Cayuga Medical 3

STATE OF NEW YORK
DEPARTMENT
OF HEALTH
Central 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, Chairman
Cayuga Medical Center at Ithaca
101 Dates Drive
Ithaca, NY 14850
RE: Complaint
Medical Recor
NYPORTS
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 the
patient's medical record, reviewed applicable facility documents and interviewed staff at
the facility. The professional staff who reviewed the patient's medical record included a
physician board-certified in critical care, pulmonary, and internal medicine.
Based on the findings from our investigation, we identified violations of regulations
concerning governing body, medical staff, nursing and respiratory care services, medical
records, quality assurance, and incident reporting, as outlined in the enclosed Statement
of Deficiencies. A Plan of Correction addressing each deficiency, including
mechanism(s) to monitor ongoing compliance, must be submitted to this office no later
than 10 business days from receipt of this letter.
Our findings were discussed with hospital staff during the investigation. Should you or
your staff have any questions regarding this case, please feel free to contact Nancy
Williams, Hospital Nursing Services Consultant, at (315) 477-8538.
Sincerely,
Roberta Gancarz, Program Director
Hospital and Primary Care Services
cc: D. Rob Mackenzie, MD
Enclosure
cl
PRINTED: 09/09/2010
FORM APPROVED
New York State Department of Health
STATEMENT OF DEFICIENCIES (Xl) PROVIDER/SUPPLIERJCLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING C
330307 07/21/2010
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
101 DATES DRIVE
CAYUGA 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 DATE
DEFICIENCY)
S 000 INITIAL COMMENTS S 000
PFI #0977
OPERATING CERTIFICATE #5401001 H
NOTE: THE NEW YORK OFFICIAL
COMPILATION OF CODES, RULES AND
REGULATIONS (10NYCRR) DEFICIENCIES
BELOW ARE CITED AS A RESULT OF
ND NYPORTS
THE PLAN OF
CORRECTION, HOWEVER, MUST RELATE TO
THE CARE OF ALL PATIENTS AND PREVENT
SUCH OCCURRENCES IN THE FUTURE.
INTENDED COMPLETION DATES AND THE
MECHANISM(S) ESTABLISHED TO ASSURE
ONGOING COMPLIANCE MUST BE
INCLUDED.
S 152 405.2 (f) (1) GOVERNING BODY. Care of S 152
patients.
The governing body shall require that the
following patient care practices are implemented,
shall monitor the hospital's compliance with these
patient care practices, and shall take corrective
action as necessary to attain compliance: (1)
every patient of the hospital, whether an inpatient,
emergency service patient, or outpatient, shall be
provided care that meets generally acceptable
standards of professional practice.
This Regulation is not met as evidenced by:
Based on findings from document review and
interview, a patient was not provided care that
met generally accepted standards of professional
practice. Specifically, the patient (Patient A) did
not have an
done early in the admission, was not evaluated in
a timely manner by a specialist, was
maintained on
espit on board
Office of Health Systems Management / Office of Long Term Care
TITLE (X6) DATE
LABORATORY DIRECTOR'S OR PROVIDERISUPPLIER REPRESENTATIVE'S SIGNATURE
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STATEMENT OF DEFICIENCIES (X1) PROVIDERSUPPLIERCLIA
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(X3) DATE SURVEY
AND PLAN OF CORRECTION
IDENTIFICATION NUMBER:
COMPLETED
A. BUILDING
B. WING
C
330307
07/21/2010
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
101 DATES DRIVE
CAYUGA MEDICAL CENTER AT ITHACA ITHACA, NY 14850
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES
ID PROVIDER'S PLAN OF CORRECTION
(X5)
DEFICIENCY)
S152 Continued From page 1
S152
and signs of and was not
timely and adequately.
Findings include:
--Per review of Patient A's medical record by a
physician board certified in critical care,
pulmonary and internal medicine:
The patient was a with recent history
of
iagnosed on 09
for which was treated with a course of
Patient was seen by a primary
medical doctor (PMD) on 09 and reportedly
doing Patient returned to PMD on /09
with complaint of
and
was re-prescribed
However, on 09, Patient A returned to the
PMD with and with
complaint
A

Patient had
been star
and
referred to Cayu Center for admission.
Patient A was a direct admit to the
did complain of some
pain at
admission but denied
Patient A was admitted with diagnosis of
At admission
had
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AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
COMPLETED
A. BUILDING
330307 B. WING
C
07/21/2010
101 DATES DRIVE
ITHACA, NY 14850
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (XS)
DEFICIENCY)
S152 Continued From page 2 S152
All cultures and sensitivities of
Patient had been started on
and
n
for
Patient was admitted at about n 09.
