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Based on observations, review of facility policies and procedures, documents, medical records (MR) and interview with staff (EMP), it was determined the Governing Body failed to assume responsibility to provide oversight and accountability in the Emergency Department by: failing to ensure policies and procedures adhere to recognized practice standards and include details to address the age specific population served in the Emergency Department (A0057, A1104), failing to ensure compliance with the Patient Rights-Condition of Participation (A0115), failing to ensure patient assessments and personal health information was completed and communicated in a safe and private setting (A0142), failing to ensure the delivery of care is provided in a safe setting (A0144), failing to ensure compliance with the QAPI-Condition of Participation (A0263), failing to ensure performance improvement plans were developed with Quality oversight and quality standards established for monitoring measurable progress (A0283, A309), failing to ensure Nurse Leadership provided oversight and direction to the nursing staff for the safety of of patients (A0386, A0395); failing to ensure compliance with the Physical Environment-Condition of Participation (A0700), failing to ensure a risk and safety assessment of the physical environment was completed in the Emergency Department (A0701).

This condition is not met as evidenced by:

Review of facility Bylaws "Amended and Restated Bylaws of The Chester County Hospital West Chester, Pennsylvania" last reviewed June 9, 2015, revealed "Article IV Board of Directors. Section 4.1. Powers and Authority. ...The goal of the Board is to manage the Hospital... (a) adopt vision, mission and values statements and develop policies for the Corporation consistent with the vision and mission and values of [name redacted].


(482.12(b) Tag - 0057): Chief Executive Officer
Observation and the information received during the survey provided evidence that the facility failed to ensure application, implementation and revision of established policies and procedures adhering to recognized practice standards for the safe delivery of hospital operations in the Emergency Department; failure to ensure Patient Rights were maintain during the delivery of patient care services and the provision of service delivery by competent staff; failure to provide oversight for an effective Quality Assessment and Improvement Program to ensure performance improvement initiatives and established corrective actions plans are addressed with oversight by the Committee and President/Chief Executive Officer until resolution of deficient practices; and failure identify risk and maintain the physical environment to ensure a safe delivery of patient care services.

(482.13(c) Tag-142): Patient Rights: Privacy & Safety
Observation and the information received during the survey provided evidence that the facility failed to ensure patient assessments were completed and personal health information was communicated in a safe and private environment in the Emergency Department.

(482.13(c)(2) Tag-0144): Patient Rights: Care In Safe Setting
Observation and the information reviewed during the survey provided evidence that the facility failed to ensure

(482.21 Tag-0263): QAPI
The information received during the survey provided evidence that the facility failed to ensure the effectiveness of the Quality Committee based upon the leadership's failure to set expectations, develop and manage corrective action plans and manage resources (operational and clinical ) adhering to practice guidelines for patient safety and support services in the Emergency Department.

(482.21(a)(b)(1)(b)(2)(i),(b)(3) Tag -0283): Quality Improvement Activities
The information received during the survey provided evidence that the facility failed to ensure
performance improvement plans were developed with Quality oversight and quality standards established for monitoring measurable outcomes.

(482.21 Tag-0309): Qapi Executive Responsibilities: The information received during the survey provided evidence that the facility failed to ensure a current Environment Of Care/Behavioral Health Area Risk Assessment was completed in the Emergency Department to assess, identify and address risk and safety issues.

(482.23(a) Tag-0386): Organization Of Nursing Services: The information received during the survey provided evidence that the Nursing Leadership failed to provide oversight of the nursing staff to ensure the safety of patients in the Emergency Department.

(482.23(b)(3): Tag-0395): RN Supervision of Nursing Care: The information received during the survey provided evidence that the facility failed to supervise nursing services in the Emergency Department to ensure the safety of the patient..

(482.41 Tag 0700): Physical Environment
Observation and the information reviewed during the survey provided evidence that the facility failed to identify, address and resolve environmental and risk issues for Emergency Department patients.

(482.41(a) Tag A-0701): Maintenance Of Physical Plant
Observation and the information reviewed during the survey provided evidence that the facility failed to ensure maintenance of the hospital's physical environment for safety for ligature risks in the Emergency Department and and cleanliness of the Emergency Department toilet room utilized for patient with behavioral health issues.

(482.55 (a)(3) Tag A-1104): Emergency Services Policies
The information received during the survey provided evidence that the facility failed to ensure policies contained details to address the patient care delivery of age specific population served in the Emergency Department.


Cross reference:
482.12(b) Standard: Chief Executive Officer
482.13 Condition of Participation: Patient Rights
482.13(c) Standard: Patient Rights: Privacy and Safety
482.13(c)(2) Standard: Patient Rights: Care In Safe Setting
482.21 Condition of Participation: QAPI (Quality Assurance Performance Improvement)
482.21 (a)(b)(1),(b)(2)(i),(b)(3) Standard: Quality Improvement Activities
482.21 (e)(1), (e)(2),(e)(5) Standard: QAPI Executive Responsibilities
482.23(a) Standard: Organization of Nursing Services
482.23(b)(3)Standard: RN Supervision of Nursing Care
482.41 Condition of Participation: Physical Environment
482.41(a) Standard Maintenance Of Physical Plant
482.22(a)(3) Standard :Emergency Services Policies

Based on review of facility policy, documents and interview with staff (EMP), it was determined the facilty's medical staff failed to ensure the provision of qualty emergency services provided to behavorial health patient in the Emergency Department (ED).

