triple antibiotic ointment packets located in the medication cabinet, expired 6/11.
-1 Atropine Sulfate injection, 1 mg, located in emergency drug box, expired 12/1/11.
-2 0.9% sodium chloride located on the PPE cart, expired 9/1/11.
-6 50 ml 0.9% Sodium Chloride for IV use, expired 8/11.
-1 50 ml 5% Dextrose for IV use, expired 8/11.

- At 11:00 AM in the primary care suite:
-2 0.9% sodium chloride IV bags located in the cabinet, expired 6/11.
-3 500 ml 0.9% Sodium Chloride IV bags, expired 9/11.
-8 triple antibiotic ointment packets located in exam room #7, expired 7/10.
-6 triple antibiotic ointment packets located in exam room #8, expired 2/10.
-3 triple antibiotic ointment packets located in the medication cabinet, expired 6/10.
-1 refrigerated influenza vial was opened, but not dated or initialed.
-1 refrigerated 60 mg syringe was labeled as Toradol, but not dated or initialed when drawn up.
-1 refrigerated tuberculin vial was opened, but not dated or initialed.
-2 10% povidone antiseptic ampules, expired 4/01.

- At 11:20 AM in the clean utility room on the Primary Care side:
-3 50 ml 5% Dextrose IV bags, expired 5/11.
-3 100 ml 5% Dextrose IV bags, expired 8/11.
-1 50 ml 0.9% Sodium Chloride IV bags, expired 8/11.
-6 10 ml 0.9% Sodium Chloride for injection, expired 7/11.

- At 11:30 AM in the sample medication room:
-1 refrigerated tuberculin vial opened, but not dated or initialed.
-1 refrigerated influenza vial opened, but not dated or initialed.

- At 11:50 AM in radiology department:
-4 0.2 mg clonidine tablets were found in the drawer of the sonogram machine.
-2 0.9% sodium chloride IV bags located in the cabinet, expired 10/11.
-4 0.9% sodium chloride IV bags located in the cabinet, expired 8/11.
-1 30 ml milk of magnesium caplet located in the cabinet, expired 3/11.

- At 1:00 PM in the intake room:
-2 500 ml of 5% Dextrose IV bags, expired 7/11.

These findings were verified with Staff #1 on 1/23/12.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 2/11/08.

Based on observation and interview, the hospital does not maintain patient rooms in a clean and sanitary manner.

Findings include:

Observation during facility tour on 1/23/12 at 11:30 AM revealed rooms #504 and 505 were not cleaned after discharge of the previous patient. White powder was found on the mattress of the 505 window bed. The toilet and sink in the restroom were also dirty. Dust was found throughout both rooms, under the beds and in corners. The hot and cold water faucet handles were in disrepair. Interview with Staff #11 on 1/23/12 revealed it had been "a few days" since the last patients were discharged from the rooms.

These findings were verified with Staff #1 on 1/23/12.

Based on observation, interview and document review, the hospital does not provide proper management of Regulated Medical Waste every 30 days as required by Part 70 of NYCRR.

Findings include:

Observation during facility tour on 1/23/12 between the hours of 10:30 AM and 2:00 PM revealed sharps storage containers located in points of use such as exam rooms and soiled holding rooms throughout the facility to be full or overfull. Interview with Staff #15 revealed the facility was having difficulty obtaining replacement containers.

Observation during facility tour on 1/24/12 at 11:45 AM revealed the Medical Waste Storeroom was filled to capacity with boxed regulated medical waste. Interview with Staff #15 revealed the contracted waste hauler had not made a pick-up in months due to lack of payment from the hospital. Review of the Stericycle medical waste manifests revealed the last date of service was May 2011.

Based on observation, the facility does not maintain patient care supplies in a manner safe for patient use.

Findings include:

Observation during facility tour on 1/23/12 revealed the following:
- At 9:45 AM in the rehabilitation unit:
-2 18 gauge IV catheters located on the PPE cart, expired 6/11.
-1 culture swab located in the medication room, expired 12/11.
-1 prep kit located in the medication room, expired 2/11.
-2 Foley catheter kits located in the medication room, expired 9/11.
-3 red top phlebotomy tubes located in the medication room, expired 2/11.
-1 purple top phlebotomy tube located in the medication room, expired 6/11.
-1 20 gauge IV catheter located in the medication room, expired 5/11.
-5 Medimark dressing change trays located in clean utility, expired 12/11.
-8 Unisex collection culture swabs located in clean utility, expired 12/31/11.
-2 bottles DermaRite Hand E Foam located in clean utility, expired 8/09.
-2 lavender top Vacutainer tubes located in clean utility, expired 11/11.
-2 blue top Vacutainer tubes located in clean utility, expired 1/11 & 7/11.

- At 11:00 AM in the primary care suite:
-1 25 mm intubation stylet located in the consultation/teaching room, expired 5/02.
-2 5.5 endotracheal tubes located in the consultation/teaching room, expired 5/02.
-1 4.5 endotracheal tube located in the consultation/teaching room, expired 5/02.
-4 duo iodine swabs located in the consultation/teaching room, expired 7/11.
-2 tongue depressors located in the consultation/teaching room, expired 9/09.
-4 duo iodine swabs located in exam room #7, expired 7/11.
-6 surgical lubricant packets located in exam room #8, expired 6/11.
-1 7.5mm Portex trach tube located in gray box on the crash cart, expired 7/11.
-3 lavender top Vacutainer tubes located in the crash cart, expired 11/11.

- At 11:50 AM in the radiology department:
-4 lavender top Vacutainer tubes located in the cardiac rehab suite, expired 12/10.
-3 blue top Vacutainer tubes located in the cardiac rehab suite, expired 12/10.
-The cabinets located in the control area had patient care supplies and cleaning supplies housed together.

- At 2:00 PM in the intake department:
-1 box of duo iodine swabs located in exam room #2, expired 7/11.

These findings were verified with Staff #1 on 1/23/11.