PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D 000 8:43G INITIAL COMMENTS PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D 000 A State Survey was conducted on January 6-10, 2014. 40 Medical Records were reviewed. Areas toured included: Emergency Department, Intensive Care Unit (ICU), 3West (Medical/Surgical Unit), Labor & Delivery, Post Partum, Pediatrics, Nursery, Operating Rooms, Endoscopy, PACU, Same Day Surgery, SPD, Pharmacy, Kitchen, Radiology, Laboratory, Nuclear Medicine, Acute Hemodialysis. D 384 8:43G-4.1(a) PATIENT RIGHTS: PATIENT D 384 RIGHTS Every New Jersey hospital patient shall have the following rights, none of which shall be abridged by the hospital or any of its staff. The hospital administrator shall be responsible for developing and implementing policies to protect patient rights and to respond to questions and grievances pertaining to patient rights. This REQUIREMENT is not met as evidenced by: Based on document review and staff interview, it was determined that the facility failed to ensure that the "Informed Consent for Surgery/Procedure" policy was implemented regarding telephone consents. Findings include: LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 03/28/14 STATE FORM 6899 G7T911 If continuation sheet 1 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D 384 Continued From page 1 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D 384 Reference: Facility policy titled, "Informed Consent for Surgery/Procedure" states, "Policy: ... Telephone Consent: If verbal or telephone consent is obtained for either an adult or minor patients, it must be witnessed by two hospital personnel and documented in the medical record ... Additionally, when this procedure is used, the written consent must be received shortly thereafter and a copy placed in the medical record ..." 1. Review of Medical Record #2 indicates that this patient underwent a procedure/treatment on 12/20/13, 12/29/13 and 1/2/14. The consents for these procedures/treatments were obtained via telephone. a. There was no evidence that a copy of the written consents for the procedures/treatment done on 12/20/13, 12/29/13 and 1/2/14 were present in the medical record. b. The above was confirmed by Staff #6. 2. Review of Medical Record #32 indicated that this patient underwent a procedure/treatment on 6/24/13, and two on 6/25/13. The consents for these procedures/treatments were obtained via telephone. a. There was no evidence that a copy of the written consents for the procedures/treatments done on 6/24/13 and 6/25/13 were present in the medical record. b. The above was confirmed by Staff #22. STATE FORM 6899 G7T911 If continuation sheet 2 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG D 447 Continued From page 2 D 447 D 447 8:43G-4.1(a)(21) PATIENT RIGHTS: PATIENT D 447 (X5) COMPLETE DATE RIGHTS The patient rights shall include at least the following: To confidential treatment of information about the patient. Information in the patient's records shall not be released to anyone outside the hospital without the patient's approval, unless another health care facility to which the patient was transferred requires the information, or unless the release of the information is required and permitted by law, a third party payment contract, a medical peer review, or the New Jersey State Department of Health. The hospital may release data about the patient for studies containing aggregated statistics when the patient's identity is masked. This REQUIREMENT is not met as evidenced by: Based on observations during a tour of the Emergency Department and staff interview, it was determined that the facility failed to ensure confidential treatment of information about all patients. Findings include: 1. During a tour of the Emergency Department, conducted at approximately 10:00 AM on 1/6/14, in the presence of Staff #5, the Urine Pregnancy Test Book was found in the unlocked Clean Utility Room of the Fast Track Area. STATE FORM 6899 G7T911 If continuation sheet 3 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D 447 Continued From page 3 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D 447 a. This book contained numerous test results recorded next to computer printed patient labels. b. These labels contained the patient names and dates of birth. c. This finding was confirmed by Staff #5. D1803 8:43G-8.1(e)(1) CENTRAL SERVICE: POLICIES D1803 & PROCEDURES Methods for processing reusable medical devices shall conform with the following or revised or later editions, if in effect, incorporated herein by reference: The Association for the Advancement of Medical Instrumentation (AAMI) requirements, "Good Hospital Practice: Steam Sterilization and Sterility Assurance." ST 46 This REQUIREMENT is not met as evidenced by: A. Based on observation and document review, it was determined that the facility failed to follow AMMI ST. 79 Guidelines for the early release of Implants. Findings Include: Reference: #1: AMMI ST.79: 2010, section (10.6.3) "Release criteria for implants" states, "Emergency situations should be defined in written guidance developed in consultation with infection prevention and control, the surgeon and risk management. Steps should be taken to reduce the frequency of emergency release of implantable items. For example, ongoing periodic reviews of the exception forms and STATE FORM 6899 G7T911 If continuation sheet 4 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D1803 Continued From page 4 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D1803 implant logs could reveal consistence patterns of events that are causing emergency release and that could be corrected." Reference: #2: The facility policy titled "Release of Implants" states, "The package or tray with the implantable device will be quarantined until the BI (Biological Indicator) is read as negative, except in an extremely rare case of a documented medical emergency." 1. On 1/6/14 at 11:00 AM, a review of BI Implantable early release records from May 2013 to December 2013 revealed two instances where devices were released prior to a negative BI for non-emergency criteria. a. On 5/20/13, a synthesis Mini Fragment #10 was released prior to the negative BI due to insufficient time between procedures. b. On 11/7/13, a Stryker Hoffman 3 external fixation system was released prior to a negative BI for non-emergency criteria. This procedure was an elective surgery, not an emergency. B. Based on observation and staff interview, it was determined that the facility failed to ensure that the processing of reusable medical devices conform with the Association for the Advancement of Medical Instrumentation(AAMI) ST79:2006 Comprehensive guide to Steam Sterilization and sterility assurance in health care facilities (ST 79 replaces and supercedes ST46 by consolidating ST 46 with 4 other AAMI standards [ST33, ST37, ST42, and ST35] approved 7/10/2009). Findings include: Reference #1: AAMI ST 79 section 6.5.1 on STATE FORM 6899 G7T911 If continuation sheet 5 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D1803 Continued From page 5 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D1803 "Transportation scheduling and routes" states, "The pickup and transport of soiled items from each area should be scheduled so that the items are transported and cleaned as soon as possible after becoming soiled." Reference #2: AAMI ST 79 section 6.5.2 on "Transportation equipment" states, "Transport system should be designed to prevent items from falling over or off during transport. Carts, reusable covers, and bins and other containers should be decontaminated after each use." 1. On 1/7/14 at 11:00 AM, one open cart containing contaminated instrument trays, waiting to be picked up by the Central Processing Department, were stored in the Soiled Storage Room of the Operating Room Suite. Staff #15 was asked how often the soiled instruments are picked up to be transported to the Central Processing Department. He/she stated that instruments are usually picked up as soon as the procedures are completed. Policies and procedures on transportation of contaminated items was not available upon request. Reference #3: AAMI ST 79 section 8.9.2 on "Storage facilities" states, "Sterile items should be stored in a manner that reduces the potential for contamination. In general, the temperature in storage areas should be approximately 240F (750F). There should be at least 4 air exchanges per hour and relative humidity should be controlled so that it does not exceed 70% (AIA 2006)." 1. On 1/7/14, a tour of the new OR Sterile Storage Rooms was conducted in the presence of Staff #15. During this time, it was determined through interview with Staff #15 that the STATE FORM 6899 G7T911 If continuation sheet 6 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D1803 Continued From page 6 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D1803 temperature and relative humidity were not being monitored in the new OR Sterile Storage Rooms. D2232 8:43G-10.1(a) DIETARY: POLICIES & D2232 PROCEDURES The dietary service shall have written policies and procedures for all dietary services that are reviewed at least once every three years, revised more frequently as needed, and implemented. This REQUIREMENT is not met as evidenced by: Based on staff interview and document review, it was determined that the facility failed to ensure that all dietary service policies and procedures are implemented. Findings include: Reference #1: Facility policy titled, "Calibrating Thermometers" states, "On or about the first of each month, all pocket and/or thermo-couple thermometers will be checked and calibrated according to the manufacturer's directions." Reference #2: Facility policy titled, "Temperature Logs" states, "To provide the highest quality of food and to prevent the growth of undesirable microorganisms and other food spoilage, food temperatures are recorded as per the attached food logs." Reference #3: The "Cooks Temperature Log Note" section states, "All hot food items must STATE FORM 6899 G7T911 If continuation sheet 7 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D2232 Continued From page 7 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D2232 reach 165 degrees Fahrenheit or above before being placed in trayline's steam table." 1. On 1/7/14, Staff #37 could not provide evidence that thermometers are calibrated on a monthly basis, as required in Reference #1. 2. On 1/7/14, Staff #37 could not provide evidence that cooks record food temperatures in the "Cook's Temperature Log" before being placed in the trayline's steam table, as required in Reference #2 and Reference #3. 3. The above findings were confirmed by Staff #37 on 1/7/14 at 11:45 AM. D2235 8:43G-10.1(b) DIETARY: POLICIES & D2235 PROCEDURES A diet manual detailing nutritional and therapeutic standards for meals and snacks, and a nutrient analysis of menus, shall be annually reviewed. A current diet manual shall be available at each nurses station and in the dietary department and medical library. This REQUIREMENT is not met as evidenced by: Based on staff interview and document review, it was determined that the facility failed to ensure that the therapeutic diet manual and the nutrient analysis of menus are reviewed annually. Findings include: 1. On 1/8/14 at 10:45 AM, Staff #33 and Staff STATE FORM 6899 G7T911 If continuation sheet 8 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D2235 Continued From page 8 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D2235 #37 could not provide evidence that the "Nutrition Care Manual" and the nutrient analysis of menus were reviewed annually. 2. The above findings were confirmed by Staff #33 on 1/8/14 at 10:45 AM. D2301 8:43G-10.6(q) DIETARY: PATIENT SERVICES D2301 The dietary service shall comply with the requirements of Chapter XII of the New Jersey State Sanitary Code, "Sanitation in Retail Food Establishments and Food and Beverage Vending Machines" (N.J.A.C. 8:24). This REQUIREMENT is not met as evidenced by: Based on staff interview, document review, a tour of the kitchen, and lunch meal observations, it was determined that the Director of Food and Nutrition Services failed to ensure compliance with the New Jersey State Sanitation Code: "Sanitation in Retail Food Establishments and Food and Beverage Vending Machines (Chapter 24)" of the NJ State Sanitary Code NJAC 8:24. Findings include: Reference #1: The Director of Food and Nutrition Services job description states, "Formulate and implement departmental policies and procedures that ensure all food preparation, food storage and food distribution areas comply with hospital, local, county, state and federal policies and sanitation standards." STATE FORM 6899 G7T911 If continuation sheet 9 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D2301 Continued From page 9 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D2301 Reference #2 : NJAC 8:24-2.1(b) states, "The person in charge shall demonstrate to the health authority knowledge of food borne disease prevention , application of the hazard Analysis Critical Control Point (HACCP) principles, and the requirements of this chapter." Reference #3: NJAC 8:24-4-2(c)2 states, "A temperature measuring device with a suitable small diameter probe that is designed to measure the temperature of thin masses shall be provided and readily accessible to accurately measure the temperature thin foods." Reference #4: NJAC 8:24-4-2(c)3 states, "Food temperature measuring devices shall be designed to be easily readable and accurate to two degrees Fahrenheit in the intended range of use and shall be calibrated in accordance with manufacturer's specifications as necessary to ensure their accuracy." Reference #5: NJAC 8:24-6.5(b) states, "The physical facilities shall be cleaned as often as necessary to keep them clean." Reference #6: 8:24-6.5(a) states, "The physical facilities shall be maintained in good repair." 