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Tag No.: A0123
Based on review of facility policy and medical records (MR) and staff (EMP) interview, it was determined the facility failed to ensure final grievance resolution letters contained the steps taken to investigate the grievance, the results of the investigation and the date the investigation was completed in two of three MRs reviewed (MR11 and MR13).
Findings include:
Review on November 3, 2022, of facility policy "Patient Complaint Management and Grievance Process," approved August 2022, revealed "...C. Grievance Process ...4. Response to Grievance ...d. The written response is to contain the following: Name of the hospital contact person Steps taken on behalf of the patient to investigate the grievance The results of the grievance process The date of completion..."
Review on November 3, 202, revealed MR11 had filed a grievance on October 12, 2022, and a final resolution letter was sent on October 19, 2022. The resolution letter did not contain the steps taken to investigate the grievance, the results of the investigation or the date the investigation was completed.
Review on November 3, 202, revealed MR13 had filed a grievance on September 15, 2022, and a final resolution letter was sent on September 20, 2022. The resolution letter did not contain the steps taken to investigate the grievance, the results of the investigation or the date the investigation was completed.
Interview on November 3, 2022, with EMP5 at 1230 confirmed the resolution letters sent to MR11 on October 19, 2022, and to MR13 on September 20, 2022, did not contain the required information.
Tag No.: A0144
Based on review of the medical staff rules and regulations, facility policy, medical records (MR) and personnel files (PF) and staff (EMP) interview, it was determined the facility failed to ensure staff limited the use of verbal orders in five of 12 MRs reviewed (MR1, MR3, MR4, MR7 and MR14); failed to document patient condition on discharge by transfer in two of ten MRs (MR2 and MR5); failed to ensure a staff member providing 1:1 observation of a behavioral health patient completed the required training in one of six PFs reviewed (PF1); failed to ensure staff documented every 15 minute observations for patients on constant observation in one of ten MRs reviewed (MR1), and; failed to ensure physician reassessments were performed for patients boarded in the Emergency Department awaiting inpatient admission or transfer to another facility in five of 14 MRs reviewed (MR1, MR2, MR3, MR5, and MR7).
Findings include:
1. Review on November 3, 2022, of the "UPMC Lock Haven Medical Staff Rules and Regulations," final approval May 12, 2021, revealed "... Article II Medical Records...2.14 Orders Verbal Orders. Verbal orders are discouraged except in emergency situations. ..."
Review on November 3, 2022, of facility policy "Physician Medication Orders Including Advance Practice Professionals," approved September 2022, revealed "...Verbal/Phone orders A. Verbal orders are limited to urgent situations in which immediate written or electronic communication is not feasible. Verbal orders are prone to high risk for errors and should be limited to only on as needed basis. ..."
Review on November 3, 2022, of MR1 revealed verbal orders on October 7, 2022, for nicotine gum 2 mg at 1619 and 2110 and lorazepam 1 mg tablet at 2109, on October 8, 2022, for sertraline 50 mg by mouth every morning at 0900, an electrocardiogram (EKG) at 1142, nicotine gum 2 mg at 1917, and lorazepam 1 mg at 2000 and 2309, on October 9, 2022, for nicotine gum 2 mg at 0157, 1222 and 2108, and bacitracin topical ointment at 1228, on October 10, 2022, for nicotine lozenge 2mg at 0554 and nicotine gum 2mg at 0723 while boarded in the emergency room (ED) awaiting inpatient placement.
Interview with EMP3 on November 3, 2022, at 1300 revealed the orders for the nicotine gum, nicotine lozenges were for nicotine cravings, the lorazepam orders were medications to help MR1 sleep, the sertraline was a continuation of a home medication for MR1 and the bacitracin ointment was for a cigarette burn suffered prior to admission. EMP3 confirmed none of these medications would be considered emergent. EMP3 further confirmed the EKG was requested for medical clearance prior to transfer for inpatient mental health treatment and was not emergent.
Review on November 4, 2022, of MR3, revealed the patient was admitted to the ED on a 302 (involuntary commitment) on September 17, 2022. Further review revealed documentation of a verbal order on September 17, 2022, at 2221 for a Nicotine 21 mg Transdermal Patch.
Interview with EMP3 on November 4, 2022, at 1035 confirmed MR3 was admitted to the ED on a 302 on September 17, 2022. EMP3 confirmed MR3 with documentation of a verbal order on September 17, 2022, at 2221 for a Nicotine 21 mg Transdermal Patch. EMP3 confirmed the Nicotine 21 mg Transdermal Patch is not an emergent medication.
Review on November 4, 2022, of MR4, revealed the patient MR4 was admitted to the ED on a 302 on September 18, 2022. Further review revealed documentation of a verbal order on September 20, 2022, at 0941 for Ibuprofen 600 mg tablet 600 mg by mouth every 6 hours prn (as need) for mild pain (1-3 on the pain scale).
