Mt Sinai Hospital Medical Center

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 34411 A. Based on document review and interview, for 2 of 6 (Pt #22 and Pt #23), clinical records reviewed for patients with pressure injuries, the hospital failed to ensure that the registered nurse supervised the care, by ensuring that patients with wounds, were assessed on admission and daily, and that wound care orders were carried out, as ordered. Findings included: 1. The hospital’s policy titled, “Guidelines: Inpatient Skin and Pressure Injury Risk Identification, Prevention, Assessment, and Treatment” (dated 1/2025), was reviewed and required, “All members of the health care team contribute to the skin and pressure injury assessment, risk identification, prevention, and treatment ...To promptly identify wounds or skin conditions, all patients have an initial skin assessment with 24 hours upon admission and daily on an ongoing basis which includes but not limits to: a. Signs of pressure over bony prominences. B. Change in color from normal skin. C. Changes in temperature-warmer or cooler. D. Change in texture-bogginess or induration. E. Patient reported sensation changes. Two caregivers must complete and document a skin assessment upon admission and/or transfer to another unit ...All inpatients have a completed age-appropriate risk assessment upon admission, every (Q) shift, and with any changes ...Document wound measurements on admission, every Wednesday, and with each new wound occurrence ...Stage 2: Consult order. Measurements: On admission finding and then every Wednesday ...” 2. The clinical record for Pt #22 was reviewed on 1/14/2026. Pt #22 was admitted on 12/25/2025, with a diagnosis of COPD exacerbation (acute respiratory illness). The clinical record included the following: - Initial Wound Consult note: (dated 12/29/2025) documented by the Wound Care Clinical Nurse Specialist (E #1) included, “Wound consult completed, wound assessment: Sacrum/coccyx: Pressure deep tissue injury with open blistering, total area measures 4x4 cm (centimeters), 25 % intact purple hyperpigmented tissue, 75 % open clean tissue ...Wound treatment plan: Sacrum/coccyx: Polymem foam drsg [dressing] Q 24 to 48 hrs [every 24-48 hours]. -Flowsheets from 1/5/2026-1/14/2026, were reviewed for wound care assessment and dressing changes. There was a wound care dressing change (polymem foam) on 1/5/2026 at 1:53 AM. The next dressing was not changed until 1/12/2026 at 7:00 PM (7 days later), not the 24-48 hours as required. Braden score was not completed on 1/13/2026, as required per shift. 3. The clinical record for Pt #23 was reviewed on 1/14/2026. Pt #23 was admitted on 1/7/2026, with a diagnosis of hyponatremia (low sodium level). The clinical record included the following: -ED (emergency department) Nursing Note (dated 1/7/2026 10:59 PM), “ ...Sacral wound noted, mepilex [wound foam dressing] placed.” -Pt #23 was admitted to 3N (Medical/Surgical) unit on 1/7/2026 at 11:23 PM. Nursing notes, including the admission note, from 1/7/2026-1/14/2026, were reviewed. The notes lacked documentation of a wound assessment (including measurements) on admission. -Flowsheets from 1/7/2026-1/14/2026, were reviewed for wound assessments and dressing changes. Flowsheets indicated that the pressure injury was staged as “Stage 2” (wound involving partial skin loss). Mepilex was placed on per nursing staff on 1/8/2026 at 8:00 PM. The subsequent mepilex foam dressing was on 1/11/2026 at 8:02 PM. (3 days later). The clinical record lacked a wound care consult that would include a treatment plan for a wound documented as “Stage 2”. 4. On 1/14/2026 at 1:50 PM, an interview was conducted with the 3N Manager (E #24). E #24 stated that floor nurses should not stage pressure ulcers, as this should be done by either the wound care nurse or by a physician. E #24 stated that nurses should do wound care assessments every shift. E #24 stated that wound care orders should be carried out as ordered. 50411 B. Based on document review, observation and interview, for 2 of 2 patients (Pt. #4 and Pt. #5) with IV (intravenous) access, the hospital failed to ensure that the IV accesses were labeled with the date and time of insertion as required by the hospital’s policy. Findings include: 1. The hospital’s policy titled, “Intravenous (IV) Catheters and Maintenance” effective 3/2021 included “... IV Procedure: Intravenous cannula/needle: ...document date and time of insertion ...” 2. During an observational tour of the 2 North Medical Surgical Unit on 1/13/2026 from 10:20 AM - 11:40 AM, 2 patients (Pt.#4 - IV access site on the left forearm, and Pt.#5 - IV access site on the left forearm) had IV access sites that were not labeled with date and time of insertion. 3. On 1/13/2026 at approximately 11:05 AM, an interview was conducted with the Director, 2 North Medical Surgical Unit (E#7). E#2 stated that IV infusion tubing should be labeled with the date and time started, and initials of staff member. E#7 stated that IV site dressings should also be labeled with the date, time and initials of staff member.”

