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24 CREE DRIVE

LOCK HAVEN, PA 17745

PATIENT RIGHTS

Tag No.: A0115

Based on the seriousness of the non-compliance and the potential effect on patient outcome, the facility failed to substantially comply with this condition.

The findings were:

482.13 Tag A-0144

The information reviewed during the survey provided evidence the facility failed to ensure inpatient admission orders were initiated which may have contributed to a delay of staff intervention in one of one applicable medical record (MR1) reviewed.

482.13 Tag A-0123

The information reviewed during the survey provided evidence the facility failed to provide a timely response to a patient grievance in one of three medical records reviewed (MR2).

A discussion took place with the survey team and the facility's administrative staff (EMP1, EMP2 and EMP6) regarding the survey team's concerns related to Patient's Rights on August 22, 2022, at 1045.

Cross reference
482.13 (c)(2) Patient Rights: Care in Safe Setting
482.13 (a)(2)(iii) Patient Rights: Notice of Grievance Decision

PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION

Tag No.: A0123

Based on review of facility policy and facility documentation and staff (EMP) interview, it was determined that the facility failed to ensure its grievance policy was followed by failing to send an interim letter within seven days of receipt of a grievance if the grievance could not be resolved within seven days for one of three grievances reviewed (MR6).

Review on August 22, 2022, of facility policy "Patient Complaint Management and Grievance Process," approved July 2022, revealed "...IV. Definitions...B. Patient Grievance: A "patient grievance" is a formal or informal written or verbal complaint made to any hospital representative or employee by a "grieving party", regarding the patient's care when the complaint is not resolved at the time of the complaint by staff present. It also includes any formal or informal written complaints of patient abuse or neglect and/or issues related to the hospital's compliance with the CMS Hospital Conditions of Participation ("CoPs")...D. Initiating a Grievance: ...Complaints and Grievances Involving Discrimination SECTION 504 /SECTION 1557: Each UPMC hospital has adopted a grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794) ("Rehabilitation Act") or the US Department of Health and Human services regulations implement the Act ...V. ...Guidelines...C. Grievance Process...4. Response to Grievances...c. On average a written response addressing resolution of the grievance will be sent to the patient/family within 7 business days of receipt of the grievance. At licensed behavioral health facilities grievances received from inpatients during their stay will be responded to in writing within 48 hours. Additionally, the patient/family will be given a copy of the complaint and final decision and a copy will be filed with Patient Relations. There are occasions when a grievance is complicated and may require an extensive investigation. If a grievance will not be resolved or if the investigation is not or will not be completed within 7 days (at DPBH 2 days when required), the PRC should inform the patient or the patient's representative of the need for additional time. Ideally, the grievance will be resolved in twenty (21) business days from the acknowledgment letter. However, there may be times when a longer response period is appropriate, the patient should be kept well informed. ..."

Review on August 23, 2022, revealed MR6 spoke with a therapist during an outpatient therapy treatment on April 19, 2022, to express concern the size of the parking space for disabled persons was not adequate to allow exit from a vehicle when utilizing a wheelchair. There was no initial/interim letter sent to MR6. Further review of MR6 revealed the final grievance resolution letter was sent to MR6 on May 18, 2022.

Interview with EMP1 on August 23, 2022, at 0915 confirmed even though the grievance filed was for a violation with Section 504 of the Rehabilitation Act of 1973, the time frames for response and resolution were the same as any other grievance. EMP1 confirmed the grievance final resolution letter was sent to MR6 on May 18, 2022, and initial/interim letter had not been sent to keep the complainant informed of the progress of the grievance.

Repeat deficiency cited on December 22, 2021.

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Based on review of facility policy, facility documentation and medical records (MR) and staff (EMP) interview, it was determined the facility failed to provide care in a safe setting by failing to ensure inpatient admission orders for continuous cardiac monitoring via telemetry and continuous pulse oximetry were initiated resulting in a delay of staff intervention in one of one applicable medical record (MR1) reviewed.