Findings include:

Based on facility Bylaws, observation, policies and procedures, documents, medical records (MR), and interview with staff (EMP), it was determined the President/Chief Executive Officer failed to provide quality oversight of patient care services in the Emergency Department (A0283, A0309) and ensure the facility's policies and procedures and staff performance competencies adhere to recognize standards of practice and appropriately address the patient population seeking and receiving care and services in the Emergency Department (A1104) , failed to ensure the Emergency Department staff was competent to provide safe care for Emergency Department patients (A0142, A0144), failing to ensure Nurse Leadership provided oversight and direction to the nursing staff for the safety of of patients (A0386, A0395) and failed to ensure a safe physical environment in the Emergency Department for patients with medical and behavioral health needs (A0701)

Findings include:

Review of the facility's "Amended and Restated Bylaws" of The Chester County Hospital West Chester, Pennsylvania, last revised June 9, 2015, revealed "Section 5.6. President/CEO. The President/CEO shall be the chief executive officer (CEO) of the Corporation. He or she shall have the responsibility to oversee the general and active management of the business of the Corporation and shall be held responsible for the application and implementation of established policies in the operation of the Hospital and shall see that all orders and resolutions are carried into effect, subject at all times to the authority of the Board, the Member and Trustees. ...The President/CEO or Chief Operating Officer (if any) shall as a member of the Joint Conferences and Patient Care Committee and shall serve on such other committees, either as a member or ex officio, as the Board or the Chair shall determine; and the President/CEO shall have such other specific responsiblities and authority as shall, from time to time, be approved by the Board by resolution, including any resolution adopting a written job description for the President/CEO. A copy of the job description, as thus approved, shall be kept on file with a copy of these Bylaws. Section 5.7. Chief Operating Officer. The Chief Operating Officer, if elected, shall, in the absence or disability or by delegation of the President/CEO, perform the duties and exercise the powers of the President/CEO and shall perform such other duties in the Hospital administration area as the Board or Executive Committee f the Board may prescribe, or as the President/CEO may delegate to him or her"

Review of facility policy "Nursing Organizational Overview" last revised February 2016 revealed "Senior Vice President, Nursing /CNO (Chief Nursing Officer) Accountability: The Chief Nursing Officer establishes the framework for nursing practice within the Hospital. Organizes, plan, directs and controls organizational process related to nursing care of patients throughout the institution. The Vice President, Nursing Services is accountable to the Chief Operating Officer and the President/CEO of the Health System.


Review of facility policy "Safety Management Plan 2019" revealed The Safety Management Plan describes the programs used to manage the Safety Management Program to reduce the risk of injury for patients... C. Safety is dynamic. Regular evaluation of the environment for work practices and hazards is required to maintain a current relevant safety program. The program should change as needed to respond to identified risks, hazards and regulatory compliance issues. ...A. The Operations Management Group and the CEO receives regular reports of the activities of the Safety Management Program from the multidisciplinary improvement team, the Environment of Care (EOC) Committee, which is responsible for the Physical Environment issues. They review reports and, as appropriate, communicate concerns about identified issues and regulatory compliance. ...Environmental tours are conducted according to an annual schedule that is approved by the Chair."


The cumulative effect of these systematic problems is evidence of the inability of the President/ CEO to provide the necessary oversight of the facility and staff (operational and clinical) in the delivery of patient care services and to maintain a safe physical environment in the Emergency Department.

These following regulations were cited and show a systemic nature of non-compliance as follows:

Cross reference:
482.13 Condition of Participation: Patient Rights
482.13(c) Standard: Patient Rights: Privacy and Safety
482.13(c)(2) Standard: Patient Rights: Care In Safe Setting
482.21 Condition of Participation: QAPI (Quality Assurance Performance Improvement)
482.21 (a)(b)(1),(b)(2)(i),(b)(3) Standard: Quality Improvement Activities
482.21 (e)(1), (e)(2),(e)(5) Standard: QAPI Executive Responsibilities
482.23(a) Organization of Nursing Services
482.23(b)(3) RN Supervision of Nursing Care
482.41 Condition of Participation: Physical Environment
482.41(a) Maintenance Of Physical Plant
482.22(a)(3):Emergency Services Policies

This CONDITION is not met as evidenced by:

Based on the systemic nature of the standard-level deficiencies related to Patient Rights, the facility failed to comply with this condition:

Findings include:

These following standards were cited and show a systemic nature of non-compliance with regards to Patient Rights as follows:

(482.13(c)-Tag-0142)
The observation tour and information reviewed during the survey provided evidence that the facility failed to ensure patient assessments conducted in hallway beds were completed and personal health information was communicated in a safe and private setting for MR3, MR4 and MR5.

(482.13(c) (2)-Tag-0144)
The observation tour and information reviewed during the survey provided evidence that the facility failed to ensure the delivery of care was provided in a safe setting.

Based on an observation tour, policy, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure patient assessments were completed and personal health information was communicated in a safe and private environment in the Emergency Department for three of three medical records reviewed (MR3, MR4 and MR5).


Findings include:

Review of facility policy "Patient Rights and Responsibilities" last reviewed September 2016 revealed " A patient has right to"...3. Every consideration of privacy concerning the medical care program. Case discussion, consultation, examination and treatment are considered confidential and should be conducted discreetly, giving reasonable visual and auditory privacy whenever possible."

Review of facility policy "Accountability and Functions of Positions" last reviewed February 2016 revealed "The Chief Nursing Officer establishes the framework for nursing practice within the Hospital. ...Physician Assistant: Accountability-Physician assistants are directly accountable to the Nursing Director of Perioperative Services, Senior Vice President, Nursing/CNO as outlined under the Vice President of Medical Affairs. Functions: Specific functions of Physician Assistant are outlined in their credentialed process.

An observation tour conducted in the facility's Emergency Department (ED) on October 3, 2019, at 4:45 PM through 5:45 PM with EMP4, EMP6 and EMP8 revealed the following:

1. Observation on October 3, 2019, of MR3, a female patient in Bay 16, admission status, 302 (involuntary commitment) revealed two security officers supporting nursing in the admission process actively engaged in deescalation efforts with MR3. Further observation revealed MR3 and one of the two security officers was engaged in a high pitched conversation, that could be heard in the emergency department. The second security officer was policing the belongs of MR3 on the floor within a plastic bag, which was partially obstructing the ED hallway corridor. In addition, ED visitors walking through the ED down the corridor observed the verbal exchange and the interactions displayed between MR3 and the security guards. No privacy curtains and or privacy screens were in use.

