Cayuga Medical 3

STATE OF NEW YORKDEPARTMENT OF HEALTHCentral New York Regional Office

217 South Salina Street' Syracuse, New York 13202

Richard F. Daines, M.D. James W. Clyne, Jr.Commissioner Executive Deputy Commissioner

September 9, 2010

Noel Desch, ChairmanCayuga Medical Center at Ithaca101 Dates DriveIthaca, NY 14850

RE: Complaint Medical RecorNYPORTS

Dear Mr. Desch:

Staff from this office have completed an investigation of the complaint referenced above,which involved allegations of inadequate medical care.

As part of our surveillance activities, professional staff visited the facility, reviewed thepatient's medical record, reviewed applicable facility documents and interviewed staff atthe facility. The professional staff who reviewed the patient's medical record included aphysician board-certified in critical care, pulmonary, and internal medicine.

Based on the findings from our investigation, we identified violations of regulationsconcerning governing body, medical staff, nursing and respiratory care services, medicalrecords, quality assurance, and incident reporting, as outlined in the enclosed Statementof Deficiencies. A Plan of Correction addressing each deficiency, includingmechanism(s) to monitor ongoing compliance, must be submitted to this office no laterthan 10 business days from receipt of this letter.

Our findings were discussed with hospital staff during the investigation. Should you oryour staff have any questions regarding this case, please feel free to contact NancyWilliams, Hospital Nursing Services Consultant, at (315) 477-8538.

Sincerely,

Roberta Gancarz, Program DirectorHospital and Primary Care Services

cc: D. Rob Mackenzie, MD

Enclosure

cl

PRINTED: 09/09/2010FORM APPROVED

New York State Department of Health

STATEMENT OF DEFICIENCIES (Xl) PROVIDER/SUPPLIERJCLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEYAND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A. BUILDINGB. WING C

330307 07/21/2010NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

101 DATES DRIVECAYUGA MEDICAL CENTER AT ITHACA ITHACA, NY 14850

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (5)PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE

TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATEDEFICIENCY)

S 000 INITIAL COMMENTS S 000

PFI #0977OPERATING CERTIFICATE #5401001 H

NOTE: THE NEW YORK OFFICIALCOMPILATION OF CODES, RULES ANDREGULATIONS (10NYCRR) DEFICIENCIESBELOW ARE CITED AS A RESULT OF

ND NYPORTSTHE PLAN OF

CORRECTION, HOWEVER, MUST RELATE TOTHE CARE OF ALL PATIENTS AND PREVENTSUCH OCCURRENCES IN THE FUTURE.INTENDED COMPLETION DATES AND THEMECHANISM(S) ESTABLISHED TO ASSUREONGOING COMPLIANCE MUST BEINCLUDED.

S 152 405.2 (f) (1) GOVERNING BODY. Care of S 152patients.

The governing body shall require that thefollowing patient care practices are implemented,shall monitor the hospital's compliance with thesepatient care practices, and shall take correctiveaction as necessary to attain compliance: (1)every patient of the hospital, whether an inpatient,emergency service patient, or outpatient, shall beprovided care that meets generally acceptablestandards of professional practice.This Regulation is not met as evidenced by:Based on findings from document review andinterview, a patient was not provided care thatmet generally accepted standards of professionalpractice. Specifically, the patient (Patient A) didnot have an done early in the admission, was not evaluated ina timely manner by a specialist, wasmaintained on

espit on board

Office of Health Systems Management / Office of Long Term CareTITLE (X6) DATE

LABORATORY DIRECTOR'S OR PROVIDERISUPPLIER REPRESENTATIVE'S SIGNATURE

STATE FORM Version NYS 11/17/2009 6899 OHSI11 If continuation sheet 1 of 22


New York State Department of HealthSTATEMENT OF DEFICIENCIES (X1) PROVIDERSUPPLIERCLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEYAND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A. BUILDING

B. WING C330307 07/21/2010

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETETAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATEDEFICIENCY)

S152 Continued From page 1 S152

and signs of and was nottimely and adequately.

