HospitalInspections.org

Based on review of facility documentation, and staff interview (EMP), it was determined that the facility failed to take all reasonable steps to conform to all applicable State, and local laws and regulations.

The facility was not in compliance with:
Medical Care Availability and Reduction of Error (MCARE) ACT Act of Mar. 20, 2002, P.L. 154, NO. 13 40 ... Section 313. Medical Facility reports and notifications. (c) .Infrastructure failure reports. --A medical facility shall report the occurrence of an infrastructure failure to the department within 24 hours of the medical facility's confirmation of the occurrence or discovery of the infrastructure failure. The report to the department shall be in the form and manner prescribed by the department.

Based on review of facility documents, medical records (MR) and staff interviews (EMP), it was determined that the facility failed to report ten of ten infrastructure failures within 24 hours of the confirmation. (MR1-MR10)

Findings include:

Review of the facility "Patient Safety Plan" Fiscal year 2016, revealed, "Introduction...Heritage Valley Health System is committed to creating an environment of safety that encourages error prevention, error identification, remediation, non-punitive reporting, and elimination of patient safety issues through reporting and feedback, education, systems redesign, and process improvement...Internal and External Reporting...Reports to the Patient Safety Authority or to the Department of Health under Act 13 (MCARE) shall be as follows:..Infrastructure Failure - Within 24 hours of confirmation or discovery of event, on a form and manner prescribed by the Authority excluding patient-identifying information..."

1. Review of MR1 on May 17, 2016, between 1:00 PM and 3:00 PM revealed the patient was admitted to the Emergency Department ED on January 25, 2016, at 8:15 AM. The patient's physician made the Decision To Admit (DTA) on January 25, 2016, at 10:47 AM. The patient was transferred to the critical care unit on January 26, 2016, at midnight. The patient was on a hold in the ED for approximately 13 hours after the physician made the decision to admit the patient.

2. Review of MR2 revealed that the patient was admitted to the ED on February 3, 2016, at 7:27 AM. The patient's physician made the DTA on February 3, 2016, at 9:24 AM. The patient was transferred to the critical care unit on February 4, 2016, at 1:45 PM. The patient was on a hold in the ED for 28 hours after the physician made the decision to admit the patient.

3. Review of MR3 revealed that the patient was admitted to the ED on February 3, 2016, at 8:02 AM. The patient's physician made the DTA on February 3, 2016, at 10:09 AM. The patient received dialysis until 4:00 PM on February 3, 2016. The patient was transferred to the critical care unit on February 4, 2016, at 1:00 AM. The patient was on a hold in the ED for 15 hours after the physician made the decision to admit the patient.

4. Review of MR4 revealed that the patient was admitted to the ED on May 13, 2016, and triaged at 9:24 AM. The patient's physician made the DTA on May 13, 2016, at 1:28 PM. The patient was transferred to a room on the third floor on May 14, 2016, at 8:45 AM. The patient was on a hold in the ED for 19 hours after the physician made the decision to admit the patient.

5. Review of MR5 revealed that the patient was admitted to the ED on March 24, 2016, and triaged at 1:37 PM. The patient's physician made the DTA to CCU on March 24, 2016, at 3:15 PM. The patient was admitted to the telemetry bed in the ED on March 25, 2016, at 10:05, AM, and transferred to the second floor on March 25, 2016, at 5:21 PM. The patient was on a hold in the ED for approximately 26 hours after the physician made the decision to admit the patient.

6. Review of MR6 revealed that the patient was admitted to the ED on February 10, 2016, at 6:19 AM. The patient's physician made the DTA on February 10, 2016, at 9:13 AM. The patient was transferred to the critical care unit on February 10, 2016, at approximately 5:15 PM. The patient was on a hold in the ED for approximately 8 hours after the physician made the decision to admit the patient.

7. Review of MR7 revealed that the patient was admitted to the ED on March 9, 2016, at 9:10 AM. The patient's physician made the DTA on March 9, 2016, at 12:25 PM. The patient was transferred to the critical care unit on March 9, 2016, at approximately 8:30 PM. The patient was on a hold in the ED for approximately 8 hours after the physician made the decision to admit the patient.