2. Observation of MR4, a female patient lying on a stretcher in Hallway A in he ED at approximately 5:45 PM. Further observation revealed CF1, a physician assistant verbally questioning and confirming medical history details. In addition, further observation revealed MR4 removing her gown to allow CF1 to perform a respiratory examination with a stethoscope.

3. Observation of MR5, a female patient lying on a stretcher in the ED hallway at approximately 5:15 PM, diagnosed with Bipolar/Schizophrenia. Further review revealed MR5 speaking softly requesting assistance, from facility staff. In addition, MR5 was observed shivering and gagging in the hallway bed. No privacy curtains and or privacy screens were in use.

An interview conducted on October 3, 2019, at 5:25 PM with EMP4, EMP6 and EMP8 confirmed patient privacy and safety was compromised for MR3, MR4 and MR5. EMP2 stated "We will have to acquire privacy screens and educate the staff that the privacy screens are to be used during patient assessments. We will take care of this immediately." EMP4 stated " We will also need to educate and train the staff on how to to communicate with patients in the Emergency Department about their personal health information when in close proximity to other patients and visitors."

Cross Reference:
482.13(c)(2) Standard: Patient Rights: Care in Safe Setting
482.23(a) Standard: Organization Of Nursing Services

Based on observation, review of facility policies and procedures, documents and interview with staff (EMP), it was determined the facility failed to ensure the delivery of healthcare services in the Emergency Department were provided in a safe environment. by competent staff.

Findings include:

Review of facility policy "Patient Rights and Responsibilities" last reviewed September 2016 revealed "Purpose: This policy applies to all employees and staff of Chester County Hospital (CCH). ...Implementation: All employee and staff of CCH...are responsible for fulfilling their duties in a respectful, competent manner. ..A patient has a right to: 1. Respectful care given by competent personnel which reflects consideration of his/her personal value and belief systems and which optimizes his/her comfort and dignity."

Review of facility policy "Nursing Organizational Overview" last revised February 2016 revealed "Senior Vice President, Nursing /CNO (Chief Nursing Officer) Accountability: The Chief Nursing Officer establishes the framework for nursing practice within the Hospital. Organizes, plan, directs and controls organizational process related to nursing care of patients throughout the institution. The Vice President, Nursing Services is accountable to the Chief Operating Officer and the President/CEO of the Health System. ...Accountability:The Nurse Director provides direction to Nursing Staff whose purpose is to provide quality-nursing care in a cost-effective manner to meet the needs of the patient population. The Nurse Director is accountable to the Senior Vice President, Nursing/CNO for the performance of the staff accountable to her/him. Functions...Evaluates policies, practices and procedures."

Review of facility policy "Continual Observation for Suicide" last reviewed May 2019, revealed " Continual observation of more than one patient may occur in the Emergency Department where the sitter will maintain direct view of the patients. Patient identifed for high risk for suicide will be assigned to a properly trained staff member assigned to the patient (s) for the purpose of continual observation. ...RN responsibilities...3. Assign another staff member to cover when one of the continual observation patients needs the full attention of the Sitter. .. Sitter Responsibilities: 1. Receive hand-off report at start of shift and when there is a change in sitter assignments. 2. Verbalize understanding of the need to obtain coverage before leaving the patient for any reason. 3. Maintain direct supervision of the patient(s). 4. Sit in a chart at the bedside. a. When observing more than on patient, maintain continual observation. 5. Use call bell for assistance and call out for help if needed."

Observation tour of the Emergency Department on October 3, 2019, at 5:25 PM with EMP2, EMP4 and EMP6 revealed MR2, a 201 patient (voluntary commitment) patient assigned a one to one (1:1) nursing assistant (sitter) revealed MR2 sitting on the stretcher (bedside) in Bay 3 and the assigned sitter sitting in a chair across the hallway corridor from Bay 3.

An interview conducted on October 3, 2019, at 5:30 PM with EMP 4, EMP6 and EMP8 confirmed the EMP12 was assigned to MR2 in Bay 3 as a sitter. EMP12 stated " I am sitting across the hallway from the patient (MR2) because the patient's mother and a male visitor with a visitor tag on his shirt are visiting with the patient. I felt they should have privacy during their conversation. If you look up the hallway you can see the mother is now having a conversation with someone else."

An interview conducted on October 3, 2019, at 5:35 PM with EMP4, EMP6 and EMP8 confirmed that EMP12 should have maintained sitting in a chair at the patient's bedside. In addition, EMP4 confirmed that the sitter sitting across the hallway corridor from Bay 3 was not compliant with the facility's policy when performing as a sitter.

________________

Based on an observation tour, and interview with staff(staff) it was determined the facility failed to ensure the delivery of healthcare services were provided in an clean environment. in the Emergency Department.

An observation tour of the Emergency Department (ED) conducted on October 3, 2019, approximately 4:45 PM to 5:45 PM revealed the following in the Patient Toilet Room (N196) designated for ED patients ED patients with behavioral health issues:
1. Ceiling vent with horizontal blades with thick layer of dust grit and grime on each blade
2. Large heavy layer of grayish black matter on the shower base.
3. Large areas of grayish black matter on the shower walls
3. Greenish white thick layering of matter on the shower head.
4 .Insect matter contained in the ceiling light

An interview conducted on October 3, 2019, at 5:18 PM with EMP4, EMP6 and EMP8 confirmed the environmental issues in the Patient Toilet Room (N196). EMP4 stated "We've had challenges with Environmental Services maintaining cleanliness of all the ED bathrooms.


Cross Reference:
482.13(c) Standard: Patient Rights: Privacy and Safety
482.41(a) Standard: Maintenance of Physical Plant
482.23 (a) Standard: Organization Of Nursing Services

Based on the systemic nature of the standard level deficiencies related to the Performance Improvement Program, the facility failed to comply with this condition.