Per nursing note at patient was
complained o on
At Patient had ith
Rapid Response Team
(referred to as the Clinical Assessment Team at
this hospital) was called.
O
percent. on exam. Diminished
Decision was made to
At were drawn. Patient was given
via
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COMPLETED
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B. WING
C
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(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
DEFICIENCY)
S 152 Continued From page 3
S 152
At patient was transferred to Was
give fo pain.
At were
on /09
At (on 09), due to continued
As per nursing documentation by the registered
nurse (RN #1) who assumed care of the patient
at in ote recorded at on
4/ 09), P A was on
Very
complaining
pain /10 (on a scale of 1-10).
Was being medicated with
and patient was
with Possibility of
discussed by physician.
At nursing documentation indicates the
patient was on
was noted to have and
was using ccessory
heard. Patient A conti
pain and was receiving
At due to patient's condition,
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A. BUILDING
B. WING C
330307
07/21/2010
101 DATES DRIVE
ITHACA, NY 14850
DEFICIENCY)
S 152 Continued From page 4 S 152
the decision was made to Nursing
note indicated that Physician #2 attempted to
patient but was unsuccessful. Physician
#2 asked that an t be paged for
assistance. An ED physician (Physician #3) came
to assist. A patient went int
and then
. No detected. Patient A was
eam) was called.
Per anesthetist (Physician #4) documentation in
chart at n 09, he/she responded to
overhead page fr Upon arrival,
was already inserted.
position. No
. Patient was
An one on 09 (time not noted on
rep revealed with
and near complete
Nursing documentation indicates that the patient
remained status post code which
lasted had
An laced during the code
rev Patient's
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ID PROVIDER'S PLAN OF CORRECTION (X5)
DEFICIENCY)
S 152
was with no
Patient continued to be was unresponsive
Despite all efforts and
patient
continued to remain An
evealed
Patient A
Due to
condition, it was decided to transfer
for
-- Discussion and conclusions in the Department
of Health physician review of this case, regarding
lapses in care, include the following:
Office of
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330307
B. WING
C
07/21/2010
101 DATES DRIVE
ITHACA, NY 14850
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVDER'S PLAN OF CORRECTION (X5)
DEFICIENCY)
Office of Heal Long Term Care
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(X3) DATE SURVEY
COMPLETED
A. BUILDING
B. WING
C
330307
07/21/2010
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(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
DEFICIENCY)
S 152
S 258 405.4 (a) (1) (i) MEDICAL STAFF Medical staff S 258
accountability.
(1) The medical staff shall establish objective
standards of care and conduct to be followed by
all practitioners granted privileges at the hospital.
Those standards shall: (i) be consistent with
prevailing standards of medical and other
licensed health care practitioner standards of
practice and conduct.
See Tag S152 for description of significant lapses
in the medical care that occurred in this case.
S 340 405.5 NURSING SERVICES.
S 340
The governing body shall ensure that the hospital
has an organized nursing service that provides
24-hour services and that meets the care needs
of all patients in accordance with established
standards of nursing practice. The nursing
services for all patients shall be provided or
supervised by a registered professional nurse
who is on duty and available at all times.
interviews, the nursing care provided to Patient A
did not meet generally accepted standards of
nursing practice. Specifically, nursing staff did
not: 1) obtain and document Patient A's
Office of Health Systems Management ! Office of Long Term Care
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COMPLETED
A. BUILDING
B. WING
C
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101 DATES DRIVE
ITHACA, NY 14850
DEFICIENCY)
at the time of admission, 2) notify a
physician of Patient A's decreased
3) perform adequate
monitoring of Patient A's while
was in the i tran
all medication orders, on / and 09, onto a
medication administration record (MAR) in a
clear, non-confusing and easy-to-follow manner,
5) administe medications, on and
09, at the frequency ordered, 6) perform
sufficient assessments of Patient A's pain and
status, even after Patient A was
started on medications for
pain and , and 7) accurately
document the events of Patient A's
Findings pertaining to (1) above include:
-Per review of the hospital policy entitled '"Vital
Signs Measurement," last revised 2/08, it requires
that vital signs (temperature, pulse, respirations,
blood pressure and in some areas, oxygen
saturation) be taken on admission.