8. Review of MR8 revealed that the patient was admitted to the ED on January 11, 2016, at 1:59 PM. The patient's physician made the DTA on January 11, 2016, at 3:56 PM. The patient was transferred to the critical care unit on January 12, 2016, at approximately 12:00 midnight. The patient was on a hold in the ED for approximately 8 hours after the physician made the decision to admit the patient.

9. Review of MR9 revealed that the patient was admitted to the ED on March 21, 2016, at 10:46 AM. The patient's physician made the DTA on March 21, 2016, at 12:58 PM. The patient was transferred to the critical care unit on on March 21, 2016, at approximately 8:27 PM. The patient was on a hold in the ED for approximately 7 hours after the physician made the decision to admit the patient.

10. Review of MR10 revealed that the patient was admitted to the ED on February 23, 2016, at 12:58 PM. The patient's physician made the DTA on February 23, 2016, at 2:56 PM. The patient was transferred to the critical care unit on February 23, 2016, at approximately 9:50 PM. The patient was on a hold in the ED for approximately 6.5 hours hours after the physician made the decision to admit the patient.

During an interview on May 16, 2016, at approximately 10:30 AM, EMP6 confirmed having patients in the ED for greater than 6 hours and stated that he/she was not aware that bed holds for more than six hours were required to be reported via the patient safety reporting system.

During an interview on May 16, 2016, at approximately 11:00 AM EMP1 confirmed that bed holds for MR1-MR10 were not reported to the Department.

Based on a review of facility documents, medical records (MR) and staff (EMP) interviews, it was determined that the facility failed to have personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient.

Findings include:

Review of facility policy "Observation of In-Patient Hold in the ED" updated 9/1/14, revealed, "Department: Emergency Services Policy: It is the policy of Heritage Valley Health system of establish guidelines regarding the care and observation of in-patient holds in the Emergency Services Department (ED)...Guidelines: A. If all possibilities of patient placement on an in-patient area have been exhausted, the patient will be held in the ED, until an in-patient bed becomes available. B. Collaborative effort between the Clinical Supervisors and Patient Flow Supervisor or designee should occur to ensure timely placement of the patient. Patients are not to be held in the ED any longer than absolutely necessary. C. Once it has been determined that the patient needs to be held in the ED pending room placement, the ED staff will make every effort to place the patient in a hospital bed. D. The ED Nursing staff will continue to document within the Electronic Health Record (EHR) while the patient is being held in the Emergency Department...F. The admitting Physician will be responsible for the care of the in-patient hold and should be notified of any changes in patient status and for further orders..."

1. Review of MR2 revealed that the patient was admitted to the Emergency Department (ED) on February 3, 2016, at 7:27 AM. The patient's physician made the Decision To Admit (DTA) on February 3, 2016, at 9:24 AM. The patient was transferred to the critical care unit on February 4, 2016, at 1:45 PM. The patient was on a hold in the ED for 28 hours after the physician made the decision to admit the patient. The census on February 3, 2016, on the critical care unit at 5:00 AM was 22, at 1:00 PM was 22, and at 5:00 PM was 22. The critical care bed capacity was and remains at 30.

2. Review of MR5 revealed that the patient was admitted to the ED on March 24, 2016, and triaged at 1:37 PM. The patient's physician made the DTA to CCU on March 24, 2016, at 3:15 PM. The patient was admitted to the telemetry bed in the ED on March 25, 2016, at 10:05, AM, and transferred to the second floor on March 25, 2016, at 5:21 PM. The patient was on a hold in the ED for approximately 26 hours after the physician made the decision to admit the patient. The census on March 24, 2016, on the critical care unit at 4:00 AM was 20, at 1:00 PM was 20, and at 5:00 PM was 20. The critical care bed capacity was and remains at 30.

During an interview on May 16, 2016, at approximately 9:30 AM, EMP2 stated that there are empty beds on each unit, but the units are not staffed to put patients in all of those beds.

