HospitalInspections.org

Based on a review of facility documents, and medical records (MR), staff interview (EMP), and observation, it was determined that Schuylkill Medical Center - South Jackson Street discontinued their Medical Surgical Services, Operating Room Services and Intensive/Critical Care Services without notification and/or approval of the Department of Health, and failed to ensure that patients requiring medical and surgical evaluation and treatment were admitted to the hospital for 39 of 39 medical records reviewed (MR16 through MR51, MR60, MR61 and MR62), and failed to ensure the Chief Executive Officer's Personnel File contained documentation of qualifications, education and experience (PF1), and failed to complete performance evaluations on six of six Management Personnel (PF2, PF3, PF4, PF5, PF6 and PF7).


Findings include:

Review on December 21, 2016, of the facility "Amended and Restated Bylaws Schuylkill Medical Center - South Jackson Street," dated August 10, 2016, revealed, "Amended and Restated Bylaws ... Article III. Purposes Section 1. Purposes. The purposes of the Corporation are as follows: (a) Providing for the general welfare of, and promoting the health of, members of the Schuylkill County, Pennsylvania community by establishing, owning, operating and maintaining an acute care hospital commonly known as Schuylkill Medical Center - South Jackson Street (the "Hospital") and associated health care facilities to provide for the diagnosis and prevention of disease and the treatment, care and cure of persons in such community ... ."

Observation tours conducted on December 21 and 22, 2016, of the facility Emergency Department (ED) revealed there were patients in the ED and that the ED physician had written orders to admit these patients.

Interview with EMP1 and EMP2 on December 21, 2016, at approximately 3:00 PM revealed the facility stopped providing Medical Surgical Services, Operating Room Services and Intensive/Critical Care Services on November 25, 2016, in preparation for the consolidation of the two hospitals. Further interview confirmed the facility did not receive the Department of Health approval to stop providing Medical Surgical services, Operating Room Services and Intensive/Critical Care Services at the facility.

A sample of medical records for patients presenting to the facility ED were selected for review for the time period of November 30 - December 22, 2016. It was revealed that 39 of 39 patients(MR) were diagnosed with an emergency medical condition and had a physician order to be admitted for medical and or surgical treatment or procedures.

Interview with EMP5, EMP7 and EMP8 on December 22, 2016, at approximately 10:15 AM revealed the ED has been holding patients in the ED for lengthy periods of time while waiting for available beds at the sister facility.


Interview with EMP2 on December 22, 2016, at approximately 1:00 PM confirmed the facility was no longer admitting patients to the Intensive Care Unit, the Medical Surgical Unit or for surgical procedures and that all patients being admitted would be transferred to the sister facility. EMP2 revealed there is not enough nursing staff at the facility to care for inpatient admissions as almost all of the nursing staff have been moved to the sister facility as part of the consolidation of the two facilities.


Review on December 29, 2016, of the facility New Employee list, no review date, revealed the following required documentation for personnel use, "Application, Interview Record, Reference Checks, Physical/Lab Test, Offer Letter, License, Working papers, Requisition, I-9 Form, Criminal HIS Check, Med Tx for Work Inj, Confidentiality Stmt, Code of Conduct, W-4 Form, Occ. Tax, Jobdes Signed, Orientation, Health Ins, Life Ins, disability, I.D. Tag, Pay Rate Form, Med. Rec. Card, Emp. Worksheet and Drug Free Policy."

Review on December 29, 2016, of PF1 revealed there was no documentation in PF1's Personnel File indicating this employee's qualifications, education and experience, application, interview, reference checks or offer letter.

Interview with PF1 on December 29, 2016, at approximately 6:00 PM revealed this employee transferred from a sister facility on September 16, 2016.

Interview with EMP19 on December 29, 2016, at approximately 6:15 PM revealed it was an oversight on obtaining all the required information for PF1 and that PF1 is not complete and did not contain this employee's qualifications, education and experience, application, interview, reference checks or offer letter.