Interview with EMP3 on November 4, 2022, at 1105 confirmed MR4 was admitted to the ED on a 302 on September 18, 2022. EMP3 confirmed the verbal order on September 20, 2022, at 0941 for Ibuprofen 600 mg tablet 600 mg by mouth every 6 hours prn for mild pain (1-3). EMP3 confirmed Ibuprofen was not an emergent medication.
Review on November 4, 2022, of MR7, revealed the patient was admitted to the ED on a 201 (voluntary commitment) on July 8, 2022. Further review revealed documentation of verbal orders on July 8, 2022, at 2233 for Melatonin 3 mg tablet 9 mg by mouth, on July 8, 2022, at 2237 for Hydroxyzine HCL 25 mg tablet by mouth, and July 8, 2022, at 2238 for Propranolol 40 mg tablet 10 mg by mouth.
Interview with EMP3, on November 4, 2022, at 1405 confirmed MR7 was admitted to the ED on a 201 on July 8, 2022. EMP3 confirmed the verbal orders on July 8, 2022, at 2233 for Melatonin 3 mg tablet 9 mg by mouth, July 8, 2022, at 2237 for Hydroxyzine HCL 25 mg tablet by mouth, and July 8, 2022, at 2238 for Propranolol 40 mg tablet 10 mg by mouth. EMP3 confirmed Melatonin, Hydroxyzine, and Propranolol were not emergent medications. EMP3 confirmed the medications verbally ordered were for discharge medications for MR7.
Review on November 7, 2022, of MR14 revealed the patient was admitted to the Med/Surg Unit, on October 1, 2022. Further review revealed documentation of a verbal order on October 2, 2022, at 1941 for a nasogastric tube for medication administration.
Interview with EMP4, on November 7, 2022, at 1000 confirmed MR14 was admitted to the Med/Surg Unit on October 1, 2022. EMP4 confirmed MR14 with documentation of a verbal order on October 1, 2022, at 2221 for a nasogastric tube for medication administration.
Interview with EMP2 on November 7, 2022, at 1005 confirmed MR14 with documentation of a verbal order on October 1, 2022, at 2221 for a nasogastric tube for medication administration. EMP2 confirmed the order for MR14's nasogastric tube was for medication administration and was not an emergent order.
2. Review on November 4, 2022, of facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA)," last reviewed February 14, 2022, revealed "... V. Procedure... 6. The QMP [qualified medical person] must certify on a certification form OR in the medical record. The certification or documentation will state the reason for transfer, patient condition, benefit/risks of transfer, receiving hospital, mode of transportation, and patient consent. ..."
Review on November 4, 2022, of MR2 revealed documentation MR2 was admitted to the ED on August 22, 2022, on a 302. Documentation noted MR2 was transferred to a Behavioral Health Facility on August 24, 2022. No documentation noted MR2's condition on discharge.
Interview with EMP3 on November 4, 2022, at 1000 confirmed documentation MR2 was admitted to the ED on August 28, 2022, on a 302. EMP3 confirmed documentation noted MR2 was transferred to a Behavioral Health Facility on August 24, 2022. EMP3 confirmed MR3 with no documentation noting MR2's condition on discharge. EMP3 confirmed the patient's condition on discharge is to be documented.
Review on November 4, 2022, of MR5, revealed documentation MR5 was admitted to the ED on September 15, 2022, on a 302. Documentation noted MR5 was transferred to a behavioral health facility on September 16, 2022. No documentation noted MR2's condition on discharge.
Interview with EMP3 on November 4, 2022, at 1115 confirmed documentation MR5 was admitted to the ED on September 15, 2022, on a 302. EMP3 confirmed documentation noted MR5 was transferred to a behavioral health facility on September 16, 2022. EMP3 confirmed MR5 with no documentation noting MR5's condition on discharge. EMP3 confirmed the patient's condition on discharge is to be documented.
3. Review on November 3, 2022, of facility policy "Care Attendant Utilization and Observation of Patients," dated May 31, 2022, revealed "...IV. Definitions: ...Safety Care Attendant: Provides patient care, support and constant observation in accordance with established policies and procedures under the direction of the RN/LPN physician, or provider with prescriptive authority. Routinely performs the UPMC patient care core responsibilities for Safety Care Attendants which includes, but is not limited to constant observation, activities of daily living such as hygiene (bath and oral care), bed making, transfer and ambulation assistance, and patient comfort measures. Psychiatric Care Attendant: Provides constant observation or special constant observation to assigned suicidal or behavioral health patients under the direction of the RN/LPN, physician, or provider with prescriptive authority. The Psychiatric Care Attendant will have limited direct care responsibilities so that the patient remains in direct eyesight or as ordered, within arm's reach at all times. As a result, the Psychiatric Care Attendant may not complete other care or ADLs for the patient that would require the Psychiatric Care Attendant to leave the room (such as going into the patient's bathroom) or turn their back on the patient. Staff functioning in the Psychiatric Care Attendant role will be informed of the reason that the patient requires a Psychiatric Care Attendant by the assigned RN/LPN. Psychiatric Care Attendants may be used in non-behavioral health departments and hospitals...."