The findings were:

The following standards were cited and show a systemic nature of non-compliance with regards to the Quality Program and Performance Improvement Programs as follows:


482.21(a)(b)(1)(b)(2)(i),(b)(3) Tag -0283): QAPI Governing Body, Standard Tag: The information reviewed during the survey provided evidence the facility failed to initiate a QAPI indicator that reflected the complexity of the hospital's Emergency Department Services pertaining to environmental risk and patient safety initiatives for patient with behavior health issues..


482.21(e)(1),(e)(2),(e)(5) Tag -0309): QAPI Executive Responsibilities: The information reviewed during the survey provided evidence the facility failed to complete a current Environment Of Care/Behavioral Health Area Risk Assessment in the Emergency Department to identify and address risk and safety issues.


Cross reference:
482.12(b) Standard: Chief Executive Officer
482.13(c) Standard: Patient Rights: Privacy and Safety
482.13(c)(2) Standard: Patient Rights: Care In Safe Setting
482.23(a) Standard: Organization of Nursing Services
482.23(b)(3)Standard: RN Supervision of Nursing Care
482.41(a) Standard Maintenance Of Physical Plant
482.22(a)(3) Standard :Emergency Services Policies

Based on review of facility policy, documentation and interview with staff (EMP), it was determined the facility failed to initiate a QAPI indicator that reflected the complexity of the hospital's Emergency Department Services pertaining to environmental risk and patient safety initiatives for patient with behavior health issues..

Findings include:

Review of facility policy "Performance Improvement Plan" last revised May 2019 revealed "The Hospital sets priorities for its performance improvement activities based upon high risk, high volume and problem prone areas that affect health outcomes, patient safety and quality of care."

A request was made on October 3, 2019, by the survey team to the facility EMP8 for Psychiatric Transfers (201-voluntary commitment) and 302 involuntary commitment) beginning January 2019 to September 2019. The following data was received: January 2019 total of 49 patients (201s and 302s combined), February 2019 total of 29 patients (201s and 302s combined), March 2019 total of 42 patients (201s and 302s combined), April 2019 total of 32 patients (201s and 302s combined), May 2019 total of 34 patients (201s and 302s combined), June 2019 total of 37 patients (201s and 302s combined), July 2019 total patients 49 (201s=49 & 302s=9), August 2019 total patient 46 (201s=37 & 302s=9), September total of 45 (201a=43 & 302s=2).

A request was made on October 3, 2019, by the survey team to the facility, EMP3 on October 3, 2019, for the the Quality Performance Improvement Committee Meeting Minutes beginning January 2019 to present (October 2019). The following committee meeting minutes were received : January 14, 2019, February 11, 2019, March 11, 2019, April 8, 2019, May 13, 2019, June 10, 2019, July 8, 2019, and August 12, 2019. No CEQI minutes were available as per EMP3 for September 2019 at the time of the on-site visit.

Review of facility document " Clinical Effectiveness and Quality Improvement (CEQI) Committee Meeting Minutes dated May 13, 2019, revealed "V. Regulatory/Quality Update...4. TJC FAQ's on Suicide Safety Assessment and Prevention Standards (Deferred)"
.
Review of facility document "Clinical Effectiveness and Quality Improvement (CEQI) Committee Meeting Minutes dated August 12, 2019, revealed "Clinical Effectiveness Team: Emergency Medicine... Barcode Medication Administration and RTA/Triage Process Change."

Review of facility document "Analysis Update 9/24/2019", elopement incident August 28, 2019, revealed "Lack of county resources to support needs of the community. Discuss with senior leadership for exploration of further discussion with Chester County officials. There were 8-11 mental health patient already in the ED (emergency department). There were not beds in the hospital, patient were boarded in the ED and other waiting in the waiting room for evaluation.:

An interview conducted on October 3, 2019, at 7:30 PM with EMP8 revealed "We are dependent on Chester County to help us place these patients. We have to work with minimum resources because the county also has limited resources. In the case of the elopement, she had been in the ED for 47 hour. We had a difficult time finding placement for her. The intent is to devise a plan of action with the county and the hospital to see if we can increase resources but also increase the quality of service we provide in the Emergency Department for these patients that have behavioral health issues.


An interview conducted on October 7, 2019, at 6:00 AM with EMP 18 confirmed that on August 27, 2019, on the 7p-7a shift there more than five patients sitting in the waiting room to be seen. "We just do not have the resources for these patients with behavioral health issues. It is difficult trying to acquire sitters for these patients and sometimes we use the nurses because we don't have sitters.

Based on review of facility policy, documents and interview with staff (EMP), it was determined the facility failed to complete a current Environment Of Care/Behavioral Health Area Risk Assessment in the Emergency Department to identify and address risk and safety issues.

Findings include:

Review of facility policy "Performance Improvement Plan" last revised May 2019, revealed "The Governing body, Board of Directors, ensures that the program reflects the complexity of the hospial's organization and services...and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors....When improvement opportunities are identified, processes are redesigned and tested, and once implement, changes are monitored for effectiveness and reliability. As much as possible, improvement work is done on the frontline, with staff that use the process being redesigned. ...The following key areas have been identified as high/risk/high volume or problem prone areas requiring ongoing systematic measurement::...Environment of Care-Ongoing measurement includes the identification of environmental or technological concerns where the hospital is exposed to risk of financial loss or to the potential or actual injury of patients, staff or visitors. Environment of care activities are coordinated through the Chester County Hospital (CCH) Environment of Care Committee.

A request was made on October 3, 2019, to the facility EMP3 and EMP11 for a current Environment Of Care/Behavioral Health Area Risk Assessment for the Emergency Department. No current documentation was provided.

Review of facility document Investigation "Analysis Update 9/24/2019", elopement incident August 27, 2019, revealed "Lack of county resources to support needs of the community. Discuss with senior leadership for exploration of further discussion with Chester County officials. There were 8-11 mental health patient already in the ED (emergency department). There were no beds in the hospital, patients were boarded in the ED and other waiting in the waiting room for evaluation."