Review on December 29, 2016, of the facility Performance Feedback (All Employees) policy, last reviewed March 2012, revealed, "Purpose: To communicate the Hospital's expectations to Supervisors/Department Managers providing performance feedback for employees. Policy: The Hospital expects Supervisors/Department Managers to provide performance feedback for employees to insure the following: 1. An effective communication process where the employee knows whether they are below, meeting, or exceeding expectations. 2. Recognizing those areas exceeding expectations. 3. Recognizing those areas below expectations and devising an action plan to help employees meet/exceed expectations. 4. Establish training needs. 5. Identifying employee potential for additional responsibilities/promotion. 6. Providing a basis for any salary adjustments. 7. Supporting disciplinary action where communicated expectations continue to fall below acceptable standards. Procedure 1. Employees normally are provided feedback during and near the end of their probation/initial review period. Thereafter, employees are provided feedback at least annually, preferably no later than March 31 for the previous calendar year. ... ."

Review of PF2, PF3, PF4, PF5, PF6 and PF7 on December 29, 2016, revealed no documentation a performance evaluation for 2015 was completed on these employees.

Interview with EMP19 on December 29, 2016, at approximately 6:20 PM confirmed performance evaluations were not completed for PF2, PF3, PF4, PF5, PF6 and PF7 for 2015.

Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that Schuylkill Medical Center - South Jackson Street failed to ensure the protection and promotion of the rights of patients by failing to take reasonable steps to determine the patient's wishes regarding transfer to another acute care facility (A-0130) for 39 of 39 MR (MR16-51 MR6 -62), and regarding end of life decisions (A-0132) for two of three MR (MR67, MR68).

Findings include:


Review on December 21, 2016, of the facility Amended and Restated Bylaws Schuylkill Medical Center - South Jackson Street, dated August 10, 2016, revealed, "Amended and Restated Bylaws ... Article III. Purposes Section 1. Purposes. The purposes of the Corporation are as follows: (a) Providing for the general welfare of, and promoting the health of, members of the Schuylkill County, Pennsylvania community by establishing, owning, operating and maintaining an acute care hospital commonly known as Schuylkill Medical Center - South Jackson Street (the "Hospital") and associated health care facilities to provide for the diagnosis and prevention of disease and the treatment, care and cure of persons in such community ... ."

Interview with EMP2 on December 21, 2016, at approximately 3:00 PM revealed the facility stopped providing Medical Surgical Services, Operating Room Services and Intensive/Critical Care Services on November 25, 2016, in preparation for the consolidation of the two hospitals. Further interview confirmed the facility did not receive the Department of Health approval to discontinue providing Medical Surgical services, Operating Room Services and Intensive/Critical Care Services at the facility.


Interview with EMP5, EMP7 and EMP8 on December 22, 2016, at approximately 10:15 AM revealed the ED has been holding patients in the ED for lengthy periods of time while waiting for available beds at the sister facility. EMP4, EMP5, EMP6, EMP7 and EMP8 revealed there were no available beds in the facility, as these units have been closed, these patients were waiting for beds at the sister facility and that the ED was not placed on diversion status. EMP6 and EMP7 confirmed that these patients were not provided a list of area facilities to choose from for transfer and admission. (A-0130)

Interview with EMP1 on December 22, 2016, at approximately 11:00 AM revealed the facility stopped providing Medical Surgical Services, Operating Room Services and Intensive/Critical Care Services on November 25, 2016, in preparation for the consolidation of the two hospitals.


Review on December 29, 2016, of facility Do Not Resuscitate (DNR) Order policy, last reviewed June 2016, revealed, "Policy: Cardiopulmonary Resuscitation (CPR) is unique among therapeutic modalities in that it is initiated without a physician order when a cardiac or respiratory arrest occurs. Specific instruction is necessary to suspend automatic initiation of CPR and other resuscitative measures. This specific instruction is call 'Do Not Resuscitate (DNR) order.' ... Definitions: ... G. No Code - Patient and/or surrogate has requested that all resuscitation efforts will be withheld and a DNR order has been placed in the chart. Procedure: 1. The Code Order must be completed by a licensed independent practitioner caring for the patient. Prior to making a code status decision review of the advanced directives or living will in the patient's medical, evaluation of the patient and discussion with patient and/or surrogate should occur with the licensed independent practitioner. ... 3. A DNR order should be reached through a consensual decision between the patient and/or surrogate and his or her licensed independent practitioner. If the patient lacks decision making capability, the patient's interests may be represented by existing advanced directives, living will and the patient's surrogate(s). ... ."