Findings include:

--Per review of Patient A's medical record by aphysician board certified in critical care,pulmonary and internal medicine:

The patient was a with recent historyof iagnosed on 09for which was treated with a course of

Patient was seen by a primarymedical doctor (PMD) on 09 and reportedlydoing Patient returned to PMD on /09with complaint of and

was re-prescribed

However, on 09, Patient A returned to thePMD with and withcomplaint

A Patient had

been star andreferred to Cayu Center for admission.Patient A was a direct admit to the

did complain of some pain atadmission but denied

Patient A was admitted with diagnosis ofAt admission

had

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New York State Department of Health FORMAPPROVED

STATEMENT OF DEFICIENCIES (Xl) PROVIDERJSUPPLIERJCLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEYAND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A. BUILDING330307 B. WING C

07/21/2010NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (XS)PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE


S152 Continued From page 2 S152

All cultures and sensitivities of Patient had been started on

andn

for

Patient was admitted at about n 09.

Per nursing note at patient was

complained o on

At Patient had ithRapid Response Team

(referred to as the Clinical Assessment Team atthis hospital) was called.

Opercent. on exam. Diminished

Decision was made to

At were drawn. Patient was given via

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New York State Department of HealthSTATEMENT OF DEFICIENCIES (Xl) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEYAND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A. BUILDING

B. WING C330307 07/21/2010



(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE


S 152 Continued From page 3 S 152

At patient was transferred to Wasgive fo pain.

At were

on /09

At (on 09), due to continued

As per nursing documentation by the registerednurse (RN #1) who assumed care of the patientat in ote recorded at on4/ 09), P A was on

Very complaining pain /10 (on a scale of 1-10).

Was being medicated with

and patient waswith Possibility of

discussed by physician.

At nursing documentation indicates thepatient was on

was noted to have andwas using ccessory heard. Patient A conti

pain and was receiving

At due to patient's condition,Office of Health Systems Management / Office of Long Term CareSTATE FORM Version NYS 11/17/2009 699 OHSI11 If continuation sheet 4 of 22



STATEMENT OF DEFICIENCIES (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (XS) DATE SURVEYAND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED







the decision was made to Nursingnote indicated that Physician #2 attempted to

patient but was unsuccessful. Physician#2 asked that an t be paged forassistance. An ED physician (Physician #3) cameto assist. A patient went int

and then. No detected. Patient A was

eam) was called.

Per anesthetist (Physician #4) documentation inchart at n 09, he/she responded tooverhead page fr Upon arrival,

was already inserted. position. No

. Patient was

An one on 09 (time not noted onrep revealed with

and near complete

Nursing documentation indicates that the patientremained status post code whichlasted had

An laced during the coderev Patient's

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New York State Department of HealthSTATEMENT OF DEFICIENCIES (Xl) PROVIDER/SUPPLIERJCLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEYAND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A. BUILDING

B. WING C330307 07/21/2010



(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETETAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)


was with no Patient continued to be was unresponsive

Despite all efforts and patient

continued to remain Anevealed

Patient A Due to

condition, it was decided to transfer for

-- Discussion and conclusions in the Departmentof Health physician review of this case, regardinglapses in care, include the following:

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEYAND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A. BUILDING

330307 B. WING C07/21/2010



(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVDER'S PLAN OF CORRECTION (X5)PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE



Office of Heal Long Term CareSTATE FORM Version NYS 11/17/2009 OHSI 11 If continuation sheet 7 of 22

PRINTED: 09/0912010FORM APPROVED

New York State Department of HealthSTATEMENT OF DEFICIENCIES (Xl) PROVIDER/SUPPLERCLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEYAND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A. BUILDING

B. WING C330307 07/21/2010



(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE



S 258 405.4 (a) (1) (i) MEDICAL STAFF Medical staff S 258accountability.