Review on November 7, 2022, of facility job description for "Care Attendant New," no date noted, revealed "Job Summary The Care Attendant provides limited patient care support, and observation services in accordance with established policies and procedures, and may be directed by the nurse or physician, to assure that the highest degree of quality patient care is maintained at all times. ... Skilled at constant observation and psychiatric observation competencies. ... Educational and Knowledge Requirements if no previous patient care training, successful completion of UPMC care attendant (sitter) training program..."
Review on November 3, 2022, revealed MR1 was admitted to the ED with a family report of suicidal ideation and was ordered a care attendant/sitter on October 7, 2022, at 1149. Further review revealed documentation PF1 was a safety sitter in the ED with MR1 on October 7, 2022, from 1900-2300.
Interview with EMP3 on November 7, 2022, at 0925 confirmed MR1 with documentation PF1 was a safety sitter in the ED with MR1 on October 7, 2022, from 1900-2300.
Review on November 7, 2022, revealed PF1's primary job was not related to direct patient care. PF1 contained no documentation of the facility safety sitter training.
Interview with EMP2 on November 7, 2022, at 1325 confirmed PF1's primary job was not related to direct patient care. EMP2 revealed the facility often utilizes staff with no primary patient care responsibilities as care attendants/safety sitters. EMP2 confirmed those staff must complete the facility "Calling all Care Attendants and Safety Sitters!" training prior to performing the role of a care attendant/safety sitter. EMP2 further confirmed there was no documentation PF1 had completed the training.
4. Review on November 3, 2022, of facility policy "Suicide Precautions/Involuntary Commitment (302, 303)," approved January 2021, revealed "...Process and Procedure...C. 1:1 Observation: ...2. 1:1 Observation is within 6 feet of the patient, 24 hours a day and includes observation in bathroom and while showering..."
Review on November 3, 2022, of facility documentation "UPMC Constant Observation Flowsheet," dated March 1, 2016, revealed "Directions: 1. RN to complete reason for constant observation at the initiation of form every 24 hours. 2. Constant Observer to document Q [every] 15 minute observations..."
Review on November 3, 2022, revealed MR1 was admitted to the ED with suicidal ideation and was ordered a care attendant/sitter on October 7, 2022, at 1149. Review of the "Constant Observation Flowsheet" for 0700 October 9, 2022, until 0700 October 10, 2022, revealed there was no documentation of observation for 0400, 0415, 0430, 0445, 0500 and 0515. Review of the "Constant Observation Flowsheet" for 0700 October 10, 2022, until 0700 October 11, 2022, revealed there was no documentation of observation for 0245, 0415, 0430, 0445, 0500 and 0515. Review of the "Constant Observation Flowsheet" for 0700 October 11, 2022, until 0700 October 12, 2022, revealed there was no documentation of observation for 0430, 0445, 0500, 0515 and 0530.
Interview with EMP3 on November 3, 2022, at 1345 confirmed during constant observation 15 minutes checks are to be documented on the "Constant Observation Flowsheet". EMP3 further confirmed the missing documentation for 0400, 0415, 0430, 0445, 0500 and 0515 on October 10, 2022, 0245, 0415, 0430, 0445, 0500 and 0515 on October 11, 2022, and 0430, 0445, 0500, 0515 and 0530 on October 12, 2022.
5. Request was made on November 3, 2022, at 1330 for a policy regarding physician reassessments when patients are boarded in the ED awaiting inpatient admission or transfer to another facility.
Interview with EMP3 on November 3, 2022, at 1330 revealed the facility did not have a policy for reassessments when patients are boarded in the ED awaiting inpatient admission or transfer to another facility. EMP3 further revealed a reassessment during a provider's shift was the accepted standard of practice at the facility. EMP3 clarified a provider shift was typically a 12-hour shift of 0700 to 1900 or 1900 to 0700, but occasionally a provider would cover a 24 shift from 0700 one day until 0700 the next day.
Review of MR1 on November 3, 2022, revealed the patient was brought to the ED by law enforcement on October 7, 2022, under a 302 (involuntary commitment). MR1 remained in the ED while the mental health crisis center searched unsuccessfully for inpatient bed placement until October 11, 2022, when a 303 hearing for an extended commitment was conducted. Further review revealed physician/provider reassessments were not documented during the following times: 1900-0700 October 7, 0700-1900 October 9, 2022, 0700 October 10 - 0700 October 11, and 1900-0700 October 11, 2022.