1. On 1/7/14, in the presence of Staff #33 and Staff #37, the following deficient practices were observed: a. Just before the start of the lunch meal trayline at 11:30 AM, Staff #38 and Staff #39 lacked a calibrated small diameter probe thermometer to record the lunch meal food items temperatures. Staff #38 and Staff #39 had a standard tip, un-calibrated thermometer for use. Staff #38 and Staff #39 could not explain or demonstrate the STATE FORM 6899 G7T911 If continuation sheet 10 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D2301 Continued From page 10 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D2301 appropriate thermometer calibration technique. Staff #37 stated that if a thermometer a is not working correctly, the staff are to dispose of it and get a new one. Refer to Reference #3 and Reference #4. b. The ware washing area walls and ceiling were not maintained clean. The walls and ceiling had an accumulation of dried food splatter residue on them. Refer to Reference #5. 2. The above findings were confirmed by Staff #37 on 1/7/14 at 11:55 AM. Reference #7: Facility policy on "72 hour dating" states, "Any food products removed and fabricated or used from its original packaging that will be wrapped or held for a later application, placed in refrigeration, will receive a date marking it 72 hours from the current date. At the conclusion of the 72 hours or date marked on the container, the product is to be discarded." 1. During a tour of the kitchen on 1/8/14, three (3) wrapped packages of pre-sliced deli-meats labeled "03-14" were found in the refrigerator. Food products, placed in refrigeration, were not dated as required in Reference #7. Reference #8: N.J.A.C. 8:24-7.2(b) states, "Only those poisonous or toxic materials that are required for the operation and maintenance of a retail food establishment, such as for the cleaning and sanitizing of equipment and utensils and the control of insects and rodents, shall be allowed in a retail food establishment..." 1. During a tour of the kitchen on 1/8/14, a spray STATE FORM 6899 G7T911 If continuation sheet 11 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D2301 Continued From page 11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D2301 bottle and a red bucket containing a solution were found in the production kitchen without proper identification labels. Reference #9: N.J.A.C. 8:24-6.2(n) states, "... outer openings of a retail food establishment shall be protected against the entry of insects and rodents by: filling of closing holes and other gaps along the floors, walls and ceilings; closed, tight-fitting windows; and solid self-closing, tight-fitting doors." 1. During a tour of the kitchen on 1/8/14, the loading doors that lead to the outside were noted with visible gaps along the door bottom. The outer opening was not protected against the entry of insects or rodents as required in Reference #9. Reference #10: N.J.A.C. 8:24-4.9(k) states, "In a mechanical operation, the temperature of the fresh hot water sanitizing rinse as it enters the manifold may not be more than 194 degrees Fahrenheit, or less than: 1. For a stationary rack, single temperature machine, 165 degrees Fahrenheit; or 2. For all other machines, 180 degrees Fahrenheit." 1. On 1/8/14 at 10:30 AM, the hot water sanitizing rinse temperature in the mechanical warewashing machine failed to reach 180 degrees Fahrenheit due to steam failure. The temperature of the warewashing machine was not maintained as required in Reference #10. Reference #11: N.J.A.C. 8:24-6.2(a) states, "The floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so that they are smooth and easily cleanable..." STATE FORM 6899 G7T911 If continuation sheet 12 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D2301 Continued From page 12 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D2301 1. During a tour of the kitchen on 1/8/14, a puddle of stagnant water was noted directly under the mechanical warewashing machine due to a clogged floor drain. The floor was not maintained as required in Reference #11. D2307 8:43G-10.10(a) DIETARY: Continuous Qual. D2307 Improvement METHODS There shall be a program of continuous quality improvement for dietary services that is integrated into the hospital continuous quality improvement program and includes regularly collecting and analyzing data to help identify health-service problems and their extent, and recommending, implementing, and monitoring corrective actions based on this data. This REQUIREMENT is not met as evidenced by: Based on staff interview and document review, it was determined that the facility failed to ensure a program of continuous quality improvement for dietary services that includes regularly collecting and analyzing data and recommending, implementing and monitoring corrective actions based on this data. Findings include: Reference #1: The Quality Improvement policy states, "Purpose: To help identify and measure nutritional related issues to determine nutrition status of hospitalized patients. To assist in evaluating performance of Dietary staff. assist STATE FORM 6899 G7T911 If continuation sheet 13 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D2307 Continued From page 13 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D2307 management in measure staffing effectiveness. to communicate nutritional activities with administration (To compile statistics to benchmark staffing requirements and productivity. Procedure Monthly data will be collected and analyzed in the following areas: Clinical Productivity, Hostess rounding, Test Trays Patient Rounding." 1. On 1/7/14 and 1/8/14, Staff #37 could not provide evidence of a dietary services quality assurance plan for 2013 and 2014; including problem identification, collecting, monitoring and analyzing data, recommending, implementing and monitoring corrective actions. 2. On 1/8/14 Staff #37 provided for review a document titled, "Food and Nutrition Compliance Grid, a listing of the state licensing standards for dietary services." This document did not contain indicators, data collection, analysis or monitoring for corrective actions for a quality improvement plan. 3. On 1/8/14 Staff #37 provided for review a document titled "Performance Measurement Plan and Findings, Year 2012" for "Temperature of Food Indicator." The benchmark indicator is documented as 80. a. The 2012 Quarterly mean scores documented for the first quarter is 86.4 b. The 2012 Quarterly mean scores documented for the second quarter is 86.46. c. The 2012 Quarterly mean scores documented for the third quarter is 82.6. d. The 2012 Quarterly mean scores documented STATE FORM 6899 G7T911 If continuation sheet 14 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D2307 Continued From page 14 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D2307 for the fourth quarter is 77.7. e. The 2013 monthly mean scores documented for January is 77.1; February is 87.5; March is 79.6; April is 77.5; May is 77.9; June is 80.2. i. Four of the six monthly scores reported in 2013 were below the facility benchmark of 80. ii. Staff #37 could not provide evidence of action plans to analyze the collected data, recommend, implement and monitor corrective actions. f. On 1/7/14 at 10:50 AM, Staff #37 stated that the food temperatures were improved and it was decided to discontinue this monitor as of June 2013. 4. The above findings were confirmed by Staff #1 on 1/8/14 at 3:15 PM. D2343 8:43G-11.5(d) DISCHARGE PLANNING: D2343 PATIENT SERVICES The patient shall participate in the development of the discharge plan, where possible. The family or significant other shall participate in the development of the plan, where possible, and when the patient is able to agree, and does agree, to their involvement. This REQUIREMENT is not met as evidenced by: Based on medical record review, staff interview, and patient/family interviews, it was determined STATE FORM 6899 G7T911 If continuation sheet 15 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D2343 Continued From page 15 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D2343 that the facility failed to ensure that discharge planning was discussed with the patient or the patient's representative and documented in the medical record. Findings include: 1. On 1/7/14, review of Medical Record #23 indicated that the patient was admitted to the facility on 12/30/13. The Case Management initial note dated 12/31/13, identified no discharge needs. The next note and final disposition dated 1/6/14 indicated the patient was being discharged to a rehabilitation center and that the patient/family was aware of the arrangement. a. There was no evidence in the medical record that any subsequent discharge planning was discussed with the patient or the patient's representative prior to the final disposition. 2. On 1/8/14, review of Medical Record #34 indicated the patient was admitted to the facility on 1/2/14. The Case Management initial note dated 1/2/14, identified no discharge needs. a. There was no evidence in Medical Record #34 of a discharge planning process, however, interview with the Patient #34's family on 1/8/14, in the presence of Staff #22, revealed that discharge planning was discussed with the Social Worker. 3. On 1/6/14 review of Medical Record #8 indicated the patient was admitted to the facility on 12/28/13. The Case Management initial note dated 12/30/13, identified no discharge needs. a. There was no evidence in Medical Record #8 of a discharge planning process, however, STATE FORM 6899 G7T911 If continuation sheet 16 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D2343 Continued From page 16 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D2343 interview with the Patient #8's family on 1/8/14, in the presence of Staff #22, revealed that discharge planning was discussed with the Social Worker. 4. The above was confirmed by Staff #16 and Staff #22. D2346 8:43G-11.5(e) DISCHARGE PLANNING: D2346 PATIENT SERVICES Discharge planning shall be initiated within 24 hours of admission in accordance with N.J.A.C. 8:43G-18.5(d) and 33.2(c). If a patient's needs for post-discharge care change after a discharge plan is developed, the plan shall be modified to meet the patient's needs. This REQUIREMENT is not met as evidenced by: Based on medical record review, review of facility policies and procedures, and staff interview, it was determined that the facility failed to ensure that the Interdisciplinary Discharge Planning and the Initial Assessment/Reassessment policies were implemented for discharge planning. Findings include: Reference #1: Facility policy titled "Interdisciplinary Discharge Planning" states, "Procedure/Process: ... 3. Case Management Responsibility: ... Case Management staff will be responsible for documentation of all findings, recommendations and interventions. K. The discharge plan will be reviewed upon notification STATE FORM 6899 G7T911 If continuation sheet 17 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D2346 Continued From page 17 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D2346 of any change in the patient's condition or situation. The plan shall be re-evaluated and documented in the medical record, as indicated." Reference #2-Facility policy titled, "Initial Assessment/Reassessment" states, "... Process: ... Reassessment will be done if there is a change in patient's condition or diagnosis. Reassessments will be documented in the interdisciplinary progress notes. Documentation must be frequent enough to provide current and pertinent communications to the health care team, but no less than once a week while the care remains open. A final note will be documented detailing all resolutions and final discharge plan(s)." 