(1) The medical staff shall establish objectivestandards of care and conduct to be followed byall practitioners granted privileges at the hospital.Those standards shall: (i) be consistent withprevailing standards of medical and otherlicensed health care practitioner standards ofpractice and conduct.This Regulation is not met as evidenced by:See Tag S152 for description of significant lapsesin the medical care that occurred in this case.

S 340 405.5 NURSING SERVICES. S 340

The governing body shall ensure that the hospitalhas an organized nursing service that provides24-hour services and that meets the care needsof all patients in accordance with establishedstandards of nursing practice. The nursingservices for all patients shall be provided orsupervised by a registered professional nursewho is on duty and available at all times.This Regulation is not met as evidenced by:Based on findings from document review andinterviews, the nursing care provided to Patient Adid not meet generally accepted standards ofnursing practice. Specifically, nursing staff didnot: 1) obtain and document Patient A's

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STATEMENT OF DEFICIENCIES (Xl) PROVIDERISUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEYAND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED


330307 07121/2010NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE





at the time of admission, 2) notify aphysician of Patient A's decreased

3) perform adequatemonitoring of Patient A's whilewas in the i tranall medication orders, on / and 09, onto amedication administration record (MAR) in aclear, non-confusing and easy-to-follow manner,5) administe medications, on and

09, at the frequency ordered, 6) performsufficient assessments of Patient A's pain and

status, even after Patient A wasstarted on medications forpain and , and 7) accuratelydocument the events of Patient A's

Findings pertaining to (1) above include:

-Per review of the hospital policy entitled '"VitalSigns Measurement," last revised 2/08, it requiresthat vital signs (temperature, pulse, respirations,blood pressure and in some areas, oxygensaturation) be taken on admission.

-Per MR review, on 09 at Registered Nurse (RN) #2 admitted Patient A(with diagnosis oand performed an Admission NursingAssessment. afteradmission, at nursing staffdocumented Patient A's as follows:

There is no documentation indicating that nursingstaff obtained Patient A's at the time ofadmission to the floor prior to theobtained at

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STATEMENT OF DEFICIENCIES (Xl) PROVIDERISUPPLIERCLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEYAND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETEDA. BUILDING

B. WING C330307 07/21/2010



(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION V5)PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETETAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATEDEFICIENCY)



--Per MR review, o 09 at nursingstaff documented that Patient A'swas There is no indication in Patient A's MRthat a physician was notified regarding the

at that time.


-- Per review of the hospital policy entitled "ICUDocumentation Guidelines," last revised 10/08,patient temperature readings must be repeatedand documented every hour if the patient is notedto be hypo or hyperthermic, unless otherwiseindicated. (The policy does not define hyper orhypothermia.)

--Per MR review, nursing staff documentedPatient A's while in the t thefollowing times on the dates noted:

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERCLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEYAND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A. BUILDING

B. WING C330307 07/21/2010






Despite being in whichcircumstance the patient' shouldhave been checked/documented times duringthis hour period of time, it was only checkedtimes.

Findings pertaining to (4) and (5) above include:

--Per MR review, on 09 atPhysician #1 gave a order for

as needed(prn) pain (route not specified). Nursing staffdocumented the order onto the MAR.

At , Physician #1 gave aorder changing the from

However, instead of discontinuing the previousorder on the MAR and writing a new order,nursing staff in the previousentry on the MAR, and

Due to this manner of documentation, uponretrospective review of the MAR, it is not evidentwhich dosage of the

as administered to the patient in theadministrations recorded.

Additionally, review of the MAR reveals thatnursing staff administered the

on /09 andon 09, rather than the every nd

then hour(s) ordered.