-Per MR review, on 09 at
Registered Nurse (RN) #2 admitted Patient A
(with diagnosis o
and performed an Admission Nursing
Assessment. after
admission, at nursing staff
documented Patient A's as follows:
There is no documentation indicating that nursing
staff obtained Patient A's at the time of
admission to the floor prior to the
obtained at
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of Health
STATEMENT OF DEFICIENCIES (Xl) PROVIDERISUPPLIERCLIA
(X3) DATE SURVEY
COMPLETED
A. BUILDING
B. WING
C
330307
07/21/2010
101 DATES DRIVE
ID PROVIDER'S PLAN OF CORRECTION V5)
DEFICIENCY)
S 340
--Per MR review, o 09 at nursing
staff documented that Patient A's
was There is no indication in Patient A's MR
that a physician was notified regarding the
at that time.
-- Per review of the hospital policy entitled "ICU
Documentation Guidelines," last revised 10/08,
patient temperature readings must be repeated
and documented every hour if the patient is noted
to be hypo or hyperthermic, unless otherwise
indicated. (The policy does not define hyper or
hypothermia.)
--Per MR review, nursing staff documented
Patient A's while in the t the
following times on the dates noted:
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A. BUILDING
B. WING C
330307 07/21/2010
101 DATES DRIVE
ITHACA, NY 14850
DEFICIENCY)
Despite being in which
circumstance the patient' should
have been checked/documented times during
this hour period of time, it was only checked
times.
Findings pertaining to (4) and (5) above include:
-- Per MR review, on 09 at
Physician #1 gave a order for
as needed
(prn) pain (route not specified). Nursing staff
documented the order onto the MAR.
At , Physician #1 gave a
order changing the from
However, instead of discontinuing the previous
order on the MAR and writing a new order,
nursing staff in the previous
entry on the MAR, and
Due to this manner of documentation, upon
retrospective review of the MAR, it is not evident
which dosage of the
as administered to the patient in the
administrations recorded.
Additionally, review of the MAR reveals that
nursing staff administered the
on /09 and
on 09, rather than the every nd
then hour(s) ordered.
Further, review of the MAR also reveals that the
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(X3) DATE SURVEY
COMPLETED
A. BUILDING
B. WING
C
330307
07121/2010
CAYUGA MEDICAL CENTER AT ITHACA 101 DATES DRIVE
ITHACA, NY 14850
ID PROVIDERS PLAN OF CORRECTION - (5)
DEFICIENCY)
S 340
medication orders transcribed/transferred
by
nursing onto the MAR for t /09 were
documented in a haphazard, unsafe manner, as
follows:
Findings pertaining to (6) include:
-Per review of Patient A's MR:
On
- at Physician #1 gave a
ord
n.
- at
#1 gave a
orde
.
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DEFICIENCY)
On 09:
- at , Physician #1 ordered
pain.
- at Physician #1 gave a order
for
pain.
- at ., Physician #1 ordered
However, while review of Patient A's MR reveals
that or both of these medications were
administered to Patient A every minutes to
hour between on /09 and
on 09, review of the nursing
documentation on the Critical Care Flowsheet
forms and in the patient notes reveals the
following:
- Pain assessments were not recorded
indicating th
(pain scale) of Patient A's pain at the time of each
administration of on 09 at
and i.e., on /09 at
Additionally,
a pain assessment was not recorded at the time
that a of was
initiated (on 09 at until
at which time nursing staff documented that
Patient A's pain was /10.
- When the patient's pain level was
documented as 10 at on 09, it
was not assessed again until hours later, at
on 09.
- Pertinent (i.e.,
and were not recorded at the time
each prn administration of (i.e.
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STATEMENT OF DEFICIENCIES (Xl) PROVIDER/SUPPLIERJCLIA
(X3) DATE SURVEY
AND PLAN OF CORRECTION
IDENTIFICATION NUMBER:
COMPLETED
A. BUILDING
B. WING
C
330307
07/21/2010
101 DATES DRIVE
ID PROVIDERS PLAN OF CORRECTION
(X5)
DEFICIENCY)
S 340
Findings pertaining to (7) include:
-Per review of the hospital policy entitled "ABC
Alert," last revised 10/07, an ABC Alert entails the
summoning of a resuscitative team for a patient
who is experiencing cardiopulmonary arrest. The
policy states" ...documentation of all activities
and events occurring during an ABC Alert will be
documented on the ABC Alert record... The
recorder, designated by the ICU RN, during an
ABC Alert, will fill out the ABC Alert record and
obtain all necessary signatures... The record
serves as a complete medication and IV record,
eliminating the need to write orders for code
medications and IVs in the patient chart. This
record will be filled out at each intervention or
every 5 minutes. Documentation will include the
events from the initial alert to the disposition of
the patient."