Interview with EMP3 on November 3, 2022, at 1330 confirmed there were no physician/provider reassessments on 900-0700 October 7, 0700-1900 October 9, 2022, 0700 October 10 - 0700 October 11, and 1900-0700 October 11, 2022.
Review on November 4, 2022, of MR2 revealed the patient was admitted to the ED on a 302 on August 22, 2022. Documentation noted MR2 was held in the ED until transferred on August 24, 2022, at 2120, to a Behavioral Health facility. Documentation noted a provider shift reassessment for August 23, 2022, 1900-0700, at 2158 and for August 24, 2022, 0700-1900 at 0951. There was no documentation of a provider shift reassessment for August 24, 2022, during the 1900-0700 shift.
Interview with EMP3 on November 4, 2022, at 1310 confirmed documentation MR2 was admitted to the ED on a 302 on August 22, 2022. EMP3 confirmed documentation noted MR2 was held in the ED until transferred on August 24, 2022, at 2120 to an inpatient behavioral health facility. EMP3 confirmed documentation noted a provider shift reassessment for August 23, 2022, 1900-0700, at 2158 and for August 24, 2022, 0700-1900, at 0951. EMP3 confirmed no documentation was noted for a provider shift reassessment for August 24, 2022, 1900-0700. Further interview with EMP3 confirmed when a patient is in the ED for an extended stay, usually due to waiting for a bed, the provider is to do a reassessment during his/her shift. EMP3 confirmed the providers shift may be a 24-hour shift (0700-0700 or 0730-0730, 1900-1900 or 1930-1930) or a 12-hour shift (0700-1900 or 0730-1930, 1900-0700 or 1930-0730).
Review on November 4, 2022, of MR3 revealed the patient was admitted to the ED on a 302 on September 17, 2022. Documentation noted MR3 was held in the ED until transferred on September 19, 2022, at 2055 to an inpatient behavioral health facility. Documentation noted a provider shift reassessment for September 18, 2022, 0730-1930 at 1827, for September 18, 2022, 1930-0730 at 0724, for September 18, 2022, 0730-1930, at 1640 for September 19, 2022, at 2006. There was no documentation of a provider shift reassessment for September 17, 2022, 1930-0730.
Interview with EMP3, on November 4, 2022, at 1320, confirmed documentation MR3 was admitted to the ED, on a 302, on September 17, 2022. EMP3 confirmed documentation noted MR3 was held in the ED until transferred on September 19, 2022, at 2055 to a behavioral health facility. EMP3 confirmed documentation noted a provider shift reassessment for September 18, 2022, 0730-1930 at 1827, for September 18, 2022, 1930-0730 at 0724, for September 18, 2022, 0730-1930 at 1640, for September 19, 2022, at 2006. EMP3 confirmed no documentation was noted for a provider shift reassessment for September 17, 2022, 1930-0730.
Review on November 4, 2022, of MR5 revealed the patient was admitted to the ED on a 302 on September 15, 2022. Documentation noted MR3 was held in the ED until transferred on September 16, 2022, at 1222, to an inpatient behavioral health facility. Documentation noted a provider shift reassessment for September 16, 2022, 1930-0730 at 0717. There was no documentation of a provider shift reassessment for September 16, 2022, 0730-1930.
Interview with EMP3 on November 4, 2022, at 1340 confirmed documentation MR5 was admitted to the ED on a 302 on September 15, 2022. EMP3 confirmed documentation noted MR3 was held in the ED until transferred on September 16, 2022, at 1222 to an inpatient behavioral health facility. EMP3 confirmed documentation noted a provider shift reassessment for September 16, 2022, 1930-0730 at 0717. EMP3 confirmed no documentation was noted for a provider shift reassessment for September 16, 2022, 0730-1930.
Review on November 4, 2022, of MR7 revealed the patient was admitted to the ED on a 201 (voluntary commitment) on July 8, 2022. Documentation noted MR7 held in the ED until transferred on July 9, 2022, at 1030 to an inpatient behavioral health facility. Documentation noted a provider shift reassessment for July 8, 2022, 1930-0730 at 0204. There was no documentation of a provider shift reassessment for July 9, 2022, 0730-1930.
Interview with EMP3 on November 4, 2022, at 1405 confirmed documentation MR7 was admitted to the ED on a 201 on July 8, 2022. EMP3 confirmed documentation noted MR7 was transferred on July 9, 2022, at 1030. EMP3 confirmed documentation of a provider shift reassessment for July 8, 2022, 1930-0730 at 0204. EMP3 confirmed no documentation was noted for a provider shift reassessment for July 9, 2022, 0730-1930.