Further, review of the MAR also reveals that the

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New York State Department of HealthSTATEMENT OF DEFICIENCIES (Xl) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEYAND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A. BUILDING

B. WING C330307 07121/2010


CAYUGA MEDICAL CENTER AT ITHACA 101 DATES DRIVEITHACA, NY 14850

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION - (5)PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETETAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)


medication orders transcribed/transferred bynursing onto the MAR for t /09 weredocumented in a haphazard, unsafe manner, asfollows:

Findings pertaining to (6) include:

-Per review of Patient A's MR:

On- at Physician #1 gave a ord n.- at #1 gave aorde .

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STATEMENT OF DEFICIENCIES (Xl) PROVIDERSUPPLIERJCLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEYAND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A BUILDING

3337B. WING C330307 B07/21/2010






On 09:- at , Physician #1 ordered

pain.- at Physician #1 gave a orderfor

pain.- at ., Physician #1 ordered

However, while review of Patient A's MR revealsthat or both of these medications wereadministered to Patient A every minutes tohour between on /09 and

on 09, review of the nursingdocumentation on the Critical Care Flowsheetforms and in the patient notes reveals thefollowing:

- Pain assessments were not recordedindicating th(pain scale) of Patient A's pain at the time of eachadministration of on 09 at

and i.e., on /09 atAdditionally,

a pain assessment was not recorded at the timethat a of wasinitiated (on 09 at until at which time nursing staff documented thatPatient A's pain was /10.

- When the patient's pain level wasdocumented as 10 at on 09, itwas not assessed again until hours later, at

on 09.

- Pertinent (i.e., and were not recorded at the timeeach prn administration of (i.e.


PRINTED: 09/0912010

FORM APPROVEDNew York State Department of Health

STATEMENT OF DEFICIENCIES (Xl) PROVIDER/SUPPLIERJCLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEYAND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETEDA. BUILDING

B. WING C330307 07/21/2010



(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (X5)PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETETAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATEDEFICIENCY)


Findings pertaining to (7) include:

-Per review of the hospital policy entitled "ABCAlert," last revised 10/07, an ABC Alert entails thesummoning of a resuscitative team for a patientwho is experiencing cardiopulmonary arrest. Thepolicy states" ...documentation of all activitiesand events occurring during an ABC Alert will bedocumented on the ABC Alert record... Therecorder, designated by the ICU RN, during anABC Alert, will fill out the ABC Alert record andobtain all necessary signatures... The recordserves as a complete medication and IV record,eliminating the need to write orders for codemedications and IVs in the patient chart. Thisrecord will be filled out at each intervention orevery 5 minutes. Documentation will include theevents from the initial alert to the disposition ofthe patient."

--Per MR review, the documentation of theresuscitation of Patient A was done by nursingstaff on the unit) Flowsheet;(not the AB r policy). Thedocumentation does not describe the initial typeof that Patient Aexperienc dication dosagesadministered (i versus during

the ons formanagement (i.e.,

ce, and the teduring

Athe staff involved in the

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New York State Department of Health FORM APPROVED

STATEMENT OF DEFICIENCIES (Xl) PROV1DERISUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEYAND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A. BUILDING ______ _____

330307 B. WING C

07121/2010NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (XE)PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE



S 356 405.5 (b) (2) (i) NURSING SERVICES. Delivery S 356of services.

(2) (i) Nursing care policies and procedures shallbe written and consistent with generally acceptedstandards of nursing practice.This Regulation is not met as evidenced by:Based on findings from document reviews andinterviews, 2 hospital policies and procedures(P&Ps) were not consistent with generallyaccepted standards of nursing practice, asfollows:(1) The Patient Controlled Analgesia (PCA) P&Placked adequate requirements for monitoring ofvital signs.(2) The Clinical Assessment Team (CAT) P&Placked description of the roles and responsibilitiesof the CAT members and lacked requirement forphysician notification when a call is made.