--Per MR review, the documentation of the
resuscitation of Patient A was done by nursing
staff on the
unit) Flowsheet;
(not the AB
r policy). The
documentation does not describe the initial type
of
that Patient A
experienc
dication dosages
administered (i versus during
the ons for
management (i.e.,
ce, and the te
during
A
the staff involved in the
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A. BUILDING ______ _____
330307 B. WING C
07121/2010
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(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (XE)
DEFICIENCY)
S 356 405.5 (b) (2) (i) NURSING SERVICES. Delivery S 356
of services.
(2) (i) Nursing care policies and procedures shall
be written and consistent with generally accepted
standards of nursing practice.
Based on findings from document reviews and
interviews, 2 hospital policies and procedures
(P&Ps) were not consistent with generally
accepted standards of nursing practice, as
follows:
(1) The Patient Controlled Analgesia (PCA) P&P
lacked adequate requirements for monitoring of
vital signs.
(2) The Clinical Assessment Team (CAT) P&P
lacked description of the roles and responsibilities
of the CAT members and lacked requirement for
physician notification when a call is made.
-Per review of the hospital P&P entitled "Patient
Controlled Analgesia (PCA)," last revised 10/07, it
states "When therapy is initiated, the patient is
assessed per policy or specific MD orders. Each
assessment will be documented on the narcotic
infusion record at least every shift and PRN per
nursing discretion. The patient's ongoing
...assessment will include level of consciousness,
respiratory rate and/or additional comments per
MD preprinted orders."
Office of Health Systems Management i Office of Long Term Care
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A. BUILDING __________
B. WING
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(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (5)
DEFICIENCY)
This P&P requires nursing staff to assess
patients beginning PCA therapy "per policy" - it
does not establish acceptable minimum
requirements for how often the patient should be
assessed, i.e., "at least every shift" is not
sufficient.
--Per review of the hospital P&P entitled "Clinical
Assessment Team," last revised 10/07, the
members of the CAT team consist of an ICU RN
and a RT (respiratory therapist). The policy does
not describe the roles/responsibilities of these
staff in CAT (rapid response) calls and does not
require that the patient's Attending Physician, or
any other physician, be notified when a CAT call
has been initiated or completed for a patient.
S 401 405.6 (b) (1) QUALITY ASSURANCE S 401
PROGRAM. Activities.
The activities of the quality assurance committee
shall involve all patient care services and shall
include, as a minimum: (1) review of the care
provided by the medical and nursing staff and by
other health care practitioners employed by or
associated with the hospital.
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B. WING C
330307
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101 DATES DRIVE
CAYUGA MEDICAL CENTER AT ITHACA 101ADAT DRIVE
ITHACA, NY 14850
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION VS)
DEFICIENCY)
S 472 405.8 (a) INCIDENT REPORTING. S 472
(a) Any incident required to be reported pursuant
to subdivision (b) of this section shall be reported
to the department's Office of Health Systems
Management on a telephone number maintained
for such purpose. Hospitals shall report such
incidents within 24 hours of when the incident
occurred or when the hospital has reasonable
cause to believe that such an incident has
occurred and shall take no more than seven
calendar days to determine whether an incident
defined in paragraph (b) (1) of this section is
reportable and subject to the requirements of this
section. The hospital shall give written notification
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within seven calendar days of the initial
notification. This notification shall be submitted in
a format specified by the department and shall
record the nature, classification and location of
the incident; medical record numbers of all
patients directly affected by the incident; the full
name and title of physicians and hospital staff
involved in the incident as well as their license,
permit, certification or registration numbers; the
effect of the incident on the patient; follow-up
treatments and evaluations planned; the
expected completion date for the hospital's
investigation and identification information
required by the department.
S 602 405.10 (a) (1) MEDICAL RECORDS. General S 602
requirements.
(1) Medical records shall be legibly and
accurately written, complete, properly filed,
retained and accessible in a manner that does
not compromise the security and confidentiality of
the records.
interviews, 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 SURVEY
COMPLETED
A. BUILDING
B. WING
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330307
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DEFICIENCY)
Findings include:
--Per review of the nursing MR documentation
regarding the of Patient A, nursing
staff documented that Physician #3
Patient A a . on 09.
However, there is no documentation by Physician
#3 describing the including the size of
the used for the , the
markings used to verify
position, or the method Physician #3 used to
confirm proper lacement at the time of
- Per review of the MAR dated 09 in Patient
A's MR, nursing staff drew lines delineating
separate areas for medication orders then written
on the MAR. Nursing staff documented physician
medication orders for " eplacement"
(lacking
and "
(lacking
has
This MAR did not provide clear, complete and
easy-to-follow directions for medication
administrations on each nursing shift. Also, upon
retrospective review, this MAR does not
accurately describe all medications administered.