Tag No.: A0166
Based on review of facility policy and medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure the patient's written nursing plan of care reflected the use of restraint/seclusion in one of four MRs reviewed (MR17).
Findings include:
Review on November 7, 2022, of the facility policy "Electronic Plan of Care," last revised October 2021, revealed "Purpose: Provide a consistent method for documenting a patient's problems and outcomes for this hospitalization and the assignment of interventions to facilitate meeting discharge criteria. Policy A plan of care is initiated on admission and is based on data gathered during the assessment. ... Planning for care, treatment, and services is individualized to meet the patient's unique needs. ..."
Review on November 7, 2022, of the facility policy "Restraint and Seclusion," dated July 1, 2022, revealed "...VIII. Use of Restraint for Non Violent/Self Destructive Behavior...C. Patient Plan of Care 1. The use of restraint and patient safety will be addressed in the patient's plan of care and/or treatment plan. ..."
Review on November 7, 2022, of MR17 revealed the patient was admitted to the facility's Med/Surg Unit on July 31, 2022, for pneumonia and respiratory failure. Documentation noted MR17 repeatedly pulling at tubes and not safety conscious. Documentation noted non-violent, soft, bilateral restraints for all extremities were ordered on August 5, 2022, at 1322. There was no documentation of a plan of care for the use of the restraints.
Interview with EMP4, on November 7, 2022, at 1145 confirmed MR17 was admitted to the facility's Med/Surg Unit on July 31, 2022, for pneumonia and respiratory failure. EMP4 confirmed there was no documentation of a plan of care for restraint use.
Interview with EMP2 on November 7, 2022, at 1150 confirmed a plan of care is initiated on a patient's admission and is to be reviewed and updated every shift. EMP2 confirmed anyone with a restraint order should have a plan of care for the restraint use.
Tag No.: A0168
Based on review of facility policy and medical records (MR) and staff (EMP) interview, it was determined the facility failed to ensure a physician order was obtained for each episode of restraint use in one of four MRs reviewed (MR17).
Findings include:
Review on November 7, 2022, of facility policy "Restraint and Seclusion," last reviewed July 1, 2022, revealed "I. Policy It is the policy of UPMC to create an environment that minimizes circumstances that give rise to the application of restraint and use of seclusion for patients and maximizes safety when utilization is necessary. Restraint or seclusion is not used as a disciplinary measure, a means of coercion, a substitute for patient care, or as a convenience for the staff. Restraint or seclusion may only be used to ensure the immediate physical safety of the patient, a staff member or others who come in contact with the patient. The least restrictive, effective intervention that is both necessary and reasonable should be selected and terminated as soon as possible. The use of restraint and seclusion must be implemented in accordance with the safe and appropriate techniques as identified in this policy. The patients' rights to dignity and well-being during use must be preserved. ... B. General Guidelines... A written time limited order from a physician and documentation of the reason must accompany all episodes of restraint and seclusion. ...VIII. Use of Restraint For Non Violent/Non Self-Destructive Behavior... A. Order (Written/Computerized Provider Order Entry Or "COPE") A physician order, order of a CRNP or order of a PA is required for restraint use. 1. The order will include: a. type of restraint (if mechanical restraint or ...) b. reason for use or continuation c. date and time of order... 4. Orders for use of restraint for Non-Violent or Non Self-Destructive patients area renewed every calendar day, by 11:59 PM, unless the patient should have a status change, such as a transfer, discharge, or death, which results in the discontinuation of the restraint. In all instances, time-limited restraint orders for Non-Violent or Non Self-Destructive are effective until 11:59 PM the following calendar day. Restraint reorders are preferentially obtained during a face to face examination of the patient by the physician although a verbal or telephone order is acceptable. ..."
Review on November 7, 2022, of MR17, revealed the patient was admitted to the facility's Med/Surg Unit on July 31, 2022, for pneumonia and respiratory failure. Documentation noted MR17 repeatedly pulling at tubes and was not safety conscious. Documentation noted non-violent restraints (soft bilateral all extremities) were ordered on August 5, 2022, at 1322. Documentation noted why restraints in place, where applied, when applied and when discontinued. Documentation noted the restraints were discontinued on August 7, 2022, at 2400 and reapplied on August 9, 2022, at 0800. Documentation noted an initial order on August 5, 2022, at 1322, a reorder on August 7, 2022, at 0956, and another initial order on August 9, 2022, at 0829. Further review revealed documentation soft bilateral all extremity restraints in place on August 6, 2022. There was no documentation of a restraint order on August 6, 2022.