1. Review of Medical Record #3 revealed the following: a. The Hospitalist's note on 8/16/13 indicated that Patient #3 was admitted to the facility on 8/16/13 with altered mental status and the diagnosis of hyponatremia, acute renal failure, elevated creatine kinase, hypochloridemia, anemia, and drug abuse. The patient was initially seen on 8/17/13 and subsequently on 8/18/13, 8/19/13, 8/20/13, 8/21/13, 8/22/13 and 8/30/13, by a Psychiatrist. The patient was diagnosed with a Psychotic Disorder and placed on Risperdal. The Hospitalist's note dated 8/18/13 indicated that the patient was to be discharged to ___ [a hospital] psychiatric ward when a bed was available. b. The patient was medically cleared and was assessed by two psychiatric hospital screeners on 8/28/13 and 8/30/13, who determined the patient did not meet commitment criteria and was not in danger to self and others. STATE FORM 6899 G7T911 If continuation sheet 18 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D2346 Continued From page 18 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D2346 c. On 8/29/13 and 8/30/13, the Hospitalist's note indicated the patient was homeless and that the social worker was aware and was trying to find a shelter post discharge. d. On 8/30/13, the Case Management note stated, "... The previous Screener who came from ... on 8/28/13 reported that the hospital should send the patient to the shelter facility. This patient has diabetes & HTN [hypertension], in addition to the psychiatric disorder. Shelter will not provide medical treatment this patient needs ..." e. On 8/31/13, 9/1/13 and 9/2/13, the Hospitalist's note indicated the patient was cleared for discharged to a psychiatric hospital; there was no mention of the patient being discharged to a shelter. f. On 8/31/13, the Case Management note indicated that a referral was made to another hospital for voluntary psychiatric admission. g. On 9/3/13, the Hospitalist note indicated that the patient was being held until a bed was found at a facility (for psychiatric admission). There was no Hospitalist notes in the medical record for 9/4/13 and 9/5/13. h. Review of a nurse's note on 9/3/13 at 4:15 PM indicated that a Dr. ____ (psychiatrist, as per Staff #1) was to see the patient. In addition, there was communication with two hospitals for evaluation/admission to a psychiatric unit and submission of patient information. The nurse documented communication with Case Management and a Physician on the unit. (i.) There was no evidence in the medical record STATE FORM 6899 G7T911 If continuation sheet 19 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D2346 Continued From page 19 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D2346 of a psychiatric exam/consult by the psychiatrist on 9/3/13, as indicated in the nurse's note, dated 9/13/13. i. On 9/5/13, during the day shift, the nurse documented in the nurses' notes that the Psychiatrist was made aware of the patient status to be discharged and that no psychiatric ward would accept the patient, according to Case Management. In addition, the nurse's note states that Case Management was conversing with the medical resident about discharge plans. In the afternoon of 9/5/13, the nurse documented that the he/she spoke with Case Management and an "order for d/c [discharge] to a shelter in ___ [name of shelter] arranged by social services." The discharge nursing instruction on 9/5/13 indicated the patient was sent to a shelter with no medications or prescriptions for medications. j. The medical record indicated that the patient was taking Protonix 40 mg. daily, Risperdone 1 mg. twice daily, Sodium Chloride 500 mg. daily, Norvasc 10 mg. daily, and Glipizide 5 mg. daily. The nurse's notes also indicate that the patient was on a one to one observation with a sitter for safety as the patient's mental status fluctuated from being calm to being agitated, with periods of confusion and acting strangely. However, from the evening of 9/2/13 to the day of discharge on 9/5/13, the patient was calm, cooperative, with some confusion. 2. With the absence of the Hospitalist's notes of 9/4/13 and 9/5/13, the Psychiatrist's note of 9/3/13 and the Social Worker final note, it could not be determined if the patient was provided a safe discharge. 3. In reviewing the Case Management STATE FORM 6899 G7T911 If continuation sheet 20 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D2346 Continued From page 20 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D2346 documentation regarding findings, recommendations and interventions for discharge planning for Patient #33, there were only two entries documented, 8/30/13 and 8/31/13. There was no evidence of a final note documenting all resolutions and final discharge plan. 4. The above referenced policies were not implemented. 5. This was confirmed by Staff #1. D2745 8:43G-12.11(a) EMERG DEPT/TRAUMA SVCS: D2745 Emerg CQI METHODS There shall be a program of continuous quality improvement for the emergency department that is integrated into the hospital continuous quality assurance program and includes regularly collecting and analyzing data to help identify health-service problems and their extent, and recommending, implementing, and monitoring corrective actions on the basis of these data. This REQUIREMENT is not met as evidenced by: A. Based on review of facility documentation and staff interview, it was determined that the facility failed to document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects for the Emergency Department. Findings include: STATE FORM 6899 G7T911 If continuation sheet 21 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D2745 Continued From page 21 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D2745 1. On 1/8/14, Staff #5 was interviewed regarding Performance Improvement projects being conducted in the Emergency Department. He/She presented two documents titled "Quality/Performance Indicators." a. The first document was measuring "tracking the time period duration of lab procedures." i. All of the data was entered in July 2013. ii. There was no evidence that the data was used to improve processes. b. The second document was measuring "applying correct ID bands to patients." i. All of the data was entered in August 2013. ii. There was no evidence that the data was used to improve processes. c. Staff #5 stated that they were comprehensive projects that involved reviews of every patient for the month indicated. i. There was no ongoing study of the information provided in the documents. d. These findings were confirmed by Staff #5 and Staff #36. B. Based on review of facility documents and staff interview, it was determined that the facility failed to ensure that data collected was used to identify opportunities for improvement and changes that will lead to improvement. STATE FORM 6899 G7T911 If continuation sheet 22 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D2745 Continued From page 22 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D2745 Findings include: 1. Review of the facility's 2013 "Quality Dashboard," conducted at approximately 9:45 AM on 1/8/14 in the presence of Staff #36, revealed the following: a. Emergency Department indicators were as follows: number of ED (Emergency Department) transfers; number of patients leaving AMA (against medical advice); number of patients left prior to triage; number of patients left before being seen by a physician; number of patients return to ED within 72 hours. i. There was no evidence that the data collected on these indicators was used to identify opportunities for improvement. b. "Codes" contained the following indicators: number of true code blues and number of rapid response calls. i. There was no evidence that the data collected on these indicators was used to identify opportunities for improvement. 2. These findings were confirmed by Staff #36. D3051 8:43G-13.4(d) HOUSEKEEPING/LNDRY/SANI: D3051 HOUSEKEEPING PT SVCS Floors shall be kept clean. This REQUIREMENT is not met as evidenced by: Based on observation, it was determined that the STATE FORM 6899 G7T911 If continuation sheet 23 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D3051 Continued From page 23 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D3051 facility failed to ensure that floors are kept clean. Findings include: 1. On 1/7/14, the floor perimeters of an unused autoclave area, located between Operating Room #1 and Operating Room #2, were unclean with old paint chips and dust accumulation surrounding the old steam generator. 2. On 1/6/13 at 10:55 AM, in the presence of Staff #4, a brown sticky substance was on the floor near the electrical service panels in the Kitchen. 3. On 1/6/13 at 11:25 AM, in the presence of Staff #4, dirt and debris was under the Nurse's Station in the Emergency Department. D3056 8:43G-13.4(h) HOUSEKEEPING/LNDRY/SANI: D3056 HOUSEKEEPING PT SVCS Walls, ceilings, and vents shall be kept clean to sight and touch and odor-free. This REQUIREMENT is not met as evidenced by: Based on observation, it was determined that the facility failed to ensure that walls are kept clean to sight and touch. Findings include: 1. On 1/7/14, chipping paint was observed along the wall perimeters of the storage area located between Operating Room #5 and Operating STATE FORM 6899 G7T911 If continuation sheet 24 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D3056 Continued From page 24 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D3056 Room #7. 2. On 1/9/14 at 9:55 AM, in the presence of Staff #4, the wall behind the headboard of the bed in Room #387 was coated with a white gritty substance that is not cleanable. D3057 8:43G-13.4(i) HOUSEKEEPING/LNDRY/SANI: D3057 HOUSEKEEPING PT SVCS Windows and screens shall be kept clean to sight and touch, and in good repair. This REQUIREMENT is not met as evidenced by: Based on observation, it was determined that the facility failed to ensure windows are in good repair. Findings include: 1. On 1/6/14 at 10:15 AM, in the presence of Staff #4, the glass window was cracked in the Conference Room. 2. On 1/6/14 at 12:00 PM, in the presence of Staff #4, the glass window was cracked in the Stress Testing Room. D3058 8:43G-13.4(j) HOUSEKEEPING/LNDRY/SANI: D3058 HOUSEKEEPING PT SVCS Mattresses, mattress pads and coverings, pillows, bedsprings, and other furnishings shall be properly maintained and kept clean. They shall be thoroughly cleaned and disinfected upon discharge of each patient. STATE FORM 6899 G7T911 If continuation sheet 25 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D3058 Continued From page 25 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D3058 This REQUIREMENT is not met as evidenced by: Based on observation, it was determined that the facility failed to ensure furnishings were properly maintained. Findings include: 1. On 1/6/14 at 12:30 PM, in the presence of Staff #4, the outer fabric of two chairs were worn through exposing the inner padding in the Same Day Surgery Waiting Area. 2. On 1/9/14 at 10:25 AM, in the presence of Staff #4, the left railing of the hospital bed in Room #304 was cracked and separated exposing electrical wiring. 3. On 1/9/14 at 10:33 AM, in the presence of Staff #4, the left railing of the hospital bed in Room #301 had paint missing. Where the paint was missing, a rust colored substance had formed. 4. On 1/9/14 at 11:20 AM, in the presence of Staff #4, the mattress pad in Room #483 was cracked, exposing the inner foam padding. 5. On 1/9/14 at 10:40 AM, in the presence of Staff #4, the chair next to the patient's bed in Room LDR #3 was missing part of the leg, causing it to sit uneven and rock back and forth. 6. On 1/9/14 at 10:40 AM, in the presence of Staff #4, the surface of the head board of the patient's bed in Room LDR #3 was chipped, exposing a surface that is not easily cleanable. STATE FORM 6899 G7T911 If continuation sheet 26 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D3058 Continued From page 26 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D3058 7. On 1/9/14 at 10:45 AM, in the presence of Staff #4, there was medical tape residue on the left arm rest in Delivery Room #1, which caused the surface to not be easily cleanable. D3059 8:43G-13.4(k) HOUSEKEEPING/LNDRY/SANI: D3059 HOUSEKEEPING PT SVCS All equipment and environmental surfaces shall be kept clean to sight and touch. This REQUIREMENT is not met as evidenced by: Based on observation, it was determined that the facility failed to ensure all equipment and environmental surfaces are kept clean to sight and touch. Findings include: 1. On 1/8/14, in the presence of Staff #6, all patient room doors in the Nursery were chipped exposing surfaces that are not easily cleanable. 2. On 1/7/14 at 10:50 AM, the "North American Drager" anesthesia machine located in the "Cysto" Operating Room contained old tape residue, peeling paint and rough, not easily cleanable drawer surfaces. 3. On 1/7/14 at 11:30 AM, a "wooden arm board" was observed in poor condition with open seams and gaps. STATE FORM 6899 G7T911 If continuation sheet 27 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D3059 Continued From page 27 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D3059 4. On 1/6/14 at 11:05 AM, in the presence of Staff #4, a transfer backboard was observed on the floor in the hallway on the first floor outside stairwell #5. 5. On 1/6/14 at 11:30 AM, in the presence of Staff #4, Exam Room Doors #1, #2, #3, and #4 in the Emergency Department were chipped exposing surfaces that are not cleanable. 