-Per review of the hospital P&P entitled "PatientControlled Analgesia (PCA)," last revised 10/07, itstates "When therapy is initiated, the patient isassessed per policy or specific MD orders. Eachassessment will be documented on the narcoticinfusion record at least every shift and PRN pernursing discretion. The patient's ongoing...assessment will include level of consciousness,respiratory rate and/or additional comments perMD preprinted orders."

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STATEMENT OF, DEFICIENCIES (Xl) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEYAND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETEDA. BUILDING __________

B. WING C330307 07/21/2010



(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (5)PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE

TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)


This P&P requires nursing staff to assesspatients beginning PCA therapy "per policy" - itdoes not establish acceptable minimumrequirements for how often the patient should beassessed, i.e., "at least every shift" is notsufficient.


--Per review of the hospital P&P entitled "ClinicalAssessment Team," last revised 10/07, themembers of the CAT team consist of an ICU RNand a RT (respiratory therapist). The policy doesnot describe the roles/responsibilities of thesestaff in CAT (rapid response) calls and does notrequire that the patient's Attending Physician, orany other physician, be notified when a CAT callhas been initiated or completed for a patient.

S 401 405.6 (b) (1) QUALITY ASSURANCE S 401PROGRAM. Activities.

The activities of the quality assurance committeeshall involve all patient care services and shallinclude, as a minimum: (1) review of the careprovided by the medical and nursing staff and byother health care practitioners employed by orassociated with the hospital.This Regulation is not met as evidenced by:


PRINTED: 09/09/2010FORM APPROVEDNew York State Department of Health

STATEMENT OF DEFICIENCIES (X1) PROVIDERJSUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEYAND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A. BUILDING

B. WING C330307 07/21/2010


101 DATES DRIVECAYUGA MEDICAL CENTER AT ITHACA 101ADAT DRIVEITHACA, NY 14850

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION VS)PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE



S 472 405.8 (a) INCIDENT REPORTING. S 472

(a) Any incident required to be reported pursuantto subdivision (b) of this section shall be reportedto the department's Office of Health SystemsManagement on a telephone number maintainedfor such purpose. Hospitals shall report suchincidents within 24 hours of when the incidentoccurred or when the hospital has reasonablecause to believe that such an incident hasoccurred and shall take no more than sevencalendar days to determine whether an incidentdefined in paragraph (b) (1) of this section isreportable and subject to the requirements of thissection. The hospital shall give written notification

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STATEMENT OF DEFICIENCIES (Xl) PROVIDER/SUPPLIERCLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEYAND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A. BUILDING

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(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETETAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)


within seven calendar days of the initialnotification. This notification shall be submitted ina format specified by the department and shallrecord the nature, classification and location ofthe incident; medical record numbers of allpatients directly affected by the incident; the fullname and title of physicians and hospital staffinvolved in the incident as well as their license,permit, certification or registration numbers; theeffect of the incident on the patient; follow-uptreatments and evaluations planned; theexpected completion date for the hospital'sinvestigation and identification informationrequired by the department.This Regulation is not met as evidenced by:

S 602 405.10 (a) (1) MEDICAL RECORDS. General S 602requirements.

(1) Medical records shall be legibly andaccurately written, complete, properly filed,retained and accessible in a manner that doesnot compromise the security and confidentiality ofthe records.This Regulation is not met as evidenced by:Based on findings from document review andinterviews, the hospital did not maintain a clear,complete and accurate MR for Patient A.

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STATEMENT OF DEFICIENCIES (XI) PROVIDERISUPPLIERtCLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEYAND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED







Findings include:

--Per review of the nursing MR documentationregarding the of Patient A, nursingstaff documented that Physician #3 Patient A a . on 09.

However, there is no documentation by Physician#3 describing the including the size ofthe used for the , the

markings used to verifyposition, or the method Physician #3 used toconfirm proper lacement at the time of

- Per review of the MAR dated 09 in PatientA's MR, nursing staff drew lines delineatingseparate areas for medication orders then writtenon the MAR. Nursing staff documented physicianmedication orders for " eplacement"(lacking

and "(lacking

has

This MAR did not provide clear, complete andeasy-to-follow directions for medicationadministrations on each nursing shift. Also, uponretrospective review, this MAR does notaccurately describe all medications administered.