Interview with EMP4, on November 7, 2022, at 1135, confirmed MR17 was admitted to the facility Med/Surg Unit on July 31, 2022, for pneumonia and respiratory failure. EMP4 confirmed documentation noted MR17 repeatedly pulling at tubes and was not safety conscious. EMP4 confirmed documentation noted non-violent restraints, soft bilateral all extremities, were ordered on August 5, 2022. EMP4 confirmed documentation noted why restraints in place, where applied, when applied, when discontinued. EMP4 confirmed documentation noted the restraints were discontinued on August 7, 2022, at 2400, and reapplied on August 9, 2022, at 0800. EMP4 confirmed documentation noted initial order on August 5, 2022, at 1322, a reorder on August 7, 2022, at 0956, and another initial order on August 9, 2022, at 0829. Further interview with EMP4 confirmed documentation of soft bilateral all extremity restraints in place on August 6, 2022. EMP4 confirmed there was no documentation of a restraint order on August 6, 2022.
Tag No.: A0172
Based on review of the medical staff rules and regulations, facility policy and medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure a provider documented a daily assessment of the need for continued use of restraint in one of four MRs reviewed (MR17).
Findings include:
Review on November 4, 2022, of the "UPMC Lock Haven Medical Staff Rules and Regulations," final approval May 12, 2021, revealed "... Article III General Conduct of Care ... 3.7 Patient Restraint Orders All Medical Staff members shall abide by federal law, TJC, and all hospital policies pertaining to restraints and seclusion. ..."
Review on November 7, 2022, of facility policy "Restraint and Seclusion," last reviewed July 1, 2022, revealed "... VIII. Use of Restraint For Non Violent/Non Self-Destructive Behavior ... A. Order (Written/Computerized Provider Order Entry Or "COPE") A physician order, order of a CRNP or order of a PA is required for restraint use. ...4. ...Restraint reorders are preferentially obtained during a face to face examination of the patient by the physician although a verbal or telephone order is acceptable. ...D. Ongoing Patient Assessment and Care Interventions... 4. The continued need for the use of restraint for Non Violent/Non Self-Destructive behavior will be reassessed and documented in the medical record..."
Review on November 7, 2022, of MR17 revealed the patient was admitted to the facility's Med/Surg Unit on July 31, 2022, for pneumonia and respiratory failure. Documentation noted MR17 repeatedly pulling at tubes and not safety conscious. Documentation noted soft, bilateral, all extremity non-violent restraints were ordered on August 5, 2022, at 1322. Documentation noted the restraints were discontinued on August 7, 2022, at 2400, and reapplied on August 9, 2022, at 0800. Documentation noted initial order on August 5, 2022, at 1322, a reorder on August 7, 2022, at 0956 and another initial order on August 9, 2022, at 0829. Further review revealed no documentation noted a provider 24-hour assessment for August 5, 2022, and August 9, 2022, or reassessments for August 6, 2022, and August 7, 2022.
Interview with EMP4, on November 7, 2022, at 1140, confirmed documentation MR17 was admitted to the facility Med/Surg Unit ED on July 31, 2022, for pneumonia and respiratory failure. EMP4 confirmed documentation noted MR17 repeatedly pulling at tubes and not safety conscious. EMP4 confirmed documentation noted soft, bilateral, all extremity non-violent restraints were ordered on August 5, 2022, at 1322. EMP4 confirmed documentation noted the restraints were discontinued on August 7, 2022, at 2400 and reapplied on August 9, 2022, at 0800. EMP4 confirmed documentation noted initial order on August 5, 2022, at 1322, a reorder on August 7, 2022, at 0956, and another initial order on August 9, 2022, at 0829. Further interview with EMP4 confirmed MR17 with no documentation of a provider 24-hour assessments for August 5, 2022, and August 9, 2022, or reassessments for August 6, 2022, and August 7, 2022.
Tag No.: A0438
Based on review of the medical staff rules and regulations, facility policy and medical records (MR) and staff (EMP) interview, it was determined the facility failed to ensure a complete medical record was maintained for each patient by failure to ensure medical records contained commitment forms in five of 12 MRs reviewed (MR1, MR3, MR5, MR10 and MR16).
Findings include:
Review on November 4, 2022, of the "UPMC Lock Haven Medical Staff Rules and Regulations," final approval May 12, 2021, revealed "... Article II Medical Records 2.1 Preparation/Completion of Medical Records The Attending Physician shall be responsible for the preparation of a complete and legible medical record for each patient. Its contents shall be pertinent and current. The record shall include identification data, complaint, personal history, family history, history of present illness, physical examination, special reports, such as consultations, clinical laboratory, radiology services, other diagnostic and therapeutic orders and results thereof, provisional diagnosis, medical or surgical treatments, operative report, pathological findings, progress notes, final diagnosis, condition on discharge, discharge summary or note, clinical résumé and autopsy report, when performed. ..."