6. On 1/6/14 at 2:10 PM, in the presence of Staff #4, a transfer backboard was on the floor next to the Pyxis machine in the Intensive Care Unit. 7. On 1/6/14 at 2:16 PM, in the presence of Staff #4, three (3) folding transfer backboards were found on the floor in the Intensive Care Unit Storage Room. 8. On 1/6/14 at 2:20 PM, in the presence of Staff #4, all patient room doors in the Intensive Care Unit were chipped exposing surfaces that are not cleanable. 9. On 1/9/14 at 10:40 AM, in the presence of Staff #4, the cabinet on the wall near the head of the bed in Room LDR #3 was chipped and cracked exposing a surface that is not easily cleanable. D3063 8:43G-13.4(n) HOUSEKEEPING/LNDRY/SANI: D3063 HOUSEKEEPING PT SVCS Effective and safe controls shall be used to minimize or eliminate the presence of rodents, flies, roaches, and other vermin in the hospital. The premises shall be kept in such condition as to prevent the breeding, harboring, or feeding of vermin. All openings to the outer air shall be STATE FORM 6899 G7T911 If continuation sheet 28 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D3063 Continued From page 28 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D3063 effectively protected against the entrance of insects. This REQUIREMENT is not met as evidenced by: Based on observation, it was determined that the facility failed to ensure all openings are effectively protected against the entrance of insects. Findings include: On 1/6/14 at 11:50 AM, in the presence of Staff #4, the East Exit door did not close completely, exposing a half inch gap. D3069 8:43G-13.4(p) HOUSEKEEPING/LNDRY/SANI: D3069 HOUSEKEEPING PT SVCS Periodic documented inspections of buildings and grounds shall be performed. Buildings and grounds shall be maintained in a clean and safe condition. This REQUIREMENT is not met as evidenced by: Based on observation, it was determined that the facility failed to ensure the building and grounds are maintained in a safe condition. Findings include: 1. On 1/6/14 at 11:30 AM, in the presence of Staff #4, the Ambulance Entrance to the STATE FORM 6899 G7T911 If continuation sheet 29 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D3069 Continued From page 29 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D3069 Emergency Department contained a large crack in the sidewalk that extends the entire width of the door causing a tripping hazard. 2. On 1/6/14 at 11:50 AM, in the presence of Staff #4, the hand railing was missing from the wall in the hallway outside the Emergency Department Waiting Room. D3084 8:43G-13.5(b) Hoskping/Lndry/Sani: D3084 HOUSEKPING SUPP/EQUIP Hand cleanser, sanitary towels, and waste receptacles or hand-drying machines shall be provided at each handwashing unit. Hand cleanser and hand-drying machines shall be approved by the infection control committee. This REQUIREMENT is not met as evidenced by: Based on observation, it was determined that the facility failed to provide a sanitary method of drying hands, and access to all handwashing units. Findings include: 1. On 1/6/14 at 11:15 AM, in the presence of Staff #4, no sanitary towels were found at the handwashing station across from bed FT 3 in the Emergency Department. 2. On 1/6/14 at 11:45 AM, in the presence of Staff #4, access to the handwashing unit was blocked by paper storage in the Emergency Department Break Room. STATE FORM 6899 G7T911 If continuation sheet 30 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D3084 Continued From page 30 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D3084 3. On 1/6/14 at 2:15 PM, in the presence of Staff #4, no sanitary towels were found at the handwashing station in the Intensive Care Unit Soiled Utility Room. 4. On 1/9/14 at 10:15 AM, in the presence of Staff #4, no sanitary towels were found at the handwashing station in the Nurses Station across from the Respiratory Room. 5. On 1/9/14 at 10:20 AM, in the presence of Staff #4, no sanitary towels were found at the handwashing station in the Respiratory Room. D3297 8:43G-14.1(d)(1)(iii)(5) INFECTN CONTRL: D3297 INFECTN CONT PROG STRUCT ORG Prevention and control: Activities shall be based on Centers for Disease Control and Prevention published guidelines and Hospital Infection Control Practices Advisory Committee (that is, HICPAC) recommendations. An exception to the adoption of the following guidelines shall be allowed providing that there is a sound infection control rationale based upon scientific research or epidemiologic data. The following published guidelines and recommendations is incorporated herein by reference, as amended and supplemented: Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force, MMWR 2002; 51 (No. RR-16), published by the Coordinating Center for Health Information and Service, available at http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf and STATE FORM 6899 G7T911 If continuation sheet 31 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D3297 Continued From page 31 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D3297 at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr51 16a1.htm This REQUIREMENT is not met as evidenced by: Based on observation, review of facility policy and procedure, and staff interviews, it was determined that the facility failed to ensure implementation of their hand washing and hand hygiene policy. Findings include: Reference: Facility policy titled, "Hand Washing Hand Hygiene" states, "...Background...Hands must be washed before glove application and after removal of gloves...Policy: It is an expectation of all MHMS (Meadowlands Hospital Medical System) employees to engage patients and visitors to help prevent the spread of infection by providing education on the practice of hand hygiene to be done at the appropriate times: 1. Before touching a patient 2. Before clean/aseptic procedure 3. After body fluid exposure risk 4. After touching a patient 5. After touching a patients surroundings...Hand washing Procedure: Wash hands when visibly soiled! Otherwise, use alcohol based handrub...Alcohol based Hand Products: A waterless-based hand cleaner may be used in place of soap and water proving[sic] that hands are not visibly soiled or contaminated with any blood or body fluids..." 1. On 1/6/14, at approximately 10:20 AM, Staff #8 was observed exiting ICU (Intensive Care Unit) Room #6 wearing a mask and gloves. Staff #8 removed his/her mask and gloves, did not perform hand washing or hand hygiene, and then STATE FORM 6899 G7T911 If continuation sheet 32 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D3297 Continued From page 32 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D3297 donned a clean pair of gloves. 2. On 1/6/14, at approximately 11:30 AM, Staff #45 was observed exiting ICU Room #2 wearing gloves. One glove was removed and disposed in a waste basket. The second glove was removed and held in his/her hand. Staff #45 walked to the Pyxis machine and touched the keys on the console with one hand, while holding the dirty glove in the other hand. 3. The above was confirmed by Staff #6. D3330 8:43G-14.1(e) INFECTN CONTRL: INFECTN D3330 CONT PROG STRUCT ORG The infection control program, with the cooperation of the infection control committee, shall share information, including problems, data, and relevant recommendations, with at least the quality improvement program, nursing service, administration, and the medical staff, and shall ensure that corrective actions are taken. This REQUIREMENT is not met as evidenced by: Based on staff interviews, review of facility policies and procedures, and review of pertinent facility documentation, it was determined that the facility failed to ensure the implementation of an effective infection control program. Findings include: Reference: Facility document titled, "Meadowlands Hospital Medical Center Infection Prevention and Control Plan", states, "...The Purpose of the Infection Prevention Program is:...2. To improve process and outcomes with STATE FORM 6899 G7T911 If continuation sheet 33 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D3330 Continued From page 33 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D3330 the principles of epidemiology for surveillance, prevention, and control of infection...The Goals of our Infection Prevention Program are to:...2. Monitor occurrence of infection and implement appropriate control measures. 3. Identify and correct problems relating to infection prevention practices... 5. Maintain compliance with state and federal regulations relating to infection prevention practices...The Scope of the Infection Prevention Program includes: 1....There is ongoing monitoring of infections of patients and personnel...5. Performance improvement Infection control practices are assessed and actions for improvement will be done accordingly..." 1. On 1/8/14, the Infection Control Program and The Infection Prevention and Control Committee Meeting Minutes for 2013 were reviewed in the presence of Staff #22. a. There was no evidence of follow up or resolution of issues/problems that were identified in the Infection Prevention and Control Committee Meeting minutes. b. There was no evidence that the members of the Infection Prevention and Control Committee were regularly reporting on monitoring of infection control practices. c. There was no evidence that the in-patient dialysis department was reporting on monitoring of infection control practices. The results of water cultures were reported to Staff #1, but dialysis was not part of the infection control plan. 2. The above was confirmed by Staff #22. STATE FORM 6899 G7T911 If continuation sheet 34 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG D3420 Continued From page 34 D3420 D3420 8:43G-15.2(d)(3) MEDICAL RECORDS: D3420 (X5) COMPLETE DATE POLICIES & PROCEDURES The inpatient's complete medical record shall include at least: Clinical/progress notes. This REQUIREMENT is not met as evidenced by: Based on review of 1 of 1 closed medical record for inclusion of clinical/progress notes and staff interview, it was determined that the facility failed to ensure that medical records are complete. Findings include: 1. Medical Record #33 revealed that this patient was admitted to the facility on 8/16/13 and discharged on 9/5/13. There was no evidence of an attending daily note/exam for 9/4/13 and 9/5/13. Furthermore, there was no evidence of a psychiatric physician note, as indicated in a nurse note of 9/3/13 which stated the physician was in to see the patient for evaluation. 2. The above was confirmed by Staff #1. D3444 8:43G-15.2(d)(11) MEDICAL RECORDS: D3444 POLICIES & PROCEDURES The inpatient's complete medical record shall include at least: Medication record reflecting the drug given, date, time, dosage, route of administration, and signature and status of the person administering STATE FORM 6899 G7T911 If continuation sheet 35 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D3444 Continued From page 35 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D3444 the drug. Initials may be used after the person's full signature appears at least once on each page of the medication record. Allergies, including allergy to latex, shall be listed on the medication record. This REQUIREMENT is not met as evidenced by: Based on review of medical records, review of facility policies and procedures, and staff interview, it was determined that the facility failed to ensure that the Respiratory Care MAR (Medication Administration Record) was completed in accordance with facility policy. Findings include: Reference #1: Facility policy titled "Medication Transcription and Documentation" states, "Process/Procedure: 1. RNs (Registered Nurses) are responsible for the transcription and validation of all medication. All medication orders will be verified and signed off by two RNs. Orders must include medication name, dose, route, frequency of medication and date of order. 2. All Computer Physician Order Entry (CPOE) medication orders are verified by the RN, transcribed to the M.A.R. (Medication Administration Record) and initialed by a second RN who has also verified the order...4. All medications are documented with date, time and nurses initials...6. Nurses corresponding signature for initials must be recorded on the lower portion of the medication record. 