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PRINTED: 09/09/2010

FORM APPROVEDNew York State Department of HealthSTATEMENT OF DEFICIENCIES (Xl) PROVIDERISUPPLIER!CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEYAND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A. BUILDING

330307 B. WING 07/21/2010NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETETAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATEDEFICIENCY)


-Per review of the American College ofRadiology (ACR) Practice Guideline forCommunication of Diagnostic Imaging Findings,last revised 2005, the format for reportingdiagnostic testing should include the time ofexamination, if relevant (e.g., for patients who arelikely to have more than one of the samediagnostic examination in the same day).

Per MR review, Patient A underwenon /09. However, both reports

present in Patient A's MR lack the times theexaminations were performed.

S 726 405.14 (b) (1) RESPIRATORY CARE S 726SERVICES.

Operation and service delivery. (1)Respiratory care services shall only be providedin accordance with specific hospitalprotocols/policies or upon the orders of membersof the medical staff. The order for respiratory careservices shall specify the type, frequency andduration of treatment, and, as appropriate, thetype and dose of medication, the type of diluent,and the oxygen concentration.This Regulation is not met as evidenced by:Based on findings from document review andinterview, the hospital's P&P regarding use ofNon-Invasive Positive Pressure Ventilation(NIPPV) lacked guidance/parameters by whichrespiratory therapy staff (RT) should assess the

Dffice of Health Systems Management I Office of Long Term CareSTATE FORM Version NYS 11/17/2009 6M OHS1 1 If continuation sheet 20 of 22



STATEMENT OF DEFICIENCIES (Xl) PROVIDER/SUPPLIERJCLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEYAND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A. BUILDING

B. WING C330307 07121/2010


CAYUGA MEDICAL CENTER AT ITHACA 101 DATES DRIVEITHACA, NY 14850

(X4) ID T SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE

TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)


effectiveness of its use and for when to conferwith a physician.

Findings include:

-Per review of the P&P entitled "Department ofRespiratory Care NIPPV Policy and Procedure,"dated 11/06, it indicates when BiPAP should beused and that the patient should be monitoredevery two hours. It lacks guidance as to how RTshould assess the effectiveness of NIPPV andwhat circumstances require discussion with aphysician/physician notification.

S 727 405.14 (b) (2) RESPIRATORY CARE S 727SERVICES.

Operation and service delivery. (2) Allrespiratory care services provided shall bedocumented in the patient's medical record,including the type of therapy, date and time ofadministration, effects of therapy, and anyadverse reactions.This Regulation is not met as evidenced by:Based on findings from document review andinterview, respiratory therapy staff (RT) did notdocument assessing the effectiveness of the useo in Patient A's care and discussingfindings with a physician.

Findings include:

-Per MR review:

An RT note dated 09 and documented attates reatment

decreased to Pt c/o pain and difficulty RN in room and is working on pts

behalf now. ncreased ... RN is aware.remain but are

Office of Health Systems Management I Office of Long Term CareSTATE FORM Version NYS 11/17/2009 6899 OHSI11 If continuation sheet 21 of 22


New York State Department of HealthSTATEMENT OF DEFICIENCIES (Xl) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEYAND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A. BUILDING

B. WING C330307 07121/2010



(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETETAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)


Pt's pain and are beingseen to by RN."

Another RT note documented on 09 at states started. Pt

The Flow Sheet form in theMR describes sets of ndcorrespondin during the theyare not timed.