An interview conducted on October 3, 2019, at 7:30 PM with EMP8 revealed "We are dependent on Chester County to help us place these patients. We have to work with minimum resources because the county also has limited resources. In the case of the elopement, she had been in the ED for 47 hour. We had a difficult time finding placement for her. The intent is to devise a plan of action with the county and the hospital to see if we can increase resources but also increase the quality of service we provide in the Emergency Department for these patients that have behavioral health issues.


An interview conducted on October 3, 2019, at 6:30 PM with EMP3 and EMP11 confirmed that the findings of the 2017 Emergency Department 2017-Behavioral Health Area Risk Assessment Grid. EMP3 stated "The last Behavioral Health Area Risk Assessment was completed in 2017. The facility has not created a current Behavioral Health Area Risk Assessment." In addition, EMP3 and EMP11 confirmed the facility had had not developed performance improvement plans for the indicators. I fully realize we are not compliant with our Performance Improvement Plan as to the addressing the EOC risk indicators in the Emergency Department and then coming up with a plan to address them . This information has not been brought to the Clinical Effectiveness and Quality Improvement Committee for 2019.

Cross reference:
482.21 Standard: Quality Improvement Activities

Based on review of facility policy, documents, medical record (MR) and interview with staff (EMP), it was determined the facility's Nursing Leadership failed to provide oversight of the nursing staff to ensure the safety of patients in the Emergency Department.

Findings include:

Review of facility policy "Nursing Organizational Overview" last revised February 2016 revealed "Senior Vice President, Nursing /CNO (Chief Nursing Officer) Accountability: The Chief Nursing Officer establishes the framework for nursing practice within the Hospital. Organizes, plan, directs and controls organizational process related to nursing care of patients throughout the institution. The Vice President, Nursing Services is accountable to the Chief Operating Officer and the President/CEO of the Health System. ...Accountability:The Nurse Director provides direction to Nursing Staff whose purpose is to provide quality-nursing care in a cost-effective manner to meet the needs of the patient population. The Nurse Director is accountable to the Senior Vice President, Nursing/CNO for the performance of the staff accountable to her/him. Functions...Evaluates policies, practices and procedures."

1. Review on October 3, 2019, of MR1, admitted on August 26, 2019, revealed chief complaint of Suicidal Ideation. Further review of MR1 revealed MR1 had plans to self-inflict additional penetrating wounds in attempt to self-harm. In addition, a review of MR1 revealed the patient eloped through the ambulance exit doorway on August 27, 2019, at 11:50 PM.

Review of MR1 revealed an encounter ED note written by EMP 13 dated August 26, 2019, at 7:44 PM "Pt (patient) got OOB (out of bed) and attempted to leave the ER (emergency room). Pt got through the doors and other staff assisted to get pt back into bed. Pt throwing her self on the ground stating that she does not want to live anymore. Pt attempting to kick. Pt lifted up and [sic] bed and placed in 4 point restraints. Pt continues to try to bite the restraints off."

Review of MR1 revealed an encounter ED note written by EMP15 dated August 28, 2019, at 12:32 AM "Went through ambulance doors after hearing that pt eloped. Pt seen walking down Marshall Street towards red light and then turned around and started walking towards the 600 building. As soon as pt saw that security was following her pt took off running behind 600 building... At this time I called 911 to have police find pt. At that time security informed us that pt was seen walking down Montgomery ave towards the high school, 911 operator notified. Security office that was following pt in vehicle called over radio that the pt had been struck by a vehicle, 911 operator notified and asked to get ambulance on scene. Charge nurse notified."`

Review of facility document Investigation ":Analysis Update 9/24/2019" revealed " The pt (patient) was under 1:1 observation in the ED (emergency department) for the next 47 hours, while pediatric 302 psychiatric placement could be found. ...Limited psychiatric resources for pediatric pts (patients) in the area. Patient had been [sic] a room but was moved to the hallway immediately before her elopement. Movement was necessary to accommodate care of critical pt. Patient told staff member she had to use the bathroom, at which time she exited the ambulance doors which was in close proximity from her stretcher. ...There were 8-11
mental health patients already in the ED."

A telephone interview conducted on October 7, 2019, at 5:59 AM with EMP18 confirmed MR1 had exited the Emergency Department via the ambulance exit/entrance doorway prior to August 27, 2019, 11:50 PM elopment. EMP18 stated "I was not told in report she had left the ED through the same ambulance exit/entrance doorway and was coaxed back into the ED by staff. I heard it mention by some of my co-workers after she eloped on August 27, 2019, at 11:50 PM. EMP18 further stated "If I had to do it over again, I would not have moved her to a hallway bed. She definitely was to close near the ambulance exit/entrance doorway. I would have definitely put her in a ED room, which would have made it harder for her to elope from the Emergency Deparment."

_________

2. Review of facility document " Weekly Email Updates"-Emergency Department Staff Notification dated September 20, 2019, at 1:51 PM from EMP4 revealed informational memo sent to Emergency Department Clinical Staff " Hi All, Please bear with me, it's another lengthy one-but I tried to make it into a digestible format. ... bullet point #5 Suicidal Ideation Patient Reminders. Bathroom Route for SI (suicide ideation) patient (or other patients at risk for elopement) should not go near the ambulance door. They should be walked around the rear of the med room."

An interview conducted on October 3, 2019, at 4:15 PM with EMP3, EMP4 and EMP6 confirmed the facility was unable to provide documentation that the emergency department staff had read the "Weekly Email Update" dated September 20, 2019. EMP4 and EMP6 was confirmed the emergency department staff had not received documented staff training for the "Bathroom Route for SI patients" but had been sent the weekly email updates. EMP4 and EMP6 was unable to confirm which Emergency Department Staff members had read or not read the email. Further interview revealed EMP4 and EMP6 was unable to confirm which ED staff had received the "Weekly Email Update".
___________________

3. Review of facility document "Orientation Manual-Patient Safely Assistant" dated March 2014 revealed "Patient Safety Assistant (PSA) Initial Competency Assessment Form. This is a legal document and proof of your competency to take care of patients. You are responsible for completing it with your preceptor...turing it in to your manager at the end of orientation. Once completed and signed, it remains in your HR employee file.