Review on December 29, 2016, of MR67 revealed this patient's physician ordered a DNR (Do Not Resuscitate) status on this patient on December 28, 2016. Further review revealed documentation MR67 was alert, oriented and able to make decisions known. There was no documented discussion with MR67 or MR67's family regarding their participation in this patient's code status discussion, nor was there evidence of a living will or an advance directive.

Review on December 29, 2016, of MR68 revealed this patient's physician ordered a DNR (Do Not Resuscitate) status on this patient on December 27, 2016. Further review revealed documentation MR68 was alert, oriented and able to make decisions known. There was no documented discussion with MR68 or MR68's family regarding their participation in this patient's code status discussion, nor was there evidence of a living will or an advance directive.


Interview with EMP20 and EMP21 on December 29, 2016, at approximately 1:15 PM confirmed MR67 and MR68 did not contain documentation of discussion with the patients or documentation of discussion with their family regarding the patient's code status. (A-0132)

Based on observation, a review of facility documents, medical records (MR) and interview of staff (EMP) it was determined that Schuylkill Medical Center - South Jackson Street, failed to provide surgical services to eight of eight patients requiring this service (MR3, MR22, MR30, MR35, MR37, MR51, MR52 and MR53) by failing to provide surgical staff (A-0941), by failing to maintain surgical equipment (A-0956) and by failing to provide immediate post-operative care. (A-0957)

Findings include:

Review on December 22, 2016, of facility document Amended and Restated Bylaws Schuylkill Medical Center - South Jackson Street, last reviewed August 19, 2016, revealed, "... Article III. Purposes. Section 1. Purposes. The purposes of the Corporation area as follows: (a) Providing for the general welfare of, and promoting the health of, members of the Schuylkill County, Pennsylvania community by establishing, owning, operating and maintaining an acute care hospital commonly known as Schuylkill Medical Center - South Jackson Street (the "Hospital") and associated health care facilities to provide for the diagnosis and prevention of disease and the treatment, care and cure of persons in such community, without discrimination on the basis of gender, creed, race, age, sexual preference, or national origin ... ."

Review on December 28, 2016, of facility policy Scope of Services Of The Surgical Services Dept., last reviewed February 11, 2016, revealed, "Subject: Scope of Services of the Surgical Department. Purpose: To define the Scope of Services with the Surgical Department. Policy: Scope of Services: The Surgical Services Department of the Schuylkill Medical Center provides services for operative and other invasive procedures and immediate postoperative care. The Department is staffed to operate the following: ASC [Ambulatory Surgical Center]/Main OR [operating room] = 9 OR's [sic] and 2 Endo Rooms - Monday thru Friday 7:00 a.m. -3:00 p.m. at ASC and 7:00 a.m. in the main OR. Staffing assignments are flexible depending on surgical volumes. (Refer to the Nursing Policy Book- "Classification Skill Mix"). An On-Call staff is available from 3 p.m. - 7 a.m. Monday-Friday, 7 a.m. - 7 a.m. on Saturday, Sunday and Holidays. ... Intra-operatively and postoperatively, the patient is continually reassessed. In the immediate postoperatively phase, the patient is under the direct supervision of the Anesthesiologist/Anesthetist who maintains responsibility for the needs of the patient until the patient is discharged from the Recovery Room when the discharge criteria is met. The Anesthesiologist discharges the patient. ... ."

Interview at approximately 2:00 PM on December 29, 2016, with EMP10 confirmed the Main OR referred to in the Scope of Services Of The Surgical Services Dept. policy is the Operating Room in the South Jackson Street facility. EMP10 also confirmed this policy is no longer current as of November 28, 2016.