Review on November 3, 2022, of facility policy "UPMC Designated Record Set," dated October 6, 2022, revealed "... II. Purpose UPMC designated record set in accordance with the Health Insurance and Portability Act (HIPAA) of 1996, and to facilitate compliance with 21st Century Cures Act. ... Definition IV. The Designated Record Set is a group of records maintained by or for UPMC that includes the medical records and billing records about individuals that is used in whole or part by or for UPMC to make decisions about individuals. The term record is defined as any item, collection, or grouping of information that includes protected health information (PHI) and is maintained, collected, used, or disseminated by or for UPMC. V. Composition of the UPMC Designated Record Set The UPMC Designated Record Set is composed of the following information, which can be found at (Included Data Elements and Excluded Data Elements). ... UPMC Designated Record Set Clinical Records Record Set Category... Assessments... Commitment Forms..."
Review on November 3, 2022, of MR1 revealed the patient was admitted to the Emergency Department (ED) on October 7, 2022, and a 302 (involuntary commitment for 120 hours) was upheld. On October 11, 2022, a 303 (extended commitment for 20 days) hearing was held. The commitment forms with the decision and signature of the hearing officer for the 303-hearing held on October 11, 2022, were not present in MR1.
Review on November 4, 2022, of MR3, revealed the patient was admitted to the ED on a 302 on September 17, 2022. MR3 did not contain a 302-commitment form.
Interview with EMP3 on November 4, 2022, at 1030 confirmed MR3 was admitted to the ED on a 302 on September 17, 2022, and MR3 did not have a copy of the 302-commitment form. EMP3 confirmed the 302 form was received from the Crisis Worker, as the Crisis Worker brought it to the ED. EMP3 confirmed the original 302 was sent to the accepting behavioral health facility. EMP3 confirmed the 302 form was to be copied and the copy placed in the medical record. Further interview with EMP3 confirmed the facility had no policy for the 302 form, as a standard process is followed.
Review on November 4, 2022, of MR5 revealed documentation MR5 was admitted the ED on a 302 on September 15, 2022. MR5 did not contain a 302-commitment form.
Interview with EMP3 on November 4, 2022, at 1100 confirmed MR5 was admitted to the ED on a 302 on September 15, 2022, and MR5 did not have a copy of the 302-commitment form. EMP3 confirmed the 302 form was to be copied and left in the medical record as the original 302 form must go with the patient on their transfer to the accepting behavioral health unit.
Review on November 4, 2022, of MR10, revealed documentation MR10 was admitted to the ED on a 201 (voluntary commitment) on October 23, 2022. MR10 did not contain a 201-commitment form.
Interview with EMP3, on November 4, 2022, at 1300 confirmed MR10 was admitted to the ED on a 201 on October 23, 2022, and MR10 did not have a copy of the 201-commitment form. EMP3 confirmed the original 201 form should be left in the medical record.
Review on November 7, 2022, of MR16 revealed the patient was admitted to the ED on a 201 on August 17, 2022. MR16 did not contain the 201-commitment form.
Interview with EMP4 on November 7, 2022, at 1105 confirmed MR16 was admitted to the ED on a 201 on October 23, 2022, and MR16 did not have a copy of the 201-commitment form. EMP3 confirmed the original 201 form should be left in the medical record.
Tag No.: A0457
Based on review of the medical staff rules and regulations, facility policy and medical records (MR) and staff (EMP) interview, it was determined the facility failed to ensure protocols/standing orders were implanted in a well-defined clinical scenario in three of 12 MRs reviewed (MR1, MR4 and MR9) and failed to ensure protocols/standing orders utilized in the emergency department (ED) were reviewed and approved annual by the medical staff and pharmacy and nursing leadership as outlined in the medical staff rules and regulations.
Findings include:
Review on November 4, 2022, of the "UPMC Lock Haven Medical Staff Rules and Regulations," final approval May 12, 2021, revealed "...Article II Medical Records...2.14(b) Standing Orders, Order Sets, and Protocols: (1) The MEC allows the use of pre-printed and electronic standing orders, order sets and protocols for patient orders when the following criteria are met: a. The MEC and the Hospital nursing and pharmacy departments must review and approve any standing orders, order sets, and protocols (collectively, "standing orders") that permit treatment to be initiated by an individual (for example, a nurse) without a prior specific order from the attending physician. b. All standing orders identify well-defined clinical scenarios for when the order is to be used. (2) The MEC will adopt the findings of the UPMC Electronic Practice Guidelines ("EPG") and/or the UPMC System Pharmacy & Therapeutics Committee, as applicable, confirming that all approved standing orders and protocols are consistent with nationally recognized and evidence-based guidelines. The MEC will also ensure that such standing orders and protocols are reviewed at least annually. (3) If the use of a standing order has been approved by the MEC, treatment may be initiated (i) by a nurse or other authorized individual acting within his or her scope of practice who activates the order; or (ii) when a nurse enters documentation into the medical record that triggers the standing order. ..."