Review of facility policy "Continual Observation for Suicide" last reviewed May 2019, revealed " Continual observation of more than one patient may occur in the Emergency Department where the sitter will maintain direct view of the patients. Patient identifed for high risk for suicide will be assigned to a properly trained staff member assigned to the patient (s) for the purpose of continual observation. ...RN responsibilities...3. Assign another staff member to cover when one of the continual observation patients needs the full attention of the Sitter. .. Sitter Responsibilities: 1. Receive hand-off report at start of shift and when there is a change in sitter assignments. 2. Verbalize understanding of the need to obtain coverage before leaving the patient for any reason. 3. Maintain direct supervision of the patient(s). 4. Sit in a chart at the bedside. a. When observing more than on patient, maintain continual observation. 5. Use call bell for assistance and call out for help if needed."


Observation tour of the Emergency Department on October 3, 2019, at 5:25 PM with EMP2, EMP4 and EMP6 revealed MR2, a 201 patient (voluntary commitment) patient assigned a one to one (1:1) nursing assistant (sitter) revealed MR2 sitting on the stretcher (bedside) in Bay 3 and the assigned sitter sitting in a chair across the hallway corridor from Bay 3.

Review of facility policy "Continual Observation for Suicide" last reviewed May 2019, revealed " Continual observation of more than one patient may occur in the Emergency Department where the sitter will maintain direct view of the patients. Patient identifed for high risk for suicide will be assigned to a properly trained staff member assigned to the patient (s) for the purpose of continual observation. ...RN responsibilities...3. Assign another staff member to cover when one of the continual observation patients needs the full attention of the Sitter. .. Sitter Responsibilities: 1. Receive hand-off report at start of shift and when there is a change in sitter assignments. 2. Verbalize understanding of the need to obtain coverage before leaving the patient for any reason. 3. Maintain direct supervision of the patient(s). 4.Sit in a chart at the bedside. a. When observing more than on patient, maintain continual observation. 5. Use call bell for assistance and call out for help if needed."

Review of facility policy "Accountability and Functions Of Positions" last revised February 2016 revealed "Nursing Assistants...Nursing Assistants are directly accountable to the Registered Nurse...Delivers direct patient care under the supervision of a professional nurse. ...Patient Safety Assistants(PSA) The PSA's are directly accountable to the Registered Nurse...Performs 1:1 direct observation for continual observation (suicide attempt) or close observation (safety reasons for confused and disoriented patients)."

Review on October 3, 2019, PF1 for EMP12, date of hire May 21, 2013 revealed " no evidence of documentation of a completed Initial Compentency Assessment Form for the role of sitter for a patient on suicide precautions. In addition, no evidence of a completed competency for the sitter role was documented in the annual Competency Assessment for NA/Tech competenecies.

An interview conducted on October 3, 2019, at 6:45 PM with EMP5 and EMP7 confirmed that the nursing staff that provide the role of a sitter receive an initial competency upon hire. EMP5 further confirmed the title of the document is titled Competency NA/Tech (Nursing Assistant/Technician). EMP5 confirmed that an annual competency for the sitter position is not required. Further interview confirmed EMP12 did not have an initial or annual competency for the sitter position. In addition, EMP5 stated "Various staff titles are utilized for the sitter position to support staff. We don't have enough staff to support the amount of behavioral health patients who come to the Emergency Department that seek our help.".


Cross Reference:
(482.23(b)(3): Standard-RN Supervision Of Nursing Care

Based on an observation tour, review of facility policies and procedures, and interview with staff (EMP), it was determined the facility failed to supervise nursing services in the Emergency Department to ensure the safety of one of one medical record reviewed (MR2).

Findings include:

Observation tour of the Emergency Department on October 3, 2019, at 5:25 PM with EMP2, EMP4 and EMP6 revealed MR2, a 201 patient (voluntary commitment) patient was assigned a one to one (1:1) nursing assistant (sitter-EMP12) revealed MR2 sitting on the stretcher (bedside) in Bay 3 and the assigned sitter sitting in a chair across the hallway corridor from Bay 3.

Review of facility policy "Accountability and Functions Of Positions" last revised February 2016 revealed "Registered Nurse:...Supervises the performance of delegated functions. ...Identifies and acts on actual and/or potential patient and environmental safety hazards. ...Nursing Assistants...Nursing Assistants are directly accountable to the Registered Nurse...Delivers direct patient care under the supervision of a professional nurse. ...Patient Safety Assistants(PSA) The PSA's are directly accountable to the Registered Nurse...Performs 1:1 direct observation for continual observation (suicide attempt) or close observation (safety reasons for confused and disoriented patients).

An interview conducted on October 3, 2019, at 5:30 PM with EMP 4, EMP6 and EMP8 confirmed EMP12 was assigned to MR2 in Bay 3 as a sitter. EMP12 stated " I am sitting across the hallway from the patient (MR2) because the patient's mother and a male visitor with a visitor tag on his shirt are visiting with the patient. I felt they should have privacy during their conversation. If you look up the hallway you can see the mother is now having a conversation with someone else."

An interview conducted on October 3, 2019, at 5:35 PM with EMP4, EMP6 and EMP8 confirmed that EMP12, the sitter should have maintained a position of sitting in a chair at the patient's bedside. In addition, EMP4 confirmed that EMP12 was not compliant with the facility's policy as a sitter by sitting across the hallway corridor from Bay 3. We will have to educate the individuals that serve in the sitter role.

Cross Reference:
(482.23(a)) Standard: Organization Of Nursing Services.

Based on a review of facility Bylaws, policies, documents, and interview with staff (EMP), it was determined the facility failed to maintain a safe physical environment for patients.