Review on December 28, 2016, of facility policy Staffing The Operating Room, last reviewed February 11, 2016, revealed, "Subject: Staffing The Operating Room. Purpose: To establish guidelines to assure that adequate personnel are available to render appropriate and correct peri-operative nursing care at all times. Policy: A Registered Nurse shall always be available to assess, plan, implement and evaluate nursing care rendered to the surgical patient. A registered nurse will always function as the circulating nurse during an operative procedure. Surgical Services Department provides services for operative procedures on a 24 hour basis. Outpatient Surgical facility is staffed on a Monday through Friday basis. The Surgical Services Department will be staffed for the operation of 9 rooms on Monday through Friday from 7:00 a.m. to 3:00 p.m. At 3:00 p.m. "2 rooms" are available comprised of two late teams (RN and ST [surgical technician]) and the call team is available for emergency procedures. The call team is available from 3:00 p.m. to 7:00 a.m. Monday through Friday, weekends and holidays for emergency procedures. A surgical team will consist of a registered nurse (circulating nurse), a scrub nurse (either a surgical technician or registered nurse with scrub experience) and an Anesthesiologist (not required if local anesthesia) CRNA [Certified Registered Nurse Anesthetist]. No cases will be done without a full surgical team. Additional staff members will be assigned based on patient call requirements. Physician Assistant will be called as required. ... ."

Review on December 28, 2016, of facility policy Proper Placement of Operative Patient Post-Surgery, last reviewed February 11, 2016, revealed, "Policy: Proper Placement of Operative Patient Post-Surgery all post-anesthesia patients will be taken to Recovery Room to react during the hours of 07:30 a.m. and 06:00 p.m. Monday through Friday, unless otherwise ordered by the attending Physician/Surgeon. Any patient requiring post-anesthesia care during hours and/or days other than those listed above, must be cared for in the Intensive Care Unit to provide optimal care and close observation for the post-operative patient. ... ."

Review on December 28, 2016, of facility policy Warming And Storage Of Intravenous Solution, last reviewed February 11, 2016, revealed, "Policy: Warming And Storage Of Intravenous Solutions And Semi-Rigid Bottles Of NSS [normal saline solution] Irrigation Policy Statement: Intravenous Solutions and Semi-Rigid Bottles Of NSS Irrigation will be warmed according to the manufacturer recommendations to ensure the integrity of the above products and in turn insure patient safety. 1. ALL Warming Units being utilized to warm intravenous solutions and semi-rigid bottles of NSS irrigation will have the temperature monitored and documented daily (see attached graphs). 2. ALL Intravenous Solutions being place in the Warming Unit will have the over wrap intact, be stamped with an expiration date of 14 days from the date the bag was placed in the unit ... 3. If the intravenous solution is not used by the expiration date; it is Disposed of immediately. ... 4. Acceptable Temperature Ranges for the warming of Intravenous solutions will be maintained at 100/104 degrees Fahrenheit- per the manufacturers [sic] recommendations. ... ."

Review on December 28, 2016, of facility policy Refrigerator Temperature Checks, last reviewed February 11, 2016, revealed, "Policy: Refrigerator Temperature Checks, Warmer Checks, Cidex Checks, Crash Cart Checks, Accu-Check Controls At The Outpatient Surgery Center. Purpose: To provide a Guideline for the Outpatient Building regarding Refrigerator Checks, Warmer Checks, Cidex Checks, Crash Cart Checks and Accu-Check Controls. Policy Statement: All Refrigerator Temperature Checks, Warmer Checks, Cidex Checks, Crash Cart Checks and Accu-Check Controls at the Outpatient Building will be conducted Monday-Friday by 06:30 a.m., during normal working hours. ... ."

A sample of medical records (MR) for patients who presented to the SMC - SJ Emergency Department for care were selected for review. It was revealed that between December 1 and December 21, 2016, eight patients of eight records were noted to be diagnosed with emergency medical conditions that required surgical procedures. These diagnoses included acute appendicitis, fractured hip/leg bones, kidney stones and respiratory issues. (MR3, MR22, MR30, MR35, MR37, MR51, MR52 and MR53)
Documentation in these medical records indicated that these eight patients were transferred to a sister facility for procedures including appendectomy, cystoscopy with stone extraction and stent placement, fracture repairs and bronchoscopy, as surgical services were no longer available at this facility.