The next note RT documented was on /09 at- it states while on

test is positive for

(Per review of the hospital P&P entitled"Department of Respiratory Care NIPPV(Non-Invasive Positive Pressure Ventilation)Policy and Procedure," dated 11/06, it states "Thepatient will be reassessed at least every twohours with written documentation via flow-sheetat bedside for acute cases.")

ffice of Health Systems Management Office of Long Term CareSTATE FORM Version NYS 11/17/2009 6899 OHSI11 If continuaton sheet 22 of 22

STATE OF NEW YORKDEPARTMENT OF HEALTHCentral New York Regional Office

217 South Salina Street Syracuse, New York 13202

Richard F Daines, M.D. James W. Clyne, Jr.Commissioner Executive Deputy Commissioner

September 9, 2010

RE: Cayuga Medical Center at IthacaComplainNYPORT

Dear Colleague:

This Notice of Violation is provided to you in accordance with Section 18 of the NewYork State Public Health Law. Section 18 requires the Department of Health to send toeach director or trustee of a health care agency or facility, notice of a violation of thePublic Health Law or the Department's regulations which could result in the revocation,cancellation, limitation or suspension of the agency's operating certificate.

Staff from this office have conducted an investigation of the complaint and Incidentreferenced above, and deficiencies were noted in the following areas of operation:

" Section 405.2 of 1ONYCRR: Governing Body* Section 405.4 of 1 ONYCRR: Medical Staff* Section 405.5 of 1 ONYCRR: Nursing Services* Section 405.6 of 1ONYCRR: Quality Assurance Program* Section 405.8 of 1 0NYCRR: Incident Reporting* Section 405.10 of 1 ONYCRR: Medical Records" Section 405.14 of 10NYCRR: Respiratory Care Services

The complete Statement of Deficiencies was sent to the facility Administrator and theChairperson or other designated principal contact of the governing body, with theexpectation that its contents would be made available to you. Please take time tosecure it and review it. Each deficiency cited is a violation of State regulations and mayresult in the imposition of a fine and/or other penalty on the facility and/or the revocation,cancellation, limitation or suspension of its operating certificate. As a member of thefacility's goveming body, you are responsible for completely correcting the identifieddeficiencies in a timely manner.

Should you wish to review the entire report, you may obtain a copy from hospitaladministration or this office.

Sincerely,

Roberta Gancarz, Program DirectorHospital and Primary Care Services

STATE OF NEW YORKDEPARTMENT OF HEALTHCentral New York Regional Office217 South Salina Street Syracuse, New York 13202

Richard F. Daires, M.D. James W. Clyne, Jr.Commissioner Executive Deputy Commissioner

September 13, 2010

Re: Cayuga Medical Center at IthacaComplaint

Dear

The New York State Department of Health (the Department) has evaluated the concerns you identified withcare provided to your at Cayuga Medical Center at Ithaca.

As part of our surveillance activities, professional staff reviewed you medical record, reviewedother pertinent facility documents, and interviewed staff at the facility. The professional staff who reviewed

your medical record included a physician board-certified in critical care, pulmonary, and internalmedicine.

As a result of this review, the facility was found to be in violation of the State Hospital Code in the followingareas:

Medical Staff Services - Inadequate medical care relative to evaluation and management of a patient'sincomplete medical record (MR) documentation.

Nursing Services - Inadequate assessments of and physician notifications about the patient's

condition; inappropriate medication administration practices and documentation; incomplete policies

and procedures (P&Ps); incomplete MR documentation.

Respiratory Care Services - Inadequate assessments of the patient's tatus; incomplete

MR documentation; incomplete P&Ps.

Medical Records - Incomplete and unclear medical record documentation.

A Statement of Deficiencies has been issued to the facility. In response, the facility will be required to provide a

written Plan of Correction and implement corrective measures, acceptable to the Department, to address these

violations.

Please accept our sincere condolences for the loss of your hank you for sharing your concerns with

the Department and providing the opportunity for facility review. If you have any questions, you may contact

Nancy Williams, Hospital Nursing Services Consultant, at (315) 477-8538.

Roberta Gancarz, program Director

Hospital and Primary Care Services

l

Documents

Cayuga Medical 3