In accordance with 42 C.F.R. Part 489.3 this deficiency constitutes Immediate Jeopardy and is a situation in which noncompliance with the requirement of participation has caused, or is likely to cause, serious injury, harm, impairment or death.

Review of the facility's Medical Staff Bylaws, last amended adopted October 9, 2018, revealed "IV. ORGANIZATION & RESPONSIBILITY. The Operations Management Group and the CEO receives regular reports of the activities of the Safety Management Program from the multidisciplinary improvement team, the Environment of Care (EOC) Committee, which is responsible for the Physical Environment issues. They review reports and, as appropriate, communicate concerns about identified issues and regulatory compliance. They also provide financial and administrative support to facilitate the ongoing activities of the Safety Program."

Findings include:

Review of facility document "Penn Medicine Chester County Hospital, Behavioral Health Area risk Assessment Grid, Emergency Department 2017" with Scoring: Add the rating for each event in the area of probability, risk, and preparedness. The total values will represent the events most in need of organization focus and resources for emergency planning. ...
Acceptance of risk is at the discretion of the organization. 1. All items with a score at or above 10 are declared a risk, which warrants regular monitoring. All items scoring below a 10 are monitored during surveillance/safety rounds.

KEY
>0-2 Very Low Risk No Extraordinary Actions Required Monitor
>3-4 Low Risk Educate, Enforce Existing Policies Monitor During EOC Tours
>5-9 Moderate Risk Educate, Enforce Existing Policies Monitor During EOC Tours
>10> High Risk Educate, Enforce/Develop Effective Monitor Target Items
Policies Monitor targeted Items During Tours

1. Electric/Other cords=8
2. Door hardware, hinges and knobs=8
3. Patient beds=6
4. Safety type electrical receptacles=8
5. Hallway items, coverings=8
6. Shower track=9
7. Bathroom grab bars=6
8. Bathroom fixtures=6
9. Smoking=6
10. Fire alarm pull=2
11. Fire extinguishers=6
12. Windows=7
13. Wastebasket liners=9
14. Staff panic alarms=7
15. Patient exam room-7
16. Objects as weapons=8
17. Eating utensils, dishes=7
18. Secured doors=7
19. Response from security=8
20. Patient assaultive behavior=8
21. Staff training=8
22. Chemicals, Soaps=6
23. Patient Personal Items removed?=8
24. Visitor Evaluation=7
25. Storage areas locked?=6
26. Protruding fixtures=9
27. Overhead fixtures-9
28. Medication security=7
29. Restraint Policy=6
30. Sprinkler heads=5
31. Previous SE (serious event) or Near Miss

An interview conducted on October 3, 2019, at 5:18 PM with EMP4, EMP6 and EMP8 confirmed the toilet room in the Emergency Department for MR1, a designated toilet room by ED management staff for behavioral health patients was not ligature resistant/ligature free. Further interview confirmed the facility had failed to perform a ligature risk assessment in the Emergency Department (ED), therefore failing to provide a safe environment for ED patients with Suicidal Ideations.

An interview conducted on October 3, 2019, at 5:57 PM with EMP3 and EMP11 confirmed that the findings of the 2017 Emergency Department 2017-Behavioral Health Area Risk Assessment Grid. EMP3 stated "The last Behavioral Health Area Risk Assessment was completed in 2017. The facility has not created a current Behavioral Health Area Risk Assessment." In addition, EMP3 and EMP11 confirmed the facility had had not developed performance improvement plans for the risk indicators to address patients with behavioral health issues in the Emergency Department.

Cross reference:
428.2.12(b) Standard: Chief Executive Officer
482.13 Condition of Participation: Patient Rights
482.13(c) Standard: Patient Rights: Privacy and Safety
482.13(c)(2) Standard: Patient Rights: Care In Safe Setting
482.21 Condition of Participation: QAPI (Quality Assurance Performance Improvement)
482.21 (a)(b)(1),(b)(2)(i),(b)(3) Standard: Quality Improvement Activities
482.21 (e)(1),(e)(2),(e)(5) Standard: QAPI Executive Responsibilities
482.24(a) Standard: Maintenance of Physical Plan
482.22(a)(3) Standard: :Emergency Services Policies

Based on an observation tour, policies and procedures and interview with staff (EMP), it was determined that the facility failed to maintain a safe physical environment in the Emergency Department.

Findings include:

Review of facility policy "Safety Management Plan 2019" The Operations Management Group and the CEO receives regular reports of the activities of the Safety Management Program from the multidisciplinary improvement team, the Environment of Care (EOC) Committee, which is responsible for the Physical Environment issues. They review reports and, as appropriate, communicate concerns about identified issues and regulatory compliance. They also provide financial and administrative support to facilitate the ongoing activities of the Safety Program."


1. Observation tour conducted of the Emergency Department (ED) on October 3, 2019, at approximately 5:15 PM with EMP4, EMP6 and EMP8 revealed the ED designated toilet room used by the ED 201 patients with an assigned one to one technician and or assistant and 302 patients with a 1:1 technician and or assistant. Further observation revealed the bathroom contained load bearing ligature points which included door handles, door hooks nurse call call pull cord (approximately 24 inches long), shower and toilet grab bars, gooseneck water faucet, wall towel holder, removable toilet seat cover, removable toilet paper holders and red hazard container with red plastic trash bags (10 gallon size or greater).

Review of MR1 revealed an encounter ED note written by EMP14 dated August 27, 2019, at 1:08 PM revealed " PCA (patient care assistant) ambulated with patient to BR (bathroom). Stayed outside door which was ajar. After a minute PCA observed patient lying on floor with eyes closed. "Awoke with gentle sharking by PCA. Dr. [name redacted] aware of incident, eval patient. reports only soreness to R (right) occiput. No visible swelling noted. "

An interview conducted on October 3, 2019, at 5:18 PM with EMP4, EMP6 and EMP8 confirmed the toilet room in the Emergency Department for MR1, a designated toilet room by ED management staff for behavioral health patients was not ligature resistant/ligature free. Further interview confirmed the facility had failed to perform a ligature risk assessment in the Emergency Department (ED), therefore failing to provide a safe environment for ED patients with suicidal ideations.
___________

Review on October 3, 2019, of MR1, admitted on August 26, 2019, revealed chief complaint of Suicidal Ideation (SI). Further review of MR1 revealed MR1 had plans to self-inflict additional penetrating wounds in attempt to self-harm. In addition, review of MR1 revealed the patient eloped through the ambulance exit doorway on August 27, 2019, at 11:50 PM.