7. Date of order and discontinuation must be recorded and initialed in designated spaces on medication record..." STATE FORM 6899 G7T911 If continuation sheet 36 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D3444 Continued From page 36 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D3444 Reference #2: Facility guideline titled, "Respiratory Care Medication Documentation" states, "A Nurse can only complete the M.A.R...If you miss a treatment a valid reason must be documented on both the M.A.R. (use appropriate code) and the respiratory treatment notes...Any blank entries before the time you initial for the first treatment given or after a reorder should be x'd out." 1. On 1/6/2014, the Respiratory Therapy MARs for Medical Records #11 and Medical Record #12, on Nursing Unit 3W, were reviewed in the presence of Staff #23 and revealed the following: a. The physician order in Medical Record #11 states, "Levalbuterol 1.25mg(milligrams)/3ML (milliliters) INHL (inhalant) Q (every) 8H (hours)." i. The physician order transcribed on the MAR states, "Xopenox Q 8 H". The dosage of the medication and the route of administration were not transcribed. ii. The MAR transcription for this medication contained two different sets of RN initials. There was only one set of RN initials and a corresponding signature recorded on the lower portion of the MAR. iii. The initial box for the 1/6/14, 12:00 AM dose of Xopenox[sic], was blank. This dose was omitted without a signature and reason for omission. b. The physician order in Medical Record #12 states, "Albuterol 3/Ipratrop 0.5 mg/3ml (Duoneb). Mix 1 package INHL Q6h ATC (around the clock). Start date/time: 12/30/2013 19:31. Stop date/time: 1/4/2014 24:00." STATE FORM 6899 G7T911 If continuation sheet 37 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D3444 Continued From page 37 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D3444 i. The MAR states that the Duoneb inhalation treatment was administered every 6 hours around the clock from 12/30/13 through the 02:00 AM treatment on 1/6/2014. Four inhalation treatments were administered to Patient #12 from 1/5/14 at 08:00 AM through 1/7/14 at 02:00 AM without a valid physician's order. ii. The route of administration was not transcribed onto the MAR. iii. There was no evidence on the MAR that this order was transcribed and verified by two RNs. iv. The MAR did not have the corresponding dates of administration (1/5/14 and 1/6/14) written in the space above the column of initial boxes. c. The physician order in Medical Record #12, written on 1/6/14 states, "Albuterol 3/Ipratrop 0.5mg/3ml INHL 3ml. Mix 1 package INHL Q8h. Start date/time: 1/6/2014 17:16. Stop date/time: 1/7/2014 17:47." i. The MAR transcription for this medication contained two sets of RN initials, however, it could not be determined if the initials were from the same RN, or two different RNs. ii. The route of administration was not transcribed onto the MAR. iii. The order was transcribed in the PRN (as needed) order section of the MAR, however, the medication was not ordered PRN. iv. The MAR entry for the 1/7/14, 12:00 AM Duoneb inhalation treatment was blank. This dose was omitted without a signature and reason STATE FORM 6899 G7T911 If continuation sheet 38 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D3444 Continued From page 38 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D3444 for omission. 2. The above was confirmed by Staff #1 and Staff #23. D3957 8:43G-18.2(a) NURSING CARE: POLICIES & D3957 PROCEDURES The hospital shall have written policies and procedures for the nursing care service that guide nursing practices in the hospital. These policies shall be reviewed at least once every three years, revised more frequently as needed, and implemented. These policies and procedures shall conform with the Nurse Practice Act, N.J.S.A. 45:11-23 and N.J.A.C. 13:37-1.4, 6.1, 6.2, 13.1 and 13.2. This REQUIREMENT is not met as evidenced by: Based on medical record review, review of facility policy and procedure and staff interview, it was determined that the facility failed to ensure that the "One to One (Sitter) Observation" policy regarding physician orders was implemented in one of one medical records (#33) reviewed. Findings include: Reference: Facility policy titled "One to One (Sitter) Observation" states, "... Initiation of 1:1 Observation: ... 3. One to one observation orders must be reviewed and renewed every 24 hours. 4. The Registered Nurse must inform the Physician or Licensed Independent Practitioner (LIP) when the patient's clinical status is such that one to one observation is no longer needed and STATE FORM 6899 G7T911 If continuation sheet 39 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D3957 Continued From page 39 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D3957 the physician must write an order to discontinue the one to one observation. The RN [registered nurse] is not to discontinue one to one observation unless ordered by a physician or LIP. 5. Documentation for patient's on one to one observation must be done every shift ..." 1. A physician order dated 8/16/13 at 08:27 in Medical Record #33 stated, "Needs 1 to 1 observation please." The patient was maintained on 1:1 observation for safety according to the nurse's documentation from 8/16/13 at 08:30 until 9/5/13 at 07:00. a. There was no evidence in the medical record that the order was renewed by the physician every 24 hours since 8/16/13. There was no evidence in the medical record that the order was discontinued. 2. The above was confirmed by Staff #1. D4110 8:43G-18.5(c) NURSING CARE: PATIENT D4110 SERVICES The nursing plan of care shall be consistent with the medical plan of care and implemented in accordance with the Nurse Practice Act. This REQUIREMENT is not met as evidenced by: Based on staff interview and document review, it was determined that the facility failed to ensure that nurses practice in accordance with the New Jersey Nurse Practice Act. STATE FORM 6899 G7T911 If continuation sheet 40 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D4110 Continued From page 40 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D4110 Findings include: Reference: The New Jersey Board of Nursing Statutes 45:11-23 states, "...Definitions...The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician..." 1. Medical Record #31 contained orders dated 1/5/12014, for "Oxycodone HCL 5 mg. [milligram]/APAP 325 mg. Tab [tablet] UD [unit dose] 1 Tablet PO [by mouth] Q4H [every four hours] PRN [as needed]; Morphine Sulfate Inj [injectable] 2 mg./1 ml [milliliter] IV [intravenous] Q3H [every 3 hours] PRN; Acetaminophen Tab 650mg PO Q6H PRN. a. The above medication orders do not contain an indication for use. Although the above medication are used for pain management, the orders are not clear as to which medication to administer first, leaving the decision to the nurse. This is not in compliance with the Nurse Practice Act referenced above. 2. Medical Record #18 contained orders dated 1/6/14, for "Ibuprofen Tab 600mg PO Q6H PRN, Acetaminophen Tab 650mg PO Q6H PRN, Oxycodonne HCL 5mg/APAP 325mg Tab UD 1 Tablet PO Q4H PRN." Review of the medication administration record indicated that the patient received Ibuprofen 600 mg. and Oxycodone HCL 5 mg./APAP 325 mg. on 1/8/14 for pain. This was confirmed by Staff #47. STATE FORM 6899 G7T911 If continuation sheet 41 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D4110 Continued From page 41 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D4110 a. The above medication orders do not include an indication for use. Although the above medications are used for pain management, the orders are not clear as to which medication to administer first, leaving the decision to the nurse. This is not in compliance with the Nurse Practice Act referenced above. 3. The above was confirmed by Staff #6. D4179 8:43G-18.6(i) NSG CARE: NSG CARE SVCS D4179 RELATED TO PHARM SVCS All drugs, needles, and syringes in patient care areas shall be kept in locked storage areas, except those drugs exempted by the pharmacy and therapeutics committee or equivalent under specified conditions. Drugs for external use shall be kept separate from drugs for internal use. This REQUIREMENT is not met as evidenced by: Based on observation during a tour of the Emergency Department and staff interview, it was determined that the facility failed to ensure that all needles and syringes are maintained in locked storage areas. Findings include: 1. During a tour of the Emergency Department conducted at approximately 10:00 AM on 1/6/14, in the presence of Staff #5, the IV (intravenous) Cart was unsecured and contained needles and STATE FORM 6899 G7T911 If continuation sheet 42 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D4179 Continued From page 42 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D4179 syringes. 2. This finding was confirmed by Staff #5. D5619 8:43G-23.1(b) PHARMACY: STRUCTURAL D5619 ORGANIZATION A multidisciplinary pharmacy and therapeutics committee, or an equivalent multidisciplinary body which includes a pharmacist licensed to practice pharmacy in New Jersey, shall meet at least quarterly and document its activities, findings, and recommendations. This REQUIREMENT is not met as evidenced by: Based on document review and staff interview conducted on 1/8/14, it was determined that the facility failed to ensure that the Pharmacy and Therapeutics (P&T) Committee met at least quarterly and documented its activities, findings, and recommendations. Findings include: 1. Upon request, Staff #31 provided P&T Committee meeting minutes dated 7/24/13 and 10/23/13. He/she stated that meeting minutes from previous P&T Committee meetings, when there was a different Pharmacy Director, could not be found. 2. On 1/10/14 at 4:30 PM, Staff #1 confirmed that the facility was unable to locate minutes of P&T Committee meetings held prior to 7/24/13. STATE FORM 6899 G7T911 If continuation sheet 43 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG D5634 Continued From page 43 D5634 D5634 8:43G-23.2(a)(4) PHARMACY: POLICIES & D5634 (X5) COMPLETE DATE PROCEDURES The pharmacy and therapeutics committee, or its equivalent, shall review, approve, and ensure implementation of policies and procedures addressing at least the following area: Admixture of intravenous solutions, including quality control and safety procedures for laminar airflow hoods and labeling. This REQUIREMENT is not met as evidenced by: Based on observation and staff interview conducted on 1/8/14, it was determined that the facility failed to ensure that the "use by date" is recorded on parenteral medications prepared by the pharmacist. Findings include: 1. At 12:30 PM, the "use by date" was lacking on the pharmacy labels in 8 of 18 parenteral medications. 2. Upon interview, Staff #31 stated that facility policy was to label each parenteral medication with a "use by date" of 24 hours from the time of dispensing. STATE FORM 6899 G7T911 If continuation sheet 44 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG D5637 Continued From page 44 D5637 D5637 8:43G-23.2(a)(5) PHARMACY: POLICIES & D5637 (X5) COMPLETE DATE PROCEDURES The pharmacy and therapeutics committee, or its equivalent, shall review, approve, and ensure implementation of policies and procedures addressing at least the following area: Storage and distribution of drugs, including at least dispensing devices (if used in the hospital), emergency drugs and kits, and control and accountability of controlled substances in accordance with applicable laws and regulations. This REQUIREMENT is not met as evidenced by: A. Based on observation and staff interview conducted on 1/8/14, it was determined that the facility failed to ensure that pharmacy services developed and implemented policies and procedures addressing drug delivery systems utilized at the facility. Findings include: 1. Upon interview, Staff #31 stated that the drug delivery system utilized on Unit 3W consisted of two methods. Many of the drugs were removed by the nurse from the Pyxis drug dispensing device. Drugs not available in the Pyxis were STATE FORM 6899 G7T911 If continuation sheet 45 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D5637 Continued From page 45 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D5637 delivered through a 24 hour unit-dose cassette exchange. a. Upon request, Staff #31 was unable to provide policies and procedures addressing the drug delivery system that had been implemented on Unit 3W. 2. Review of patient medication cassettes on 1/8/14 in Unit 3W revealed numerous discrepancies (Refer to Tag 5697). Staff #31 confirmed that many of the "extra" medications found in the medication cassettes were available in the Pyxis drug dispensing device on the unit. Upon request, Staff #31 was unable to provide policies and procedures or evidence of practices that addressed the control and accountability for medications removed from the Pyxis drug dispensing devices. 