Findings include:

Review on August 22, 2022, of facility policy "Patients' Notice and Bill of Rights and Responsibilities," dated January 4, 2021, revealed "...Staff and Environment You have a right to: 1. Receive respectful care given by competent personnel in a setting that: a. is safe and promotes your dignity, positive self image and comfort; ...Other Healthcare Services You have a right to: 1. Emergency procedures to be implemented without unnecessary delay. ... "

Review on August 22, 2022, revealed MR1 was admitted from the emergency department (ED) to the medical/surgical unit on August 11, 2022, at approximately 1200. Admission orders written by CF1 at 1235 included continuous cardiac monitoring via telemetry and continuous pulse oximetry. There was no documentation in MR1 that a telemetry monitor or pulse oximeter had been applied. Documentation revealed MR1 had been found on August 12, 2022, at 0012 with no pulse. The rapid response team (RRT) was called, and it was determined MR1 had a DNR order and was pronounced deceased by CF3 at 0015. The last note prior to MR1's arrest was by PF3 who documented adjustment of MR1's BiPAP mask (Bilevel positive airway pressure, a mechanical breathing device that is used to provide mild air pressure to keep the airways open) at 2304. There was no further documentation to indicate how long MR1 was in distress prior to being found pulseless.

Interview with EMP1 on August 22, 2022, at 1315 revealed during an internal investigation of MR1's death, it was discovered the admission orders for continuous cardiac and pulse oximetry monitoring had not been initiated. EMP1 confirmed when a patient is on telemetry for cardiac monitoring and/or pulse oximetry events related to heart rate and rhythm and/or a decrease in pulse oximetry an alarm would alert in the patient's room and at the nurses' station signifying distress. EMP1 further confirmed there was no documentation to indicate how long MR1 was in distress prior to cardiac/pulmonary arrest.

Repeat deficiency cited on December 22, 2021.

NURSING SERVICES

Tag No.: A0385

Based on the seriousness of the non-compliance and the potential effect on patient outcome, the facility failed to substantially comply with this condition.

The findings were:

482.23 Tag A-0385
The information reviewed during the survey provided evidence the facility failed to ensure nursing staff on the medical/surgical unit were provided adequate supervision regarding following approved facility policies.

A discussion took place with the survey team and the facility's administrative staff (EMP1, EMP2, and EMP6) regarding the survey team's concerns related to Patient's Rights on August 22, 2022, at 1045.

Cross reference
482.23 (b)(6) Nursing Services: Supervision of Contract Staff

SUPERVISION OF CONTRACT STAFF

Tag No.: A0398

Based on review of facility policy and medical records (MR) and staff (EMP) interview, it was determined the facility failed to ensure staff reported a patient event per approved facility policy in one of one MR reviewed (MR1); failed to ensure pain medications were administered as ordered for two of six MRs reviewed (MR1 and MR9); failed to ensure to pain assessment / reassessment was documented for one of six MRs reviewed (MR9); failed to ensure documentation of provider receipt of a critical value in one of one MR reviewed (MR1); failed to ensure performance of 24 hour chart check in four of four MRs reviewed (MR2, MR3, MR4 and MR5), and; failed to ensure cardiac monitors were placed on patients at the time of order for three of five medical records (MR12, MR13, and MR14).

Findings include:

Review on August 22, 2022, of facility policy "Disclosures of Serious Events/Outcomes of Care," dated July 28, 2022, revealed "I. Policy/Purpose/Scope It is the policy of UPMC to comply with the standards of the Joint Commission and, as applicable, the Pennsylvania Medical Care Availability and Reduction of Error Act ("Mcare"), 40 P.S. §1303.101, et. seq. ...III. Disclosure of Outcomes of Care...A. Joint Commission Standards...3. Reporters and other staff shall notify the attending physician and/or other physicians involved in a patient's care about any Reportable Patient Event that has or could affect the patient's clinical care and shall document the Patient Event in the patient's medical chart... B. General Recommendations for Physician Communications of Outcomes of Care... 3. Notification of significant events or information should be given to the patient as soon as practicable. ... C. Recommendations for Communicating Serious Events and Unfavorable Outcomes...3. The timing, content and persons present at any discussion of an event or condition should be clearly and carefully documented. ..."

Review on August 22, 2021, of facility policy "Initial Incident/Event Reporting (IIER)," dated December 31, 2021, revealed "...V. Procedure A. Reportable Patient Events...4. Physician Notification. The attending physician and/or other physician(s) involved in the care of the patient should be notified of any Reportable Patient Event that has or could affect clinical care. The patient's medical record and IIER should indicate notification of the physician(s). 5. Documentation in Patient Record. The relevant clinical facts surrounding the Patient Event (and the notification of the event to the attending or other physician(s)) should be recorded in the patient's medical record. ..."