Review on November 7, 2022, of facility policy "SH Emergency Department Advanced Triage Protocols," last approved September 2020, revealed "Purpose: The purpose of emergency department advanced triage protocols is to expedite medical treatment and improve patient safety by initiating protocols approved by the on-site provider group and based on the patient's presentation as assessed by the on duty Registered Nurse (RN). Responsibility: Based on professional nursing assessment, it is the responsibility of the Emergency Department RN to initiate site specific advanced triage protocols as approved by the site provider group, especially during times of increased patient volumes and/or incidents involving multiple patients. It is the responsibility of the emergency department provider (e.g. MD, DO, PA-C, CRNP) to be familiar with the advanced triage protocol orders and add additional orders as deemed necessary based on patient presentation. The physician group is responsible for maintaining a current and approved set of protocols for their site. Process/Procedure: Based on professional nursing assessment, the approved site protocols can be entered into CPOE by the triage or staff nurse as orders per protocol. If unsure, RN will consult emergency department provider prior to initiating. ..."
Review on November 4, 2022, of facility documentation "Protocol Orders for SUS ED Advanced Triage Protocols," updated April 2022, revealed "...Suspected Overdose/ETOH Oxygen, Drug Screen, Urine with THC..ETOH level, Ammonia (NH3) Level, Pulse Oximetry Patient Care 92, Stat, Titrate )2 via nc [nasal cannula] for a saturation >92%. If >92%, room air only. High Sensitivity Troponin ST, Once Lactic Acid Level, Plasma, Cardiac Monitoring - Emergency Room Only Stat, 6, HR, Constant Indication ED POCT Glucose Whole Bloodwork Communication Stat, ONCE Communication to Nursing - Once Assess. Airway, Breathing, circulation (notify provider of deficiency immediately) EKG 12 Lead T;N, Stat, Once, Reason: chest pain CBC with Differential (includes Platelets) ST, Once Acetaminophen Level ASA Salicylate) Level Saline Lock Stat Comprehensive Metabolic Profile/CMP..."
Review on November 3, 2022, of MR1 revealed upon admission to the ED for paranoid delusions and family report of suicidal ideation on October 7, 2022, the following orders were placed per protocol: serum alcohol, salicylate (ASA), acetaminophen and ammonia levels, a complete blood count (CBC), comprehensive metabolic profile (CMP), urine drug screen, and urine infection test level.
Interview with EMP3 on November 4, 2022, at 0930 revealed the facility does not have an ED protocol for a behavioral health patient. EMP3 revealed the ED RNs review the "Suspected Overdose/ETOH" protocol and do not initiate the entire protocol but select orders from within the protocol based on nursing judgement.
Review on November 7, 2022, of MR4 revealed an admission to the ED on September 18, 2022, on a 302. Initial orders entered per nursing under protocol orders included a urine drug screen, serum alcohol level, CMP, ASA, CBC and acetaminophen level.
Interview with EMP3 on November 7, 2022, at 1030 confirmed the orders for the urine drug screen, serum alcohol level, CMP, ASA, CBC and acetaminophen level were entered by nursing and noted "per protocol" . EMP3 further confirmed there were no protocols specific to patient presentation of behavioral health issues and the orders were selected from the "Suspected Overdose/ETOH" protocol.
Review on November 7, 2022, of MR9 revealed an admission to the ED on September 20, 2022, on a 302. Initial orders entered per nursing under protocol orders included a urine drug screen, serum alcohol level, CMP, ASA, CBC, urinalysis, and acetaminophen level.
Interview with EMP3 on November 7, 2022, at 1030 confirmed the orders for the urine drug screen, serum alcohol level, CMP, ASA, CBC, urinalysis, and acetaminophen level were entered by nursing and noted "per protocol". EMP3 further confirmed there were no protocols specific to patient presentation of behavioral health issues and the orders were selected from the "Suspected Overdose/ETOH" protocol.
Interview with EMP1 on November 7, 2022, at approximately 1000, confirmed the selection of orders from within the "Suspected Overdose/ETOH" protocol does not meet the requirement for the use of a protocol based on a well-defined clinical scenario. EMP1 revealed the protocols in place in the ED were last approved by the Medical Executive Committee (MEC), Pharmacy & Therapeutics Committee (P&T) and Nursing Leadership in 2020. EMP1 further confirmed updates to the protocols were implemented in April 2022 without approval by P&T and Nursing Leadership.