Review of MR1 revealed an encounter ED note written by EMP 13 dated August 26, 2019, at 7:44 PM revealed "Pt got OOB (out of bed) and attempted to leave the ER (emergency room). Pt got through the doors and other staff assisted to get pt back into bed. Pt throwing her self on the ground stating that she does not want to live anymore. Pt attempting to kick. Pt lifted up and bed and placed in 4 point restraints. Pt continues to try to bite the restraints off."

Review of MR1 revealed an encounter ED note written by EMP15 dated August 28, 2019, at 12:32 AM revealed " Went through ambulance doors after hearing that pt eloped. Pt seen walking down Marshall Street towards red light and then turned around and started walking towards the 600 building. As soon as pt saw that security was following her pt took off running behind 600 building... At this time I called 911 to have police find pt. At that time security informed us that pt was seen walking down Montgomery ave towards the high school, 911 operator notified. Security office that was following pt in vehicle called over radio that the pt had been struck by a vehicle, 911 operator notified and asked to get an ambulance on scene. Charge nurse notified."

An observation tour of the Emergency Department (ED) on October 3, 2019, 4:50 PM with EMP4, EMP6 and EMP8 observed that the ambulance exit/entrance doorway was open to the outside of the ED. The surveyor accompanied by EMP4, EMP6 and EMP8 walked through the open ambulance exit/entrance doorway to the outside of the Emergency Department which was accessible to SI patients in the ED at the time of the on-site investigation. Further observation revealed that the ambulance exit/entrance doorway had a push button door release to the outside of the Emergency Department, which was accessible to the existing SI emergency department patients.

An interview conducted on October 3, 2019, at 4:15 PM with EMP3, EMP4, EMP6 and EMP8 confirmed that MR1 was in the ED for 47 hours, admitted to the ED on August 26, 2019, at 1:09 AM and eloped from the ED on August 27, 2019, at 11:50 PM. Further interview confirmed MR1 exited the ED through the same ambulance exit/entrance doorway to the outside of the ED. In addition, it was confirmed that the ambulance exit/entrance doorway with the push button door release continues to be a exit doorway without added security resources since the SI patient elopement on August 27, 2019, at 11:50 PM.

Cross Reference:
482.12(b) Standard: Chief Executive Officer
482.13(c)(2) Standard: Patient Rights: Care in Safe Setting

Based on a review of facility Bylaws, policy, documents and interview with staff (EMP), it was determined the Governing Body failed to ensure the facility's Administrative, Medical Leadership and Emergency Department leadership failed to ensure policies and procedures governing service delivery for patients with suicidal ideations in the Emergency Department were reviewed and revised .

Findings include:

Review of facility Bylaws "Medical Staff of Penn Medicine Chester County Hospital" last amended and adopted October 9, 2018, revealed "In accord with the " Purposes of the Medical Staff " described in Article II of these Bylaws to " insure that all patients . . . receive high quality care, " " assume overall responsibility for establishing standards for and reviewing the quality of all medical care provided to patients in The Hospital, " and " provide education and . . . maintain educational standards among the Staff, " and in keeping with the Mission of The Chester County Hospital to provide " high quality care . . . within the constraints of fiscal management, " The Medical Staff of The Chester County Hospital in cooperation with the Hospital ' s Quality Management Department will regularly and continuously review the quality of care provided to Hospital inpatients and outpatients. The objectives of this quality of care review are to optimize patient outcomes, reduce morbidity and mortality, promote the most efficient use of limited resources, and provide opportunities for continuing medical education."

Review of facility policy "Continual Observation for Suicide" last reviewed May 2019, revealed " Continual observation of more than one patient may occur in the Emergency Department where the sitter will maintain direct view of the patients. Patient identifed for high risk for suicide will be assigned to a properly trained staff member assigned to the patient (s) for the purpose of continual observation. ...RN responsibilities...3. Assign another staff member to cover when one of the continual observation patients needs the full attention of the Sitter. .. Sitter Responsibilities: 1. Receive hand-off report at start of shift and when there is a change in sitter assignments. 2. Verbalize understanding of the need to obtain coverage before leaving the patient for any reason. 3. Maintain direct supervision of the patient(s). 4. Sit in a chart at the bedside. a. When observing more than one patient, maintain continual observation. 5. Use call bell for assistance and call out for help if needed."

Review of facility document Analysis Update 9/24/2019" revealed " Action Items and Possible Countermeasures... 2. Update policies and practices to ensure suicidal ideation patients require 1:1 (one to one) and is in alignment with Joint Commission standard. Further review revealed the Director of Emergency Services was to ensure the policy was updated. The action status the "Continual Observation for Suicide" policy was documented in the Analysis Update document as pending and the action was to occur ASAP-as soon as possible.

Review of facility document "The Joint Commission Standards FAQ Suicide and Suicide Risk Reduction" revealed "For patient identified as high risk for suicide, constant 1:1 visual observation should be implemented (in which a qualified staff member is assigned to observe only one patient at all times) that would allow the staff member to immediately intervene should the patient attempt self-harm."

An interview conducted on October 3, 2019, at 5:40 PM with EMP7 and EMP10 confirmed that the the policy had not been updated. EMP7 confirmed that the policy did not adhere to the Joint Commission standard.

Cross Reference:
482.12(b) Standard: Chief Executive Officer
482.21 (e)(1), (e)(2),(e)(5) Standard: QAPI Executive Responsibilities
482.23(a): Standard: Organization Of Nursing Services