3. Upon interview, Staff #31 confirmed that facility policy requires that each pocket within the Pyxis drug dispensing device is numbered and have the same medication in it, since the device prompts the user to take the medication needed by pocket number. Mixing medications within the same pocket can increase the risk of medication errors. Review of Pyxis drug dispensing devices in the Operating Room (OR) Suite and Unit 3W revealed the following instances when the drawers were not properly maintained. a. Upon review of drawer #6 in the Pyxis drug dispensing device located in the OR Suite, on 1/8/14 at 11:00 AM, the following discrepancies were found: i. Dextrose 50% was stored in the same pocket as Lidocaine 2%. STATE FORM 6899 G7T911 If continuation sheet 46 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D5637 Continued From page 46 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D5637 ii. Sensorcaine 0.5% was stored in the same pocket as Levofloxacin in 5% Dextrose. iii. Mannitol 25% was stored in the same pocket as topical benzocaine. iv. Silvadene cream was stored in the same pocket as Propofol. v. Dextrose 50% was stored in the same pocket as lidocaine 100mg syringes. vi. Pockets for Vancomycin 500mg, aminophylline 250mg/10ml, Cetacaine topical spray, and Lidocaine 1% preservative free were empty. b. Review of the Pyxis drug dispensing device on Unit 3 West A revealed that the pocket numbers were missing in 3 of the 6 drawers reviewed. B. Based on observation, document review and staff interview conducted on 1/8/14, it was determined that the facility failed to ensure implementation of policies and procedures addressing emergency carts. Findings include: Reference: Facility policy titled "Code Cart Check" states, "Policy: Each code cart shall be locked at all times. The locking mechanism shall be a numberd snap off lock..." and "Procedure/Process: 1. Each code cart will be checked on a daily basis whenever patients are present on the specific unit...2. On the first of every month, the code cart will be opened and the expiration dates of supplies will be checked and replaced as necessary." STATE FORM 6899 G7T911 If continuation sheet 47 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D5637 Continued From page 47 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D5637 1. The Pediatric Code Drug Box, located between the Same Day Stay and the Operating Rooms, was locked with a thick plastic strap that could not be easily broken. Scissors were needed to cut the strap. 2. Review of the Code Cart Check on the code cart, located between the Same Day Stay and the Operating Rooms, indicated that the Pediatric Code Cart had last been checked on 9/16/13 (there was a change in lock number at that time). The same lock had also remained on the cart from 4/2/13 until 6/2/13. 3. Review of the Code Cart Check on the code cart, located between the Same Day Stay and the Operating Rooms, indicated that the Adult Code Cart had not been checked between 10/25/13 and 1/5/14. 4. These findings were confirmed by Staff #3. D5673 8:43G-23.3(b) PHARMACY: STAFF D5673 QUALIFICATIONS A pharmacist licensed to practice pharmacy in New Jersey shall be responsible for compounding, preparing, labeling, transferring between containers, and dispensing drugs, including direct supervision of supportive personnel, as defined at N.J.A.C. 13:39-1.2. This REQUIREMENT is not met as evidenced by: Based on staff interview, it was determined that the facility failed to ensure that the dispensing of STATE FORM 6899 G7T911 If continuation sheet 48 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D5673 Continued From page 48 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D5673 medications in medication cassette drawers is performed by pharmacy personnel under the supervision of a pharmacist. Findings include: 1. Upon interview on Unit 3W on 1/10/14, Staff #40 stated that the nurse will remove from the Pyxis, drug dispensing device medications that are needed for his/her medication pass for all the patients and place them in the medication cassettes. He/she would then administer the medications from the cassette. The preparation of patient medication cassette drawers is a dispensing function that should only be performed by pharmacy personnel under the supervision of a pharmacist. 2. Upon request, Staff #31 was unable to provide a policy and procedure addressing this practice. D5688 8:43G-23.6(b) PHARMACY: PATIENT D5688 SERVICES The hospital shall have in effect a unit dose drug distribution system with individual cassettes or containers which bear the patient's identification. The system shall cover at least the medical/surgical, obstetric, pediatric, and psychiatric units and include scheduled cart exchanges at least every 24 hours, including weekends and holidays. This REQUIREMENT is not met as evidenced by: Based on observation and staff interview conducted on 1/8/14, it was determined that the STATE FORM 6899 G7T911 If continuation sheet 49 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D5688 Continued From page 49 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D5688 facility failed to ensure that it had in effect, a unit dose drug distribution system with individual cassettes that bear the patient's identification. Findings include: 1. Review of medication cassette drawers on Unit 3W revealed that the patient cassette drawers were labeled with a room number and no patient identification. 2. This finding was confirmed by Staff #31. D5691 8:43G-23.6(b)(1) PHARMACY: PATIENT D5691 SERVICES An alternative method of distributing drugs approved by the Department of Health may be substituted for the unit dose drug distribution system if the method has been demonstrated to the Department to have at least equivalent clinical effectiveness. This REQUIREMENT is not met as evidenced by: Based on staff interview conducted on 1/8/14, it was determined that the facility failed to notify the Department of Health of an alternate method of distributing drugs prior to implementing the method. Findings include: On 1/8/14 at 11:00 AM, Staff #31 stated that the primary method for obtaining medications on Unit 3W was through the Pyxis drug dispensing device. Only medications that were not available STATE FORM 6899 G7T911 If continuation sheet 50 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D5691 Continued From page 50 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D5691 in the Pyxis were dispensed directly from the pharmacy to individual medication cassette drawers. Staff #31 stated that the facility had not notified the Department of Health in order for the Department to determine if the method had at least equivalent clinical effectiveness a 24 hour unit-dose medication cassette exchange. D5697 8:43G-23.6(d) PHARMACY: PATIENT D5697 SERVICES The pharmacy service shall develop and implement a system of control for legend drug doses. A pharmacist licensed to practice pharmacy in New Jersey shall check each cassette or container of drugs prepared by supportive personnel, as defined at N.J.A.C. 13:39-1.2, before it is delivered to a patient care unit. This REQUIREMENT is not met as evidenced by: Based on observation, document review and staff interview, it was determined that the facility failed to ensure that pharmacy services has oversite and control over the distribution of drugs and biologicals. Findings include: 1. On 1/8/13 at 12:00 Noon, the contents of three (3) patient medication cassettes were compared with the medication administration records (MAR) and the physician's orders on Unit 3W. The contents of the cassettes did not reconcile with the physician's orders in the following instances: STATE FORM 6899 G7T911 If continuation sheet 51 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D5697 Continued From page 51 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D5697 a. For Patient #34: i. There were 8 Senokot in the cassette drawer. The order was for Senokot 2 tablets at bedtime. Administration of 2 tablets was documented on the MAR on 1/7/14 at 10:00 PM. Staff #31 confirmed that there should not be any Senokot in the medication cassette drawer at this time. ii. There was one unit-dosed (UD) amlodipine 10mg in the cassette. This medication was not on the MAR, nor was there a physician's order for it. This was confirmed by Staff #31. iii. There was one UD doxazosin 4mg in the cassette. This medication was not on the MAR, nor was there a physician's order for it. This was confirmed by Staff #31. iv. There was one Lovenox 40mg/0.4ml in the cassette. The medication was on hold. Upon interview, Staff #31 confirmed that this medication was removed from the Pyxis and should not be in the cassette. v. There was one furosemide 20mg vial in the cassette. This medication was not on the MAR, nor was there a physician's order for it. This was confirmed by Staff #31. b. For Patient #36: i. Two (2) UD atorvastatin 40mg were in the cassette. Administration of 2 tablets on 1/7/14 at 10:00 PM was recorded on the MAR. Staff #31 confirmed that there should not be any atorvastatin in the cassette at this time. ii. Four (4) UD ondansetron 4mg were found in the cassette. This medication was not on the STATE FORM 6899 G7T911 If continuation sheet 52 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D5697 Continued From page 52 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D5697 MAR, nor was there a physician's order for it. This was confirmed by Staff #31. iii. One Nicotine Transdermal System 21mg was found in the cassette. This medication was not on the MAR, nor was there a physician's order for it. This was confirmed by Staff #31. c. The medication cassette drawer for Patient #35 contained a 100ml bag of parenteral 0.9% Sodium Chloride that had been taken out of the overwrap and had a piece of tape with illegible writing on it. It could not be determined if a medication had been added to the bag. Staff #31 was unable to determine why this was in the cassette drawer. D5712 8:43G-23.6(i) PHARMACY: PATIENT SERVICES D5712 Drugs in single dose or single use containers which are open or which have broken seals, drugs in containers missing drug source and exact identification (such as lot number), and outdated medications shall be returned to the pharmacy for disposal. This REQUIREMENT is not met as evidenced by: A. Based on observation and staff interview it was determined that the facility failed to ensure that outdated medications were not available for patient use. Findings include: 1. The following expired medications were found STATE FORM 6899 G7T911 If continuation sheet 53 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D5712 Continued From page 53 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D5712 in the Operating Room (OR) Pyxis drug dispensing device on 1/8/14 at 11:00 AM: a. Four (4) vials of diltiazem 50mg/10ml, expiration date 8/1/13. b. Two (2) vials of diltiazem 50mg/10ml, expiration date 6/13. c. Two (2) vials of aminophylline 250mg, expiration date 9/1/13. d. One (1) vial of flumazenil 0.5mg/5ml, expiration date 5/13. 2. The following expired medications were found in the OR #6 Pyxis on 1/8/14 at 11:10 AM: a. Three (3) nifedapine capsules, expiration date 12/13. b. One (1) ampule of epinephrine 1:10,000, expiration date 11/13. c. One (1) vial of vecuronium 10mg, expiration date 11/13. 3. The following expired medications were found in the OR #4 Pyxis on 1/8/14 at 11:30 AM: a. One (1) vial of furosemide 100mg/10ml, expiration date 12/13. b. Three (3) vials of verapamil 5mg/2ml, expiration date 5/1/13. c. One (1) vial of vecuronium 10mg, expiration date 5/13. d. Six (6) vials of vecuronium 10mg, expiration STATE FORM 6899 G7T911 If continuation sheet 54 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D5712 Continued From page 54 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D5712 date 11/13. 4. These findings were confirmed by Staff #31. D5742 8:43G-23.10(c) PHARMACY: CONT QUAL D5742 IMPROVMNT METHODS The pharmacy service shall inspect at least once every two months all patient care areas in the hospital, and at least once every three months all other areas of the hospital where drugs intended for administration to patients are dispensed, administered, or stored. The pharmacy service shall maintain a record of the inspections. Identified problems shall be addressed. This REQUIREMENT is not met as evidenced by: Based on document review and staff interview conducted on 1/8/14, it was determined that the facility failed to ensure that pharmacy service inspected at least once every two months, all patient care areas in the hospital, and at least once every three months, all other areas of the hospital where drugs intended for administration to patients are dispensed, administered, or stored. Findings include: Reference: Facility policy titled "Medication Area Evaluations" states, "Procedure: A. All areas of the Hospital where medications are stored are to be evaluated/surveyed by a Pharmacist of (sic) his/her designee monthly or as required...C. The Pharmacist or designee shall fill out an evaluation report indicating all findings...K. Compliance STATE FORM 6899 G7T911 If continuation sheet 55 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D5742 Continued From page 55 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D5742 results shall be trended and monitored when improvement is needed." 