Review of MR1 on August 22, 2022, revealed admission orders were written by CF1 at 1235 on August 11, 2022, for continuous cardiac monitoring and continuous pulse oximetry. There was no documentation in MR1 of the initiation of pulse oximetry or cardiac monitoring via telemetry. Further review revealed MR1 had been found on August 12, 2022, at 0012 with the BiPAP off and alarming. MR1 had no pulse. The rapid response team (RRT) was called, and it was determined MR1 had a DNR order and was pronounced deceased by CF3 at 0015. PF6 documented a phone call to MR1's daughter to advise her the patient had been found pulseless and had expired. There was no documentation in MR1 of the lack of continuous cardiac and pulse oximetry monitoring, notification to the physician and notification of the family regarding the event.

Interview with EMP1 on August 22, 2022, confirmed the orders for continuous cardiac monitoring and continuous pulse oximetry had not been initiated. EMP1 further confirmed this was a serious event and that information, along with notification to the physician and disclosure to the family regarding the event, should have been documented in MR1.

Review on August 23, 2022, of facility policy, "Physician Medication Orders Including Advanced Practice Professionals," last revised February 2022, revealed "Purpose: To ensure that orders are accurately received, written, transcribed, verified and implemented for the correct patient. ... Responsible Persons...Medication Ordering Guidelines...H. All medication orders will include the name of the medication, dose, route, specific frequency. PRN indication and specific area for topical application. 1. All PRN medications must be qualified as to the prescriber's intent. PRN medications cannot have the same indication for use. The order must be clarified so each order is differentiated from the other. (For example: pain must be clarified to mild pain (pain scale 1-3), moderate pain (pain scale 4-6), or severe (pain scale 7-10). ..."

Review on August 22, 2022, of facility policy, "Pain Management Policy," last reviewed March 25, 2021, revealed "... II. Purpose The purpose of this policy is to provide direction to health care providers regarding the assessment and management of pain... V. Assessment All patients will be screened for the presence of pain upon admission, at regular intervals and prior to and following an invasive procedure. If present, pain shall be assessed. The assessment will include a pain severity scale (see Appendix A), location, description and level of sedation, using an age appropriate sedation scale defined by the hospital and patient population. ... B. Reassessment for the presence of pain following pain-relieving interventions is essential for effective pain management. Reassessment will include intensity, using an appropriate pain scale or a description of behaviors and physiological response, level of sedation (per age appropriate sedation scale), and outcome. ..."

Review on August 22, 2022, of MR1 revealed an order acetaminophen/oxycodone 5/325 mg 1 tablet every 4 hours as needed for moderate pain (4-6). MR1 also had an order for patient preference with pain medication administration protocol which authorizes administration of a less potent ordered pain medication based on patient preference. Further review of MR1 revealed administration of 1 tablet of acetaminophen/oxycodone 5/325 mg for a pain scale of 7 on August 11, 2022, at 2111. There was no documentation in MR1 of patient preference for a less potent pain medication.

Interview with EMP2 on August 22, 2022, at 1030 confirmed MR1 reported severe pain (7-10) and the acetaminophen/oxycodone given was for moderate pain (4-6).

Review on August 22, 2022, of MR9, revealed documentation MR9 received hydromorphone 0.5 mg. IV, on August 22, 2022, at 0822 for foot pain rated at a pain scale 5. Documentation noted the hydromorphone IV 0.5 mg. order was for pain scale of 7-10.

Interview with EMP4, on August 22, 2022, at 1100, confirmed MR9 with documentation MR9 received hydromorphone 0.5 mg. IV, on August 22, 2022, at 0822, for a pain scale of 5 - foot pain. EMP4 confirmed the hydromorphone IV 0.5 mg. order was for pain scale of 7-10 and MR9 had acetaminophen with hydrocodone PO 10/325mg order for pain scale of 4-6.

Further review on August 22, 2022, of MR9 revealed documentation MR9 had a pain assessment at 0822, of pain scale 5 - foot pain. MR9 with no documentation noted of a pain reassessment following the hydromorphone given.

Interview with EMP4, on August 22, 2022, confirmed MR9 with documentation of a pain assessment at 0822 of pain scale 5 for foot pain and no assessment following pain-relieving intervention.