Tour of the Surgical Suite at 10:30 a.m. on Thursday, December 22, 2016, revealed the area was locked, an alarm was activated, no lights on in the area and no staff present on the area. (A-0941)

Tour of the Cystoscope Room revealed no operating room table, no anesthesia machine and minimal supplies in the room. (A-0956)

Tour of Operating Room 2 (OR 2) revealed no anesthesia machine and minimal orthopaedic supplies. (A-0956)

Tour of the hallway of the Surgical Suite revealed a white board hanging on the wall which stated the following:"No laparoscopic cases can be done. 11/30/16 effective immediately all inpatient OR cases will go to [name of sister facility]. Exceptions C-section [cesarean section], or post-delivery emergencies (D&E [dilatation and evacuation] or hyster [hysterectomy]). No C-arm at South [this facility], only portable x-ray available. Endo stored in Room 2. One anesthesia machine in Room 1. "Ships container - sent to [name of sister facility]"

Review on December 28, 2016, of facility document OR [operating room] Warmer Unit, no review date, revealed, "OR Warmer Unit 1. Must record temperature daily. 2. Top warmer is to contain only blankets 3. Top warmer must maintain a temperature of 120 degrees F [Fahrenheit] - 124 degrees F. 4. Lower warmer is to contain the IV's [intravenous] and saline on the top two shelves. The bottom shelf is for extra linens. 5. Lower warmer is to be maintained between 100 degrees F - 104 degrees F. 6. All IV's and saline must have expiration dates. 7. Saline expires in 60 days. 8. IV's expire in 14 days. ... ."

Tour of the Sub Sterile Room between OR1 and the Cystoscope Room revealed a warming cabinet which contained two 1000 cc intravenous bags of sodium chloride with expiration dates of December 6, 2016; two 1000 cc intravenous bags of sodium chloride with expiration dates of December 8, 2016; one 1000 cc intravenous bag of sodium chloride with expiration dates of December 9, 2016; The warming cabinet also contained four 1000 cc intravenous bags of lactated ringers with expiration dates of December 9, 2016 and one 1000 cc intravenous bags of lactated ringers with expiration date of December 9, 2016. The checklist on the warming cabinet indicated the last date the temperature of this unit was checked was November 25, 2016. (A-0956)

Tour of the Holding Area in the surgical suite revealed a temperature checklist on the refrigerator listing the last date the temperature was checked was November 25, 2016. (A-0956)

Interview with EMP9 at 11:30 AM on December 22, 2016, confirmed the warming cabinet contained two 1000 cc intravenous bags of sodium chloride with expiration dates of December 6, 2016; two 1000 cc intravenous bags of sodium chloride with expiration dates of December 8, 2016; one 1000 cc intravenous bag of sodium chloride with expiration dates of December 9, 2016. The warming cabinet also contained four 1000 cc intravenous bags of lactated ringers with expiration dates of December 9, 2016 and one 1000 cc intravenous bags of lactated ringers with expiration date of December 9, 2016. The checklist on the warming cabinet indicated the last date the temperature of this unit was checked was November 25, 2016. (A-0956)

Tour of the Recovery Area revealed no patient monitors, no medications, empty supply cabinets and a code cart with no checklist indicating it had been checked. A vacant space was noted beside a cabinet with copper pipe protruding from the wall. (A-0956)

Interview with EMP9 at 11:30 AM on December 22, 2016, confirmed the Operating Suite was closed at the time of the tour. EMP9 confirmed the Recovery Room was also closed and that patients were to go to the Intensive Care Unit (ICU) for recovery from surgery. EMP9 also confirmed the ICU was currently closed. EMP9 confirmed the above findings in the Cystoscopy Room, OR2, the hallway and Recovery Area. (A-0957)

Interview with the EMP10 at approximately 7:00 PM on December 22, 2016, confirmed an ice machine and blanket warmer were removed from the Recovery Room and that the Recovery Room had been closed since November 28, 2016. (A-0957)