1. Review of pharmacy unit inspections reports on 1/10/14 revealed that they have not been done monthly. Examples include, but are not limited to the following areas: a. Endoscopy Suite was last inspected on 3/19/13. b. Operating Room was last inspected on 3/19/13. c. Anesthesia 1 (Pyxis station) was last inspected on 11/27/12 d. Anesthesia 5 (Pyxis station) was last inspected on 11/27/13. e. Anesthesia 7 (Pyxis station) and Anesthesia 4 (Pyxis station) were last inspected on 10/19/12. f. Post Anesthesia Care Unit was last inspected on 4/2/12. g. The Emergency Department was only inspected on 11/24/13 and 12/19/13 in 2013. h. Unit 4W (Pediatric Unit) was last inspected on 10/9/12. i. The Nursery was last inspected on 2/20/12. j. Labor & Delivery was only inspected on 12/15/13 and 3/28/13 in 2013. k. Post Partum was only inspected on 12/28/13 in 2013. STATE FORM 6899 G7T911 If continuation sheet 56 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D5742 Continued From page 56 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D5742 l. Intensive Care Unit was only inspected on 12/20/13 in 2013. m. Unit 3W was only inspected 11/29/13 and 10/25/13 in 2013. 2. Upon request, Staff #31 was unable to provide evidence that findings of unit inspections were trended and monitored when improvement was needed. D5745 8:43G-23.10(d) PHARMACY: CONT QUAL D5745 IMPROVMNT METHODS A quality improvement program of the pharmacy service shall monitor, at a minimum, the use of drugs, including medication errors and use of antibiotics. Serious or consistent patterns of medication error shall be reported to the pharmacy and therapeutics committee or its equivalent. This REQUIREMENT is not met as evidenced by: Based on staff interview conducted on 1/10/14, it was determined that the facility failed to ensure that pharmacy service monitored, at a minimum, the use of drugs, including the use of antibiotics and medication errors. Findings include: Upon request, Staff #31 was unable to provide evidence of a pharmacy quality improvement program that included the monitoring of antibiotics and medication errors. STATE FORM 6899 G7T911 If continuation sheet 57 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG D5769 Continued From page 57 D5769 D5769 8:43G-24.4(a) PLANT MAINTENANCE: PLANT D5769 (X5) COMPLETE DATE MAINT SERVICES Records of preventive maintenance inspections and repairs of electrical and mechanical systems shall be maintained for at least one year. This REQUIREMENT is not met as evidenced by: Based on observation, it was determined that the facility failed to ensure electrical and mechanical systems are maintained. Findings include: 1. On 1/8/14 in Labor and Delivery Room #2, in the presence of Staff #6, the fetal monitor was over due for service. The service tag expired on 12/13. 2. On 1/8/14 in the Nursery Unit, in the presence of Staff #6, the intravenous pump was over due for service. The service tag expired on 11/13. a. The monitor and the neonate scale were over due for service. The service tag expired on 12/13. 3. On 1/6/14 in the 3 West Unit, in the presence of Staff #22, the defibrillator on top of the code cart was over due for service. The service tag expired on 11/13. 4. On 1/6/14 at 11:30 AM, in the presence of Staff #4, the Code Master XL attached to the Code Cart in the Emergency Department Exam Room #1, was over due for service. The service tag expired on 11/13. STATE FORM 6899 G7T911 If continuation sheet 58 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D5769 Continued From page 58 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D5769 5. On 1/6/14 at 11:55 AM, in the presence of Staff #4, the Respiratory Ventilator in the CT Scan Suite, was over due for service. The service tag expired on 10/13. D5784 8:43G-24.4(f) PLANT MAINTENANCE: PLANT D5784 MAINT SERVICES Floors, ceilings, and walls shall be free of cracks and holes, discoloration, residue build-up, water stains, and other signs of disrepair. This REQUIREMENT is not met as evidenced by: Based on observation, it was determined that the facility failed to ensure floors, walls and ceilings were kept free of cracks, holes, residue build-up, discoloration, and other signs of disrepair. Findings include: 1. In Labor and Delivery Room #4, the monolithic floor had cracks at the base cove. a. This was confirmed with Staff #6. 2. On 1/6/14 at 11:00 AM, in the presence of Staff #4, the drywall was chipped and tiles were missing in the dish washing section of the Kitchen. 3. On 1/6/14 at 11:20 AM, in the presence of Staff #4, two holes were found exposing the drywall in the Emergency Department across from Triage #2. STATE FORM 6899 G7T911 If continuation sheet 59 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D5784 Continued From page 59 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D5784 4. On 1/6/14 at 11:30 AM, in the presence of Staff #4, molding was missing exposing an unfinished surface on the wall behind Registration in the Emergency Department. 5. On 1/6/14 at 12:05 PM, in the presence of Staff #4, ceiling tiles were discolored in the hallway to the MRI Trailer. 6. On 1/9/14 at 9:55 AM, in the presence of Staff #4, the wallpaper was peeling off the wall and missing in a 3 inch by 36 inch section, in the hallway outside Room #387. 7. On 1/9/14 at 10:10 AM, in the presence of Staff #4, two holes were in the wall at the head of the bed in Room #303. D5820 8:43G-24.13(e) FIRE & EMERGENCY D5820 PREPAREDNESS Exits, stairways, doors, and corridors shall be kept free of obstructions. This REQUIREMENT is not met as evidenced by: Based on observation, it was determined that the facility failed to ensure exits and exit doors are kept free of obstructions. Findings include: 1. On 1/6/14 at 10:55 AM, in the presence of Staff #4, the exit access in the Kitchen was reduced due to a cart blocking the exit. STATE FORM 6899 G7T911 If continuation sheet 60 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D5820 Continued From page 60 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D5820 2. On 1/6/14 at 11:10 AM, in the presence of Staff #4, the exit door to the Doctor's Parking Lot could not be opened. D6159 8:43G-27.1(b) CONTINUOUS QUAL D6159 IMPRVMNT: STRUC ORGANZTN The hospital shall have a hospital-wide continuous quality improvement program based on a written continuous quality improvement plan that is implemented and that monitors the quality of patient care. This REQUIREMENT is not met as evidenced by: A. Based on a review of facility documentation and staff interview, it was determined that the facility failed to ensure that quality indicators were measured, analyzed, and tracked. Findings include: 1. Review of the facility's 2013 "Quality Dashboard," conducted at approximately 9:45 AM on 1/8/14 in the presence of Staff #36, revealed the following: a. Case Management had the following indicators for which there was no evidence that data was submitted in 2013: AMI (Acute Myocardial Infarction) re-admissions within 30 days, pneumonia re-admissions within 30 days, and heart failure re-admissions within 30 days. b. Pharmacy had the following indicators for which there was no evidence that data was STATE FORM 6899 G7T911 If continuation sheet 61 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D6159 Continued From page 61 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D6159 submitted in 2013: ADR's (adverse drug reactions), pharmacy interventions accepted, and narcotics discrepancies - unresolved. c. HIM (Health Information Management) had the following indicators for which there was no evidence that data was submitted in 2013: Delinquency rate: % records incomplete within 30 days, H&P (History and Physical) on in-patient chart within 24 hours, H&P within 30 days of surgery and reviewed prior to the procedure, telephone orders signed within 24 hours, written orders timed, dated, and signed, OP (operative) reports dictated within 24 hours, OP note done immediately following surgery, D/C (discharge) summary documented, suspensions, number of patients transferred for services not provided by hospital/higher level of care. d. The following categories on the "Quality Dashboard 2013" were found to be missing data: i. Acute myocardial infarction had no data recorded from July 2013 to December 2013. ii. Pneumonia had no data recorded from July 2013 to December 2013. iii. Heart failure had no data recorded from July 2013 to December 2013. iv. Surgical Care Improvement Project had no data recorded from July 2013 to December 2013. v. Stroke had no data recorded from July 2013 to December 2013. vi. Venous Thromboembolism had no data recorded from July 2013 to December 2013. STATE FORM 6899 G7T911 If continuation sheet 62 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D6159 Continued From page 62 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D6159 vii. Global Immunization had no data recorded from July 2013 to December 2013. viii. Case Management had no data recorded from November 2013 to December 2013. ix. Mortality Review had no data recorded from October 2013 to December 2013. x. Infection Prevention had no data recorded from October 2013 to December 2013. xi. Risk Management had no data recorded from July 2013 to December 2013. xii. Patient Satisfaction had no data recorded from June 2013 to December 2013. xiii. Press Ganey In-patient had no data recorded from July 2013 to December 2013. ixx. Press Ganey Emergency had no data recorded from July 2013 to December 2013. xx. Press Ganey Ambulatory had no data recorded from July 2013 to December 2013. xxi. HCAHPS had no data recorded from July 2013 to December 2013. xxi. Patient Volumes had no data recorded from July 2013 to December 2013. 2. These findings were confirmed by Staff # 36. B. Based on review of facility documentation and staff interview, it was determined that the facility failed to ensure that medical errors and/or adverse patient events were measured, analyzed, and tracked. STATE FORM 6899 G7T911 If continuation sheet 63 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D6159 Continued From page 63 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D6159 Findings include: 1. Review of the facility's 2013 "Quality Dashboard," conducted at approximately 9:45 AM on 1/8/14 in the presence of Staff #36, revealed the following: a. There was no data available on medical errors for the year of 2013. b. There was no data available on adverse patient events for the year of 2013. c. There was no evidence that the facility was collecting data, analyzing, and/or tracking medical errors or adverse patient events. 2. These findings were confirmed by Staff #36. D6744 8:43G-31.2(a)(2) RESPIRATORY CARE: D6744 POLICIES & PROCEDURES The respiratory care service shall have written policies and procedures that are reviewed at least once every three years, revised more frequently as needed, and implemented. They shall include at least: The duties and responsibilities of respiratory care practitioners. This REQUIREMENT is not met as evidenced by: Based on medical record review, review of policies and procedures and staff interviews, it was determined that the facility failed to ensure that respiratory therapy patient assessments are STATE FORM 6899 G7T911 If continuation sheet 64 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D6744 Continued From page 64 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D6744 performed in accordance to facility policy. Findings include: Reference: Facility policy titled "Charting Policy," states, "Policy: Charting shall be done on the Respiratory Therapy Treatment Notes in CAREVUE...This form shall reflect the following information:...d. Patient response to therapy, and adverse effects and other clinical observations that might provide the physician information with which to evaluate patient progress...Entries must be made after each treatment/procedure performed." 1. On 1/6/2014, 6 out of 6 medical records (#1, #2, #3, #11, #12, and #13) had only the post respiratory therapy treatment vital signs documented in the respiratory care service therapy record notes. a. Staff #10, Staff #11 and Staff #23 stated that patient assessments are performed pre [before] and post [after] each treatment/procedure performed. The respiratory care service therapy record notes are entered into the electronic medical record post treatment/procedure. 2. Staff #10 stated that the patient's response to therapy and adverse effects of the treatment/procedure cannot be fully assessed without comparing the vital signs before and after each treatment/procedure performed. D6774 8:43G-31.7(a) RESPIRATORY CARE: PATIENT D6774 SERVICES There shall be an organized program for teaching patients to administer their own therapy, with STATE FORM 6899 G7T911 If continuation sheet 65 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D6774 Continued From page 65 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D6774 adequate supervision and documentation, in any case where it is appropriate for the patient and where the patient is able to receive and follow therapy instructions. This REQUIREMENT is not met as evidenced by: Based on medical record review, review of policies and procedures and staff interviews, it was determined that the facility failed to ensure that respiratory therapy patient/family teaching-interdisciplinary education is performed in accordance with facility policy. Findings include: Reference: Facility policy titled "Patient/Family Teaching-Interdisciplinary Education Record, Volume: Respiratory Therapy Department" states, "POLICY: To document the interdisciplinary process of patient/family and teach in a collaborative and consistent manner. PROCESS:...8. Assess Learning Need - All Practitioners...All practitioners will assess learning needs of the Patient/Family. Indicate Assets/Barriers to Learning. Determine what you want patient and family to achieve...9. Response Code: Evaluate Patient/Family according to when expected outcome was achieved. Document the actual outcome of teaching Patient/Family using the code. If the Patient/Family did not meet expected outcome - mark appropriate response code. Re-evaluate reinforced teaching outcome and document." 