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S 602
-Per review of the American College of
Radiology (ACR) Practice Guideline for
Communication of Diagnostic Imaging Findings,
last revised 2005, the format for reporting
diagnostic testing should include the time of
examination, if relevant (e.g., for patients who are
likely to have more than one of the same
diagnostic examination in the same day).
Per MR review, Patient A underwen
on /09. However, both reports
present in Patient A's MR lack the times the
examinations were performed.
S 726 405.14 (b) (1) RESPIRATORY CARE S 726
SERVICES.
Operation and service delivery. (1)
Respiratory care services shall only be provided
in accordance with specific hospital
protocols/policies or upon the orders of members
of the medical staff. The order for respiratory care
services shall specify the type, frequency and
duration of treatment, and, as appropriate, the
type and dose of medication, the type of diluent,
and the oxygen concentration.
interview, the hospital's P&P regarding use of
Non-Invasive Positive Pressure Ventilation
(NIPPV) lacked guidance/parameters by which
respiratory therapy staff (RT) should assess the
Dffice of Health Systems Management I Office of Long Term Care
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STATEMENT OF DEFICIENCIES (Xl) PROVIDER/SUPPLIERJCLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING
B. WING C
330307
07121/2010
CAYUGA MEDICAL CENTER AT ITHACA 101 DATES DRIVE
ITHACA, NY 14850
(X4) ID T SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
DEFICIENCY)
effectiveness of its use and for when to confer
with a physician.
Findings include:
-Per review of the P&P entitled "Department of
Respiratory Care NIPPV Policy and Procedure,"
dated 11/06, it indicates when BiPAP should be
used and that the patient should be monitored
every two hours. It lacks guidance as to how RT
should assess the effectiveness of NIPPV and
what circumstances require discussion with a
physician/physician notification.
S 727 405.14 (b) (2) RESPIRATORY CARE S 727
SERVICES.
Operation and service delivery. (2) All
respiratory care services provided shall be
documented in the patient's medical record,
including the type of therapy, date and time of
administration, effects of therapy, and any
adverse reactions.
interview, respiratory therapy staff (RT) did not
document assessing the effectiveness of the use
o in Patient A's care and discussing
findings with a physician.
Findings include:
-Per MR review:
An RT note dated 09 and documented at
tates 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 Care
PRINTED: 09/09/2010
FORM APPROVED
STATEMENT OF DEFICIENCIES (Xl) PROVIDER/SUPPLIER/CLIA
(X3) DATE SURVEY
COMPLETED
A. BUILDING
B. WING
C
330307
07121/2010
101 DATES DRIVE
ID PROVIDER'S PLAN OF CORRECTION (X5)
DEFICIENCY)
S 727
Pt's pain and are being
seen to by RN."
Another RT note documented on 09 at
states started. Pt
The
Flow Sheet form in the
MR describes sets of nd
correspondin during the they
are 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 "The
patient will be reassessed at least every two
hours with written documentation via flow-sheet
at bedside for acute cases.")
ffice of Health Systems Management Office of Long Term Care
STATE FORM
If continuaton sheet 22 of 22
STATE OF NEW YORK
DEPARTMENT
OF HEALTH
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 Ithaca
Complain
NYPORT
Dear Colleague:
This Notice of Violation is provided to you in accordance with Section 18 of the New
York State Public Health Law. Section 18 requires the Department of Health to send to
each director or trustee of a health care agency or facility, notice of a violation of the
Public 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 Incident
referenced 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 the
Chairperson or other designated principal contact of the governing body, with the
expectation that its contents would be made available to you. Please take time to
secure it and review it. Each deficiency cited is a violation of State regulations and may
result 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 the
facility's goveming body, you are responsible for completely correcting the identified
deficiencies in a timely manner.
Should you wish to review the entire report, you may obtain a copy from hospital
administration or this office.
Sincerely,
Roberta Gancarz, Program Director
STATE OF NEW YORK
DEPARTMENT OF HEALTH
217 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 Ithaca
Complaint
Dear
The New York State Department of Health (the Department) has evaluated the concerns you identified with
care provided to your at Cayuga Medical Center at Ithaca.
As part of our surveillance activities, professional staff reviewed you medical record, reviewed
other 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 internal
medicine.
As a result of this review, the facility was found to be in violation of the State Hospital Code in the following
areas:
Medical Staff Services - Inadequate medical care relative to evaluation and management of a patient's
incomplete 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
l

Cayuga Medical 3

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