Every finding on record at Staten Island University Hospital

Observed in Record Review. In 8 of 13 patient records reviewed, The HCO did not ensure the patient's care plan goals were specific, measurable, realistic, and relevant over time. For example, the surveyor noted on 11630RRHV#1, 10370RRHV#3, 145NHV#2, 7634NHV#3, 10587NHV#4, 10804NHV#5, 9550NHV#6, and 11263NHV#7 care plan problems and goals included statements such as: “ adjustment need d/t change in patient's physical status. Goal: For Patient, Family/Friends, adjust to changed and changing physical condition by 8/9/23, Problem: bowel elimination constipation due to change in ADL's, For facility staff, achieve regular bowel function w/o s/s complications, using medication...., pt/family will understand techniques required to adapt to life change by 3/23, Anxiety Symptomatology due to change in health status, CPG: for pt, PCG demonstrate effective coping patterns, by 5/20/23., CO/Circulatory function CHG DSM due to complexity of the regimen. Both leg +4 edema. PCG: for pt, experience reduction in edema, by 7/10/23. problem airway clearance altered due to infection, For pt improvement of the movement of air in and of lungs lung gestion & rhinitis. evaluate every week by 6/22/23. Anxiety Symptomatology due to thereat to self-concept. For patient, demonstrate personal judgement of self-worth Pt needs to be productive. Adjustment needs due to change in pt's physical status, goal: for pt, family/friends, adjust to changed and changing physical condition. Adjustment needs due to impaired cognition, For patient, demonstrate reduced anxiety/fear, by 4/12/2023. bowel elimination constipation due to immobility, goal: for attending physician cg, family/friends, hired caregiver, maximize the ability of the gastrointestinal tract to form and evacuate stool effectively, using medication. skin/membrane integrity impaired due to disease process. Stage 2 right buttock, goal: for facility staff, identify/participate in behavior to reduce risk of infection, treat right buttock stage 2 as per md orders, by 6/6/23.” These goals do not contain specific information that can be accurately measured, to assist the staff in determining whether the patient is progressing towards achieving goals, and often do not change from one certification period to the next. These findings were reviewed, discussed, and confirmed with the Care Managers, Quality Managers, and Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, The HCO staff failed to adhere to the organization’s infection control policy as outlined. For example, on 11630RRHV#1, the surveyor observed the aides providing personal care, washing, and changing the patient’s brief, adjusting bed siderails, etc., moving between dirty areas to clean, without changing gloves in between. The organization’s Infection Prevention and Control policy requires gloves to be changed when going from dirty to clean area. These findings were reviewed, discussed, and confirmed with the Care Managers, Quality Managers, and Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, The aide care plan did not provide directions for personal care, specific to the patient’s diagnosis/condition. For example, on 11630RRHV#1, the surveyor noted the patient was receiving oxygen at 4 liters, via nasal cannula and had a chest tube in place. The aide was observed lying the patient flat in the bed, even though the patient’s chief complaint was shortness of breath. There were no instructions to the aide on the care plan related to patient positioning, respiratory considerations, or parameters for notifying the nurse. Additionally, on 10370RRHV#3, there were no specific instructions on the aide care plan regarding positioning and transfer, for a patient who required strict movement precautions, due to advanced bone metastases. Standards require a qualified person, responsible for supervision of the home health aide, provide written patient care instructions that specify aide duties. These findings were reviewed, discussed, and confirmed with the Care Managers, Quality Managers, and Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, The HCO did not ensure the patient’s discharge summary was completed and made available to the physician or licensed practitioner. For example, the surveyor noted on 9462RRDC#1 and 6309RRDC#2 the patient was discharged from the organization. The patient’s health record did not contain a discharge summary, nor was there any communication, informing the physician or practitioner who was assuming care of the patient that a summary was available. Standards require a discharge summary be completed for patients who discharge from the program alive. These findings were reviewed, discussed and confirmed by the Quality Manager, Care Manager and The Administrator.

Observed in Building Tour. A penetration was observed by the surveyor in the room- Electrical Closet. Multiple communication cables were observed through the wall/ceiling that did not have fire stop material around the exit point. An approximate half inch gap was noted. This penetration site was corrected on site with the appropriate fire stop material by the conclusion of the survey. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.

Observed in Building Tour. The Hospice did not ensure that the water utilized for patients remained adequately hot at all times. Based on a review of the available documentation and discussions with the facility managers, the Hospice did not test water temperatures in the facility based hospice unit.

Observed in Building Tour. The Hospice did not consistently store refrigerated food under sanitary conditions. During a tour of the kitchen, the surveyor observed multiple opened food items that did not have a date. A opened package of sausage links and popsicles were observed in the freezer and were not dated. Two bottles of salad dressing and a carton of whip cream were observed opened in the refrigerator with no dates. Based on discussions with the clinical manager, food should be discarded within three days.