1. On 1/6/14, Staff #23 stated that respiratory care education begins with a referral from the physician to Respiratory Therapy Services. Staff STATE FORM 6899 G7T911 If continuation sheet 66 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D6774 Continued From page 66 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D6774 #10, Staff #11 and Staff #23 stated that the respiratory therapist who performs the initial assessment should assess the learning needs of the patient/family and document teaching in the medical record. a. On 1/6/14, at approximately 2:15 PM, Staff #23 confirmed that Medical Record #11 and Medical Record #13 did not have evidence that patient/family respiratory care education was performed by the respiratory therapist. 2. The respiratory care patient/family education form states the topic taught was "Respiratory Care." a. The specific respiratory care subject(s) taught (such as how to use an incentive spirometer, or how to do pursed lip breathing) was not included on the form, therefore, it can not be determined if one or more topics were addressed, or if all patient and family learning objectives were achieved. b. The above finding was confirmed by Staff #10. 3. On 1/6/2014, 3 out of 6 medical records (#1, #2, and #3) did not have evidence that teaching was reinforced or educational needs were re-evaluated, as required in the above referenced policy. a. Staff #11 stated , "I only do it once," in reference to education for respiratory care. b. The above finding was confirmed by Staff #10. In addition, Staff #10 stated, "I see we need to do another education when treatments change." STATE FORM 6899 G7T911 If continuation sheet 67 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG D6777 Continued From page 67 D6777 D6777 8:43G-31.7(b) RESPIRATORY CARE: PATIENT D6777 (X5) COMPLETE DATE SERVICES Written treatment plans, and respiratory therapy goals shall be written by the licensed respiratory care practitioner. The written treatment plans shall supplement the respiratory care orders written by physicians and become part of the medical record. This REQUIREMENT is not met as evidenced by: Based on medical record review, review of policies and procedures and staff interviews, it was determined that the facility failed to ensure that respiratory therapy patient care plans are in accordance with facility policy. Findings include: Reference: Facility policy titled "Patient Assessment and Care Plan, Volume: Respiratory Therapy Department" states, "Policy:...Assessment, and Care Plan will be done within 24 hours of receipt of physician's orders. Procedure: Responsible Party Responsibility Respiratory Care Practitioners...Formulate plan. State what, in your opinion, needs to be done to meet therapeutic goals. Indicate short or long term plans, educational needs or recommend a change of modification of therapy...Reassessment will be done every Five days that the patient is receiving therapy or when there is a significant change in the patient's condition." STATE FORM 6899 G7T911 If continuation sheet 68 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D6777 Continued From page 68 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D6777 1. On 1/6/2014, 6 out of 6 medical records (#1, #2, #3, #11, #12 and #13) did not indicate that the respiratory assessment and care plan included short or long term plans. 2. On 1/6/2014, 6 out of 6 medical records (#1, #2, #3, #11, #12 and #13) did not indicate that the respiratory assessment and care plan included educational needs. 3. On 1/6/2014, 4 out of 4 medical records (#1, #2, #3, and #12) did not indicate that the respiratory assessment and care plan was reviewed or revised. 4. The above findings were confirmed by Staff #10. D7035 8:43G-33.2(a) SOCIAL WORK: POLICIES & D7035 PROCEDURES The social work department shall have written policies and procedures that are reviewed at least once every three years, revised more frequently as needed, and implemented. The policies and procedures concerning the scope of social work services shall address the following areas: counseling, discharge management and planning, social work assessment, consultation and referral, patient advocacy, community liaison, and education. This REQUIREMENT is not met as evidenced by: A. Based on document review and staff interview, it was determined that the facility failed to ensure that a discharge plan evaluation was STATE FORM 6899 G7T911 If continuation sheet 69 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D7035 Continued From page 69 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D7035 performed as per physician order and per the Interdisciplinary Discharge Planning policy. Findings include: Reference: Facility policy titled "Interdisciplinary Discharge Planning" policy states, "Procedure/Process: ... 3. Case Management Responsibility: ... C. Initial assessment shall be completed on all patients that meet social service high risk criteria and/or patients referred to the Case Management staff for intervention. This assessment shall be completed within 48 working hours of admission/referral ..." 1. In Medical Record #33, a physician order dated 8/16/13 at 8:14 AM states, "Social work consult now please, for living arrangement and placement." 2. There was no evidence in the medical record of an initial discharge planning evaluation completed within 48 working hours of referral. 3. The above was confirmed by Staff #1. B. Based on medical record review and review of facility policies and procedures, it was determined that the facility failed to ensure that the discharge planning evaluation was complete. Findings include: Reference: Facility policy titled "Interdisciplinary Discharge Planning" states, " Procedure/Process: ... 3. Case Management Responsibility: B. The Case Management Department will initiate discharge planning either through high risk screening, referral from patients/families, or from members of the STATE FORM 6899 G7T911 If continuation sheet 70 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D7035 Continued From page 70 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D7035 interdisciplinary team who identify patients needing intervention, this is done to ensure continuity of care. C. Initial assessment shall be completed on all patients that meet social service high risk criteria and/or patients referred to the Case Management staff for intervention. This assessment shall be completed within 48 hours of admission/referral. ... D. The Case Management staff is responsible for assessing the psychological, social, environmental, and financial impact of illness on patients and their families. This will be accomplished through interviews with patients and their family members. ... " 1. Medical Record #8 indicated the patient was admitted to the facility on 12/28/13. The Case Management initial assessment, completed on 12/30/13, lacked evidence that the patient's psychological, social, environment, and financial impact of illness on patient's and their family members was assessed, as required by the above referenced policy. 2. Medical Record #23 indicated the patient was admitted to the facility on 12/30/13. The Case Management initial assessment, completed on 12/30/13, lacked evidence that the patient's psychological, social, environment, and financial impact of illness on patient's and their family members was assessed, as required by the above referenced policy. 3. Medical Record #25 indicated that the patient was admitted to the facility on 12/15/13. The Case Management initial assessment, completed on 12/17/2013, lacked evidence that the patient's psychological, social, environment, and financial STATE FORM 6899 G7T911 If continuation sheet 71 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D7035 Continued From page 71 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D7035 impact of illness on patient's and their family members was assessed, as required by the above referenced policy. C. Based on review of 1 of 1 medical record, of a patient returning to a nursing home, it was determined that the facility failed to ensure that the Transfer-Return to Nursing Home policy was implemented. Findings include: Reference: Facility policy titled "Transfer-Return to Nursing Home" states, "Process: ... Case Management will follow patient's medical condition and document in patient medical record every 3 days or if patient's discharge plan changes ..." 1. Medical Record #21 indicated the patient was admitted to the facility on 12/23/13. The Case Management initial assessment was completed on 12/24/13. The next Case Management final disposition note, dated 1/6/14, indicated the patient was returned to the Nursing Home. a. There was no evidence that the Case Management staff documented in the medical record every three days, the patient's medical condition or if the patient's discharge plans changed, as required by the above referenced policy. D. Based on review of two medical records of patients who required post hospital care and staff interview, it was determined that the facility failed to ensure that the Patient Choice policy was implemented regarding the patient and/or individual acting on the patient behalf was STATE FORM 6899 G7T911 If continuation sheet 72 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D7035 Continued From page 72 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D7035 provided a list of post acute care providers to choose from for post hospital care. Findings include: Reference: Facility policy titled "Patient Choice" states, "... Procedure: The following steps shall be performed to ensure patients are given a free choice and provided a meaningful opportunity to select a post acute provider/service: Home Care, ... Sub acute Care, Rehabilitation ... The CM [case manager] staff will offer each patient or family/legal representative a list of approved providers that are appropriate for the level of care needed ... K. If a referral has been made for services post discharge, the medical record must include documentation of the patient's selection." 1. On 1/7/14, review of Medical Record #23 indicated the patient was admitted to the facility on 12/30/13 with signs/symptoms of a cerebral vascular accident. The initial Case Management assessment performed on 12/31/13 indicated that no discharge needs were identified at that time and Case Management would continue to assess and assist with discharge planning. The next note by the Case Manager, performed on 1/6/14 stated, "Final disposition." The note indicated the patient was being discharged to a rehabilitation facility and that the patient's ... [family member] was notified of the transfer. a. There was no evidence in the medical record that the patient or family was provided with a list of rehabilitation facilities to choose from for post hospital care. 2. On 1/7/14, review of Medical Record #25 indicated the patient was admitted to the hospital on 12/15/13. The initial Case Management STATE FORM 6899 G7T911 If continuation sheet 73 of 74 PRINTED: 10/31/2014 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: MEADOWLANDS HOSPITAL MEDICAL CENTER (X4) ID PREFIX TAG A. BUILDING: ______________________ (X3) DATE SURVEY COMPLETED B. WING _____________________________ 10906 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 01/10/2014 STREET ADDRESS, CITY, STATE, ZIP CODE 55 MEADOWLANDS PKWY SECAUCUS, NJ 07094 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D7035 Continued From page 73 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE D7035 assessment performed on 12/17/13 indicated that no discharge needs were identified at the time and to continue with assessment and assistance with discharge planning. On 12/18/13, the Case Manager's final disposition note indicated the patient was discharged to a rehabilitation center. The patient and the patient's family were aware of arrangements/plan and agreed to it. a. There was no evidence in the medical record that the patient or family was provided with a list of rehabilitation centers to choose from for post hospital care. 3. The above was confirmed by Staff #22. STATE FORM 6899 G7T911 If continuation sheet 74 of 74