During an interview on May 18, 2016, at approximately 2:00 PM EMP1 confirmed that MR2 and MR5 were on bed holds in the ED for more than 24 hours.

Based on review of facility documents, observation and staff interviews (EMP), it was determined that the facility failed to ensure mechanical systems throughout the hospital were maintained in such a manner that the safety and well-being of patients was assured.

Findings include:

Review of facility policy on May 20, 2016, "Preventive Maintenance" reviewed by facility June 2013, indicated, "Preventative Maintenance...Engineering. Policy: It is the policy of the engineering Department to conduct preventive maintenance (PM) in all areas of the physical plant on selected equipment. Procedure: Engineering personnel will conduct preventive maintenance in all areas of the physical plant and on selected equipment. All PM tasks will be classified according to their potential effect on patients, employees and visitors' safety and care. All tasks dealing with Life Safety will have the highest priority. Tasks having a high impact on patient care will have the second priority. All other tasks will be the lowest priority. ..."

1. During a tour on May 17, 2016, at approximately 12:30 PM, EMP14 stated that ceiling tiles were frequently replaced in the intersection on the first floor between the Emergency Department (ED) administrative hallway and the public hallway.

2. Tour on May 17, 2016, at 2:30 PM, revealed a kitchen dish cleaning area, located directly above the ED administrative hallway. There was a puddle of water located on this floor between two drains.

3. Review of Emergency Department work orders revealed that there were six work orders for a wet or stained ceiling tile located outside of the Emergency Department administrative area between March 7, 2016 and present date.

During an interview on May 16, 2016, at approximately 9:30 AM, when asked if there had been a ceiling leak, EMP5 indicated that around two months ago there was a stain on a ceiling tile. EMP5 indicated, "The tile was replaced. and as far as I know whatever caused the leak was fixed."
When asked on May 17, 2016, at approximately 11:45 AM about a leak and ceiling tile replacement in the ED corridor area, EMP14 stated, "Yes, there is a place in the cross corridors outside of the ED where we have had recurrent leaks. We replace the tile when there is a wet spot noted." EMP14 indicated that there is an area in the kitchen where the water runs on to the floor during the dish rinsing process. [this is directly above the ED corridor] EMP14 indicated, "That floor in the kitchen needs to be sealed." When asked for the projected date for the floor project, EMP14 shared that there was no projected replacement date at this time.

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Based on facility documents, tour of the facility and staff interviews (EMP), it was determined that the facility failed to ensure a clean environment was maintained within the facility.

Findings include:

Review of the Crothal "Area: Kitchen/Cafe/Trash Assist Job Title: Housekeeping Aide" on May 18, 2016, at approximately 1:00 PM revealed, "...4 pm Coffee Shop - Pull Trash/boxes. Kitchen...Sweep and Scrub Cart Storage Sweep and Scrub Cold Production Sweep and Scrub Hot Food Production Pull out all carts with wheels and clean behind tray line. Pot Washer - Dish Room...Report facilities issues to supervisor..."

Review of the facility "Infection Prevention Plan...Fiscal Year 2016", revealed, "The Infection Prevention Program is established by Heritage Valley Beaver to assist in providing quality healthcare and to promote the well being of patients, employees, and visitor...The goal of the Infection Prevention Plan is to provide a safe environment to prevent the spread of infection in a cost-effective manner...An Infection Prevention Committee has been established for Heritage Valley Health System that includes the following members: Infection Prevention Coordinator...Director of Engineering...Manager of Dietary..."

1. Tour of the kitchen dish cleaning area on May 17, 2016, at 2:30 PM, revealed walls that were dingy and covered with smears of undetermined particles. The brick floor below the dish cleaning equipment was black. A streak of soap was noted below the soap dispenser, which caused the tiles to be yellow in color instead of white/off white. There were two large black rubber mats near the drain and when lifted there was a puddle of water and a rancid odor detected. There was also a slimy substance noted to the underside of these mats.

Interview on May 17, 2016, at 2:30 PM EMP16 confirmed the above findings.