Review on August 22, 2022, of facility policy "Critical Values Results Reporting," approved March 2022, revealed "...1. RN/RT Documentation for critical laboratory or point of care testing (POCT): ...1. The RN will document the receipt of the critical value and the notification of the provider in the Critical Results Notification Form. ..."

Review on August 22, 2022, of MR1 revealed PF6 attempted to notify CF2 of a critical troponin level received by PF6 on August 11, 2022, at 2302. There was no documentation CF2 returned the call to PF6.

Interview with EMP3 on August 22, 2022, at 1315 confirmed there was no documentation in MR1 of a return call from CF2 to receive the critical value.

Review on August 22, 2022, of facility policy "Physician Medication Orders Including Advanced Practice Professionals," approved February 2022, revealed "...Transcription of Orders and Computer Physician Order Entry (CPOE): ...M. the RN assigned to the patient is responsible for knowledge of the orders and is accountable for nursing action(s) relative to the orders. 1. The RN assigned to the patient (or designee) will review the chart a minimum of every 24 hours and will enter or document via electronic entry chart reviewed, sign, date and time the chart."

Review of open MRs (MR2 MR3, MR4 and MR5) on August 23, 2022, revealed MR2 was admitted on August 18, 2022. There was no nursing staff documentation of a 24-hour chart check from the admission date until present. Review of MR3 revealed and admission date of April 13, 2022. There was no nursing staff documentation of a 24-hour chart check from the admission date until present. Review of MR4 revealed and admission date of August 20, 2022. There was no nursing staff documentation of a 24-hour chart check from the admission date until present. Review of MR5 revealed and admission date of August 11, 2022. There was no nursing staff documentation of a 24-hour chart check from the admission date until present.

Interview with EMP3 on August 23, 2022, at approximately 1400, confirmed there was no documentation of 24-hour chart checks in MR2, MR3, MR4 and MR5. EMP3 further confirmed the facility does not have a process to perform 24-hour chart checks.

Review on August 23, 2022, of facility policy, "Cardiac Rhythm Monitoring," last reviewed August 27, 2021, revealed "...III. Purpose The purpose of this policy is to establish the minimal criteria necessary to safely manage patients receiving cardiac rhythm monitoring. ...6. Cardiac monitoring documentation will be completed in the electronic medical record as per each facility's defined procedures."

Interview with EMP3 on August 23, 2022, at 0920 revealed the accepted standard of practice for the unit for patients on telemetry is that when the cardiac monitor is placed on the patient, a strip is printed off and placed in the medical record. A strip is then printed off every four hours and placed in the medical record.

Review on August 23, 2022, of MR12, revealed documentation cardiac monitoring was ordered by provider on August 21, 2022, at 0736. The cardiac monitoring time on strip was noted at 1103.

Interview with EMP7, on August 23, 2022, at 0945, confirmed MR12 with documentation cardiac monitoring was ordered by provider on August 21, 2022, at 0736, and the cardiac monitoring time on strip was at 1103. EMP7 confirmed when the cardiac monitor is placed on the patient, a strip is printed off and placed in the medical record. A strip is then printed off every four hours and placed in the medical record.

Interview with EMP3, on August 23, 2022, at 0920, confirmed cardiac monitor placement is not documented when is put in place. A cardiac strip is printed off at that time and is placed in the medical record, and a strip is printed every four hours and placed in the medical record.

Review on August 23, 2022, of two medical records (MR13 and MR14), revealed documentation MR13 and MR14 were on cardiac monitoring.

Interview with EMP7, on August 23, 2022, at 1045, confirmed documentation MR13 and MR14 were on cardiac monitoring.

Further review on August 23, 2022, of MR13, cardiac monitoring was ordered by provider on July 31, 2022, at 1150. The time on the cardiac monitoring strip was noted at 1332.

Interview with EMP7, on August 23, 2022, at 1115, confirmed MR13 with documentation cardiac monitoring was ordered by provider on July 31, 2022, at 0736 and the cardiac monitoring time on strip was at 1103.

Further review on August 23, 2022, of MR14, cardiac monitoring was ordered by provider on July 31, 2022, at 0630. The cardiac monitoring time on strip was noted at 2015.

Interview with EMP7, on August 23, 2022, at 1145, confirmed MR14 with documentation cardiac monitoring was ordered by provider on July 31, 2022, at 0630 and the cardiac monitoring time on strip was at 2015.

Repeat deficiency cited on December 22, 2021.