“MONITORING RADIATION EXPOSURE CFR(s): 482.26(b)(3) Radiation workers must be checked periodically, by the use of exposure meters or badge tests, for amount of radiation exposure. This Standard is not met as evidenced by: 36774 Based on observation, document review, and interview, for 2 of 2 agency radiology technicians observed (E #27 and E #28) working in the radiology department, the hospital failed to ensure that the technicians were wearing radiation monitoring badges to monitor radiation exposure. Findings include: 1. On 1/13/2026 between approximately 11:00 AM through 11:30 AM, observational tour of the radiology department was conducted. During the tour, two agency radiology technicians (E #27 and E#28) were observed not wearing radiation monitoring badges. 2. On 1/14/2026, the hospital’s policy titled, “Radiation Protection-Personnel Monitoring Badges” (1/2026) was reviewed and indicated, “ ... Responsibilities: All SHS Radiology, Nuclear Medicine and Cardiology Staff. Procedures: Personnel working with radioactive materials shall be monitored for their respective radiation exposure utilizing a monthly and/or quarterly radiation film badge monitor ... Proper Storage and Handling of Monitoring Badges: A. It is the caregiver’s responsibility to wear and to safely store the monitoring badge to prevent loss and accidental exposure ...” 3. On 1/15/2026, the hospital’s radiology dosimeter reports (radiation exposure monitoring report) for 2025, were reviewed. The reports did not include radiation monitoring for E #27 and E #28. As of survey date 1/16/2026, there was also no record available regarding E #27 and E #28’s radiation exposure levels. 4. The personnel files for the agency radiology technicians (E #27 and E #28), were reviewed: E #27 assignment start date was 12/29/2025, with an assignment stop date of 4/04/2026. E #27 works 40 hours a week. E #28 assignment start date was 12/21/2025, with an assignment stop date of 3/21/2026. E #28 also works 40 hours per week. 5. On 1/13/2026 at approximately 11:30 AM, an interview was conducted with E #27 (Agency Radiology Technician). E #27 stated that E #27 has been working Monday through Friday since December 2025 and have not been assigned a radiation monitoring badge. 6. On 1/15/2026 at 11:30 AM, an interview was conducted with E #29, Manager, Radiology Department. E #29 stated that the two agency radiology technicians perform X-ray procedures. E #29 stated that E #29 ordered badges for the two agency radiology technician, but the badges have not arrived. E #29 stated that technicians should be wearing badges while in the hospital in order to monitor their radiation exposure. 7. On 1/16/2026 at approximately 10:20 AM, a telephone interview was conducted with MD #7 (Radiation Safety Officer). MD #7 stated that the hospital radiation exposure levels for staff have not exceeded the 10% radiation exposure occupational limit. MD #7 stated, “From statutory standpoint, they are not legally required (to wear monitoring badges)” because of very low levels of radiation exposure. However, when asked how the hospital monitors staff’s exposure if staff are not wearing badges, MD #7 stated that staff’s radiation exposure will not be able to be monitored if staff are not wearing the badge.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 50411 Based on observation, document review, and interview, the hospital failed to ensure that the medical students adhered to hand hygiene protocol as required by their policy. Findings include: 1. On 1/13/2026 from 10:20 AM through 11:40 AM, an observational tour of the 2 North Medical Surgical Unit was conducted. During the tour, seven (7) medical students were observed entering a patient room on the surgical step down unit without performing hand hygiene. 2. On 1/14/2026, the hospital’s policy titled “Hand Hygiene (Effective 1/2024)” was reviewed and included, “...Additional Moments for Hand Hygiene - Before initial contact with a patient or items in their environment; this should be done on entry to the room or bed space, even if the patient has not been touched...” 3. On 1/13/2026 at approximately 11:07 AM, an interview was conducted with the Director of Surgical Stepdown and Surgical Intensive Care Unit (E#6). E#6 stated that all staff and visitors should perform hand hygiene before entering a patient’s room and upon exiting.”